Seizure Treatment Plan - Day 4

Stella had 3 full doses of Gabapentin yesterday; it is making her even more disoriented. 

At 12:15pm today she had yet another seizure.  Again, lasting about 20 minutes.  Less than one hour later she had another.  This last one was the “worst” one she’s had so far.  At one point, as I held her tightly, her entire body seized into a hard rock; it felt like she had turned to stone.  This lasted for just a few seconds and I felt her muscles relax and then she just sat there shaking.  We made the decision that 5 seizures in less than 48 hours was too much (I believe it is called a “cluster”) and we decided to go back to the ER.  Although this was in the middle of the day, the “regular” hospital was closed as this is Independence Day. 

By the time we arrived in the ER it had been one hour since Stella’s last seizure began and she was just coming down from it; this was the longest one yet.
 

ER vet examined Stella and came back to us to explain what he thought should be done.  He stated that there was no more waiting to put Stella on anti-seizure medication.  When we asked about the possible live damage or failure he explained that we were at a point where we needed to think about her overall well-being versus just the liver.  He stated that although anti-seizure medication CAN cause liver damage it doesn’t mean it will happen.  If Stella continues to have seizures, the seizures WILL cause brain damage.  So tending to her seizures now takes precedence over what MAY happen to her liver.
 

The ER vet told us we should leave Stella in the hospital overnight so that he can start loading her with Phenobarbital; the anti seizure medication.  We asked why we could not do this at home and he responded that although we could go home with Phenobarbital pills they would give her a loading dose thru an IV so that it gets to her system immediately to hopefully stop the seizures sooner.  He stated they would monitor her closely throughout the night and we could pick her up tomorrow afternoon.  He told us the Phenobarbital would make her really loopy and he expects that she will sleep most of the next 24 hours.  We proceeded to ask a gazillion questions about seizures and Epilepsy.  The ER vet was very patient and tried to answer as many questions as possible but pointed out he is just there to stabilize Stella.  All the neurologic and treatment questions should be posed to the neurologist.  We knew this of course but you know how it is when you’re worried and scared and given so much information to process; your brain doesn’t stop to pause and your mouth just keeps going. Incidentally, the neurologist will not be back in the office until Monday 7/8, four days from now so hopefully Stella will be stabilized until we can speak with her about future plans.
 

Later in the evening we called the ER to check on Stella.  The ER vet said that Stella is responding really well and remains alert.  He said he was surprised as most dogs usually “pass out”  from the heavy medication but he also pointed out that there were a lot of Pug Lovers working on the shift and they were giving Stella a lot of attention.  There’s nothing Stella loves more than adoring fans!!



 

Seizure Treatment Plan - Day 3

This morning Stella had another seizure; the duration was about 20 minutes. We called the ER (it was very early in the morning and the “regular” hospital section was not quite open yet).  We spoke with an ER vet and inquired whether or not giving Stella just two doses of Gabapentin per day as opposed to the prescribed three might be the cause of this additional seizure.  We have only been giving her two doses per day because our schedules would make two of the doses just a few hours apart which is not recommended.  ER vet stated she was unsure but that we needed to do whatever we could to try to give Stella the three doses a day as close to eight hours apart as possible.  She asked if we could have someone come into our house in the middle of the day or if we could set an alarm clock to give her one in the middle of the night.  Once Stella is on the Gabapentin three times a day, should she have another seizure, we should bring her back to the hospital/ER.

 

We discussed what we needed to do to make this happen.  We have decided that we will have to come home from work during our lunch time each day to assure Stella gets the pill three times a day.  Luckily we only live 15 minutes from our workplace so it is just a matter of scheduling.  If this is what it takes to get her back to normal, then this is just what we’ll have to do.  This regimen started today.

 

Later this evening, approximately 12 hours from this morning’s seizure, Stella had another one.  Again, lasting about 20 minutes.  As usual, I sat on the floor with her and held her as she cuddled into me, shaking and looking scared.  As with the other seizures she was unresponsive to our voices or movement but remained seemingly conscious – I say “seemingly” because her eyes remain open, whether or not she is actually “conscious” during the seizures we do not know.  

 

Four hours later I walked into the room and it appeared to me she may have just finished another bout of seizure activity.

 

As of this writing, Stella is sleeping quietly on our bed next to her sister Betty.

 

By the way, we find it interesting that Betty (nor the cat) has any reaction whatsoever to Stella’s seizures.  I wonder what they think?  Do they know just to leave her alone?  Are they aware of what’s happening?

Seizure Treatment Plan?

Spoke with the neurologist’s assistant again today (who, in turn spoke to the neurologist on our behalf).  She states that the treatment plan for now is to keep Stella on the Gabapentin 100mg and wait.  The suspected diagnosis is “Idiopathic Epilepsy”; “Epilepsy with no known cause”.
 

We are to continue with the Gabapentin and if another seizure should occur we are to call.  The neurologist wants to wait as long as possible before putting Stella on anti-seizure medications because they are very powerful and can be damaging to the liver  We were told it can cause liver failure.  If we are lucky the Gabapentin will be enough to stop further seizures since Stella’s are considered relatively “mild”.
 

Stella remains fairly disoriented.  We are hopeful her body will adjust to the medication and she will return to her silly, joyful, Puggy self.

Spinal Tap Results

Got a call from the neurologist’s assistant today stating that Stella’s CSF tap (Cerebrospinal Fluid) results were normal; no meningitis or other viral infection.  We were told there was an abnormality but that it is linked to Stella’s protruding discs as the neurologist indicated would probably happen.  I asked the assistant how we are going to proceed going forward and she said we would need to speak with the neurologist on Monday as she is off today.  For now, we are to keep Stella on the Gabapentin 100mg until further notice.  We informed the assistant that we are giving Stella Gabapentin twice a day as opposed to the prescribed three times a day due to our schedule and the fact that two of the doses would be fairly close together.  She confirmed with us that it is better to give the doses only twice a day rather than have two of the doses be only a few hours apart.

Meanwhile we have noticed the Gabapentin is making Stella fairly loopy.  She seems disoriented and has not been as animated.

Later in the day I called our regular vet to get her opinion on treatment options.  Dr. A said she wants to defer all of Stella’s neurologic care to the neurologist.  Once the neuro has the treatment course that is right for Stella she, our regular vet, will maintain the treatment from that point with medication dispensing, follow-up bloodwork, etc.

We will speak with the neurologist on Monday (7/1) and find out the treatment course and suspected diagnosis.

 

Another seizure...and then another...

Yesterday (6/26) we came home from work it and was a day like any other.  Stella greeted us at the door and then ran off to grab a toy (her strawberry ice cream cone) and then proceeded to tease me with it so I would mock scold her “hey, that’s MY ice cream…”; something we do every single day.  She and her sister, Betty, went out into the yard to relieve their bladders and then “walkies” was announced and they came running to put their harnesses on.  We noticed Stella was walking a bit slowly but it was very humid and we know she has that torn anterior cruciate ligament (see previous post).  We decided to cut the walk short and went back home; we had walked 2 blocks total.

As we walked in the door we proceeded to take off their harnesses as usual and the girls went to the water bowl.  Unfortunately both of us were in different rooms for just a moment when I walked back into the kitchen to find Stella “coming down” from what appeared to me to be another seizure.  She was completely disoriented, staring at nothing in particular and trembling.  I sat down on the floor and she immediately cuddled herself into me.  I held her and talked to her with a soothing voice all the while she trembled and stared off.  She was unresponsive to me saying her name and would not look at me.  Several minutes later I tried to move away from her but she was aware enough to know that I had moved and then slid herself back in between my legs.  As a test, I tried to give her a treat;  she smelled it in my hand but seemed confused as to what to do.
 

We remembered what the oncologist told us in April when we reported Stella’s first seizure (at least the first one that we know of).  Dr. F. had consulted with the neurologist at that time and we were told if it happened again we were to go to the emergency room.  At that moment it did not appear that Stella was in imminent danger so we chose to drive the 40 minutes to the specialty hospital’s emergency room rather than the one 5 minutes away from our house.  The specialty hospital is where Stella sees the oncologist, the orthopedic surgeon and where the neurologist is.  To keep continuity with all of Stella's health issues we feel it is important to try to keep all of her care at one facility if possible.  When we arrived Stella could walk, but very clumsily.  We explained what happened to the ER technician and she then took Stella to be examined by the Emergency Room physician.  10 minutes later they called us into a room.  The ER physician walked in with Stella bouncing next to her eating a cookie and then she proceeded to eat two more cookies.  She seemed back to normal.  From the time we noticed her behaving oddly to this time it had been approximately 1 hour.  The ER physician stated that all of Stella’s vitals were normal and because she appeared to be fine she did not want to give her any medication.  She stated that we could leave Stella at the hospital overnight where they would monitor her and the neurologist would see her in the morning or we could take her home and play it by ear.  Since Stella was bouncing about we decided to take her home.  The rest of the evening she seemed like she was 95%, just a little bit off, and she slept quietly throughout the night.

Today (6/27) at 5am, 12 hours from the seizure, we walked into the room and again saw her coming down from another apparent seizure.  She was standing and appeared to be frozen in mid walk with one paw up staring at the wall;  she looked like a statue.   Again I sat on the floor with her and she collapsed into my arms just wanting to be held. 

With both seizures she did not lose consciousness, she did not pee, vomit or defecate, and she did not attempt to vocalize.

We immediately put her in the car and drove back to the specialty hospital emergency room.  When we got there the ER physician (a different one) stated that he thought Stella appeared normal but we insisted to him, as her owners, we KNEW she was not normal and would need to see the neurologist.  We also discussed the fact that the neurologist had consulted with the oncologist in April and was the one who recommended an MRI should a series of seizures occur. 
 

Since we didn’t have a formal appointment and because Stella was seemingly not in immediate danger we were told to leave her at the hospital and the neurologist would see her at some point during the day and call us.  We were assured that until the neurologist saw her she would be monitored by the staff.
 

We told the ER physician that we indeed wanted Stella to have the MRI but wanted to be called PRIOR to anything being done to her outside of a physical exam.  We also told the ER technician this before we left.  The reason for this, explained in detail in an earlier post, was because we had a dog that had an MRI that showed a catastrophic event; the dog had no hope and would die within weeks.  Instead of calling us first, the surgeon chose to have our dog woken up and THEN called us to tell us the bad news.  So instead of giving us the option of having him put down while he was still under anesthesia, he was woken up and we then had to have him put down an hour later.  It was such a horrifying and infuriating experience.  We swore we would NEVER let that happen again and so we make our wishes CLEAR before signing off on anything. 
 
Luckily this was early in the morning and Stella had not eaten anything since dinner last night so she was good to go for an MRI or any procedures requiring anesthesia. 
 

Later in the afternoon we received a call from the neurologist’s assistant.  She stated they were about to start the MRI.  I asked if Stella was under anesthesia yet and when she replied “yes” I got a bit upset and told her we specifically asked to be called FIRST.  The assistant stated she was never told this and was very upset with the staff.  I told her the reason why we wanted to be called and said the bottom line was we just wanted to be clear that Stella is not to be woken up if there is a catastrophic finding; we were to be called first.  She said she understood and we told her we would head back to the hospital so we could speak with the neurologist when the MRI was finished.  A minute later the phone rang and it was the neurologist herself calling to apologize that they did not receive our instructions.  Dr. C. reiterated that what they would be looking for on the MRI would be any abnormalities in the brain, like a brain tumor.  She explained that dogs with Epilepsy are typically diagnosed before the age of 3 and that later in life it can often times be caused by a brain tumor or other abnormality.

We headed to the hospital and when we arrived they had just finished the MRI.  Incidentally, this was the first time meeting the neurologist.  We had spoken to her on the phone only; she was recommended to us by our regular vet and the oncologist. Dr. C. told us that there was no tumor activity and that the MRI was negative for any abnormal findings; thank goodness.  She also said they performed another abdominal ultrasound (which, oddly, we don't recall them telling us they wanted to do) and that her organs remain free of Mast Cell Tumors (just as with the last ultrasound  in April) and there was nothing alarming to indicate seizure activity.  She did however state that Stella had a “disc protrusion” in her neck.  Dr. C. believes this protrusion, although pressing on her spinal cord somewhat, was not likely to cause the seizures.  She also stated that they would not perform the surgery to repair these discs as the more pressing issue is the seizures and it should be addressed first. She explained that because Stella had not gotten into any toxins or had any head injuries there was a possibility of a viral infection such as Meningitis.  To test for Meningitis they would need to perform a Cerebrospinal Fluid (or CSF) collection; also known as a spinal tap.  Unlike with humans the spinal fluid is not collected through a puncture in the lower back, but from the neck and brain stem area.  Dr. C. explained that the risk was fairly high in doing this type of procedure because of the location of the needle puncture.  We asked if something were to happen to Stella as a result of the tap, would it appear days or weeks from now or would she know right away.  Dr. C. stated they would know right away as it would be obvious while they had her on the table. 

We discussed the situation in detail with Dr. C. getting her opinion on whether or not we should pursue the tap.  We had to make this decision fairly quickly as Stella was still anesthetized.  In the end we decided that because we still do not know what is causing the seizures, the neurologist said it was the obvious next step to take, and given the fact that she was already anesthetized and would possibly save her from anesthesia an additional time (good golly this dog has had a lot of anesthesia in her lifetime) we would allow the tap to be performed.  Also, Dr. C. said Stella should have no pain from the tap afterwards.  
 

One other thing we discussed was the fact that IF something horrible did happen at least Baby Girl was under anesthesia and wouldn’t feel anything, even if we had to let her go.
 

A short while later Dr. C. came into the waiting area and said everything went well and we should have at least preliminary results by tomorrow.  She did however warn us that the results may not come back as 100% normal because of the disc protrusion but that the results should still be able to tell us whether or not Stella has a viral infection.

In the meantime, Dr. C. has prescribed a pain medication, Gabapentin 100mg.  This medication although meant for pain (if Stella's disc issue should bother her) is known to possibly help prevent seizures when given at a high dose.  We are to give Stella this medication (pills) three times a day.  The technician explained to us that the medication can make Stella "loopy" and should it make her too loopy we can reduce it to twice a day. 
 

We waited several more hours for Stella to recover from the anesthesia and then took her home where she has been sleeping soundly after her big eventful day.

 

 

More Opinions - Same Plan of Action

Stella had her appointment with the Oncologist today.  An abdominal ultrasound was also performed.  As I stated previously, she was due for her annual abdominal ultrasound in August but in light of the 3^rd Mast Cell Tumor discovery and removal we decided to bump up her appointment.  We informed the oncologist about Stella’s torn ACL, possible neurologic defect associated with her spine and our recent appointment with the orthopedic surgeon (at this same facility).

Good news – the ultrasound was “clean”.  THANK GOODNESS!

Dr. F. was pleased that the ultrasound was clean but was concerned about the seizure episode that Stella had recently (described two posts ago).  She asked us to describe exactly what happened that day and why we thought it was a seizure.  After our description she agreed it was indeed a seizure and then asked us the following questions:

 

• Had Stella ever had a seizure or similar episode before, to our knowledge?

We had not witnessed an episode like this before however we described to Dr. F. about two occurrences when Stella was a puppy. Once when she was a few months old and another time about a year later Stella had, what looked like to us, two “fainting” episodes where she suddenly collapsed and regained her composure within seconds (described in a very early post).  Both times our veterinarian (at the time) could not find anything wrong with her.  Based on our description of events surrounding these "fainting spells” Dr. F. believes they are unrelated and that Stella truly fainted.
 

• During the seizure was Stella vocalizing or attempting to vocalize?  No.

• During the seizure did Stella appear to be conscious?

Stella’s eyes were open however they were glazed over. She looked as if she were in a trance and was completely unresponsive to our voices or movements. 
 

• During the seizure was Stella moving her legs and/or paws; also called “paddling”?  (Dr. F. demonstrated this and it reminded us of when the dogs “run” when they are sleeping)

Stella was not moving her limbs in that motion but she was pushing her head into my chest as I sat on the floor with her as if she could not get close enough.  Although I was holding her tightly it seemed like she did not realize this and kept pushing into me vigorously.

• Could Stella have possibly gotten into anything or ingested any human medication?

We are very careful about not leaving chemicals of any kind anywhere where the pets can get to it.  I suppose we can’t say with 100% certainty that we didn’t possibly drop one of our pills on the floor but neither of us recalls having done so or spilling a bottle or even missing a pill.  Occasionally teenagers in our neighborhood throw something over our privacy fence but we never leave the dogs outside by themselves (as we have a growing coyote problem) and when we see the dogs start to hover over something we immediately tend to it – it is usually a candy wrapper, apple core, that sort of thing.  Squirrels as well often times drop something in our yard as they’re attempting to carry it up a tree.  To our knowledge we never saw Stella eat anything outside, except the usual twigs and grass; incidentally we do not fertilize our lawn. 

• During the seizure was Stella drooling?  No.

• During the seizure did Stella urinate or defecate?  No.

• Did Stella seem confused after the seizure?

Immediately following the seizure Stella seemed somewhat confused or dazed like she couldn’t figure out what just happened.  After several minutes she was acting like her normal self; wanting dinner, etc.

• Prior to the seizure had Stella hit her head at any time?  No - not to our knowledge.

During our appointment Dr. F. consulted with the neurologist and together they examined Stella; we were not present during this examination.  According to Dr. F. the neurologist was pleased with Stella’s response to stimulus, her eye movement, her energy and her cheerful Pug self.  They did notice Stella slightly drag her back right paw from time to time as they walked her around the facility.  We had not noticed this but Dr. F. said it is very slight and is typical of dogs with a neurologic deficit (her torn ACL is on the left).  As I sated in the previous post the orthopedic surgeon stated this deficit could be a pinched nerve or compression along the spine and could “work itself out”.  I recall years ago when I had a Greyhound he too had a neurologic deficit and would walk directly on top of his knuckles, so much so that they bled…..poor thing :(    Both doctors, along with the orthopedic surgeon, agree that this possible neurologic deficit is unrelated to the seizure.  And the oncologist stated seizures are unrelated to MCT’s.

For now, the plan is to watch and wait; just as with her knee and neurologic deficit.  The doctors agree that if Stella has another seizure we are to bring her back at which point they will do an MRI of her brain and spine.  If Stella should have multiple seizures in one day, such as in the middle of the night or on a weekend, we are to go to the emergency room immediately for anti-seizure medication until the neurologist can see her.

The biggest concern with seizures is the possibility that Stella will have what is called a Grand Mal seizure – which in laymen’s terms would be “the mother of all seizures”; a BIG one where she may lose consciousness or injure herself. 

I know there may not be any way for us to detect if Stella’s has another seizure when we are not at home but we asked Dr. F. what signs to look for if she should have a Grand Mal seizure.  Dr. F. responded that dogs will typically urinate or defecate during a Grand Mal seizure; of course having two dogs this could happen anyway.  Dr. F. stated that in the case of a Grand Mal seizure Stella would release urine and/or feces without trying and may be laying in it when we find her or will have it on her body – as opposed to a dog who will naturally squat and then walk away from it.  She said we may find vomit on Stella or she may appear extremely lethargic.  She may also be unconscious.  She said if Stella has a Grand Mal seizure we WILL at least suspect it as “something” will not be right.

As always we will watch Stella closely and try not to worry too much – fat chance on the latter.  As instructed by the orthopedic surgeon we will take her for easy walks as much as she wants, trying not to tire her “bum” knee.  If everything remains quiet we will see the oncologist for a check-up in 6 months.
Don’t get me wrong - as much as we worry and as paranoid as we feel at times,  we don't let the worry consume us and we do enjoy every moment with our girls and their lives are as full as can be…..as are their bellies! 

 

 

Plan of Action? Wait and see...

We took Stella to see the orthopedic surgeon today.  Dr. G. examined her and confirmed that she has a partial tear in her left ACL.  He observed the way she walked, sat and her overall physical behavior and stated that she “looked good”.  Upon physical manipulation however he discovered a possible secondary issue – of course.  We’ve had this type of maneuver done with our dogs in the past; while in a standing position the dog’s paws are individually flipped knuckle side down.  Most dogs will immediately flip the paw right side up or will pull their paw away from the person.  Stella flipped her paws back, except the back right paw took about 5 seconds.  Dr. G. let her walk around a bit more and then re-flipped each paw; the back right took 5 seconds again.  As I said, we’ve had this happen before so we knew what it indicated; confirmed by Dr. G, a neurological issue, specifically an issue somewhere along her spine.

We described to Dr. G. the seizure episode that Stella had last week.  He told us that the seizure activity is unrelated and is a THIRD concern.

Because of the possible glaucoma issue mentioned by our regular vet the other day, Dr. G. wants Stella to see her ophthalmologist to rule that out as the cause for some of the unusual behavior; perhaps her equilibrium was off.  Assuming her eyes are fine he wants to proceed with a conservative approach. Because Stella is almost 9 years old, is not super-active, is a couch potato, not limping, walking well, has a good appetite, etc. we will wait and see what presents itself first, if anything.  If she should start limping or show signs of pain with walking we are to bring her back to him for a possible MRI and/or surgery.  If she has another seizure we are to make an appointment with the neurologist – if necessary, we will make an appointment with the neurologist at this same facility to keep the continuity of Stella’s specialized care under one roof.

Incidentally, Dr. G. said Stella’s ACL will not heal itself.  The goal is to not let it get worse.  In the state that it is in now it may be tolerable to her; we also have no idea how long it has been this way.  He also stated that the neurological deficit could heal itself if it is something minor in nature.  He told us to watch Stella for pain or injury but let her decide if she wants to go for walkies, if she wants to take the little doggy steps up to the couch or would rather be lifted, if she wants her bowl elevated, etc.  She will be our guide as to what steps to take next.

So to sum up the current events, Stella has:

• a torn ACL
• a possible neurological deficit
• had one seizure that we’re aware of
• a possible glaucoma issue
• had a third Mast Cell Tumor removed a few weeks ago

We were able to get an appointment today to see Stella’s ophthalmologist and drove there after our appointment with the orthopedic surgeon.  We were told that Stella’s eyes look fine – well, as fine as Stella’s eyes can look.  Dr. S. told us that her eyes are exactly what he expected and unchanged from her last appointment less than a year ago.  He also informed us that there is no such thing as “borderline glaucoma” for dogs – there is for people but not for dogs.  He said dogs either have it or they don’t, period.  Their eye pressures are either normal or through the roof.  Being a defined specialty we certainly can’t fault our regular vet for being concerned and suggesting we get Stella’s eyes checked.  At least we now know her eyes did not play into any of the odd behavior.  ONE thing to scratch off our list.

We tried to schedule Stella’s abdominal ultrasound for today to save a trip but was unable to coordinate this with the oncology section.  After her 3^rd MCT removal a few weeks ago we discussed with the oncologist having her ultrasound sooner rather than waiting the full year (August).  Dr. F. is fine with this as it does not require anesthesia and is of no harm to Stella.  We recalled the conversation from 2011 - that if an MCT appears on one of her organs Stella would start chemo immediately.  I can’t stand the thought that something may be growing inside her and we wouldn’t know for 4 more months.  The ultrasound is scheduled for April 15.