Identifying neurological diseases made easier

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In his keynote address at the 2022 Atlantic Coast Veterinary Conference, Fred Wininger, VMD, MS, DACVIM (Neurology), breaks down identifying neurological diseases with a checklist of questions

Fred Wininger, VMD, MS, DACVIM (Neurology), closed out the final day of the Atlantic Coast Veterinary Conference (ACVC) with his keynote presentation, “The Gait Game.”1 He turned the process of identifying and diagnosing neurological diseases into a checklist of questions clinicians follow to make a diagnosis.

Fred Wininger, VMD, MS, DACVIM (Neurology), and his parents, John and Iris Wininger. (Photo by John Hydrusko)

Fred Wininger, VMD, MS, DACVIM (Neurology), and his parents, John and Iris Wininger. (Photo by John Hydrusko)

A New Jersey native, Wininger graduated from the University of Pennsylvania College of Veterinary Medicine. After completing a small animal rotating internship at the University of Georgia, he finished his neurology/neurosurgery residency at Washington State University. To make neurology seem more accessible to general practitioners, Wininger began his talk saying, “What made a lot of us veterinarians is that we know something a little bit different about animals than the normal person that sits next to us. And so, the goal of this talk is to not teach you something new. It's all inside you. You know when a dog is not right. It's to give you a language to be able to turn it into something that you can put into practice.”

He added, “I want to make you guys so comfortable with neurology that—as opposed to taking that dog with 2 endocrine diseases, urinary tract infection, their skin is falling off—you choose to take the ataxic dog, and that’s the case you want to tackle.”

Wininger tells attendees to look at neurology like a game or puzzle. He said, “The reason why it's a puzzle game, is because the nervous system is different than all other systems. If you look at this liver or kidney, it doesn't matter if you're in the quadrant lobe or the right lobe or the cranial pole or caudal pole, it's all the same stuff, right? It's all going to be doing the same functional thing. But the nervous system is segmented into pieces [and] into blocks. And if a piece of that system is affected structurally, then it leads to a different functional outcome.”

From there, Wininger goes through questions to ask yourself when seeing a patient’s gait:

  • First: Is it neurologic? Does the gait evaluation show a neurological issue or orthopedic issue? Wininger said, “When we look at gait, one of the most important things is we look at is cadence, timing, [and] beats… If you're struggling to determine if a dog is orthopedic vs neurologic, consider what the types of arrhythmias—is it consistently wrong, or is it inconsistently wrong.”
  • Second: What does the gait look like? Is there an increased stride length or is it short and choppy? Upper motor neuron (UMN) dysfunction can have signs of increased stride length and increased muscle tone. On the other hand, lower motor neuron (LMN) dysfunction has signs of decreased muscle tone and a short choppy gait.
  • Third: What form of ataxia is it? Propriospinal, cerebellar, or vestibular? Wininger reminds attendees that these are not mutually exclusive, meaning a patient can have multiple or all 3. Propriospinal is characterized as the “drunken sailor walk,” often coupled with a spastic/long stride gait suggesting UMN dysfunction. Patients are often thought of as overstepping or “floating.” Cerebellar is characterized as hyper/dysmetria (goose stepping), truncal swaying, and intention tremors. Vestibular is characterized by imbalance often manifest as “wall walking, coupled with a head tilt and nystagmus.”

With these questions, Wininger hopes neurology can be broken down and simplified so that general practitioners can feel more confident when a potential neurology case comes into the clinic. He said, “So remember that the best tool you have is not an MRI, and it's not necessarily a visit to the neurologist, it's your iPhone. Take videos of these cases.” Wininger stresses that taking videos of patients to evaluate their gait and watching them multiple times can help improve diagnosis confidence. He continued, “So the point is, that if you see this over and over in your practice, then you can get really good at it.”

Reference

Wininger, F. The gait game. Presented at Atlantic Coast Veterinary Conference; Atlantic City, New Jersey. October 10-12, 2022.

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