{"id":1060,"date":"2014-05-01T01:17:56","date_gmt":"2014-05-01T01:17:56","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1060"},"modified":"2022-04-13T18:58:08","modified_gmt":"2022-04-13T18:58:08","slug":"the-canine-seizure-patient-four-important-questions","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/neurology\/the-canine-seizure-patient-four-important-questions\/","title":{"rendered":"Seizures and Dogs: 4 Important Questions"},"content":{"rendered":"<p><span class=\"helvbold-9-5\">E<\/span><span class=\"garamond-9-5\">pilepsy in dogs <\/span>is a common disease\u2014thought to affect up to 1 in 20 dogs\u2014and potentially life threatening.<sup>1<\/sup> A useful working understanding is essential for the small animal practitioner.<\/p>\n<hr \/>\n<p><strong>Editor\u2019s Note:<\/strong> 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 <a href=\"https:\/\/todaysveterinarypractice.com\/issue-archives\/\">issue archive<\/a>.<\/p>\n<div class=\"in-article\">\n<hr \/>\n<\/div>\n<p class=\"basic-paragraph\">When a patient presents for an episode of odd behavior or movement, the clinician must immediately consider 4 questions:<\/p>\n<ol class=\"list1\">\n<li class=\"blue-numbering\"><span class=\"x80-20-0-5-blue\">Are the events described by the owner (or recorded on video) truly a seizure?<\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"x80-20-0-5-blue\">Can an underlying cause be identified and treated versus treating only the seizure?<\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"x80-20-0-5-blue\">Should an anti-epileptic drug (AED) be administered?<\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"x80-20-0-5-blue\">If medical therapy is pursued, which AED should be chosen?<\/span><\/li>\n<\/ol>\n<div class=\"orange-box\">\n<h2>PROFILE OF EPILEPSY IN DOGS<\/h2>\n<h3><span class=\"bluboldheader\">Definition<\/span><\/h3>\n<p><strong>Epilepsy<\/strong> is defined as 2 or more seizures, at least 24 hours apart, resulting from a nontoxic, nonmetabolic cause.<\/p>\n<p>An <strong>epileptic seizure<\/strong> is defined as <em>a transient occurrence of signs, symptoms, or both due to abnormal, excessive, or synchronous neuronal activity in the brain<\/em>.<sup>2<\/sup> Seizure events can result from:<\/p>\n<ul>\n<li>Disease localized to the brain (symptomatic\/structural)<\/li>\n<li>A reaction of the healthy brain to a metabolic or toxic insult (reactive)<\/li>\n<li>An unknown or genetic cause (idiopathic).<\/li>\n<\/ul>\n<p>In human medicine, the term <em>idiopathic<\/em> has been replaced by the terms <em>genetic<\/em> or <em>seizure of unknown cause<\/em>.<sup>2<\/sup><\/p>\n<h3><span class=\"bluboldheader\">Classification by Frequency<\/span><\/h3>\n<p>Seizures can be classified into 3 categories based on frequency.<sup>3<\/sup><\/p>\n<ol>\n<li><strong>Cluster<\/strong>: 2 or more seizures within 24 hours<\/li>\n<li><strong>Acute repetitive<\/strong>: 2 or more seizures within 5 to 12 hours, separate from normal seizure pattern<\/li>\n<li><strong>Status epilepticus<\/strong>: Continuous seizure for 5 or more minutes or 2 or more seizures with no recovery between seizures<\/li>\n<\/ol>\n<h3><span class=\"bluboldheader\">Classification by Breed<\/span><\/h3>\n<p>In veterinary medicine, epilepsy is considered genetic when the frequency in a breed exceeds that of the general population (eg, Petit Basset Griffon Vendeen).<sup>4<\/sup> Classifying seizures by breed is important\u2014certain types of genetic epilepsy have different prognoses, and much interest exists with regard to using dogs as models for human epilepsy.<\/p>\n<p>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.<sup>5<\/sup> Conversely, the Lagotto Romagnolo has seizure onset at 5 weeks, which spontaneously resolves by 13 weeks, similar to benign familial neonatal seizure in humans.<sup>6<\/sup><\/p>\n<\/div>\n<h2 class=\"left-justified\"><span class=\"aquabold\">1. IS THE EVENT A SEIZURE?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">There are many behaviors, events, and diseases that mimic a true seizure (<strong>Table 1<\/strong>).<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#606060;border-radius:3px;\"><div class=\"su-box-title\" style=\"background-color:#939393;color:#FFFFFF;border-top-left-radius:1px;border-top-right-radius:1px\">Table 1. Behaviors, Events, &amp; Diseases with Seizure-Like Appearance<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:1px;border-bottom-right-radius:1px\">\uf06e Atlantoaxial subluxation<br \/>\n\uf06e Breed and drug induced dyskinesia\/movement disorders<br \/>\n\uf06e Cataplexy, narcolepsy, rapid eye movement (REM) sleep disorder<br \/>\n\uf06e Cervical muscle spasm<br \/>\n\uf06e Chiari malformation\/syringomyelia associated episodes<br \/>\n\uf06e Encephalitis<br \/>\n\uf06e Episodes of neuromuscular disease<br \/>\n\uf06e Exercise-induced collapse<br \/>\n\uf06e Extreme agitation<br \/>\n\uf06e Head bobbing\/tremor syndromes<br \/>\n\uf06e Intermittent decerebrate\/decerebellate rigidity<br \/>\n\uf06e Jaw chomping\/fly biting<br \/>\n\uf06e Metabolic\/toxic event<br \/>\n\uf06e Myoclonus<br \/>\n\uf06e Syncope<br \/>\n\uf06e Vestibular episode<\/div><\/div><\/span><\/p>\n<h3><span class=\"bluboldheader\">Electroencephalography<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Electroencephalography (EEG) records the brain\u2019s electrical activity and is considered by many human physicians to be an essential tool for characterizing seizure events (<strong>Figures 1\u20133<\/strong>). 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.<sup>7<\/sup><\/span><\/p>\n<p class=\"left-justified\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.58.45-AM.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"size-full wp-image-4724 aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.58.45-AM.png\" alt=\"Screen Shot 2015-06-18 at 10.58.45 AM\" width=\"315\" height=\"897\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.58.45-AM.png 315w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2014\/05\/Screen-Shot-2015-06-18-at-10.58.45-AM-105x300.png 105w\" sizes=\"(max-width: 315px) 100vw, 315px\" \/><\/a><\/p>\n<h3 align=\"LEFT\">Observation<\/h3>\n<p align=\"LEFT\">Identification of a seizure is most often achieved by comparing the observed event to what is considered a typical seizure.<\/p>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\"><strong>Generalized tonic clonic seizures<\/strong> typically last 1 to 2 minutes, and characteristically feature loss of consciousness, muscle tone and movement (tonic\/clonic), jaw chomping, and profuse salivation, followed by gradual return to consciousness and normal ambulation.<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\"><strong>Partial or nonconvulsive seizures<\/strong> are more difficult to recognize, with the latter requiring an EEG recording during the event.<sup>8<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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.<sup>9<\/sup> Accordingly, clinicians should be aware that they may be treating nonepileptic events with an AED.<sup>10<\/sup><\/span><\/p>\n<h2 class=\"left-justified\"><span class=\"aquabold\">2. DOES THE SEIZURE HAVE AN UNDERLYING CAUSE?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Identifying an underlying cause for the seizure yields better seizure control, quality of life, and accurate prognosis. The most recent seizure classification system\u2014by cause\u2014groups seizures into 3 causes: genetic, structural\/metabolic, and unknown.<\/span><\/p>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">Genetic &amp; Unknown Causes<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Diagnosis of <strong>idiopathic epilepsy<\/strong> (IE) is made when:<\/span><\/p>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Genetic basis is suspected<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Testing has failed to reveal a cause for the seizure.<\/span><\/li>\n<\/ul>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">Structural\/Metabolic Causes<\/span><\/h3>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Diagnosis of structural epilepsy is often made by magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) analysis, with common causes, including brain tumor, infarct or hemorrhage, or encephalitis.<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Technically, most metabolic causes of seizure are not a form of epilepsy because the brain itself is normal and reacting to an extracranial insult, which once eliminated, results in cessation of seizure.<\/span><\/li>\n<\/ul>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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:<\/span><\/p>\n<h3 class=\"tabs-and-bullets\"><span class=\"bluboldheader\">Age<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">As 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.<sup>11<\/sup><\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Breed<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">There 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.<sup>12<\/sup> In young (1\u20135 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.<\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Behavior<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">Even subtle behavior changes around the time of the first seizure indicate that a patient is likely to have symptomatic epilepsy (<strong>Table 2<\/strong>).<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#606060;border-radius:3px;\"><div class=\"su-box-title\" style=\"background-color:#939393;color:#FFFFFF;border-top-left-radius:1px;border-top-right-radius:1px\">Table 2. Common Behavior Changes in Dogs with Structural Brain Disease<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:1px;border-bottom-right-radius:1px\">\uf06e Aggression<br \/>\n\uf06e Inappropriate elimination<br \/>\n\uf06e Irritability<br \/>\n\uf06e Lethargy\/head pressing<br \/>\n\uf06e Not greeting owners<br \/>\n\uf06e Restless at night<br \/>\n\uf06e Sleeping more during the day<\/div><\/div><\/span><\/p>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Examination Findings<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">If 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.<sup>10<\/sup><\/span><\/p>\n<p class=\"indent-125\"><span class=\"garamond-9-5\">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:<\/span><\/p>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Confusion<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Circling to one side<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Postural reaction<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Menace deficits on one side.<\/span><\/li>\n<\/ul>\n<h2 class=\"left-justified\"><span class=\"aquabold\">3. SHOULD AN AED BE ADMINISTERED?<\/span><\/h2>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">AED drug therapy is recommended if any of the following are present\/occur:<\/span><\/p>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Structural cause for the seizure<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Severe first seizure or post-ictal period<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Owner preference to reduce chances of another seizure.<\/span><\/li>\n<\/ul>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">For IE, I recommend AED therapy after 1 or 2 seizures in a 6- to 12-month period for several reasons:<\/span><\/p>\n<ol class=\"list1\">\n<li class=\"blue-numbering\"><span class=\"garamond-9-5\">Although rarely life-threatening, seizures are very upsetting to owners, and a recent owner survey showed that most owners felt the only acceptable seizure control is no seizure.<sup>13<\/sup><\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"garamond-9-5\">AED therapy likely reduces the chance of a life-threatening seizure\/status epilepticus.<\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"garamond-9-5\">Although controversial, there is both bench-top and clinical data that demonstrates every seizure a patient experiences increases the chance for another seizure, independent of the seizure cause. In other words, seizure begets seizure.<sup>14,15<\/sup><\/span><\/li>\n<li class=\"blue-numbering\"><span class=\"garamond-9-5\">Newer generation AEDs do not have as many side effects or organ toxicities compared to older AEDs, and are now available in generic or cost-effective formulations (<strong>Table 3<\/strong>).<sup>16-18<\/sup><\/span><\/li>\n<\/ol>\n<p><span class=\"garamond-9-5\"><sup><div class=\"su-table su-table-alternate\"><\/div><\/sup><\/span><\/p>\n<div class=\"orange-box\">\n<h3>AED Monitoring<\/h3>\n<p>Serum drug concentrations can be monitored for many AEDs (<strong>Table 3<\/strong>). I will assess serum concentrations when:<\/p>\n<ul>\n<li>Starting a new AED in a difficult to control patient<\/li>\n<li>Toxicity is suspected at a relatively low dose<\/li>\n<li>Abandoning an AED due to poor seizure control.<\/li>\n<\/ul>\n<p>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:<\/p>\n<ul>\n<li>Physical examination<\/li>\n<li>Serum biochemical profile<\/li>\n<li>Complete blood cell count<\/li>\n<li>Urinalysis.<\/li>\n<\/ul>\n<\/div>\n<h2 class=\"left-justified\"><span class=\"aquabold\">4. WHICH AED SHOULD BE CHOSEN FOR THERAPY?<\/span><\/h2>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Maintenance Therapy<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">When and which AED to apply in the clinical setting remains uncertain and controversial (see <strong>Studies Evaluating AED Efficacy &amp; Safety<\/strong>). Some reasonable guidelines for seizure management are to:<\/span><\/p>\n<ul>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Use one medication at a time<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Choose medications with best efficacy, lowest cost\/dosing interval, fewest side effects, and lowest risk of toxicity.<\/span><\/li>\n<\/ul>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>Table 3<\/strong> lists AEDs in the order they are used by most neurologists in our clinic.<sup>11,19<\/sup><\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>When to Change.<\/strong> 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,<sup>17<\/sup> and fewer than half the dogs on phenobarbital and\/or bromide are seizure-free without adverse medication-related side effects.<sup>20<\/sup><\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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.<\/span><\/p>\n<div class=\"orange-box\">\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Studies Evaluating AED Efficacy &amp; Safety<\/span><\/h3>\n<p class=\"left-justified\">In veterinary medicine, placebo-controlled or crossover studies to determine the effectiveness or side effects of a sole AED (monotherapy) are lacking.<\/p>\n<p class=\"left-justified\">Multiple studies have evaluated the addition of a newer generation AED (ie, pregabalin, levetiracetam, zonisamide) to phenobarbital \u00b1 bromide therapy, resulting in at least a 50% reduction in seizure frequency.<sup>21-23<\/sup> 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.<sup>24<\/sup> One explanation for the placebo effect is <em>regression to the mean<\/em>\u2014a term used to describe fluctuations in biological variables that occur over time, and take the form of a sine wave around the mean.<sup>24<\/sup><\/p>\n<p class=\"left-justified\">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.<sup>25<\/sup><\/p>\n<\/div>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>Transition Period.<\/strong> 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\u2014only 6% of status epilepticus cases in one study resulted from low AED concentration.<sup>26<\/sup> 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 <strong>Step-by-Step: Transitioning to Newer Generation AEDs<\/strong>.<\/span><\/p>\n<div class=\"orange-box\">\n<h3><span class=\"aquabold\">Step-by-Step: Transitioning to Newer Generation AEDs<\/span><\/h3>\n<ol>\n<li><strong>For 1 week<\/strong>, add a new AED to the patient&#8217;s current regimen.<\/li>\n<li><strong>For the next 5 days<\/strong>, reduce the dose of the former AED by 50%.<\/li>\n<li><strong>For the next 5 days<\/strong>, reduce the frequency of the former AED to once a day.<\/li>\n<li><strong>Discontinue<\/strong> administration of the former AED.<\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>If <strong>marked sedation, ataxia, or weakness<\/strong> are noted with the new AED, more rapid tapering or discontinuation of the former AED is advised.<\/li>\n<li>If <strong>marked increase in seizure frequency<\/strong> is noted in the following weeks to months, a return to the former AED or addition\/substitution of a new, different AED is recommended.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol>\n<li style=\"list-style-type: none\"><\/li>\n<\/ol>\n<\/div>\n<h3 class=\"left-justified\"><span class=\"bluboldheader\">Rescue Therapy<\/span><\/h3>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">AED therapy\u2014additional or different, oral or parenteral\u2014to control cluster seizures or status epilepticus is called <em>rescue therapy<\/em>. 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.<sup>27<\/sup> Furthermore, a 25% mortality rate among all dogs that present for status epilepticus has been reported.<sup>26<\/sup><\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>Predicting Seizures.<\/strong> Recent EEG evidence suggests seizures in dogs are not random events, and that forecasting seizures is possible.<sup>28<\/sup> 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.<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>Oral Therapy.<\/strong> 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.<sup>29<\/sup><\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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 (<strong>Table 4<\/strong>).<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><div class=\"su-table su-table-alternate\"><\/div><\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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.<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><strong>Other Types of Therapy.<\/strong> Intranasal (IN), subcutaneous (SC), intramuscular (IM), and rectal AED administration have been advocated when (<strong>Table 5<\/strong>):<\/span><\/p>\n<ul>\n<li class=\"left-justified\"><span class=\"garamond-9-5\">Patient is unable to swallow<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Rapid cessation of seizure activity is required<\/span><\/li>\n<li class=\"blue-bullets\"><span class=\"garamond-9-5\">Intravenous (IV) route is unavailable.<\/span><\/li>\n<\/ul>\n<p><span class=\"garamond-9-5\">I advise owners to give levetiracetam (60 mg\/kg SC) plus midazolam (0.2 mg\/kg IM) <em>or<\/em> diazepam injectable solution (2 mg\/kg by rectum).<\/span><\/p>\n<div class=\"su-table su-table-alternate\"><\/div>\n<p class=\"left-justified\"><span class=\"garamond-9-5\">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<\/span><\/p>\n<p class=\"left-justified\"><span class=\"garamond-9-5\"><div class=\"su-youtube su-u-responsive-media-yes\"><iframe width=\"600\" height=\"400\" src=\"https:\/\/www.youtube.com\/embed\/2joYFvuHNGk?\" frameborder=\"0\" allowfullscreen allow=\"autoplay; encrypted-media; picture-in-picture\" title=\"\"><\/iframe><\/div><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Epilepsy in dogs is a common disease, and potentially life threatening.<\/p>\n","protected":false},"author":187,"featured_media":18480,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":10660,"footnotes":""},"categories":[366],"tags":[13],"class_list":["post-1060","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-may-june-2014","tag-peer-reviewed","column-features","clinical_topics-neurology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Seizures and Dogs: 4 Important Questions<\/title>\n<meta name=\"description\" content=\"Epilepsy in dogs is a common disease, and potentially life threatening. 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