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case_images: Abdominal ultrasound exam, with color Doppler reveal portocaval shunt. VP = portal vein. VCC = caudal cava vein. AO = abdominal aorta.
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case_images: Abdominal CT exam. Large extrahepatic portocaval shunt, Bichon dog, 3 months. Following the caudal vena cava (CVC) from the caudocranial direction, it is observed that it runs parallel to the portal vein to the prerenal level (cranial to the kidneys), where it gives a ventral branch that descends ventro-laterally to the left, follows the small curvature of the stomach, then turns to the right and joins the portal vein (PV) at the level of the hepatic hilum.
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case_images: CT). For a rapid diagnosis and due to financial reasons, the owner agreed to advanced imaging, and temporarily declined the bile acid testing. CT examination under chemical restraint (Ketamine, Kepro, Deventer, The Netherlands, at 0.1 mg/kg IV and medetomidine, Domitor, Orion Pharma, at 0.05 mg/kg IV) revealed a large extrahepatic porto-caval shunt (Figure 2) associated with multiple conical cortical brain lesions that were hypodense, with reduced or absent contrast uptake, along with more extensive biconvex lesions, including along the cerebral sulci (Figure 3).
case_images: Cerebral CT exam in a Bichon dog, 3 months old, with portocaval shunt. Multiple hypoattenuated lesions with little to no contrast enhancement, some located in the cortex with a conical shape, others more extensive and biconvex, as well as along the cerebral sulci.
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case_images: CT). For a rapid diagnosis and due to financial reasons, the owner agreed to advanced imaging, and temporarily declined the bile acid testing. CT examination under chemical restraint (Ketamine, Kepro, Deventer, The Netherlands, at 0.1 mg/kg IV and medetomidine, Domitor, Orion Pharma, at 0.05 mg/kg IV) revealed a large extrahepatic porto-caval shunt (Figure 2) associated with multiple conical cortical brain lesions that were hypodense, with reduced or absent contrast uptake, along with more extensive biconvex lesions, including along the cerebral sulci (Figure 3).
case_images: EEG recording for 10 s. The nearly normal cerebral activity of the patient immediately after the CT study, while still under medetomidine-ketamine anesthesia, showed slow, symmetric background activity characterized by delta waves (with a frequency of 1-4 Hz). Each second of the recording is delimited by the yellow vertical markings.
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case_images: The electrical activity of the brain was characterized by almost normal waves, represented by slow, symmetrical, and predominantly delta-wave background activity (Figure 4).
case_images: Slow background rhythm, theta (same patient) appears as the effects of anesthesia from the CT examination wear off. Compared to the previous image, a gradual increase in frequency and amplitude can be observed.
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case_images: In the case of anesthesia, once its effect ends, background activity is characterized by the appearance of a high-frequency waves that gradually pass through theta rhythms (Figure 5) to alpha and beta rhythms, with the latter marking the onset of waking status.
case_images: Periodic discharges with low frequency but high amplitude, reaching and exceeding 150 microvolts. Clinically, the patient exhibited paddling movements and rhythmic vocalizations synchronized with the graphoelements.
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case_images: Graphoelements could be identified in all leads, both in mono- and bipolar montages in a synchronous clinical context, represented by the installation of pedaling movements and rhythmic vocalizations (Figure 6).
case_images: This figure displays a 20 s segment, compressed from the previous EEG trace, revealing the hypersynchronization of cerebral electrical activity. The primary graphoelements, which may resemble spikes, consist of sharp and slow wave complexes with three distinct phases, known as "triphasic waves".
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case_images: In addition to the hypersynchronized cerebral electrical activity, "bilateral triphasic waves" (Figure 7) were identified.
case_images: The morphology of bilateral symmetric triphasic waves is characterized by a high amplitude (exceeding 70 microV) and consists of three distinct phases: an initial small negative deflection, a prominent positive deflection, and a prolonged, slow negative deflection that gradually increases in amplitude. These waves exhibit a diffuse and bilaterally synchronous distribution.
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case_images: These were characterized by complexes with a moderate to high amplitude (100-300 muV) of a frequency of 1.5 to 5 Hz (Figure 8).