Journal of Equine Veterinary Science 31 (2011) 611-614

Journal of Equine Veterinary Science

journal homepage: www.j-evs.com

Case Report

Hydrocephalus in an American Miniature Horse Foal: A Case Report

and Review
Ryan A. Ferris DVM, MS, DACT, Jenni Sonnis DVM, Brett Webb DVM, Alicia Lindholm DVM,
Diana Hassel DVM, PhD, DACVS, ACVECC
James L. Voss Veterinary Teaching Hospital, Colorado State University, Fort Collins, CO

a r t i c l e i n f o a b s t r a c t

Article history: A 6-year-old multiparous American Miniature Horse mare was presented at 324 days of
Received 24 December 2010 gestation for evaluation of vaginal bleeding. A manual obstetrical examination was
Received in revised form performed and the cervix was found to be open with the fetus in transverse position. The
10 February 2011
mare was sedated and placed under general anesthesia. Attempts made to mutate the
Accepted 03 March 2011
fetus were unsuccessful. A cesarean section was performed and the foal was noted to be
Available online 18 May 2011
in transverse position with marked enlargement of the cranium. The abdominal incision
was closed in a routine manner, and the mare recovered from anesthesia without inci-
Keywords:
Foal
dent. Postoperative treatment consisted of unixin meglumine, gentamicin sulfate,
Hydrocephalus potassium penicillin, oxytocin, and intravenous uid therapy. The mare was discharged
Dystocia to the owners 4 days after surgery. A lateral radiograph of the fetus was obtained and
Caesarian section conrmed hydrocephalus. On necropsy, it was found that the calvarium measured 59 cm
in circumference and was dome-shaped, the neuropil and leptomininges measured only
1 to 2 mm in thickness, the brainstem and cerebellum were reduced in size, and there
was moderate distension of the third ventricle with stenosis of the mesencephalic
aqueduct. Inammatory and neoplastic causes of mesencephalic aqueductal obstruction
were ruled out by histopatholgy. This represents a classic case of hydrocephalus because
of stenosis of the mesencephalic aqueduct, which to our knowledge has not been
previously reported in a miniature foal. Further investigation is warranted into the
pathogenesis of mesencephalic aqueduct stenosis in foals, which has now been reported
in several equine breeds.
Published by Elsevier Inc.

1. Introduction mesencephalic aqueduct resulted in hydrocephalus. To the

Hydrocephalus in the equine neonate is associated with
dystocia and/or severe neurological debilitation resulting
in a stillbirth or a live foal that necessitates euthanasia. This
report describes a miniature horse mare that was pre-
sented for dystocia because of severe fetal hydrocephalus.
Necropsy of the fetus determined that stenosis of the
authors knowledge this is the rst case report to describe
the cause of hydrocephalus in a miniature horse foal, and it
illustrates the need for further diagnostic evaluation of
hydrocephalic foals to determine the pathogenesis of this
disease.
2. Clinical Report

A 6-year-old multiparous American Miniature Horse

Corresponding author at: Ryan A. Ferris, DVM, MS, DACT, Equine
Reproduction Laboratory, Colorado State University, 3194 Rampart Road,
Fort Collins, CO 80521.
E-mail address: rferris@colostate.edu (R.A. Ferris).
mare was presented to the James L. Voss Veterinary
Teaching Hospital, Colorado State University, for evaluation
of vaginal bleeding. The mare had been bred by live cover
and was estimated to be at 324 days of gestation.

0737-0806/$ - see front matter Published by Elsevier Inc.

doi:10.1016/j.jevs.2011.03.005
612 R.A. Ferris et al. / Journal of Equine Veterinary Science 31 (2011) 611-614

The mare was bright and alert, with a heart rate of 72

beats/min and a respiratory rate of 24 breaths/min. The
mare was actively showing signs of labor, with abdominal
contractions and restlessness. A manual obstetrical exam-
ination was performed and the cervix was found to be open
with the fetus in transverse position with the dorsal
processes of the spinal column palpable. No response was
detected from the fetus when the skin and/or neck were
pinched.
Because of the small size of the mare and anticipated
difculty of correcting a transverse mutation in a standing
horse, general anesthesia was elected. The initial goal was to
attempt vaginal delivery; cesarean section was an option
only if vaginal delivery was unsuccessful. The mare was
sedated with xylazine (TranquiVed, Vedco Inc., St. Joseph,
MO; 0.4 mg/kg, IV) and anesthesia was induced by admin-
istration of ketamine hydrochloride (KetaVed, Vedco Inc.,
St. Joseph, MO; 1.25 mg/kg, IV) and (Diazepam, Hospira Inc.,
Lake Forest, IL; 0.08 mg/kg, IV). Anesthesia was maintained
with isourane and oxygen. The surgery table was sloped,
and the hind end of the mare was elevated to assist in
Fig. 1. Radiograph of foal with severe cranial deformation. Note the ground
positioning of the fetus. Attempts were made to mutate
glass appearance of the uid within the skull consistent with hydrocephalic
the fetus; however, these attempts were unsuccessful. uid.
A cesarean section was elected over a fetotomy so as to
minimize trauma to the reproductive tract of the mare.
The mare was prepared for abdominal surgery and calvarium was found to have marked doming and enlarge-
administered preoperative medications including unixin ment, with the calvarium (Fig. 2) measuring 59 cm in
meglumine (Banamine, Intervet Schering-Plough Animal circumference. The cerebrum was markedly distended with
Health, Union, NJ; 1 mg/kg, IV), gentamicin sulfate (Gen- a sac-like appearance. The remnant cerebral neuropil and
taVed 100, Vedco Inc., St. Joseph, MO; 6.6 mg/kg, IV), and the leptomininges measured only 1 to 2 mm in most areas
potassium penicillin (PzerPen, Pzer Inc., New York, NY; with little recognizable thalamus (Fig. 3). The brain was
22,000 IU/kg, IV). A ventral midline incision was made xed in 10% formalin to facilitate sectioning and gross
cranial to the pubis and extended to a length of 30 cm to evaluation. The brainstem and cerebellum were reduced in
accommodate the size of the uterus. The uterus was visu- size and there was marked dilation of the rostral third
alized, exteriorized, and isolated by using moist lap ventricle, with stenosis of the mesencephalic aqueduct
sponges and a sterile, impermeable drape. A hindlimb was (Fig. 4). The thoracic and peritoneal cavities and axial skel-
identied and stay sutures were placed through the uterus, eton were free of gross abnormalities.
from the tarsus to the hoof. A 20-cm incision was made Evaluation of serial histologic sections beginning at
through the uterus and chorioallantois. The foal was noted the level of the rostral colliculi and extending caudad
to be in transverse position with severe enlargement of the revealed dilation of the cranial aspect of the mesencephalic
cranium. The chorioallantois was detached from the uterus aqueduct with marked segmental narrowing of the caudal
and was removed with the fetus. The uterine incision was aspect of the mesencephalic aqueduct. No physical
closed with 2-0 Biosyn (Covidien, Norwalk, CT) in a simple obstruction was identied between the rostral and caudal
continuous appositional pattern; this was oversewn with segments. The surface of the mesencepahlic aqueduct was
2-0 Biosyn in a Cushing suture pattern. Oxytocin (Oxytocin, devoid of ependymal cells. There were no appreciable
Vedco Inc., St. Joseph, MO; 5 U, IV) was administered to
facilitate uterine involution and the abdomen was lavaged
with 4 L of warm physiologic saline (0.9% Na Cl) solution.
The abdominal incision was closed in a routine manner, and
the mare recovered from anesthesia without incident.
Postoperative treatment consisted of unixin meglu-
mine (1 mg/kg, IV, q 12 hours) for 4 days, gentamicin
sulfate (6.6 mg/kg, IV, q 24 hours) for 4 days, potassium
penicillin (22,000 IU/kg, IV, q 6 hours) for 4 days, oxytocin
(2 units, IV, q 12 hours) for 2 days, and intravenous uid
therapy with Plasmalyte (Baxter, Deerled, IL; 3.3 ml/kg/hr)
for 2 days. The mare was discharged to the owners 4 days
after the surgery.
A lateral radiograph (Fig. 1) of the fetus was obtained,
which conrmed the clinical diagnosis of hydrocephalus
with typical ground glass appearance of the hydroce-
phalic uid lling the calvarium. On necropsy, the Fig. 2. Lateral view of the foals cranium.
 R.A. Ferris et al. / Journal of Equine Veterinary Science 31 (2011) 611-614 613

pressure differential between the subarachnoid space and

Fig. 3. Gross photograph of the calvarium. The thin epithelium covering the
open fontanelle was removed causing the thin uid-lled cerebrum to
collapse. Note that the remnant cerebral neuropil and the leptomeninges
measured only 1 to 2 mm in most areas.
inammatory cells, increased glial cells, or vascular prolif-
eration within the periaqueductal grey matter.
3. Discussion
Hydrocephalus results from a disturbance in the ow
of cerebral spinal uid (CSF) and reabsorption. CSF is
produced primarily by the choroid plexus and to a smaller
extent by secondary extrachoroidal sites within the brain.
CSF is secreted at a constant rate regardless of the rate of
reabsorption and/or intracranial pressure. Absorption of
CSF is a passive process driven in a linear fashion by the
the venous circulation. Hydrocephalus develops when
there is either reduced absorption of CSF or overproduction
of CSF. Failure of CSF reabsorption by the pacchionian
granulations is uncommon as compared with obstructive
lesions preventing movement of CSF within the brain [1].
Obstructive lesions causing hydrocephalus are classied as
either internal or external. Internal hydrocephalus is the
inability of CSF to ow from the ventricles to the spinal
canal, as compared with external hydrocephalus where CSF
can ow from the ventricles to the spinal canal. Internal
hydrocephalus can develop when obstruction occurs in the
foramen of the fourth ventricle, median aperture, inter-
ventricular foramen, or the mesencephalic aqueduct [2].
Congenital hydrocephalus has been reported to have an
incidence of approximately 3% (18/608) in foals submitted
for necropsy [3]. Of these, 10 of 18 were identied on the
basis of a severely enlarged cranium, whereas the
remaining eight had normal cranium conformation and
were only identied when the skull was opened. A breed
predilection is not acknowledged, but previous reports
have mentioned hydrocephalus occurring in Arabians [4],
Ponies [5], Quarter Horses [6,7], Standardbreds [8], and
Thoroughbreds [9].
A report of seven foals with congenital hydrocephalus
born to the same Standardbred stallion failed to identify
evidence of an autosomal recessive or X-linked defect
responsible for causing hydrocephalus [8]. At least six
forms of congenital hydrocephalus have been identied in
cattle, with known breed propensity and potential routes of
inheritance identied [4].
Postmortem and histological evaluation of the foal
presented in this case report indicated severe cranium
deformation associated with congenital internal hydro-
cephalus caused by stenosis of the mesencephalic
aqueduct. In the veterinary literature, only four cases of

Fig. 4. Gross photographs of two serial transverse sections (approximately 2 cm wide) of mesencephalon at the level of the rostral colliculus. The rostral colliculus
appears fused at the top of both sections. The rostral section (left) shows marked dilation of the third ventricle (arrow) at the rostral aspect of the mesencephalic
aqueduct, which is grossly inapparent because of the stenosis. The caudal section (right) shows the stenotic segment of the mesencephalic aqueduct (surrounded
by square). Both sections show considerable atrophy of the dorsolateral aspect (upper).
614 R.A. Ferris et al. / Journal of Equine Veterinary Science 31 (2011) 611-614
congenital hydrocephalus have been well-documented
including, one foal affected by Dandy-Walker syndrome
[10], one affected by agenesis of the corpus callosum [11],
one with internal hydrocephalus and dilation of the
mesencephalic aqueduct [9], and one with internal and
external hydrocephalus associated with stenosis of the
mesencephalic aqueduct [7]. To our knowledge, the caus-
ative lesion of hydrocephalus has not been previously
reported in a miniature foal.
Stenosis of the mesencephalic aqueduct is the most
commonly reported cause of congenital hydrocephalus in
human neonates [12]. A vast majority of neonates affected
by stenosis of the mesencephalic aqueduct are stillborn or
die within 48 hours of life. A previous case report of a foal
affected with hydrocephalus associated with the mesence-
phalic aqueduct has not demonstrated altered cranium
conformation. The foal in the previous case report was
presented for veterinary examination because of poor
suckle reex, dissociation with surroundings, aimless
wandering and bumping into surroundings, lack of bonding
to the dam, depression, proprioceptive decits, blindness,
and head tremors [7,9]. Computed tomography was
required to diagnose hydrocephalus in these case reports
[7,9]. One of the foals was euthanized within 48 hours of life
[9] and the other was treated with a ventriculoperitoneal
shunt but was later euthanized because of encephalitis [7].
Foals with altered cranium conformation may have
a greater incidence of dystocia. In one study, congenital
hydrocephalus accounted for 5% of dystocias [13]. No breed
predilection was identied, but others have reported
a greater incidence of hydrocephalus associated with
dystocia in ponies [5,14].
It is relatively easy to identify a dystocia because of
hydrocephalus if the foal is in normal cranial longitudinal
position. A greatly enlarged, often uid-lled cranium with
open fontanelles will be identied on vaginal examination.
Hydrocephalus should also be suspected in caudal longi-
tudinal presentation in which fetal expulsion ceases after
passage of the hindlimbs and thorax. In this case, we were
unable to identify the enlarged cranium on vaginal exam-
ination because of the transverse presentation of the foal
and limited ability to mutate the fetus because of the size of
the vaginal canal. The hydrocephalus in this case did not
directly cause the dystocia but resulted in fetal malposition
because of fetal death or the inability of the fetus to
orientate into a normal presentation as a result of the
enlarged calvarium.
Vaginal delivery of a foal with hydrocephalus can be
attempted if the enlarged cranium is reduced in size to
allow passage through the birth canal. Reduction may be
achieved by collapsing the cranium with a nger knife [15].
When manual reduction of the cranium and vaginal
delivery is unsuccessful, a fetotomy or cesarean section is
warranted. The decision of fetotomy or cesarean section is
based on economic consideration, experience of the
veterinarian, and availability of equipment [15].
Resolution by fetotomy of a dystocia because of hydro-
cephalus requires the removal of the dorsal half of the skull
via a single fetotomy cut. This is accomplished by placing
a wire saw loop positioned behind the ears of the fetus,
with the head of the fetotome positioned in the mouth of
the foal or near the eye [15]. The dorsal half of the fetal skull
can be easily removed, followed by the remainder of the
fetus. Foals affected by hydrocephalus often have a smaller
than average body size that rarely interferes with passage
of the fetus [15].
When a cesarean section is elected to be performed, the
future fertility of the mare following cesarean section is
often a concern. Although mares may conceive following
a cesarean section, the live foal rate is less than expected,
with a range of 11% to 60% [16,17]. It has been suggested
that the reduced live foal rate is more likely because of
excessive vaginal trauma caused by prolonged attempts at
vaginal delivery as compared with the effects of the
cesarean section [16,17].
In conclusion, this case report is unique in dening the
cause of internal hydrocephalus in a miniature horse foal.
Further investigation is warranted into the pathogenesis of
mesencephalic aqueduct stenosis in foals, as this lesion
appears to be a common cause of hydrocephalus affecting
multiple breeds in the equine industry.
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