Today we are going to meet Benny, a young Labrador with a history of seizures. Over the last year, his vet diagnosed the cause of his seizures, the owners have been managing his condition very well, and the vets even helped Benny during an emergency. But let’s start from the beginning…

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Meet Benny

Benny is a 4-year-old, male, entire, black Labrador retriever who had been coming to the same vets since he was a puppy. Apart from an ear infection when he was young, he was only seen for his yearly vaccinations until recently. He lives with just his owners and is always up to date with his flea and worming treatments. Benny’s owners thought it would be sensible to insure him, so they have done so since they first got him.

The First Seizure

One day, when Benny was two, his owners rang the vets in a bit of a panic, telling the receptionist that Benny had had a seizure, though he seemed okay now. The owners were told to bring Benny straight down for examination. 

At the vets, the owners were first asked what had happened: Benny was playing in the garden, appearing to be chasing some flies, when he suddenly stopped, fell onto his side and started convulsing. He didn’t appear to be conscious, and he urinated and defaecated. The owners weren’t sure how long it lasted, but guessed around 2 minutes. He recovered quite quickly, but seemed to be tired and went for a drink. They said that nothing like this had happened before. 

The vet agreed a seizure sounded likely, and examined Benny

On examination, Benny was bright and bouncy. His pupils and eyes looked normal and reacted to light well. He had no pain in any of his limbs, his neck or his spine. His heart and breathing were normal, as was his temperature. In fact, apart from being a little overweight, Benny had no clinical signs. 

Based on the history and examination, the vet concluded Benny had likely had a full tonic-clonic seizure. They advised of two approaches: one was to monitor Benny closely over the next few days – just like in humans, isolated seizures do occur and don’t always indicate underlying disease. In Benny’s case, this wouldn’t be unreasonable. The other option would be to start investigations for causes of the seizure. Now a little calmer, the owners opted to take Benny home. 

Before they left, the vet dispensed some rectal diazepam – this is a mild sedative that, should Benny seizure again, can be inserted into his bottom to try and stop the seizure. 

He also told them of three emergency scenarios that require an immediate vet visit:

1) a seizure that lasts longer than 5 minutes;
2) a seizure that is very violent;
3) cluster seizures, where Benny comes in and out of a seizure repeatedly within 24 hours.

They also told Benny’s owners to stay calm, dim the lights, if possible, move Benny away from any objects he could hit, and try and film the event. The owners were very glad Benny was ok, and took him home. 

What Is Seizuring?

A seizure is sudden uncoordinated electrical activity in the brain. Seizures can be focal, affecting just one part of the body, or generalised, affecting the whole of the body. The symptoms of seizures vary and include behavioural changes, salivation, aggression, running, vocalisation, collapse, loss of consciousness, convulsions, and loss of bladder and bowel control. Severe seizures cause a rapid increase in body temperature (hyperthermia) that can be fatal. Other complications include aspiration of vomit or fluid and pneumonia, damage to the heart and other organs, trauma from hitting nearby objects, and electrolyte (blood salt) abnormalities. Many seizures will also have behavioural changes before (pre-ictal) and after (post-ictal). Benny’s fly-catching may have been a pre-ictal symptom.

Seizures can be caused by conditions either intra-cranial (within the brain) or extra-cranial (outside of the brain), including metabolic abnormalities, toxins, hypoxia, hyperthermia, congenital liver or kidney disease, brain trauma, brain cancer, coagulation issues, epilepsy, and congenital brain disease. 

The Second Seizure

Benny was fine for a few months and didn’t need to visit the vets, until the owners rang to report a second seizure. They were much calmer this time, knowing how to manage it better. They had given him some rectal diazepam; and Benny’s seizure ended shortly after. They came to the vets straight away for a check-up and once again his examination was unremarkable.

Given Benny had had two seizures in only a few months, the vet was a little more concerned there may be an underlying cause and recommended preliminary investigations. This started with a blood test to rule out metabolic and organ problems. They also checked Benny’s blood pressure. All of these tests were normal. This meant Benny most likely had a problem within the brain itself. The vet advised Benny’s owners could either start anti-seizure medication now, or continue investigation with a specialist neurologist.

Referral

Benny’s owners were quite keen to have some answers but were concerned about the costs of referral to a neurologist. The vet advised that referral medicine can cost thousands of pounds to pay for the vet’s expertise and advanced equipment. However, he reminded them that Benny was insured, and they may be able to claim for his referral. Relieved, the owners checked with their insurers, who confirmed they would cover Benny’s investigation, and an appointment with a veterinary neurologist was made. 

At the referral vets, the vet again asked for full history from Benny, and repeated the clinical and neurological examination. Their findings matched the referring vet’s notes, and there were no significant abnormalities. 

The neurologist advised that to find out the cause of Benny’s seizures, they would require him to undergo a general anaesthetic. The owners agreed, and Benny was anaesthetised by their team. While under a GA, the vet took a sample of his cerebrospinal fluid (CSF). This was taken very carefully using a long needle inserted at the base of his neck, into the spine. The CSF was analysed for signs of bacteria, inflammatory cells, cancerous cells, and other parameters. This was all normal. Finally, Benny had an MRI scan of his brain and spinal cord. MRI (Magnetic Resonance Imaging) is a specialised imaging technique where the machine uses the alignment of protons in the body to produce a highly detailed image.

The vets were looking for changes on the MRI that may have indicated inflammation, infection, cancer or low blood flow to the brain. Thankfully, they found none of these. This meant that Benny’s final diagnosis was idiopathic epilepsy, likely caused by an unknown chemical imbalance within the brain. Idiopathic epilepsy is most common in dogs from around 6 months to six years old.

Medical Management

Now with a complete diagnosis, the owners were happy to start treatment for Benny’s epilepsy. This involved powerful anti-seizure medication given daily. The most common drugs are phenobarbital, imepitoin, sodium/potassium bromide, levetiracetam, diazepam, midazolam and gabapentin. Phenobarbital and imepitoin are normally recommended as first-line drugs.

Benny initially started on phenobarbital tablets twice a day. These drugs are potent, so the owners were told the vets needed to monitor Benny’s liver function closely – phenobarbital is broken down by the liver, so will put strain on it over time. They recommended testing Benny’s liver function before they started the drug too, to ensure it was safe. Benny’s liver function test was normal, so they began phenobarbital.

Knowing that Benny’s treatment would likely be life-long, the owners wanted to check their insurance would still cover him. Luckily, they had good insurance and Benny was covered for conditions up to £5000 per year, which was more than enough for his phenobarbital tablets and blood tests. 

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After being on phenobarbital for 4 months, Benny hadn’t had any seizures or significant side effects. The owners were very happy Benny was doing well.

Benny’s Emergency

Things were going well, until Benny went to stay with a relative over Christmas. Though the owners had told the relative Benny needed twice daily medication, the relative got confused and missed his dose. The vets were rung one quiet December afternoon with the relative in a panic, shouting that Benny was fitting and he didn’t know why. The relative was advised to bring Benny straight to the vets. 

The relative made his way with Benny to the vets and rushed him into the waiting room. Benny was actively convulsing, so the vets took him straight through to their prep room. Benny was in a state called status epilepticus, where he was having a prolonged seizure. Given the relative had taken 10 minutes to arrive, it had lasted at least this long, making the situation an emergency. 

The vets and nurses first assessed his basic parameters – checking his heart and circulation, breathing rate, airways and temperature. His temperature was already 40.8°c, much too high. The nurses attached an ECG to monitor his heart and placed an intravenous catheter into his forearm. A mask was placed over his face to give him supplemental oxygen.

The priority now was to stop Benny’s seizuring

He was first given intravenous diazepam. At the same time, the nurses worked hard to reduce his temperature, using cold towels, fans, opening the windows, and ice packs – if his temperature remained high for too long, it could have caused brain damage or even death. The first bolus of diazepam was insufficient, so a second was given, which finally stopped his seizuring. His temperature had now dropped to 39.7c, still high but coming down. 

Benny was incredibly wobbly, scared and disorientated after his long seizure, so the vets recommended they keep Benny in for monitoring throughout the evening. During this time, a blood sample was taken to check his electrolytes were normal, he was given some IV fluids to restore those he lost during the seizure and was monitored regularly. He was quite distressed, so a mild sedative injection was given too. Due to inactivity, he started to get cold, so warming was started instead of cooling.

After an evening of monitoring, the relative took a tired but happier Benny home, very grateful that the vets had averted a disaster. 

The Future

Apart from his unfortunate episode with the relative (who did not receive a Christmas card that year!), Benny has been doing very well. The owners are very careful with his phenobarbital and ensure he now always gets his twice a day tablets. He has not seizured since the status epilepticus episode and is otherwise doing very well. The owners are aware his seizuring may restart one day, and they may need to adjust his medication, but they feel positive that Benny is happy.

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