QUIZ + ANSWER: Is the dog in this movie having a seizure or syncope?

RE: QUIZ + ANSWER: Is the dog in this movie having a seizure or syncope?

Mark Hedberg — Thu, 03 Sep 2015 16:26:12 GMT

I figured it was cardiac, because a cardiologist posted it. You specialists are predictable like that. :p

RE: QUIZ + ANSWER: Is the dog in this movie having a seizure or syncope?

Mike Martin — Thu, 03 Sep 2015 13:37:13 GMT

Well done VS.org members. In general when I show this movie at the start of my collapse presentation, based on a show of hands, most audiences will be 2/3rds neuro v 1/3rd cardiac. So at nearly 50% getting it correct, you are much better than average. :)

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Thu, 03 Sep 2015 13:32:25 GMT

ANSWER

ECG showed the presence of 3rd degree (complete) AV block (heart block). Although that in itself does not explain the collapsing directly, as most dogs with heart block with a rate of 25-35/min will walk in happy and tail wagging. But in this case, there was a failure of the escape rhythm with periodic ventricular arrest, ie. no QRSs thus no pulses leading to an acute profound hypotension and collapse (see ECG below).

In this dog, the collapsing was variable in duration, this movie showing the most severe form, with initial opisthotonus, urination, then good recovery. The start of the collapse was sudden and the dog would fall on the ground with a bang.

I'm hoping the take-home message is do not assume that things that might look like a seizure (or sounds like one from an owner's description) is. Sometimes it is better to run and ECG or Holter, before considering a GA for an MRI.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Aine Seavers — Thu, 03 Sep 2015 09:33:01 GMT

The problem for me is that when the spasms are at maximum arc, we cant see the face and eyes- so then much extra data not being processed by us -how much is poor responsiveness but not actually unconsciousness in this dog? The spasms seem too tetanic for heart blocks (but I would be still be checking). It reminds me of the startled dogs with Lafora but if no light/noise/excitement trigger then unlikely.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Thu, 03 Sep 2015 08:55:59 GMT

[quote user="Aine Seavers"]with loss of consciousness which this dog doesnt really do.[/quote]

Interesting thought. For me, this dog was unresponsive prior to the point when it urinates and starts to 'come round'.

[quote user="Aine Seavers"]Would still like to know what the diet and sibling history is as well. Did you do an optic exam and where the optic discs normal in shape and size and vessel integrity etc?[/quote]

Normal diet and nothing remarkable. Siblings were unaffected and parents alive and well. Optic exam was normal.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Aine Seavers — Thu, 03 Sep 2015 00:54:14 GMT

as opposed to emprosthotonos:-) Do we know what the trigger is for this collapse ? was there a startle response inducing the collapse as in Lafora? I see lipopthymia or conscious collapse in hypothyroid and some cardiac cases. For me syncope means collapse with loss of consciousness which this dog doesnt really do. Would still like to know what the diet and sibling history is as well. Did you do an optic exam and where the optic discs normal in shape and size and vessel integrity etc?

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Wed, 02 Sep 2015 18:48:43 GMT

Opisthotonus - correct - a few have mentioned this now.

Yes, this is present at the start of the movie, until urination when she relaxes out of this.

I've noticed at various lectures that people have been taught to pronounce this differently. This is how the dictionaries pronounce it. Link

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Wed, 02 Sep 2015 18:36:28 GMT

[quote user="Mike Dale"]The dog does not seem to be totally unconscious,[/quote]

Consciousness is a term we have been over-taught in veterinary. Technically its a "symptom" which we do not appreciate as the third party (however I do use the term symptom in speaking with owners). The clinical sign we should refer to is "responsiveness".

For me, this dog was unresponsive in the very early part of the event, in this movie, I would estimate responsiveness returns shortly during/after she urinates.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Wed, 02 Sep 2015 18:29:13 GMT

[quote user="Aine Seavers"]do we get to see biochemistry on this dog- glucose, insulin, and ratio of eithe[/quote]

Good question. Bloods are a very important part of a routine work-up. They need to be fasted (>12 hours) in search of hypoglycaemia. Electrolytes are important and ACTH test in case of Addisions (including atypical form). Liver function and bile acids for shunts. Hypothyroidism can lead to bradyarrhythmia and potentially collapse (uncommon but I've see it). Haematology is important but - if performed early on, then repeat haematology >24 hours later for blood loss.

ALL bloods were normal in this case.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Hannah Wynne Richards — Wed, 02 Sep 2015 16:03:16 GMT

Come ON Mike We're all getting impatient!

Even if it isn't a mild electric shock - I want to know if I'm right in thinking it isn't either cardiac or neurogenic

Wynne

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Sarah Jane Denny — Wed, 02 Sep 2015 15:58:28 GMT

I vote cardiogenic-opisthothonus and lack ictal signs

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

mariette asselbergs — Wed, 02 Sep 2015 15:58:08 GMT

[quote user="Mike Martin"]

[quote user="Robin Grimmer"]Syncope tends to occur during activity whereas seizures are usually at rest[/quote]

This happens when walking around.

[quote user="Robin Grimmer"]The opishtotonus, extensor rigidity and spontaneous urination do make it appear more like a seizure.[/quote]

Again aninteresting observation and I believe this is what most of us have been taught in vet school. Is it true? 99% of those that taught us did not get to see the real event either :) What does everyone else think?

[/quote]

I have seen hundreds of sheep, goats and cattle with Cowdria ruminantium causing opisthotonus and paddling due to increased cranial pressure. That looked just like this, but of course no sudden recovery.

Mariette

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Geoff Holt — Wed, 02 Sep 2015 15:42:10 GMT

Cardiogenic syncope gets my vote! Extensor rigidity + very quick recovery would make me think this. Time for a holter!

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Phil Tricklebank — Wed, 02 Sep 2015 13:48:19 GMT

I go for cardio, because she voided urine.

104 votes, it's answer time Mike!

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Dale — Wed, 02 Sep 2015 13:27:31 GMT

The dog does not seem to be totally unconscious, the limb movements are not full on tonic clonic and the recovery is pretty swift without typical post ictal disorientation. My money is on syncope. As for a non cardiac /non seizure cause I'm struggling to think of anything that would be so briefly periodic with complete (apparent) recovery.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Aine Seavers — Wed, 02 Sep 2015 13:14:40 GMT

do we get to see biochemistry on this dog- glucose, insulin, and ratio of either etc, are there eeg tracings, does it occur in hot or in cold weather, what is the inter episode frequency etc.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Aine Seavers — Wed, 02 Sep 2015 13:09:17 GMT

But dog is still mentally alert though- if a collapse its a conscious one so hence if syncope is actually the correct term to use for this collapse.

Movement disorders can be types including 4 postional and exertion etc plus then we have chaennelopathis - we still dont have enough information to really nail this down as yet. Are any of the litter available for us to know clinical history on as well. Do we know anything about diet, recent medications etc?

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

David More — Wed, 02 Sep 2015 12:45:05 GMT

Syncope. Typical rigid extension of fore limbs and head and neck but 'passive' not thrashing violently, plus the quick recovery once circulation stabilises.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Aine Seavers — Wed, 02 Sep 2015 12:15:53 GMT

why not a lipothymia event or a movement disorder rather than true seizure or cardiac syncope

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Tue, 01 Sep 2015 12:51:12 GMT

[quote user="David Mills"]Think of it as a bit like x-ray film-reading - the background clinical details don't change the film in front of you...[/quote]

Good thought..

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Tue, 01 Sep 2015 12:49:59 GMT

[quote user="Clive Ansell"]How often are the attacks? any pattern to them? are the getting more frequent or more severe?[/quote]

They started happening 2 weeks ago. Occur randomly, some days none, but other days a few, maybe a few within a short period of time. The dog collapsed 3 times within an hour with me.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Mike Martin — Tue, 01 Sep 2015 12:48:09 GMT

[quote user="Nhombokisheni"] So far all I have is a dog, just walking around and suddenly either looses consciousness or experiences sudden total weakness and exibits this episode, then gets up and trots away as if nothing happened.[/quote]

Correct. That's exactly correct. The collapses happen suddenly and without warning.

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Clive Ansell — Tue, 01 Sep 2015 12:36:35 GMT

[quote user="Mike Martin"]

[quote user="Clive Ansell"]Think I would run an ECG in the first instance if possible during an attack.[/quote]

What if the ECG was normal when it walked into your consulting room?

[/quote]

I think I would repeat the ECG preferably with a 24 hour Holter. In addition of course to a full exam, neuro exam and basic blood work.

If a sensible client, get them to observe for more info during any further attacks; look for mm colour, cyanosis, maybe get them to count heart rate and pulse.

How often are the attacks? any pattern to them? are the getting more frequent or more severe?

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

David Mills — Tue, 01 Sep 2015 12:30:24 GMT

[quote user="Nhombokisheni"]

This maybe all you see on video, but pre and post behaviour descriptions from the owner you surely did get hey. How about a few more clues. So far all I have is a dog, just walking around and suddenly either looses consciousness or experiences sudden total weakness and exibits this episode, then gets up and trots away as if nothing happened. My take is that this is not cardiogenic. Its more likely a seizure (post-ictal behaviour can be apparently normal) or its something else. How long has this been going on and any link to travel history....

[/quote]

I have seen this video before on one of Mike's excellent CPD events, but I think you are asking for too much - the point of the video is not to diagnose the condition but whether this behaviour (which most of us never get to see in practice) is cardiogenic or neurogenic (or something else). As you say, with neurogenic the pre- and post-ictal behaviours are inconsistent, and normally what people have been taught at college. Think of it as a bit like x-ray film-reading - the background clinical details don't change the film in front of you...

RE: QUIZ: Is the dog in this movie having a seizure or syncope?

Nhombokisheni — Tue, 01 Sep 2015 12:16:42 GMT