Thank you very much and good evening, everyone. I'm going to talk to you tonight about mimic of epileptic seizures. As you probably know, for a general practitioner, epileptic seizures is definitely the most common neurological presentation.
So why it is important tonight to talk about mimic of epileptic seizures? Well, the reason is very simple is that compared to a lot of presentation, paralysed dog, a dog with a head tilt, a dog that is a toxic, you will very rarely see the epileptic seizures when the animal is presented. And you're going to solely rely on the description given by the owner.
And sometimes there may be no, no, no doubt that what the owner is describing is a typical epileptic seizures, but sometimes what the owner are trying desperately to describe you. Remember that it was a very traumatic, you know, episode for the owner to witness may not be an epileptic seizures. And it takes a lot of skill.
And good clinical habit to try to identify it first whether or not what the are trying to describe to you is an epileptic seizures or not. And if there is one take a message to take from this presentation tonight, is that if you have any doubt, this for example, the first event, well, before to do a lot of tests. Just ask the owner if he happened again to get a video footage.
Now we all have a mobile phone with us, and it's very easy to pick up the phone, get a video, because nothing will replace a video in terms of information to distinguish any epileptic seizures from one of the mimic. So because, before I start, to dive into the topic, I just wanted to put it back into how we usually approach a neurological case. The traditional approach, which, you know, for the last 20 years I've always followed religiously, is an animal is presented to me.
Well, I'm not going to assume he has a neurological problem. The first thing I'm going to do is to ask myself, is it actually a neurological problem or could it be another body system responsible for the presenting complaint? And that it's particularly relevant for presentation like collapse or seizures.
The next question, when I've ruled out non neurological problems and how I do that, well, it may be if you have a physical exam ruling out over body system. The next step is to do a neurological exam to establish where the lesion is in the nervous system. That's what we mean by getting an anatomic diagnosis.
When I know where to look, then I can Go to number 3, which is, well, what kind of disease process could be causing the problem. And only then when I know where to look, when I know what I'm looking for, I can then cherry pick the diagnostic test that will help me to progress in the diagnosis. And sometimes, this will mean positively identifying the problem, or sometimes you may be ruling out everything but one possibility and make a diagnosis of exclusion.
So, while I'm telling you that, because again, These animals that will be presented to you for suspected seizures often there will be normal or neurological exam. And often their physical exam would be normal. So you again rely very much on the other description or at best with the video.
In terms of diagnostic tests, well, don't think that doing a lot of tests can be the getaway card because a lot of conditions I'm going to describe to you are functional brain disorder. If you take the example of idiopathic epilepsy, if you do MRIs, CSF, blood, you will find nothing. And if the description of the owner.
Is consistent with an epileptic and finding the thing as the meaning. I mean I'm dealing with iddiopathic epilepsy. However, you may also find no nothing on examination with paroxy multi dyskinesia.
So again, doing tests may not be the getaway card unless you've done. To follow this approach and the first step is to know, you know, am I dealing with a neurological problem and what kind of problem maybe dealing with. So I'm going to give you a video too of non-neurological and neurological mimic of epileptic seizures.
As I said, the first step is to ask yourself, is it a neurological problem? And as I said, nothing replaces the video, but Same way, the kind of question I'm going to ask myself looking at the video will be the same question I will ask you and if you don't have a video. If there's any trigger for the event, is it related to excitement, to stress?
Is the exercise related? Is the animal aware when he's having one of these episodes, which body part is affected? Is the animal stiff in terms of limb function or is it plaid?
Is the animal showing any autonomic sign? What is the duration of the event? Can I see the mucus membrane if there's a pre-oppocyclical phase.
So look at this cat. Again, that's a home video. And this cat was having what you described as very small feet.
But when you look at the video, you will see that these events are very short. During the event, the animal lose postal tone. Difficult to see on the video, but he seems to suddenly lose awareness and then pick himself up.
So very short duration, no trigger, many events like that. And when I see a video like that, well, I can tell you already an epileptic seizures won't be on my mind because epileptic seizures usually have motor activity in Ipa while this cat is having loss of posteral tone. So I need to think, well, what kind of disease process could cause loss of sterile tone, loss of awareness.
And that comes down into two categories, non neurological codes, I'm going to think about syncope. And neurological cause, I'm going to think about narcolepsy cataplexy. This card for your interest at syncope due to a brady arrhythmia.
So no neurological cause that could mimic seizures come down to cardiovascular, which is the big category, metabolic and respiratory disease. Look at this video there. That's a dog I think what you described a collapse of feet.
And you will see that this dog is outside. He was getting excited and playing with the other little mates. And what's going to happen is that this dog is going to have progressive loss of postal tone.
Loss of awareness and then the dog is scrabbling. And then you become more limp. This dog was having a syncope and syncope is again a common mimic of epileptic.
But compared to epileptic seiz, the syncope tend to be related to exercise, excitement, sometimes cough. Sometimes defecation, as you know, syncope will cause loss of posteral tone, will cause also sudden loss of awareness. The way it could be confused in epileptic seizures, but after the animal collapse.
It's going to become flaccid, but very quickly the animal may go intoistotenous. He may sometimes urinate and then he may try to stand up again and scrabbling on the floor, and that could sometimes lead the owner to describe it as an epileptic seizure. Metabolic disease can sometimes also mimic epileptic seizures, and very often the owner will describe partial seizures.
That's the kind of word they will use. Look at this boxer there and he was referred to me for suspected, brain tumour. He was an older boxer.
He was having this partial seizure that described by the owner who was actually a vet. And you can see that during a walk, usually end of the day, this dog was having sudden loss of posteral tone again. Loss of awareness.
And juddering of the head, then you, you're going to see this juddering on a few of, of this footage in a sec. Again, when you've got something happening during a walk like that, seizures won't be very high on my list because most of the epileptic seizures tend to you out of the blue, as opposed to be touring when the dog is outside, when the dog is playing or the dog is walking. And with event that wax and went like that, that should ring the bell of cardiovascular disease, which again would be possible on the box there, but also metabolic disease.
Now, interestingly, this dog was only fed once a day, usually in the evening, and he was taken for a walk first, before to be fed, and this event were occurring, you know, later in the day, so away from feeding. And the first thing when I've got something like that with this juddering of the, this absence and this loss of posteral tone, I'm going to listen to the heart to look for arrhythmia. But if it's normal, I'm going to do blood tests and especially looking for hypoglycemia, and that's what this dog had when the dog was starved for 12 hours.
His glycemia was very low and his insulin was very high, and the dog was diagnosed with hypoglycemia due to insulinoma. Other conditions, metabolic conditions that could mimic an epileptic seizures, hypocalcemia and hypoglycemia and hypocalcemia are definitely the two most common metabolic mimics of an epileptic seizure. And why?
Because the hypocalcemia, as you can see on this video, the dog is going to have cramp. So this dog was having cramp affecting. Different limb as he walked, he was starting to cramp and that's not only, you know, is a mimic of epileptic seizures but also a mimic of another condition, a paroxysmal condition called paroxysmal dyskinesia, as you're going, we're going to see a bit later.
So remember before to, you know, consider. A neurological problem, especially in epileptic seizures. Think of cardiovascular disease and metabolic disease, especially hypoglycemia and hypocalcemia.
If you rule out non neurological causes, then the next step is to know where the problem is, and with mimic of epileptic seizures, the large majority will be brain events. But the issue is that a lot of these brain events will be functional disorder and therefore you will expect normal investigation in terms of blood tests, in terms of imaging, in terms of spinal fluid analysis. And it's very important, therefore, to get a good idea of what could be the neurological nature of this paroxy malt, because again, the test will be normal.
It would be important to do the test because in a small number of dogs, it could be an underlying structural brain disease, but most of the time it would be normal in terms of investigation and you rely again on the first step, which is the video footage. So what are these brain events that could mimic an epileptic seizures? Well, aside from epileptic seizure, we'll briefly review the different types of a brain event would be narcolepsy, cataplexy.
Some dogs may have vestibular attack. The big mimic is paroxysmal dyskinesia, and finally, very rarely, as you know, structural brain disease like neoplasia progress, the dog could be normal for a while, but he may have small events due to fluctuation in entracranial pressure. Epileptic seizures, just to remind you what they are, they are a so brain disorder and in the large majority of cases, they are due to idiopathic epilepsy.
Less commonly would be neoplasia or structural brain disease, neoplasia or inflammatory disease of the brain, and the third category would be metabolic or toxic disease. When you have an epileptic seizures, they are often follow, they followed by postal period where the animal will be very confused, it may be attack sick, he may be blind temporary, he may be very thirsty. His postal period lasts for a few seconds to a few hours.
And this political phase can be important to distinguish from non-epileptic events like for example, narcolepsy, cataplexy, but also paroxysmal dyskinesia. When does the Eus take place? Theus, which is the series itself, tends to occur usually out of the blue for no reason.
We'll see a few, a few, a few exceptions to that, but in a large majority of cases, the owner described happen when the dog is quiet, middle of the night or early hours of the morning. In the large majority of cages, the actres lasts no more than a few minutes, maybe 2 or 3. The owner will often say it lasts longer than it is, and very rarely the owner may be able to sense the dog is going to have a fit by witnessing a preactile period, the dog may be very clingy, maybe very, very confused, a bit of absence.
The large majority of dogs will have what we call a generalised clinical chronic seizures. And with a generalisttonicoclonic sis, the whole of the cortex will be activated from the onset of the feet. A small number will have partial seizures compared to generalised, the epileptic foci is confined to a vision of the cortex and therefore the, the physical manifestation of the feet will reflect where the the foci is which some example.
And this partial seizures can sometimes be difficult to differentiate from non-epileptic events. And finally, the third category will be seizures that start partial with secondary generalised. So in dogs, a large majority will have generalised seizures and a small number partial.
When you go with cats, well, you'll be about 5050, maybe 50% of cats will have generalised seizures, 50% will have partial. So what will look like a typical epileptic seizures in dogs. You've got an example here, the typical grand mal generalised clinical chronic seizures.
You can see this dog having violent motor activity in niper, jumping off the jaw, the eye open, but the dog is unaware of his surroundings. There is autonomic manifestation which are not always seen, but they are seen that's another criteria to recognise an epileptic seizure with this increase in salivation. And that will last for a minute or two before the dog will enter a postican phase.
So that's the most common type of seizures we see in dogs. They usually, you know, most of the owner will be able to describe something that looks like this video. In cats, things can be very difficult sometimes to recognise.
More than 50% of cats will experience partial seizures, but very often they tend to be what we call psychomotor seizures, and they tend often to be confined to the face. You can see this cat having twitching of the face. Especially more on one side and a salivation.
In addition, the cat will be, will have some abnormal behaviour, and you can see that this cat not only is twitching, but it also seems to be afraid of something that is not there. Hence the term psychomotor seizure, mixture of motor abnormal motor activity, focal motor activity, and abnormal perception of the environment or abnormal sensorium. So quite common in cats and again, not often, you know, we present you the the cat thing having seizures.
This is another type of psychomotor seizures. On this car and this cat was having many events where he was having dilated pupil twitching of the, the, the whiskers, twitching of all the ears, and he was growling as well. They were lasting for a few seconds and then he was recovering like now.
And then entering again another psychomotor seizures. So the cat's ear is recovering and then is going to enter again in one of the psychomotor seizures. Don't ask me why this cat is wearing pants.
You can see again this cat having another psychomotor seizures. I just wanted to spend a few minutes on this, the condition that this cat was suffering because it's a fairly common cause of psychomotor seizures, especially in young headed cat. This condition has been named complex partial seizures with oral facial manifestation, which is more descriptive term.
Now, on the right, you can see the MRI scan of a normal cat transverse section. And below this cat. And what you can see here is a mark, hyperintensity.
This is a T2 weighted images of a part of the brain called the hippocampus, which is part of the lambic system. And in humans, there is a condition called lambic encephalitis that looks very similar to the condition that this, the cat and the this cat was, was suffering from. Lambic encephalitis in human is caused is an autoimmune disease, often triggered by a tumour, which is not the case in, in the cat, the equivalent of that condition.
So it's a paraneoplastic lambic encephalitis. And in humans, there is antibodies that target the voltage-gated potassium channel complex. And this complex is particularly dense in the hippocampus.
Now, this cat with hippocampal necrosis. Tend to have high frequency of psychomotor seizures that tend to occur in cluster and this happened for a few weeks until they enter a spontaneous remission. And we tend to treat them only with symptomatic antiepileptic drugs.
Most of the cat will then be fine. A small number may remain epileptic, lifelong, and they may require lifelong antiepileptic treatment. But usually, the MRI will be fairly characteristic of this lambic encephalitis.
However, other condition could cause similar MRI changes, especially sometimes you could have a neoplasia in the piriform lobe, but could cause postectile changes in the brain, especially affecting the hippocampus. Also, severe seizures can cause that or vascular disease and it's therefore very important to analyse your MRI carefully to make sure that there is no other disease that this changes in the hippocampus. I mentioned to you that most of the epileptic seizures tend to occur out of the blue for not, with no trigger, with the exception.
Some cats can have triggers, seizures triggered by sound, and it's something that we've been evaluating. A few years ago, Mark Larry and I, and, we call that reflex auditory seizures. Typically, it tends to affect all the cat aller than 10, and we find that the beermen were predisposed.
But for a given cat, they tend to respond to a specific sound, and the sound could be the click of the mouse, the click of the keyboard on your computer. It could be tin foil, the crackling of the tinfoil, it could be the sound of the spoon on the metal ball, and that tends to cause myoclonia. Which you're going to see on this cat.
So the crinkling hair of a rapper was causing this cat to have this myoclonia, but also they can sometimes in addition to myoclonia have generalised seizures. And this is probably best seen with this cat. You can't hear the sound, unfortunately.
But you can see that in this myoclonia. And then he fall into a generalised tonic or clonic seizures, and only a specific sound was causing that. This cat was normal all his life and only when he reached about 11 years old started to suffer this reflex auditory seizures.
Now we look at how to manage them and you go without saying, but the best way to manage them is to avoid the trigger. And is to avoid the sound, but some of the sounds are, you know, sometimes inevitable. And the way to treat them, if you have to give antiepileptic drug is to treat with levetiracetam.
We compare between phenobarbital and levetiracetam, and you know, there was no doubt levetiracetam is the way to go. In dogs, sometimes also epileptic seizures can be triggered by some sound or sometime light, and this is best exemplified in miniature wider dachsund. And you can see that this miniature widerdaxone is having myochronic seizures, and they are caused by the flickering of the TV.
Now, miniature widerdaund are predisposed to a condition called cause Lafora disease, which is a human condition that cause progressive myoclonic epilepsy. Diaz of onset is usually about 7 years of age. It is an autosomal recessive disease caused by a mutation.
Which is slightly different mutation than the human one. And this mutation affect the protein that is very important in the metabolism of glycogen. Consequently, the cell and the neuron especially are unable to metabolise glycogen, and they accumulatelara body which are clump of abnormal glycogen which cause ultimately dying of the cell.
The way to treat this progressive myoclinic epilepsy in widerdaxone but overbreed are predisposed corgi, also beagle, German shorter pointer is to give levetiracetam. Also, if it's triggered by light, especially sunlight, some, doggy, sunglasses, fogle have been created as well to prevent the sunlight triggering this myoclinic seizures. So typically an epileptic seizures is a paroxysmal event, which means apart from the few exceptions I've mentioned, tend to happen out of the blue when nobody is expecting them.
Very short duration with motor activity niper. Often, but not exclusively, there will be autonomic sign. Often there is altered awareness and behaviour.
And they tend to last only a minute or two, sometimes followed by a postal phase. All these criteria are quite important when we try to distinguish them from over mimic. Remember that common thing are common and if despite the video, you still have a doubt and this suspected feet happening quite often.
It's a good practise to put the animal on antiepileptic drug and see if on medication then a reduction or a total stop of this suspected epileptic seizures which will then directly confirm to some degree that you're dealing with an epileptic fit as opposed to a mimic. So what are the non-epileptic seizures? Well, they are important to recognise because again, very often the animal will not be having a suspected fit in front of you.
And you may make decisions about diagnostic tests, but also about treatment, sometimes lifelong treatment on something that you haven't seen. So important from the start to ask the right question, but also ideally to get a video and to go through the list of questions. Onset, duration, motor activity, awareness that helps you to differentiate epileptic from non-epileptic seizures.
So the non-epileptic event, the first one we're going to talk about is narcolepsy cataplexy. And here is a video of a dog that was suffering many episodes of narcolepsy cataplexy. It was caught during one year and you can see the dog is totally asleep.
There is no motor activity, then the dog is going to try to stand up. And typically narcolepsy cataplexy is triggered by excitement and for a dog you'd be going for a walk, also being fed, or stress. And you can see this dog here being stressed about where he is suddenly will collapse, lose awareness and no motor activity or motor activity in Ipo.
So narcolepsy is a functional disorder, exceptionally will be triggered by a structural brain disease. To form a sporadic form or a familial form, breed are predisposed, especially Doberman and Boxer. And the familial form is due to a genetic mutation causing a lack of hypocritin.
Receptor. Well, the familial form is caused by a decrease in the CSF hypocritin. Hypocritin is a neuropeptide and it is very important in keeping you awake.
And with narcolepsy, typically you're going to fall asleep at inappropriate time and this is often seen with loss of postal tone which we refer on narcolepsy. Typically, this event will occur during the RAM phase of the sleep, so you will have rapid eye movement during the event, and it's something that you can witness on EEG. It may not be practical in the dog, but it's the way it will be investigated in human.
And the way to treat narcolepsy is to give tricyclic antidepressants such as imipramine, clomipramine. Or, alpha to antagonists like UMbin or SSRI. And in my experience, you usually start one drug and often the animal will develop functional tolerance with time and then you end up switching to another category of medication.
Over mimic of epileptic seizures are so-called vestibular attacks, not to be confused with the idiopathic vestibular syndrome. With idiopathic peripheral vestibular syndrome, you will have an acute onset of vestibular signs, but usually they take a few hours, sometimes a few days or a few weeks to recover. What I'm talking here is a very short vestibular event lasting no more than a few minutes.
As with any vestibular event, what we like you to recognise is that the animal before falling may be drifting to one side. He may have vestibular sign which may be head tilt, but also nystagmus, which was the case on this dog, and it's only this nystagmus and the fact that the owner described the dog drifting to one side before he fall but pointing toward the vestibular attack. The dog recovered within less than a minute.
So what are the pathophysiology of this vestibular attack? They could be peripheral or central and peripheral, they usually again functional disorder affecting the inner receptors of the balance. In humans, there is a condition called benign paroxysmal vertigo.
Which is caused by abnormality within this semicircular canal and the utricle. Where the autoly may become detached and irritate the sensor, two conditions are recognised canal illichesis or cupiolichesis. But again, it's a functional disorder.
Also, they may be caused by TIA and especially in dogs. It's something that we see less commonly by humans, but it is something that has been recognised, especially in predisposed breed like cavali king sharks or spaniels in general, but also greyhounds. And often these dogs may have a few TIA before they experience a brain infarct where the vestibular event will now last for far longer than a day.
It's been also described that recurrent vestibular paroxysm or vestibular attack can be caused by systemic hypertension and it's been described in the dog. Probably the most common mimic of epileptic seizures in dogs is paroxysmal dyskinesia. What is paroxysmal dyskinesia?
Well, pararoxysmal means an event occurring out of the blue in the background of normal motor function. Dyskinesia means that it's an involuntary movement of a body part. Hyperkinetic means that it's an exaggerated normal or exaggerated abnormal movement of a body.
Typically with dyskinesia, the animal will have motor activity in hyper, usually hyperflexion or hyperextension affecting synchronously different limb. Mountation will be normal. There will be no autonomic sign.
But the duration could be a few minutes, like an epileptic seizures, but often will last far longer than an epileptic seizure. So the the way to distinguish would be the fact that it tends to affect all four limbs. The frequency of the motor activity is less than an epileptic seizure.
The dog will be fully aware of his surrounding or we may be shocked about what's happening and the duration can be very long. In humans, there will be normal enterectal EEG during the event which helps to differentiate with an epileptic seizures. Here is an example of paroxysmal dyskinesia.
Again, tend to happen out of the blue, sometimes stress caused by stress or excitement. You can see that this dog is freezing and suddenly lifting one forelimb on the left. He seems to be aware of his surroundings, obviously shocked by what's happening, but the dog has no control on the movement that is taking place.
Hence the term dyskinesia. Now the dog is going to lay down. And you can see that you start to lift sequentially different limb.
While remaining aware of the surroundings, and there is no way this could be an epileptic seizures. If you affect both sides of the body, if it was an epileptic seizures, that will imply that the whole cortex on both sides is activated and the dog should not be aware of his surroundings. This event on Baddo lasted for nearly 10 minutes, which you don't expect with an epileptic seizures again.
In humans, there are different types of paroxysmal dyskinesia, and they are classified depending on the trigger, the frequency, and also the duration and the response or not anti-epileptic drug. Paoxysmal kinesogene dyskinevia is usually precipitated by sudden movement. They tend to have many events in a day, very short duration, less than 2 minutes, and they typically respond to anti-epileptic drugs.
While the next one, paroxysmal non-kinesogenic dyskinesia, is precipitated by excitement, alcohol, caffeine, fatigue, the duration is much longer. The, the frequency is not as high, but as I said, the duration would be more than 5 minutes and they typically do not respond to anti-epileptic drug. And what we see in dogs is mostly the equivalent of paroxysmal non-kinesogenic dyskinesia.
So they may be presented to you because they've been labelled as being epileptic. They've been put on anti-epileptic drug and they do not respond at all. That should ring the bell.
Maybe we're not dealing with any epileptic seizures, but with a paroxysmal non-kinesis and dyskinesia. And this condition, they've been known in the veterinary world for decades. However, until not so long ago, they were not believed to be anything but epileptic seizures and partial seizures, so they've been mislabeled for decades as partial seizures.
And you may have heard this condition under a different name because they breed specific dyskinesia. In Cavali King Charles, you may have heard the term episodic falling or collapsing cavalier in border terrier, CCS or spike disease, also Labrador, Labrador dyskinesia, and Scotti ramp. But all these names that has been given to these different breeds come under the same umbrella of paroxysmal dyskinesia.
What are dyskinesia and how they differ from an epileptic seizures. Epileptic seizures arise from the cerebral cortex. Well, dyskinesia tend to tend to arise mostly from the basal ganglia.
They are a functional disorder due to an abnormality in the network between the cerebellum, the thalamus, and the basal ganglia. They were believed in some cases to be a channelopathy due to a genetic mutation, but I'm going to see some cases may be due to membrane protein mutation as well. And in humans, they can coexist with epilepsy.
As I said, the one that was possibly first described more than 40 years ago and labelled as episodic falling or collapsing cavalier. You can see on this video, They tend to occur at a young age, immature dog, triggered by excitement or stress. Duration can be very long, and they also labelled in the past deer stalking because of posture that affecting dogs tend to occur.
And you can see like the first dog we saw, Zakkita, the dog is having tramping of the, the, the, the limb, tramping, tramp tramping as well of, the trunk. But the animal is fully aware of his surroundings with no autonomic sign. And the duration can sometimes be far longer than an epileptic seizures.
We've put quite a few years studying this episodic falling in, Kavala in Charles, and we're very lucky over 10 years ago to identified, with a, a team of, scientists I was working with, but this conditionsharks is caused by a mutation in the Brevian gene. Which has led then development of the genetic tests that help diagnose and again remember they are functional disorder. So all your MRI, CT, blood, CSF will be normal, but thankfully there is a genetic test that helps to confirm the disease and also help in terms of bleeding.
This, episodic falling respond very well to acetazolamide. You can see on the video, another example of episodic falling. Sometimes the animal doesn't collapse, it's just having lifting.
Having crump in, in the limbs at various time. So acetazolamide is adri carbonic inhibitor. And why they respond to aceazolamide is that acetozolamide promote metabolic acidosis barrier.
By doing so, it will also cause metabolic acidosis within the cells and the neuron. And that has to affect, that will affect the neuronal excitability by decreasing the potassium channel conductance cell membrane. Acezalamide will need to be given as a lifelong treatment and it's important to regularly, maybe on a monthly basis monitor the potassium so.
Before that, I used, before we discover that azalamide working, we used to treat them with clonazepam and they tend to respond very well to clonazepam. However, like in humans, they tend to develop functional problems but. However, some dog may not respond to acezalamide with time, and you still have the option to ask that will not be very common.
Overall, you need to treat the dog as a lifelong treatment. After studying the cavalier King Charles, we decided maybe about 8 years ago to focus on another commonly affected breed called, the, the Bordeteria, and this condition was labelled in the Bordoteria canine epilepsyid cramping syndrome and believed by many clinicians, including fellow neurologists, as being a partial. Hi, Lauren.
I don't know if if you can hear me. We're just having a few sound problems. We can't hear you anymore.
I'm just wondering if you can dial in on the number. That you, that you have. Me?
Oh, I can hear you now. We're just having a few sound problems, Laurent. Can you hear me?
Yeah, I can hear you very well now. I don't need, do you want to just call in on the number, the phone number and dial in? I think it might be the sound might be a bit better.
OK, no problem. Thank you. Yeah, we can hear you now.
I think you're still on your microphone, but yeah, so, he's not responding and so I, I carry on with the, the microphone and tell me if he doesn't work. No problem. This does sound a bit better, so yeah, carry on.
So the cavali, the, the border terrier, a lot of these dogs tend to have boring me, but also vomiting and diarrhoea. And the age of onset was anytime between 10 weeks to 2 years in the study that we've done. So when we look at the phenotype and we did this study in the Bordetterrier, we found out that typically they do not respond to antiepileptic drugs, but a lot of pet owner was telling us that these dogs tend to respond or the event may be triggered by diet.
So we look a little bit more deeper at what kind of diet the dogs were receiving, and the common denominator was the presence of gluten in the diet. Some pet owner was telling us that giving certain treats that happened to content diet could trigger one of these events. And that has led us to look at what's happening in humans, and we find that in human paroxysmal dyskinesia can be triggered by gluten.
Now We've done further study to look a little bit more as the role of gluten in this canine epileptoid syndrome in Borteria. And as you know, gluten is a protein, but you find often in the diet, and this protein can cause an immunological reaction that often targets the gut, and that's what we call celiac disease, but in humans it can also cause neurological disease, especially ataxia, seizures, dyskinesia, and also dermatological changes as well. So we've done this study on Booter where we measure the antibodies against gluten, which are the anti-transglutamina2, an anti-gliadin antibody on the cohort of Borderteria with dyskinesia, and we then fed this borderteria for 9 months with a gluten-free diet.
And what we find is that as we put this dog on a gluten-free diet, the antibody tighter against gluten go to the normal level, but these dogs stop having this canine epileptoid cramping syndrome or dyskinesia. So in B, we've shown that they are predisposed to gluten sensitivity. Probably there's a genetic predisposition.
And in that breed, gluten can trigger dyskinesia as well as in some of them, but not all of them gastrointestinal sign. So the way to treat dyskinesia in border terrier is to put them on the gluten-free diet. And doing this antibody can be very useful to confirm the disease and also to distinguish between epileptic seizures.
This was a subsequent study that we did and we took a court of booterrier with video footage suggestive of dyskinesia and also epileptic seizures, and we were looking at the antibody. To see how good the antibodies were to distinguish between epileptic feet and dyskinesia, and you can see that with both the anti glidine and anti-transglutaminase, the antibodies are very good to distinguish between epileptic seizures and dyskinesia. However, if the dog is having GI sign or dermatological sign, the antibody may be high as well, so it's something to remember.
Important as well to use the antibody to monitor how well the owners are strict in giving a gluten-free diet, because if you put a dog on a gluten-free diet and the owner report is not really helping by doing the antibody, if the antibody is still high, then that shows that the dog is still having access to gluten, and it could be a treat. It could be when the dog go outside, it may be eating horse manure that contain grain. So this sensitivity gluten has only been notified in border area in terms of causing this kinesia.
So in Kavali King Charles, as I said, there is a genetic mutation. A genetic mutation for dyskinesia has also been identified in soft cotton coated witenteria. In mutation is the PIGN gene.
And in all the other breed, there is still to find a genetic mutation. In border area, as I say, it's caused by this by gluten sensitivity. Very rarely, dyskinesia can be triggered by drugs, phenobarbital and also propofol, and very, very rarely caused by structural brain disease.
However, there's still a debate whether or not the disease is causing or precipitating, the, the event. So how do we distinguish dyskinesia from an epileptic seizures and you've got an example of a cat here. The consciousness is maintained and is not affected.
There is no autonomic sign. The motor activity is in hyper, but there's not high frequency of movement like tonicoclonic movement. There is usually no postitile behaviour.
They tend to last a few seconds to an hour or two. They tend to start abruptly and end abruptly. And in some breed, there may be genetic marker like cavelicking sharks of soft witen cotanterer.
These are the type of mimic of dyskinesia, the most common one being syncope, hypocalcemia, partial epileptic seizures, narcolepsy, catapplexy, vestibular dysfunction, or myochemia caused by peripheral nerve hyperexitability. How do we treat dyskinesia? And how do we manage them in terms of management, I will say that the video will be key there because if you have a breed that is predisposed to dyskinesia and the video is consistent with the dyskinetic episode, then I don't tend to do any further tests.
However, if it's a breed that I've not seen before with dyskinesia, an older dog, I will do MRI and CSF to rule out a structural brain disease as a possible trigger. If I'm dealing with a cavalicing Charles or soft soft coated wheat and tea, we'll do the genetic test. And if I've got a border teria, I will then do the the gluten antibody as we discussed.
Treatment of dyskinesia depends on the breed. Cavile in Charles is the lucky one because we know acetazolamide works very well, but it's a lifelong treatment. Border terrier will require to go on an exclusive gluten-free diet.
Most of them do not respond to antiepileptic drug, as they are usually non-kinesogenic dyskinesia. And you know, like a human, you, it's not very often that you will treat paroxysmal non-kinesin dyskinesia because their frequency can be very erratic. Typically, they tend to have a few during a week or two and then nothing for many weeks or months.
And only exceptionally when the frequency is very high, then you try different medication. The first one would be acetazolamide. And I will do that for at least 2 to 3 weeks.
And if it doesn't work, move to the next one, clonazepam and then dantrole levetiracetam or fluoxetine. Very important before you start any drug to assess the natural history. What is the pattern in that particular dog?
Because often they tend to have a lot of events for, as I say, a few days to a few weeks and then nothing for a few months and then go back again to have a few episodes. When the owner are likely to seek veterinary assistance when the dog is having an event, and if you start treating the dog there and it's not meant to have any event, then you may wrongly think the drug is working. So before you start any drug.
Maybe observe. The natural history for 2 to 3 months. Only treat if the dog is having many events a week, and I will say unless they are coming every day or every couple of days, I usually do not treat and explain to the owner, well, we just have to monitor.
And this is what we did in the Labrador Retriever and Jacqueselter. We followed a group of them for about 5 years, and we saw that in usually they start at young adults, they tend to be triggered by a sudden movement and startle. There is a male bias.
13 to have many events for a few days. That's what we refer to as cluster, maybe wrongly. And with time, a 3rd will enter remission.
And 3/5% will have a decrease in the frequency of this event as they get older. We also find that having many events for a few days was a prediction for entering remission. And that's why, you know, we don't tend to treat them because a lot of them with age will get better and they typically do not respond to anti-epileptic drug.
That's it. I hope that this video too has giving you a good insight on what to look for, and remember, in any doubt. Try to obtain a video footage.
Look at the video footage, trying to analyse is the animal aware, what is, if there's any trigger, what is the motor activity, the duration, autonomic sign, if there's a postcyclal phase. Thank you very much for your attention, and we've got 5 minutes before to move to the next presentation for a few questions. Thank you very much, Lauren.
I've got one question coming from Sheila, about a case. Can you tell us anything about so-called flycatching? The case is a young Siberian husky.
She seems to have progressed sometimes to epilepsy type episodes, but mostly is aware, just snapping the air and can be distracted, but it can be very frequent and debilitating. Yeah, that's a very good question. And this, I could have put a video of fly catching in the non neurological cause because a recent study has shown that they are not as food before epileptic activity.
For a long time they were believed to be psychomotor seizures and only recent study has shown that the evidence are more toward a behavioural disorder. Rather than, an epileptic activity. Typically, they do not respond to anti-epileptic drug or partially respond, however, they tend to respond, to fluoxetine.
So, but, is more and more evidence that we're dealing with a, a, a behavioural disorder along the line of compulsive disorder, and also some of these dogs at EEG recording that show that there is no epileptic waveform, during the event itself. Thank you. I've just had another one come through on the chat.
Can a dog with Cushing's develop seizures? So, I will say it's in theory possible, for two reasons. If the cushing is caused by a macroadenoma, in that case, there will be a structural disease in the brain triggering it.
Cushing could potentially cause seizures, if there is hypertension. But outside of that, cushing should not cause seizures and it may be comorbidity. OK, thank you.
Lauren, just having a look here. I've got another one. I have a cat with myoclonia, mostly facial fasciculation and hypersalivation.
Some hyperkinesia, but lessening. Is it epileptic form, it's responding to Keppra. Keppra.
Yeah, it's probably a myoclonic epilepsy, myoclonic epilepsy, specific tend to respond very well to Keppra, levetiracetam. So I'm not surprised because in human and also in cat and dog, is the anti-epileptic drug of choice for myoclonic seizures. It'd be interesting to know if this cat is an older cat, and whether or not it's triggered by sound.
Because it may be one of these, auditory reflex seizures. OK, thank you, Lauren. I'll see if that was from Jill.
I'll just see if she has any more information on the cat. OK, 4 years old, and triggered by handling. By handling.
Yeah, so it's probably just a myoclonic epilepsy, obviously not the feline auditory reflex seizures. But the most important is that he's responding to the, to, to, to the Keppra, which is the anti-epileptic drug of choice for myoclonic epilepsy. Thank you.
And I think that's all the questions we've got in so far. What I will let you do, Lauren, is, I don't know if you can change your presence over to your next one. Before I do that, I just wanted, just to introduce a Facebook page that Simon Platt and I run called Veterinary Neurology.
Some of you may have already stumbled on, on that page. We put a lot of neurological video like the video you've seen today, and it's just to try to make neurology more approachable, to a wider audience. You're very welcome to join us.
It's totally free. We've got nearly 30,000 followers, so please feel free to join. It's called veterinary neurology.
