Seizures occur in up to 5% of dogs and can be life threatening. Dr. Bush identifies how to determine whether the patient is having a seizure, if there is an underlying cause requiring treatment, and when an anti-epileptic drug should be administered. Arts Show
William BushVMD, Diplomate ACVIM (Neurology) William Bush, VMD, Diplomate ACVIM (Neurology), serves as a staff neurologist and residency director at Bush Veterinary Neurology Service, which he launched in 2005. His research interests are in electroencephalography. Dr. Bush received his VMD from University of Pennsylvania, after serving as a naval officer; then completed a rotating internship in medicine and surgery at North Carolina State University and residency in neurology and neurosurgery at UPenn, where he earned research and teaching awards. Read Articles Written by William Bush Shutterstock.com/Bull's-Eye Epilepsy in dogs is a common disease—thought to affect up to 1 in 20 dogs—and potentially life threatening.1 A useful working understanding is essential for the small animal practitioner. Editor’s Note: This article was originally published in 2014. Please use this content for reference or educational purposes, but note that it is not being actively vetted after publication. For the most recent peer-reviewed content, see our issue archive. When a patient presents for an episode of odd behavior or movement, the clinician must immediately consider 4 questions:
PROFILE OF EPILEPSY IN DOGSDefinitionEpilepsy is defined as 2 or more seizures, at least 24 hours apart, resulting from a nontoxic, nonmetabolic cause. An epileptic seizure is defined as a transient occurrence of signs, symptoms, or both due to abnormal, excessive, or synchronous neuronal activity in the brain.2 Seizure events can result from:
In human medicine, the term idiopathic has been replaced by the terms genetic or seizure of unknown cause.2 Classification by FrequencySeizures can be classified into 3 categories based on frequency.3
Classification by BreedIn veterinary medicine, epilepsy is considered genetic when the frequency in a breed exceeds that of the general population (eg, Petit Basset Griffon Vendeen).4 Classifying seizures by breed is important—certain types of genetic epilepsy have different prognoses, and much interest exists with regard to using dogs as models for human epilepsy. Border collies have a 2-year median survival from time of seizure onset, with 94% affected by cluster seizures, 53% status epilepticus, and 71% rate of drug resistance.5 Conversely, the Lagotto Romagnolo has seizure onset at 5 weeks, which spontaneously resolves by 13 weeks, similar to benign familial neonatal seizure in humans.6 1. IS THE EVENT A SEIZURE?There are many behaviors, events, and diseases that mimic a true seizure (Table 1). Table 1. Behaviors, Events, & Diseases with Seizure-Like Appearance Atlantoaxial subluxation ElectroencephalographyElectroencephalography (EEG) records the brain’s electrical activity and is considered by many human physicians to be an essential tool for characterizing seizure events (Figures 1–3). However, EEG is not a readily available clinical tool in veterinary medicine, and a first-time EEG recorded between seizures in an epileptic human or dog has about a 25% chance of identifying the event as a seizure.7 ObservationIdentification of a seizure is most often achieved by comparing the observed event to what is considered a typical seizure.
In human medicine, classifying events by description alone (without EEG) is accurate, but also allows overdiagnosis of nonepileptic events as seizures. Therefore, observation has high sensitivity, low specificity, and low positive predictive value.9 Accordingly, clinicians should be aware that they may be treating nonepileptic events with an AED.10 2. DOES THE SEIZURE HAVE AN UNDERLYING CAUSE?Identifying an underlying cause for the seizure yields better seizure control, quality of life, and accurate prognosis. The most recent seizure classification system—by cause—groups seizures into 3 causes: genetic, structural/metabolic, and unknown. Genetic & Unknown CausesDiagnosis of idiopathic epilepsy (IE) is made when:
Structural/Metabolic Causes
Because MRI and CSF analysis are expensive and not readily available, the primary care clinician is often faced with making a difficult decision about whether to refer a patient or simply prescribe an AED. Key factors in assessing a seizure patient include: AgeAs a guideline, dogs with IE typically have their first seizure between 6 months and 6 years of age. However, at seizure onset, about 20% of dogs older than 6 years, and 2% of dogs younger than 6 months, do not have an identifiable cause for seizure.11 BreedThere are, however, some exceptions to the age rule noted above. Seizure is a very common presenting complaint in dogs with brain tumors such that, in certain breeds (eg, golden retriever, boxer, Boston terrier, French bulldog), even 1 seizure at 4 years or older should be cause for concern.12 In young (1–5 years of age), small breed dogs (eg, pug, Chihuahua, Maltese, poodle) that have 3 or more seizures within a few months, meningoencephalitis of unknown etiology (MUE) should be considered a likely cause for the seizures. BehaviorEven subtle behavior changes around the time of the first seizure indicate that a patient is likely to have symptomatic epilepsy (Table 2). Table 2. Common Behavior Changes in Dogs with Structural Brain Disease Aggression Examination FindingsIf a neurologic examination performed between seizures has abnormal results, there is a high probability that a structural brain lesion is the cause of the seizure. However, 30% of brain tumor patients will have a normal examination, and 18% of idiopathic epileptics can have a transiently abnormal examination.10 It is useful to observe a seizure patient in the examination room to evaluate gait and behavior, coupled with an examination of the postural reactions and menace response. As a guideline, the following findings suggest structural disease, although other causes are possible:
3. SHOULD AN AED BE ADMINISTERED?AED drug therapy is recommended if any of the following are present/occur:
For IE, I recommend AED therapy after 1 or 2 seizures in a 6- to 12-month period for several reasons:
AED MonitoringSerum drug concentrations can be monitored for many AEDs (Table 3). I will assess serum concentrations when:
Although uncommon and often not reported, liver, kidney, bone marrow, immune, and urinary calculi problems are possible consequences of AED administration. Therefore, the following are recommended, at minimum, every 6 to 12 months based on therapy and patient needs:
4. WHICH AED SHOULD BE CHOSEN FOR THERAPY?Maintenance TherapyWhen and which AED to apply in the clinical setting remains uncertain and controversial (see Studies Evaluating AED Efficacy & Safety). Some reasonable guidelines for seizure management are to:
Table 3 lists AEDs in the order they are used by most neurologists in our clinic.11,19 When to Change. Side effects or lack of efficacy can prompt the need to change AEDs. Studies show that only about 70% of dogs are well controlled on an AED,17 and fewer than half the dogs on phenobarbital and/or bromide are seizure-free without adverse medication-related side effects.20 Treating with multiple AEDs may be beneficial because they act on a broader range of mechanisms or synergistically; however, side effects can be additive, and determining which AED is effective is difficult when more than one medication is administered. Generally, I recommend using one AED at a time; therefore, AEDs often need to be switched rather than added. Studies Evaluating AED Efficacy & SafetyIn veterinary medicine, placebo-controlled or crossover studies to determine the effectiveness or side effects of a sole AED (monotherapy) are lacking. Multiple studies have evaluated the addition of a newer generation AED (ie, pregabalin, levetiracetam, zonisamide) to phenobarbital ± bromide therapy, resulting in at least a 50% reduction in seizure frequency.21-23 However, placebo has been shown to reduce the number of seizures in dogs 79% of the time, and also reduces seizure frequency by 50% in 29% of patients.24 One explanation for the placebo effect is regression to the mean—a term used to describe fluctuations in biological variables that occur over time, and take the form of a sine wave around the mean.24 When levetiracetam was evaluated as an add-on in a placebo-controlled, randomized, crossover study, a significant reduction in seizure frequency was not observed; however, quality of life was considered better on levetiracetam relative to placebo.25 Transition Period. Abrupt cessation or missed doses of AEDs is a common cause of seizure and status epilepticus in humans. This may be of less concern in dogs—only 6% of status epilepticus cases in one study resulted from low AED concentration.26 Nevertheless, tapering the dose prior to stopping an AED is recommended. Risk of seizure can be further reduced if at least one AED is maintained in the therapeutic range during the transition. See Step-by-Step: Transitioning to Newer Generation AEDs. Step-by-Step: Transitioning to Newer Generation AEDs
Rescue TherapyAED therapy—additional or different, oral or parenteral—to control cluster seizures or status epilepticus is called rescue therapy. Rescue plans for epilepsy patients are recommended because, among dogs being treated for IE, a 59% incidence of status epilepticus and higher rates of cluster seizures have been described.27 Furthermore, a 25% mortality rate among all dogs that present for status epilepticus has been reported.26 Predicting Seizures. Recent EEG evidence suggests seizures in dogs are not random events, and that forecasting seizures is possible.28 Therefore, while therapy can be initiated after a seizure, it can potentially be administered before a seizure, as many owners feel they can predict when seizures will occur. Oral Therapy. Oral rescue therapy is appropriate if time to next seizure is an hour or greater, allowing for gastrointestinal absorption and development of useful serum concentration. For example, levetiracetam takes about 81 minutes to reach maximal serum concentration following oral administration.29 Although studies are lacking, administration of an extra dose of maintenance AED and initiation of a novel AED for a short period of time (pulse therapy) is advised to control cluster seizures and status epilepticus (Table 4). I advise owners to give a dose of AED used for pulse therapy between seizures to assess side effects, and determine best tolerated dose, prior to using the medication in the post-ictal period. Other Types of Therapy. Intranasal (IN), subcutaneous (SC), intramuscular (IM), and rectal AED administration have been advocated when (Table 5):
I advise owners to give levetiracetam (60 mg/kg SC) plus midazolam (0.2 mg/kg IM) or diazepam injectable solution (2 mg/kg by rectum). AED = anti-epileptic drug; CSF = cerebrospinal fluid; EEG = electroencephalography; IE = idiopathic epilepsy; IM = intramuscular; IN = Intranasal; IV = intravenous; MRI = magnetic resonance imaging; MUE = meningoencephalitis of unknown etiology; SC = subcutaneous References
What metabolic disorders cause seizures in dogs?The most common causes of reactive seizures were intoxications (39%, 37 dogs) and hypoglycaemia (32%, 31 dogs). Hypocalcaemia was the most frequent electrolyte disorder causing reactive seizures (5%) and all five of these dogs had ionised calcium concentrations ⩽0.69 mmol/L.
What is a metabolic cause of a seizure?Metabolic seizures can be caused by various metabolic disorders including amino acids metabolic disorders, disorders of energy metabolism, cofactor-related metabolic diseases, purine and pyrimidine metabolic diseases, congenital disorders of glycosylation, and lysosomal and peroxisomal disorders (Table 1).
What are metabolic disorders in dogs?Causes of Metabolic & Endocrine System Disorders
Diabetes, thyroid disorders, Cushing's disease, and Addison's disease are common disorders in pets. Some disorders occur because of inherited problems. Other disorders may develop as a part of normal aging or obesity.
What can cause a dog to suddenly start having seizures?What Can Cause Seizures in Dogs?. Eating poison.. Liver disease.. Low or high blood sugar.. Kidney disease.. Electrolyte problems.. Anemia.. Head injury.. Encephalitis.. |