EVALUATION OF THE COMPUTED TOMOGRAPHIC “SENTINEL CLOT SIGN” TO IDENTIFY BLEEDING ABDOMINAL ORGANS IN DOGS WITH HEMOABDOMEN

Diagnosis of type III von Willebrand disease in a standard dachshund

Type III von Willebrand disease is a rare coagulopathy, with published reports only existing for four canine breeds - Dutch Kooiker Hounds, Shetland Sheepdogs, Chesapeake Bay Retrievers and Scottish Terriers. A 2-year and 9-month-old male neutered standard dachshund was presented for hypovolaemic shock and a ventral neck mass. One previous bleeding episode following routine castration was reported. The patient's packed cell volume fell from 27% to 15% during hospitalisation, and computed tomography identified changes to the ventral neck consistent with fluid accumulation, assumed to represent haemorrhage. A further, similar lesion was identified within the cranial mediastinum. The patient was managed with a combination of isotonic crystalloids (Hartmann's solution), synthetic colloid (Geloplasma), alongside administration of blood products (packed red blood cells and fresh frozen plasma). A Von Willebrand factor antigen assay confirmed Type III von Willebrand disease. The patient made a full recovery. This report is the first to describe Type III von Willebrand disease in a standard dachshund.

Computed tomographic features of suspected arterial pseudoaneurysm in the head and neck of four dogs

Computed tomography is a valuable diagnostic technique in the clinical work-up of dogs with oropharyngeal trauma and bleeding. Traumatic extravasation can manifest as a pseudoaneurysm. A pseudoaneurysm is an extraluminal accumulation of blood that is contained by the adventitia layer or neighboring tissues. The purpose of this retrospective, multicenter, observational case series study was to describe the CT features in dogs with presumed oropharyngeal arterial pseudoaneurysm and its potential association with trauma. Imaging archives were searched for canine patients with head and neck CT studies showing visible extravasation of contrast-enhanced blood contained by soft tissue structures. Medical records of these patients were reviewed for oropharyngeal bleeding or trauma and reported. Four dogs met the inclusion criteria. CT findings included a well-defined, confined area of vascular contrast enhancement adjacent to the common carotid artery or its branches. The mean contrast enhancement in the corresponding artery and pseudoaneurysm lesion was similar, suggesting that these lesions represent active arterial extravasation. Four-dimensional CT was performed in one case and demonstrated contrast medium leaking from an artery and being contained by adjacent soft tissue structures. All dogs had a history and imaging findings consistent with oropharyngeal bleeding and trauma. Arterial pseudoaneurysm should be considered as a differential diagnosis in dogs with oral trauma and CT features of a well-defined, periarterial, strongly contrast-enhancing lesion.

Retrospective evaluation of the diagnostic utility of computed tomography in dogs with nontraumatic hemoperitoneum: 26 cases (2015-2020)

OBJECTIVE

To describe the appearance of lesions noted on abdominal computed tomography (CT) in dogs with spontaneous hemoperitoneum and determine the utility in using CT to differentiate benign from malignant lesions.

DESIGN

Retrospective case series.

SETTING

Single-center, university veterinary teaching emergency service.

ANIMALS

Twenty-six dogs presented between 2015 and 2020 with spontaneous hemoperitoneum confirmed via abdominocentesis with pre- and postcontrast abdominal CT performed prior to surgery or euthanasia.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

On histopathological diagnosis, 20 of 26 lesions were found to be malignant, and 6 of 26 were benign. Two radiologists reviewed the CTs. Radiologist 1 correctly identified 5 of 6 (83.3%) benign cases and 18 of 20 (90%) malignant cases. Radiologist 2 correctly identified 2 of 6 (33.3%) benign lesions and 18 of 20 (90%) malignant cases. Of the 10 imaging descriptors evaluated, none were significantly associated with the histological diagnosis.

CONCLUSIONS

Results from the current study suggest that abdominal CT imaging of spontaneous hemoperitoneum cases is not a reliable indicator of malignancy versus benignancy. As such, prognosis should not be defined using this modality alone prior to emergency surgery and instead should be concluded based on the clinical course of the patient and histopathological findings of the resected tissues after surgery.

Non-coagulopathic hemothorax in a dog: A case report

An 8-year-old, female-spayed, Blue Heeler presented with suspected non-coagulopathic spontaneous, hemothorax with neoplasia as the most likely differential as coagulation parameters were normal and no obvious history of trauma was reported. Computed tomography scan was crucial for diagnosis of a traumatic partial vascular avulsion injury that was successfully managed supportively.

Arterial malformations leading to bilateral spontaneous renal hemorrhage in a dog

OBJECTIVE

To describe the clinical presentation, diagnostic imaging, management, and follow-up of a dog that presented with sequential, bilateral, spontaneous, subcapsular and perirenal hemorrhage (Wunderlich syndrome) due to bilateral renal arterial malformations.

CASE SUMMARY

A 9-year-old intact male Field Spaniel presented for acute onset abdominal pain following a possible syncopal episode. Abdominal ultrasonography, contrast-enhanced ultrasound, and computed tomography (CT) revealed right-sided perirenal hemorrhage that extended into the peritoneum. The dog was discharged following stabilization with analgesia, fluid therapy, and tranexamic acid. One month later, the patient presented with identical clinical signs. A CT scan at this stage revealed bilateral kidney infarcts with new left-sided perirenal hemorrhage. Abdominal ultrasound and contrast-enhanced ultrasound were repeated and showed similar findings. Follow up with four-dimensional CT angiography revealed bilateral renal arterial malformations, likely causing spontaneous renal hemorrhage and secondary subcapsular hematomas , retroperitoneal and peritoneal hemorrhage.

UNIQUE INFORMATION PROVIDED

This is the first reported case of both bilateral renal arterial malformations and bilateral spontaneous subcapsular and perirenal hemorrhage in the absence of neoplasia, coagulopathy, or trauma in a dog. Advanced imaging modalities, including selective angiography, were required to diagnose this condition successfully. Arterial malformations should be considered as a differential diagnosis in cases of hemoretroperitoneum. Nephrectomy due to perirenal hemorrhage should be cautiously considered, especially in the absence of angiography, because of the sequential bilateral nature of this case. Conservative management in this case resulted in a good long-term outcome 10 months later.

Outcomes and Blood Product Use in 89 Surgically Managed and 79 Medically Managed Cases of Acute Spontaneous Hemoperitoneum in the Dog

Objective: To describe a population of dogs with acute spontaneous hemoperitoneum (ASH) that were treated with either surgical or medical management in the first 12 h after presentation, and to perform a preliminary investigation into whether there were differences in achieving cardiovascular stabilization or patterns of red blood cell (RBC) transfusion between patients treated with early (<12 h) surgery vs.medical management. Design: A retrospective multicenter preliminary study performed on 168 dogs presenting with ASH between January 2015 and May 2019. Patients were excluded if they were euthanized or discharged from hospital within the first 12 h, or if clinical records were incomplete. All patients received appropriate medical stabilization efforts. Statistical analysis was performed comparing patients that underwent early (<12 h) surgery and those that did not. Results: Eighty-nine patients were in the early surgical group and 79 patients in the medical group. A significantly higher proportion of medical cases were euthanized (p < 0.001). A significantly higher proportion of early surgical cases were discharged from hospital (p = 0.005). There was no statistically significant difference between groups in achieving cardiovascular stabilization (OR 1.07 p = 0.82). A higher proportion of patients with body-weight over 20 kg achieved stabilization within 12 h than those with body-weight of 20 kg or less (62.7 vs. 41.4%, p < 0.01). A higher proportion of patients with splenic conditions achieved stabilization than patients with non-splenic conditions (56.5 vs. 28.6%, p = 0.05). The odds of receiving an RBC transfusion were higher in the early surgical group than the medical group [OR 3.81 (p < 0.001)]. Conclusions: This preliminary study did not identify a significant difference in the ability to achieve cardiovascular stabilization in the first 12 h in dogs with ASH that underwent early surgical intervention vs. those managed medically. Patients in the early surgical group were more likely to receive a RBC transfusion than those in the medical group. At this time the decision on whether to pursue medical or early surgical management should be made on a case by case basis.

Dorsal mediastinal haemorrhage in dogs: four cases (2010-2018)

OBJECTIVE

This retrospective case series describes the clinical presentation and CT findings of dogs with presumed mediastinal haemorrhage with no apparent identifiable underlying cause.

MATERIALS AND METHODS

Medical records were searched for dogs with presumed or suspected mediastinal haemorrhage of non-thymic origin. For all dogs, data on signalment, history, physical examination, treatment and outcome were collected by reviewing the medical records. Follow-up information was collected by telephone interviews with the owners and/or their primary-care veterinarians.

RESULTS

Four dogs were included. All survived to discharge with apparent resolution of the mediastinal haemorrhage (based on repeat imaging and/or clinical signs) with supportive treatment alone. Follow-up information was available from 2 months to 5 years following discharge, and none of the patients showed a recurrence of clinical signs during this period.

CLINICAL SIGNIFICANCE

This case series highlights that presumed haemorrhage into the mediastinum can occur in dogs without an obviously identifiable cause and, whilst rare, should be considered as a cause of dorsal mediastinal masses and may be successfully managed with supportive care alone.

Diagnostic accuracy of postmortem computed tomography for bleeding source determination in cases with hemoperitoneum

Aim

The aim of this retrospective study was to determine the accuracy of postmortem computed tomography and different radiological signs for the determination of the bleeding source in cases with hemoperitoneum confirmed at autopsy.

Methods

Postmortem computed tomography data of consecutive cases with hemoperitoneum confirmed at autopsy were reviewed by two raters, blinded to the autopsy findings. The determination of possible bleeding sources was based on the presence of the sentinel clot sign, blood or sedimented blood surrounding an organ, intraparenchymal abnormal gas distribution, and parenchymal disruption. The bleeding source and the cause of hemoperitoneum (traumatic, surgical, natural, or resuscitation) as reported in the autopsy report were noted. The survival intervals of the deceased were calculated when information about the time of an incident related to death was available in the autopsy reports.

Results

Eighty-five cases were included in the study. Postmortem computed tomography showed 79% sensitivity and 92.1% specificity for the detection of the bleeding source. The sentinel clot sign was associated with surgical or natural causes of hemoperitoneum and longer survival intervals. Sedimented blood around the bleeding source was associated with resuscitation. Abnormal gas distribution within organs and combination of multiple radiological signs provided higher sensitivity.

Conclusion

Postmortem computed tomography provides moderate sensitivity and high specificity for determining the bleeding source in cases with hemoperitoneum. Different PMCT signs are associated with different causes of hemoperitoneum and survival intervals.

Anal sacculiths may be an incidental finding in dogs

Mineral-attenuating material is occasionally seen in the anal sacs of dogs during abdominal CT studies. This retrospective, descriptive study was performed to estimate the prevalence and CT appearance of this mineral-attenuating material. A total of 357 abdominal CTs were reviewed retrospectively. The mineral-attenuating material was most easily identifiable using the brain window setting (window width: 120 HU; window level: 40 HU). In the current study, the prevalence of mineral-attenuating material in the anal sacs was 7.6% (95% confidence interval, 5.0-10.8%) with 48.1% bilateral involvement and equal distribution in the right and left in dogs with unilateral involvement. Successful collection and material analysis were performed in three dogs. The material was determined to be 100% dried blood, 100% waxy matter, and a "small amount of fat enmeshed in unidentified noncrystallined material." Given the CT appearance and the Hounsfield unit of these mineral-attenuating material within the anal sacs, the term "anal sacculiths" is proposed. All dogs with anal sacculiths within this study population did not have any reported disease of the anal sacs.

CT characteristics of primary splenic torsion in eight dogs

Splenic torsion is a rare potentially life-threatening condition characterized by rotation of the spleen around the gastrosplenic and phrenosplenic ligaments leading to occlusion of venous drainage and arterial supply. This retrospective study describes the CT characteristics for dogs with surgically confirmed splenic torsion from 2013 to 2018 using the submissions to a large multinational teleradiology database. Eight dogs had the splenic torsion confirmed with surgery. Seven of eight cases had histology confirming congestion, hemorrhage, and necrosis, and one had concurrent myelolipoma infiltration. The CT characteristics included an enlarged (8/8), rounded (7/8), folded C-shaped spleen (8/8) with a difference of median parenchymal attenuation between pre- and postcontrast of +1.15 HU (Hounsfield units). Other common features included a mainly homogeneous parenchyma on pre- and post-contrast images (6/8), lack of subjective and objective vascular and parenchymal contrast enhancement (6/8) and free peritoneal fluid (6/8). A "whirl sign" was seen in the majority of cases (7/8) alongside a strongly hyperattenuating center (95-416 HU) on the precontrast images (5/7), which has not been previously described in the veterinary literature. Gastric position was normal in all cases. More variable CT characteristics of the confirmed torsions were attributable to suspected partial torsion and myelolipomatous infiltration. Overall, primary splenic torsion confirmed with surgery showed consistent characteristics on CT.

Diagnostic imaging for the assessment of acquired abdominal vascular diseases in small animals: A pictorial review

Advances in interventional radiology and surgical techniques now allow complex abdominal diseases to be more successfully treated in small animals. Abdominal vascular alterations, acquired as individual process or as complication of other lesions such as neoplasia, can be life-threatening or at least greatly limit curative interventions of underlying diseases. Computed tomography (CT) and high-definition ultrasonography are now readily available in veterinary referral centers. Yet, there is little information currently available on the use of these modalities for the diagnosis and characterization of these vascular alterations. The purpose of this article is to review the CT and ultrasonographic findings of acquired vascular diseases in the abdomen of dogs and cats, using both the veterinary and human medicine literature as references, and highlighting essential concepts through figures.

Computed tomography attenuation value for the characterization of pleural effusions in dogs: A cross-sectional study in 58 dogs

CT attenuation value can help to differentiate exudate from transudate in people. The aim of this cross-sectional study was to assess the utility of CT in characterizing pleural effusions based on attenuation values in a population of dogs having CT and diagnostic thoracentesis within 48 h of each other. The CT attenuation values were determined using four circular, same size, regions of interest (ROIs) placed on the same CT slice with the greatest quantity of fluid. Values of each ROI were recorded and the mean of the four ROIs mean values (mean of the means) was calculated and considered as the CT attenuation value of that patient. The final population included 23 proper inflammatory exudates, 15 chylous effusions, 12 hemorrhagic effusions and 8 transudates. The median of 'mean of the means' values were: exudate 19.22 HU (8.23 to 37.66 HU); chylous effusion 10.26 HU (-0.90 to 15.37); hemorrhagic effusion 31.65 HU (18.10 to 54.97), and transudate 11.20 HU, (-2.52 to 16.59). CT accurately differentiated hemorrhagic from chylous effusion (AUC 1.0, P < 0.0001) and hemorrhagic effusion from transudate (AUC 1.0, P < 0.0001); CT-values allowed good accuracy in distinguishing exudates from transudates [AUC 0.87 (95%, CI: 0.74-1.0; P < 0.0001)]. HU attenuation values did not accurately differentiate between transudates and chylous effusion. A cutoff value of 34.68 HU (sensitivity of 96% and specificity of 95%) discriminated between exudates and hemorrhagic effusions. CT-value <12.15 HU had a sensitivity of 94% and specificity of 78% for identify transudate or chylous effusion.