WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Miriam Lodewyks — Fri, 01 Mar 2024 14:25:33 GMT

My own labrador had about 5 seizure events that I know of, in his life. I would have started meds if his bloods were aberrant, or if he had more than 2 seizures in 12 months, which he never did.
At 12 he had a vestibular event that warranted an MRI - completely normal.

So my threshold for medicating is >2/12months or other concurrent abnormalities.

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Anthony Dennison — Mon, 19 Feb 2024 13:21:45 GMT

[quote userid="4181" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-seizure-or-cluster-of-seizures/243654#243654"]While I don't disagree with your approach in practice, the ACVIM Small Animal Consensus Statement on Seizure Management in Dogs suggests starting AEDs following "Acute repetitive seizures or, status epilepticus (ictal event ≥5 minutes or ≥3 or more generalized seizures within a 24‐hour period)" - ie your young dog having had a single cluster of seizures.
Didn't see his lecture so not sure what it contained, but Helger Volk is an author on this consensus statement.[/quote]

Sorry, I didn't really elaborate or give details on this. the lecture was 'Having the end in mind in epilepsy management'.

It was an overview of the AEDs available, pro's and cons, and new thoughts on the holistic approach to it. He showed a slide that had seizure events in un-medicated dogs - some had 2 or 3 seizures close together, and none for years. I wouldn't say he was advocating not treating at all, but having things like this in mind.

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Arlo Guthrie — Tue, 06 Feb 2024 10:25:19 GMT

I was wondering if anyone was going to highlight the consensus statement on cluster seizures earlier in the thread!

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Rob Loxley — Tue, 06 Feb 2024 08:17:00 GMT

[quote userid="11308" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-seizure-or-cluster-of-seizures/243650#243650"]There are a few dogs on our books that have been on phenobarb for years after a single seizure/cluster as a young dog. I am trying to convince owners to trial weaning them off the meds as they may not be needed[/quote]

While I don't disagree with your approach in practice, the ACVIM Small Animal Consensus Statement on Seizure Management in Dogs suggests starting AEDs following "Acute repetitive seizures or, status epilepticus (ictal event ≥5 minutes or ≥3 or more generalized seizures within a 24‐hour period)" - ie your young dog having had a single cluster of seizures.
Didn't see his lecture so not sure what it contained, but Helger Volk is an author on this consensus statement.

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Anthony Dennison — Mon, 05 Feb 2024 13:05:52 GMT

First fit? Clinical examination, check for any neuro deficits, if all clinically healthy, nothing else. Bloods only if the owner insisted.

Bloods if any further seizures or if clinically unwell, work up from there.

There are a few dogs on our books that have been on phenobarb for years after a single seizure/cluster as a young dog. I am trying to convince owners to trial weaning them off the meds as they may not be needed. Been successful once so far.

Holger Volk did a good lecture on this at LVS in November

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Arlo Guthrie — Thu, 01 Feb 2024 08:36:57 GMT

I deleted it and we're discussing the point privately!

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Rob Loxley — Wed, 31 Jan 2024 22:47:22 GMT

[quote userid="3169" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-seizure-or-cluster-of-seizures/243558#243558"]Was my post deleted or did it fail to post?[/quote]

I’m sure I read something earlier?

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Michael Woodhouse — Wed, 31 Jan 2024 21:38:49 GMT

[quote userid="2100" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-seizure-or-cluster-of-seizures/243550#243550"] was just going to do that, actually, but hoping we might have few more people post thoughts before I do. [/quote]

Was my post deleted or did it fail to post?

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Arlo Guthrie — Wed, 31 Jan 2024 15:29:12 GMT

[quote userid="8958" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-seizure-or-cluster-of-seizures/243534#243534"]As editor, can we finish each of these, get an expert opinion and move on to the next one please?[/quote]

I was just going to do that, actually, but hoping we might have few more people post thoughts before I do.

RE: WHAT WOULD YOU DO: Young dog presented having had its first seizure or cluster of seizures?

Neil Wheadon — Tue, 30 Jan 2024 23:17:00 GMT

Hi Arlo

As editor, can we finish each of these, get an expert opinion and move on to the next one please?

This has the potential to be an interesting thing to do

Neil

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Clive Ansell — Wed, 17 Jan 2024 10:26:59 GMT

[quote userid="8958" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-single-or-cluster-of-seizures/243419#243419"]Every time we follow our instinct/evidence by saying ‘it’s soft tissue’ we are guessing. In nearly every case we’ll be right, but in the occasional case we won’t be leading to guilt,loss of confidence and possibly complaint.[/quote]

You're doing yourself down here.

If it is a guess, it is an educated or an informed guess based on your training and X years of clinical experience. We are not wrong in the cases we don't get right first time, it is not a missed or mis-diagnosis, we just have not yet reached a diagnosis.

By definition, diagnosis is a stepwise process. In these cases, unless it is someting glaringly obvious, we are usually stating "it is likely/probably/maybe a soft tissue injury" or "it is in keeping with osteoarthritis" and my advice would be restricted exercise/lead exercise/rest along with a short course of NSAID/other analgesia, then if no better we will need to reassess things.

Anecdote time: I was recently discussing a similar scenario wih younger colleagues. We had been seeing a lot of vomiting dogs, and almost all were responding well to a one injection of Maropitant. Someone was worried that they/we were going to miss an intestinal foreign body. My take on this, is that any vomiting dog may have a FB, but most, almost all, will not. In the few that have, it would be a case of not yet diagnosed, not missed.

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Neil Wheadon — Tue, 16 Jan 2024 23:06:17 GMT

This is a separate discussion but it’s the ‘what if ?’ scenario.

As a profession we can now offer so much

As vets, we know that rarely things will be found

Take a case, I saw today. 6 year old dog with a shoulder lameness for over a year, responds to metacam. I can feel a swelling over the shoulder, it’s almost certainly soft tissue but can I rule out a tumour? No because, I haven’t got x-ray eyes and anyway advanced imaging may give a definitive diagnosis and the prognosis.

The dog is insured, the owner has an athletic dog in her house for another 7-9 years, so I have to refer, as I’m a GP vet and don’t have a CT scanner in the basement.

Every time we follow our instinct/evidence by saying ‘it’s soft tissue’ we are guessing. In nearly every case we’ll be right, but in the occasional case we won’t be leading to guilt,loss of confidence and possibly complaint.

Some deal with this better than others, as differentials, knowledge and technical ability increase, vets will naturally take less risk.

Neil

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

David Mills — Tue, 16 Jan 2024 20:34:36 GMT

Young would be any dog under the upper range, say <6yo. Bit pointless to get bogged down in too much detail.

Seizures are dramatic and visible so owners normally want something "done". But listing side effects of phenobarb normally assuages their issues.

First presentation - nothing even for clusters that have finished.

Bloods - why? If they're sick enough systemically to be seizuring then there will be other clinical signs than seizures.

Same for MRI.

I think it was Mark Lowrie on a CPD course said his heart drops when a healthy young dog with a few seizures is booked in for MRI as it's always going to be IE.

Rectal diazepam is a good placebo - by the time they've got it ready and found the bum hole the seizure has normally stopped.

Possibly one of the most over investigated presentations?

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Lucy Fleming — Tue, 16 Jan 2024 14:21:09 GMT

Much the same as the others:

Physical examination and history - looking in particular for any inter-ictal signs that might suggest intoxication (that may be a Glastonbury specific thing though), and trying to determine if it was a true seizure, especially if the description by the owner isn't completely typical.

Discuss running bloods, though I wouldn't necessarily be too concerned if the owner doesn't want to do this, especially if the dog had only had one fit. If it was younger than 1 year I'd probably suggest a little harder, ideally adding in a BAST, or if it had clustered and I thought needing treatment was sightly more likely.

Briefly mention "diagnosis of exclusion" and that sometimes referral is needed for further work up, but I wouldn't exactly offer/ suggest it.

If only one fit, I'd send them on their merry way. In the dim and distant past I vaguely remember being taught that cluster seizures were an indication for treatment, but in real life as with everything I'd say it's much less black and white. Particularly worried owners might get a rectal diazepam tube to give them something to think about while any future seizure probably stopped by itself. Hopefully they would use it on the dog.

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Joyce Whitehead — Tue, 16 Jan 2024 13:51:00 GMT

Exactly as above, full history, examination and baseline bloods and to rule out for instance a shunt. I would very rarely refer these unless owner insisted. Generally if all ok on bloods etc I’d advice to monitor for now (especially if a single seizure) and to keep a diary of activity and any pattern to behaviours or activity leading up to a fit. With clusters I’d be monitoring carefully to see if they recur as in my experience they are harder to control. In a young dog I’d also advise considering neutering as it often seems to lessen the risk of further seizures.

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Clive Ansell — Tue, 16 Jan 2024 13:39:50 GMT

[quote userid="2100" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-single-or-cluster-of-seizures/243408#243408"]Would you make any distinction between the dog presented after its first single seizure and one that presented after its first cluster of seizures?[/quote]

usually not, but as always it would depend upon the individual case and client, and the severity and duration of the attack(s)

As always, there is not a one size fits all answer.

Most cases in young otherwise healthy dogs, there will be NSF on routine blood work or advanced imaging, and it really serves to exclude possible causes of seizures.

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Arlo Guthrie — Tue, 16 Jan 2024 11:13:23 GMT

[quote userid="5012" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-single-or-cluster-of-seizures/243407#243407"]Alternatively, if a one off single event could just monitor for now, and keep a detailed seizure diary of events. [/quote]

Clive Ansell Would you make any distinction between the dog presented after its first single seizure and one that presented after its first cluster of seizures?

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Clive Ansell — Tue, 16 Jan 2024 10:12:25 GMT

Full and thorough history, signalment and examination, including neurological examination, to begin with. Almost always unremarkable with NSF.

Age? breed? predisposition to epilepsy.

Ask the client to describe the event in detail. was it actually a seizure? or something else; syncope? reverse sneezing?

Recent access to known or possible poisons. toxins, medicines, anti-parasitics etc?

History of trauma?

Would advise, suggest, offer baseline blood work including hepatic function and starved glucose. Usually around £200 - £250. Almost always come back with NSF.

Alternatively, if a one off single event could just monitor for now, and keep a detailed seizure diary of events.

I would not usually be discussing referral, MRI/CT scanning or CSF taps at the initally consultation unless prompted to by the client.

RE: WHAT WOULD YOU DO: Young dog presented having had its first single or cluster of seizures?

Arlo Guthrie — Tue, 16 Jan 2024 08:50:49 GMT

[quote userid="4181" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-had-its-first-single-or-cluster-of-seizures/243405#243405"]Presented 'having its 1st seizure', or 'having had' it's 1st seizure and no longer seizuring at presentation?[/quote]

Rob Loxley. Morning. Sorry, having had. Have amended. Would have thought it reasonably rare animals are presented whilst fitting as I didn't think seizures typically last that long (not in humans anyway).

In either scenario (cluster or single)

Young - erm, I would defer to my learned colleague on that one (what did you have in mind when you proposed the question David Mills?) I would have assumed <5

RE: WHAT WOULD YOU DO: Young dog presented having its first single or cluster of seizures?

Rob Loxley — Tue, 16 Jan 2024 08:43:53 GMT

[quote userid="2100" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-its-first-single-or-cluster-of-seizures"]What would you do for a young dog presented having its first single or cluster of seizures?[/quote]

Presented 'having its 1st seizure', or 'having had' it's 1st seizure and no longer seizuring at presentation?

Having had a single seizure, or having had a cluster of seizures?

Define young: <1yr versus 1-7yrs?

Broadly - history, clinical exam, baseline bloods, treatment very much swayed by single or cluster or presented in status. Advanced imaging rare though we have had picked up a hydrocephalus (though breed and abnormal inter-ictal behaviour was maybe a pointer).

I suspect insured animals are more likely to get referred for MRI early on.

RE: WHAT WOULD YOU DO: Young dog presented having its first single or cluster of seizures?

Clive Ansell — Tue, 16 Jan 2024 08:32:42 GMT

[quote userid="8958" url="~/f/clinical-questions/30875/what-would-you-do-young-dog-presented-having-its-first-single-or-cluster-of-seizures/243402#243402"]

'How many abnormalities did they spot on advanced imaging for young fitting dogs?'

'None'

[/quote]

I have still had clients insist and demand a referral for advanced imaging in such cases, against my advice that it is not indicated. Wealthy neurotic clients in a posh area. Yet to see a report where a CNS lesion has been found.

Last one was an 18 month healthy Labrador, only one small seizure. £3500 later, a report came back with no findings on MRI or CSF analysis, and underlined at the bottom "Probably idiopathic epilepsy" (I had stated suspect idiopathic epilepsy in my referral letter) (note the word probably, and not definitely too)

RE: WHAT WOULD YOU DO: Young dog presented having its first single or cluster of seizures?

Neil Wheadon — Mon, 15 Jan 2024 21:39:58 GMT

There will be lots of replies to this, probably along the same lines, but here's an anecdote

I asked a nurse a few years ago with whom I was on a shift at Vets Now

'I see you work in the neurological part of a referral centre'

'Yes'

'How many abnormalities did they spot on advanced imaging for young fitting dogs?'

'None'

Neil