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Topic:Neurology

Neurology in horses encompasses the study of the equine nervous system, including its structure, function, and associated disorders. The equine nervous system is divided into the central nervous system (CNS), consisting of the brain and spinal cord, and the peripheral nervous system (PNS), which includes nerves extending throughout the body. Neurological conditions in horses can manifest as gait abnormalities, behavioral changes, or sensory deficits. Common neurological disorders include equine protozoal myeloencephalitis (EPM), cervical vertebral stenotic myelopathy (CVSM), and equine herpesvirus myeloencephalopathy (EHM). Diagnostic approaches may involve clinical evaluation, imaging techniques, and laboratory tests. This page compiles peer-reviewed research studies and scholarly articles that explore the anatomy, pathophysiology, diagnosis, and management of neurological disorders in horses.
Effects of Hippotherapy and Horse-Riding Simulators on Gross Motor Function in Children with Cerebral Palsy: A Systematic Review.
Journal of clinical medicine    January 6, 2025   Volume 14, Issue 1 283 doi: 10.3390/jcm14010283
Ortega-Cruz A, Sánchez-Silverio V, Riquelme-Aguado V, Alonso-Perez JL, Abuín-Porras V, Villafañe JH.: Cerebral palsy (CP) can have a negative impact on gross motor function. Conventional hippotherapy and horse-riding simulators (HRS) have shown promising results on gross motor function in populations with neurological disorders. This review aims to update the knowledge on the effectiveness of hippotherapy on gross motor function in children with CP. : A search was conducted in Academic Search Ultimate, CINAHL, Medline complete, and PEDro covering publications between 2012 and 2022. Two authors identified studies that met the inclusion criteria; a third author resolved discrepancies. Studies ...
Anesthesia and Myopathies of Horses.
The Veterinary clinics of North America. Equine practice    December 30, 2024   Volume 41, Issue 1 165-180 doi: 10.1016/j.cveq.2024.11.008
Castro D, Clark-Price S.Pre-existing muscle disorders in horses can often be subtle and may only become evident during or after anesthesia. Advancements in veterinary medicine, along with increased knowledge and research in this field, help minimize anesthesia-related problems. Adequate preanesthesia assessment, early disease diagnosis, and proper management are crucial in minimizing risks to the neuromuscular system during general anesthesia.
Effectiveness of Equine-Assisted Activities and Therapies for Children with Autism Spectrum Disorder: An Update.
Children (Basel, Switzerland)    December 8, 2024   Volume 11, Issue 12 1494 doi: 10.3390/children11121494
Zoccante L, Sabaini S, Bonatti SM, Rigotti E, Lintas C, Marconi M, Zaffanello M.Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition requiring personalised therapeutic approaches. This study evaluated the effectiveness of Equine-Assisted Activities and Therapies (EAATs) in 86 children with varying ASD severity levels (levels 1-3). Methods: Vineland Adaptive Behaviour Scales and the Parenting Stress Index were used. Between May 2022 and October 2023, participants completed 20 weekly sessions of 45 min each, tailored to their individual needs. Results: Children with level 3 ASD demonstrated greater challenges in communication (level 1: 67.1 ± 29.0 vs. l...
Non-invasive scalp recording of electroencephalograms and evoked potentials in unanesthetized horses using a 12-channel active electrode array.
Frontiers in veterinary science    December 2, 2024   Volume 11 1470039 doi: 10.3389/fvets.2024.1470039
Itoh K, Kikumura N, Maeda T, Hirata S, Ringhofer M.Despite the long history of the horse-human bond, our understanding of the brain and mind of horses remains limited due to the lack of methods to investigate their brain functions. This study introduces a novel methodology for completely non-invasive, multi-channel recording of electroencephalography (EEG) and evoked potentials in awake horses to examine equine auditory cortical processing. The new approach utilizes specially designed brush-shaped active electrodes that facilitate stable signal acquisition through the hair coat by penetrating electrode pins and integrated pre-amplifiers. A 12-...
Skeletal Muscle Biopsy.
The Veterinary clinics of North America. Equine practice    November 28, 2024   Volume 41, Issue 1 31-45 doi: 10.1016/j.cveq.2024.10.003
Valberg SJ, Porter A.Muscle biopsy is often required to provide a definitive diagnosis for neuromuscular disorders and can be performed using open surgical or percutaneous needle biopsy techniques. Fresh samples that are subsequently frozen in the laboratory are preferred by laboratories engaged in research, whereas formalin-fixed muscle is processed by diagnostic laboratories with specialized tinctorial and immunohistochemical techniques. Interpretation by an experienced histopathologist, combined with the signalment, history, and clinical input, is essential for establishing a diagnosis. This article outlines be...
Twelve-year review of horse-related trauma registry presentations to a regional Australian Emergency Department.
ANZ journal of surgery    November 16, 2024   Volume 94, Issue 12 2245-2250 doi: 10.1111/ans.19304
Neville EK, Neville CC, Hicks H.The size, strength, and unpredictability of horses, makes any interaction a potential situation for minor to severe injury. Despite this, horses continue to be popular for work and recreational activities. There have been five recent Australian publications that have examined various aspects of horse-related trauma, but none have been conducted in regional New South Wales (NSW). This study aims to report on the pattern of horse-related trauma that met the Institute of Trauma Injury Management's (ITIM) Trauma Registry criteria for people who presented to the emergency department at a regional N...
A Randomized Feasibility Study of Rehabilitation Targeting Upper Extremity Function and Participation Using Hippotherapy and the Equine Environment for Children with Cerebral Palsy and Autism Spectrum Disorder.
Journal of integrative and complementary medicine    November 8, 2024   Volume 31, Issue 2 196-208 doi: 10.1089/jicm.2024.0292
Mazzarella J, Heathcock JC. Children with upper extremity neuromotor impairments often have decreased participation in life activities. Hippotherapy and rehabilitation in the equine environment might be effective in targeting participation, given the community context and natural activity involvement. This randomized controlled feasibility trial assessed recruitment, retention, treatment fidelity, and acceptability of rehabilitation using hippotherapy and the equine environment, targeting upper extremity function and participation for children with neuromotor impairments to inform a larger trial. This 6-month trial occ...
Pneumocephalus due to temporohyoid osteoarthropathy in a 16-year-old Friesian mare.
Journal of equine veterinary science    October 26, 2024   Volume 143 105210 doi: 10.1016/j.jevs.2024.105210
Witt P, Stas EKL, Hardeman LC, van Proosdij ER, Weerts EAWS, Lloyd-Edwards RA, Veraa S, Kranenburg LC, van den Boom R.A sixteen-year-old Friesian mare was admitted to the university clinic with the following clinical signs: anorexia, weight loss, fever, bilateral nasal discharge, unilateral facial paralysis and a non-healing corneal lesion. Endoscopic examination of the upper airways showed thickening of the proximal portion of the right stylohyoid bone. Computed tomography imaging showed pneumocephalus due to grade 3 unilateral temporohyoid osteoarthropathy (THO) with fracture of the petrous temporal bone. The horse did not improve following medical treatment. Surgical intervention was declined by the owner ...
A systematic review of the prevalence of post-operative complications after general anaesthesia in adult horses (2000-2023).
Equine veterinary journal    October 24, 2024   Volume 57, Issue 4 827-861 doi: 10.1111/evj.14416
Loomes K, de Grauw J, Gozalo-Marcilla M, Redondo JI, Bettschart-Wolfensberger R.Equine post-operative morbidity represents a significant concern for both veterinary surgeons and horse owners. Objective: To estimate the prevalence of post-operative complications in horses after elective/non-abdominal surgery or colic surgery. Methods: Systematic review. Methods: A database search identified eligible studies which reported the prevalence of equine post-operative complications published as a full paper in English in a peer-reviewed journal between 2000 and 2023. Studies were evaluated using the JBI Critical Appraisal Checklist for Prevalence Studies and GRADE (Grading of Rec...
Urinary incontinence and sabulous cystitis in mares: report of five cases.
Brazilian journal of veterinary medicine    October 21, 2024   Volume 46 e005024 doi: 10.29374/2527-2179.bjvm005024
de Melo UP, Ferreira C.This report describes five cases of urinary incontinence in Quarter Horse mares associated with the development of sabulous cystitis. The animals in this study had a history of persistent urinary incontinence for eight months, with clinical signs of continuous dribbling urine during rest and movement. The initial treatment with antibiotics and anti-inflammatory drugs was ineffective. Clinical examination revealed severe scalding in the perineal region and on the medial aspect of the hind limbs, along with neurological signs such as ataxia, hind limb paresis, and diminished perineal reflexes. T...
Attenuation of the neuropathogenic equine herpesvirus type 1 strain Ab4p in hamsters by a single amino acid mutation (D752N) in viral DNA polymerase ORF30.
The Journal of veterinary medical science    October 9, 2024   Volume 86, Issue 12 1273-1278 doi: 10.1292/jvms.24-0338
Nishimura F, Fukushi N, Sakai H, Fukushi H.Equine herpesvirus type 1 (EHV-1) causes abortion, respiratory infection, and neurological diseases (equine herpesvirus myeloencephalopathy) in horses. A single nucleotide polymorphism (SNP) associated with a single amino acid in the DNA polymerase gene (ORF30, in which D752 is neuropathogenic and N752 is non-neuropathogenic) of EHV-1 has been associated with neuropathogenicity in horses. We constructed an EHV-1 Ab4p ORF30 N752 mutant and a repair virus to examine the effect of a D752N mutation on the neuropathogenicity of the virus in Syrian hamsters. The N752 mutation did not affect viral gr...
Equine Herpesvirus Type 1 ORF76 Encoding US9 as a Neurovirulence Factor in the Mouse Infection Model.
Pathogens (Basel, Switzerland)    October 2, 2024   Volume 13, Issue 10 865 doi: 10.3390/pathogens13100865
Nayel M, Kasem S, Fukushi N, El-Habashi N, Elsify A, Salama A, Hassan H, Yanai T, Ohya K, Fukushi H.Equine herpesvirus type 1 (EHV-1) causes rhinopneumonitis, abortion, and neurological outbreaks (equine herpesvirus myeloencephalopathy, EHM) in horses. EHV-1 also causes lethal encephalitis in small laboratory animals such as mice and hamsters experimentally. EHV-1 ORF76 is a homolog of HSV-1 US9, which is a herpesvirus kinase. Starting with an EHV-1 bacterial artificial chromosome clone of neuropathogenic strain Ab4p (pAb4p BAC), we constructed an ORF76 deletion mutant (Ab4p∆ORF76) by replacing ORF76 with the rpsLneo gene. Deletion of ORF76 had no influence on replication, cell-to-cell spr...
Fecal microbiome and functional prediction profiles of horses with and without crib-biting behavior: A comparative study.
Journal of equine veterinary science    September 20, 2024   Volume 142 105198 doi: 10.1016/j.jevs.2024.105198
Martínez-Aranzales JR, Córdoba-Agudelo M, Pérez-Jaramillo JE.Crib-biting is a stereotyped oral behavior with poorly understood etiology and pathophysiology. The relationship between the gut microbiome and brain function has been described in behavioral disorders such as schizophrenia, depression and anxiety in humans. In horses, studies of behavioral problems and the microbiome are very limited. This study aimed to characterize the fecal microbiome and the predicted functional profile of horses with and without aerophagia. Fecal samples were collected from 12 Colombian Creole Horses of both sexes, divided into two groups: group 1, composed of six horses...
Effects of hippotherapy on motor function of children with cerebral palsy: a systematic review study.
Italian journal of pediatrics    September 19, 2024   Volume 50, Issue 1 188 doi: 10.1186/s13052-024-01715-9
Cerebral palsy includes a spectrum of neurodevelopmental disorders caused by brain damage, leading to impairment of movement, posture, and balance for a lifetime. There are many therapeutic interventions for cerebral palsy. One of them is hippotherapy, an alternative physical therapy. It is a type of equine-assisted activity and therapy where children with cerebral palsy and motor function skills interact with a horse. We aimed to study the effects of hippotherapy, as an alternative therapy, on the motor function of children with cerebral palsy. We performed a review of the latest literature o...
Pharmacokinetics and thermal anti-nociceptive effects of oral morphine in horses.
Frontiers in veterinary science    September 17, 2024   Volume 11 1461648 doi: 10.3389/fvets.2024.1461648
Knych HK, Steinmetz SJ, Traynham ML, McKemie DS, Kass PH.Morphine is an effective analgesic in horses, however, IV administration at therapeutic doses has been shown to produce dose-dependent neuroexcitation and unwanted gastrointestinal effects. The analgesic effects of morphine have, at least in part, been attributed to the morphine-6-glucuronide (M6G) metabolite. Oral administration to horses results in comparable M6G concentrations to that achieved following IV administration of a therapeutic dose without the adverse effects. The anti-nociceptive effects have not yet been reported. In the current study the thermal anti-nociceptive effects of sin...
Breaking Latent Infection: How ORF37/38-Deletion Mutants Offer New Hope against EHV-1 Neuropathogenicity.
Viruses    September 16, 2024   Volume 16, Issue 9 1472 doi: 10.3390/v16091472
Hu Y, Zhang SY, Sun WC, Feng YR, Gong HR, Ran DL, Zhang BZ, Liu JH.Equid alphaherpesvirus 1 (EHV-1) has been linked to the emergence of neurological disorders, with the horse racing industry experiencing significant impacts from outbreaks of equine herpesvirus myeloencephalopathy (EHM). Building robust immune memory before pathogen exposure enables rapid recognition and elimination, preventing infection. This is crucial for effectively managing EHV-1. Removing neuropathogenic factors and immune evasion genes to develop live attenuated vaccines appears to be a successful strategy for EHV-1 vaccines. We created mutant viruses without ORF38 and ORF37/38 and vali...
Effect of repetitive transcranial magnetic stimulation on trigeminal-mediated headshaking in 17 horses.
Journal of veterinary internal medicine    September 12, 2024   Volume 38, Issue 5 2758-2765 doi: 10.1111/jvim.17194
Franzen V, Gruber NA, Klußmann S, Schoster A, May A.Trigeminal-mediated headshaking is a neuropathic facial pain condition in horses. No treatment has been entirely successful. Repetitive transcranial magnetic stimulation (rTMS) is used in human medicine as a treatment for various neuropathic pain conditions, and good results have been achieved in cases of trigeminal neuralgia. Objective: Apply rTMS to horses with trigeminal-mediated headshaking (TMHS) and to evaluate tolerability, application of the setting, and success rate. Methods: Seventeen horses with nonseasonal signs of TMHS. Methods: Other underlying causes of headshaking were ruled ou...
Acute myeloid leukemia-M1 in a horse with neurologic signs and necrotizing enterocolitis. Lee J, Mordoh S, Mirza M, Carossino M, Del Piero F.An 18-y-old American Saddlebred mare was admitted with fever and acute onset of neurologic signs including grade 3 of 5 ataxia, difficulty in prehension, and dull mentation. Because of financial restraints, desired testing could not be performed; the horse's condition declined despite supportive treatment, and euthanasia was elected. Postmortem examination revealed petechiae and ecchymoses in the meninges and neuroparenchyma of the encephalon. Blast-like neoplastic round cells were identified within the vasculature and areas of hemorrhage in the neuroparenchyma, the intestinal submucosa, and o...
CNS and Thorax Injury and Associated Risks Factors in Equestrian Sports.
Sports health    August 29, 2024   19417381241275655 doi: 10.1177/19417381241275655
Crawford AE, Picken LK, Gabriel FD, Quade J, Gould S.Equestrian sports continue to gain popularity in the United States and are associated with a high injury rate, especially involving the central nervous system and thorax. Due to this high rate of injury and the potential for long-term consequences associated with participation, an understanding of the unique risks of this sport is needed. Unassigned: To describe severe injury in equestrian sports and review the role that protective gear plays in injury mitigation. Unassigned: The PubMed Database was searched using the search terms "equestrian" and "horse" combined with "spinal cord injury," "h...
Impact of equine herpesvirus-1 ORF15 (EUL45) on viral replication and neurovirulence.
Veterinary microbiology    August 22, 2024   Volume 298 110234 doi: 10.1016/j.vetmic.2024.110234
Kasem S, Yu MHH, Alkhalefa N, Ata EB, Nayel M, Abdo W, Abdel-Moneim AS, Fukushi H.Equine herpesvirus 1 (EHV-1) causes respiratory illness, fetal loss, perinatal mortality, and myeloencephalopathy. This study investigated ORF15's impact on virus infectivity and neurovirulence. The Ab4p neurovirulent strain of EHV1 was used as a backbone to create Ab4p attB, Ab4p∆ORF15, and Ab4p∆ORF15R chimeras via BAC DNA transfection into RK-13 cells. Viral growth kinetics, plaque size, transcription, and growth were assessed in MDBK cells, mouse neurons, and fetal equine brain cells. Neurovirulence was evaluated post-intranasal inoculation into male CBA/N1 SPF mice, measuring signs, vi...
Radiological abnormalities of the cervicothoracic vertebrae in Warmblood horses with primary neck-related clinical signs versus controls. Dyson S, Quiney L, Phillips K, Zheng S, Aleman M.Radiological observations at the cervicothoracic junction in horses with or without related clinical signs have not been comprehensively described. The aim was to evaluate the seventh cervical (C7) to second thoracic (T2) vertebrae in horses with neck-related clinical signs (neck pain and/or stiffness, neck-related forelimb lameness, or general proprioceptive [spinal] ataxia) and control horses. This prospective analytical cross-sectional study included 127 control horses and 96 cases, examined using standardized clinical and radiological protocols. Univariable logistic regression was used to ...
Correlation between kinematic parameters, ataxia and ground-to-lip distance in detomidine sedated horses.
Equine veterinary journal    August 14, 2024   doi: 10.1111/evj.14207
Izquierdo-Moreno J, de Paz MI, Manso-Díaz G, Villalba-Orero M, López-Sanromán J.An accurate evaluation of the degree of sedation is mandatory to adjust the dosage of sedative drugs. Objective: To determine the correlation between head height above the ground and ataxia degree in horses sedated with detomidine and the correlation existing between accelerometric variables and both parameters. Methods: Retrospective study. Methods: Twelve horses were given 0.01 mg/kg of detomidine hydrochloride iv. Measured accelerometric parameters, with one accelerometer positioned between both sacral tuberosities, included speed, stride frequency and length, regularity, dorsoventral, lo...
Bee-Inspired Healing: Apitherapy in Veterinary Medicine for Maintenance and Improvement Animal Health and Well-Being.
Pharmaceuticals (Basel, Switzerland)    August 9, 2024   Volume 17, Issue 8 doi: 10.3390/ph17081050
Stevanović J, Glavinić U, Ristanić M, Erjavec V, Denk B, Dolašević S, Stanimirović Z.This review aims to present current knowledge on the effects of honey bee products on animals based on in vivo studies, focusing on their application in clinical veterinary practice. Honey's best-proven effectiveness is in treating wounds, including those infected with antibiotic-resistant microorganisms, as evidenced in horses, cats, dogs, mice, and rats. Propolis manifested a healing effect in numerous inflammatory and painful conditions in mice, rats, dogs, and pigs and also helped in oncological cases in mice and rats. Bee venom is best known for its effectiveness in treating neuropathy an...
Lipofuscin accumulates in ganglionic neurons in chronic equine dysautonomia. Tan Yi Shean L, Milne EM, Shaw DJ, Maxwell S, Del-Pozo J.Lipofuscin is a complex mixture of highly oxidized, cross-linked macromolecules that accumulates in neurons with age and some neurodegenerative diseases. Equine dysautonomia (ED) is a polyneuropathy that mainly affects autonomic and enteric nervous systems, resulting in alimentary tract dysfunction. Our main aim was to determine whether neuronal lipofuscin increased with increasing duration of ED. We investigated the prevalence of lipofuscin in cranial cervical ganglia of horses with acute (AED), subacute (SED), and chronic ED (CED), young controls (of similar age to ED cases), and aged contro...
Nerve entry points in the mimic musculature of the horse head.
Anatomia, histologia, embryologia    August 5, 2024   Volume 53, Issue 5 e13099 doi: 10.1111/ahe.13099
Wolschrijn CF, Smit IH, Schouten J, Moller Te NCR.Facial expressions are important in pain recognition in horses, but current observation-based pain scales remain subjective. A promising technique to quantitatively measure subtle changes in expression patterns, including changes invisible to the human eye, is surface electromyography (sEMG). To achieve high-quality and reliable sEMG signals, unilateral placement of bipolar electrodes is required in relation to the motor endplates (MEP). We aimed to localize the nerve entry points (NEPs; where the nerve branch first pierced the muscle belly) and the direction of the terminal nerve endings to e...
Management of paracondylar process fracture in three horses.
Equine veterinary journal    July 18, 2024   Volume 56, Issue 6 1193-1200 doi: 10.1111/evj.14202
Beldeanu S, Tay MCA, Daniel C, Dosi MCM, Hahn CN, James O, Townsend NB, Liuti T, Schwarz T, Parkinson NJ.Fractures of the paracondylar process of the occipital bone may cause headshaking, neck pain and neurologic deficits. The condition is being recognised more frequently with increasing availability of computed tomography. However, to date only limited information is available as to presentation, treatment, surgical approach and outcome. Objective: To describe the clinical signs, imaging findings, treatment, surgical approach and outcome in three horses diagnosed with paracondylar process fracture. Methods: Retrospective case series. Methods: Clinical records and diagnostic images of affected ca...
An anatomical study of the subarachnoid space surrounding the trigeminal ganglion in horses-in preparation for a controlled glycerol rhizotomy in equids.
Frontiers in veterinary science    July 18, 2024   Volume 11 1424890 doi: 10.3389/fvets.2024.1424890
Becker R, Haenssgen K, Precht C, Khoma OZ, Hlushchuk R, Koch C, Kaessmeyer S, de Preux M.Equine trigeminal-mediated headshaking is a painful neuropathic disorder comparable to trigeminal neuralgia in humans. The selective destruction of pain fibers within the trigeminal ganglion, called rhizotomy, is the surgical treatment of choice for idiopathic trigeminal neuralgia refractory to medical treatment in humans. The human trigeminal ganglion is enclosed by a dural recess called the Meckel's or trigeminal cave, in which the ganglion is surrounded by a cerebrospinal fluid (CSF)-filled subarachnoid space. During glycerol rhizotomy, glycerol is percutaneously injected in this CSF-filled...
Use of a poll-mounted accelerometer for quantification and characterisation of equine trigeminal-mediated headshaking.
Equine veterinary journal    July 17, 2024   Volume 57, Issue 3 645-653 doi: 10.1111/evj.14132
Pickles KJ, Marlin DJ, Williams JM, Roberts VLH.Equine trigeminal-mediated (TGM) headshaking (HS) is a neuropathic facial pain syndrome characterised by varying intensity and frequencies of head movements and signs of nasal irritation. An accurate method for quantification and/or characterisation of HS severity is lacking. Objective: To develop and validate an objective measure of TGMHS. Methods: Prospective case control study. Methods: Horses presenting for investigation of HS were recruited alongside those presenting for forelimb lameness (LAME) and pre-purchase examination as well as healthy controls (CONTROL). Head movement data were co...
Study Protocol: Pegasus: psychotherapy incorporating horses for ‘therapy-resistant’ adolescents with autism spectrum disorders, a study with series of randomised, baseline controlled n-of-1 trials.
BMC psychiatry    July 10, 2024   Volume 24, Issue 1 499 doi: 10.1186/s12888-024-05879-w
den Boer JC, Klip H, Blonk A, Lenselink M, Kaijdoe SPT, Tielkes M, van Zandbeek A, Bres G, Herinx M, Staal WG, Rommelse N.For people with autism spectrum disorder (ASD), daily life can be highly stressful with many unpredictable events that can evoke emotion dysregulation (ED): a strong difficulty with appropriately negative affect regulation. For some of the patients with ASD, treatment as usual does not prove to be effective for ED. They may be at risk of life-long impairment, development of other disorders and loss of motivation for most regular forms of therapy. A highly promising method that may prove effective for therapy-resistant individuals with ASD is Psychotherapy incorporating horses (PIH). PIH uses t...
[Brainstem auditory evoked responses in horses with hearing loss and during general anesthesia].
Schweizer Archiv fur Tierheilkunde    July 8, 2024   Volume 166, Issue 7 379-392 doi: 10.17236/sat00428
Kuhlmann C, Scheidemann W, Bachmann M, Schusser GF.The brainstem auditory evoked response (BAER) is a diagnostic approach to examine the hearing system of horses objectively. The aim of this BAER examination was the diagnosis of conductive or sensorineural hearing loss or deafness in horses with external otitis, head trauma, headshaking, tinnitus or skittish horses with eye disease. Brainstem dysfunction is induced by intracranial hypotension. BAER was used in horses with colic surgery which had a low arterial blood pressure during general anesthesia. The endoscopic finding of the guttural pouch was the ipsilateral mild to severe hypertrophy o...