Stroke or Trauma?

[Rebecca, Irena Farm]

I guess this is one for AK Dog Doc! Have I mentioned how VERY cool it is to have you here?

 

My Ben dog had to go to the vet - nausea, dehydration, most of all he wasn't wanting to work right - seemed a bit "spacey".

 

The vet noticed a lack of response in his pupils and guessed he either had a stroke or trauma to the head. At the moment we're basically treating for both - prednisone, crate rest for a week.

 

I'm really scared - I just lost a dog to massive stroke in January - and Ben's only seven. On the other hand, he's been doing a lot of work lately since he is my husband's dog now and I've been sidelined this whole lambing season. The last time he worked full time, four years ago, his CEA made him run into a post and he gave himself a concussion. This is why he's not our main dog!

 

We wonder whether that happened again - is there any way to tell the difference superficially? If he has a bad concussion versus a stroke, might we need to be a little more proactive in treating this?

 

It's been three days and his eyes are still unresponsive - otherwise he's alert but pretty depressed. I'm scared!

 

I'll be talking to our vet again tomorrow but I thought I'd throw this out as something you'd probably only see in a Border Collie! "Is it a stroke or did he run into a post really hard while herding sheep out of sight from the handler?"

 

Worried,

[juliepoudrier]

Becca,

I'm sorry to say that I don't have any helpful advice, but I *will* be praying for Ben and for you.

 

J.

[AK dog doc]

Hi Rebecca (and thanks for the kudos! - sorry I didn't see this sooner; I was on call.)

 

It's not always so, but very commonly, a stroke will show unilateral signs - which often means that the dog has uneven pupil size (this is called anisocoria). I wonder a bit about the dehydration - that isn't something I'd expect to see with either a concussion or a stroke, per se - I can picture a mechanism, such as "I feel dizzy when I lower my head to drink, so I won't drink", but it isn't a classical sign. Also, strokes often cause weakness or paralysis on only one side, or else some other sign that is unilateral. As an expample, Keetna, Finn's mother, had a small cerebrovascular accident (ie, stroke) about a year ago, which only affected her vestibular system - the vestibular system provides balance, so she was dizzy, vomiting (from being dizzy), unable to right herself, had nystagmus (where the eyes track side to side in the head without the head turning), had a head tilt to one side, and wanted to circle to one side if she was set on her feet. Her signs all had a sidedness to them (except for the vomiting). She recovered with a little prednisone and some nursing care and is now completely normal (she did tend to cross-track with the back legs for a week or two, and had a slight drift to the left in her forward gait for maybe three weeks, but now you'd never know it happened.)

 

At any rate, the signs the dog would have following a stroke would depend on where the stroke was in the brain or the spinal cord, but generally they'd be more on one side or the other and not affect both sides evenly. A concussion could affect both sides evenly, or not, depending on where the impact to the head occurred. If it was a blow from the side, the opposite side of the brain would get slammed up against the inside of the skull (this is called a contra-coup injury) and then that side of the brain would swell and have decreased function until the swelling went down. Whiplash type injuries can make the entire brain swell evenly, and a blow to the front of the head (as in crashing into something head-on) could make the back of the brain swell evenly on both sides. As the back of the brain is where the visual cortex is, this could cause a decrease in vision, even if the eyes are normal - BUT: pupillary light reaction (PLR, where the pupils constrict when light shines on the eye) is NOT controlled by the visual cortex. So if Ben seems to have decreased vision, that could be as a result of injury to the visual cortex OR because of injury to the eye or the optic nerve. If he has decreased PLRs, that has nothing to do with the visual cortex and then I'd be looking at doing a retinal exam and checking some bloodwork to see if there's a metabolic problem that might be contributing. If that all turns out normal, maybe a neurologist would be helpful, since there can be injury to the nerve that makes the pupil constrict as well.

 

If this were my dog, I'd be thinking about bloodwork anyway, because of the dehydration. One of the things that I thought of when you mentioned he was both dehydrated and just "off", not himself, etc, was the possibilty of a virus (which would affect his whole body and knock him off his game) or a metabolic problem that might do the same. That might explain some depression (although that could also be partly due to him being removed from work - a change in routine). I'd also be thinking about having an opthalmologist look at his eyes, since if he DID have a blow to the head, he might have retinal or other eye injury that could explain the abnormal PLRs.

 

A rare disease (but an underdiagnosed one, since we often forget to think of it, since it IS rare), and one that might cause some of the signs you're reporting, is Addison's disease (JFK had that, you know). Some people think I'm over-eager to look for this disease and accuse me of looking for an Addisonian behind every bush - but on the other hand, I've diagnosed six in ten years (and I *think* I'm on number seven right now, but the tests haven't come back yet), and this is a disease that they tell you in school you'll diagnose once a decade, if that. If I'm already going 6 or 7 to one on diagnosing it, I'd say it's underdiagnosed. I don't think I magically attract Addisonians - I think I find them because I LOOK for them. At any rate, it's a very difficult diagnosis because it mimics practically every other disease you can think of, and requires special testing to track down. There's a screening test - the sodium:potassium ratio - but there are rare Addisonians who have the disease but have a normal ratio, so to be certain you have to run the ACTH stimulation test. Up here that's a bit expensive - about $200, since it has to be shipped on ice to the lab, and we have no in-state lab to run it - so it isn't usually a first-wave test. Unfortunately, having given the dog steroids will likely make the test results invalid for a while - you'd have to withdraw the steroids for a period before you can run it. On the plus side, if Ben IS Addisonian, the steroids will help him. They're just not enough by themsleves to solve the problem.

 

At any rate, if Ben had either a stroke or a concussion, you're on the right track with rest and steroids, and I'm not sure I'd get more agressive with it just yet; I'd reserve that for if he isn't responding or starts to get worse. If he has a systemic problem (like infection or metabolic disease), running some bloodwork would be in order (I'd probably do a CBC, panel and electrolytes). I'll cross my fingers that it's something minor and in a few days he'll be out terrorizing sheep again, but certainly ping me if you have other questions or if I've not answered your original ones adequately.

[Rebecca, Irena Farm]

Thanks so much for the VERY valuable information! I was in agonies over the idea it might have been a stroke - though of course now we've got to figure out what it is exactly. There are no unilateral symptoms that I can tell.

 

We did a complete CBC two days ago which showed nothing. We just did a baseline a couple of months ago too, coincidentally.

 

What he kept doing on the sheep was going past them like they weren't there - very unlike him - he's a "clear the field or die doing it" type of dog. I wonder whether it was just that the bright sunlight those days was hurting his eyes.

 

Ben is worse today. He acts miserable. He has terrible diarrhea and still is not drinking - I'm pretty sure he's dehydrated again but I'm not good at judging these things specifically. Still no response from his pupils. He's also tearing out his hair in big bloody chunks along his flanks.

 

We're still pretty sure he clunked his head but he's the kind of dog with fragile health, that one thing will start a domino effect in him. We struggled for years with this and that until we switched to a raw diet. This is the first issue we've had in the two years since then.

 

I wonder now whether he's having a severe relapse of his Lyme disease, which happens every so often when he's stressed out. I'll also do a heavy duty search on Addison's and bring it up tomorrow. My vet is wonderful to say, yes, let's pursue that option if you feel it's a possibility. No ego problems there.

 

I'll be keeping you up to date on his progress. Thanks again - you're a doll!

[Denise Wall]

AK doc,

 

Are unresponsive pupils consistent with Addison's in dogs? I understand the human symptoms of the disease and see the other indications in Becca's dog.

 

Denise

[AK dog doc]

Hmmm, didn't know about the prior Lyme disease history; I'd definitely bring that up with your (most excellent-sounding! ) vet as well, in case there's a tie-in with some sort of weird vasculitis or something.

 

As a BTW, the signs of dehydration that you can readily check at home are:

 

1) The mucous membranes (the lips or gums are easist to check) should be slippery or moist when you first touch them, not sticky or dry. If they're sticky or dry, he's behind on his hydration (one caveat - if the dog has had his mouth open in dry air that sometimes will dry off the membranes more than expected.)

 

2) The skin, when plucked up into a "tent" over the shoulderblades, should snap back down immediately. If it is even a little slow to return to its normal shape, the dog is likely to be dehydrated (one caveat here: this test requires at least a little (ie normal) amount of subcutaneous body fat in order to be accurate, so interpret it in concert with the other signs, and don't check this over the neck - normally hydrated lean dogs often have slow return to normal on the skin turgor test if you do it over the neck. That's why I go over the back, between the shoulderblades.)

 

3) Capillary refill is often prolonged in dehydrated animals (again, interpret in concert with the other signs, as prolonged CRT is also seen in other situations) - blanch the gums or inside of the lip with your thumb (press firmly but not hard) and see how long it takes to see the color return. It should be returning within 2 seconds BY A WATCH - this is a lot longer than you think, so actually time it.

 

Denise, to answer your question about the slow PLRs - no, you're absolutely right that this isn't a classical sign of Addison's disease (that's what makes me think an optho exam +/- a neuro exam may be useful). However, since Addison's disease is not called "The Great Imitator" for nothing (the sneaky bugger!) , it's possible that it IS related. The mechanisms I'd think of for that would be related partly to electrolyte disorders - electrolytes are necessary for normal nerve and muscle function, so abnormal levels can cause abnormal function of the nerves and muscles (which would include those running the show up in the eyeball.) Another mechanism is related to shock - we very often see the dilated unresponsive pupil in a shocky animal - and an Addisonian CAN easily be in shock, since they cannot bring their normal compensatory mechanisms on line. If it were nothing but the dilated unresponsve pupils I'd be looking elsewhere than the metabolism for the problem (at least to start with), particularly in a dog with underlying CEA. However, the depression, the recurrent dehydration, and now the diarrhea are making me think there's something else going on. It is not always the case, but it is *usually* the case, that if we see multiple signs, they're all coming from one underlying disease. So (without being able to see the dog, which admittedly dramatically ups my chances of being wrong) I'm looking for some single source of all the problems. I admit I could easily be barking up the wrong tree with Addison's - it could be a virus or something from the Lyme disease ro something else entirely. (What's the BC equivalent of barking up the wrong tree? Penning in the wrong shed?) However, one of the reasons I always check for Addison's, if in doubt, is that it can readily be fatal if not diagnosed and treated, so I tend to look for it and keep it in mind whenever I have a vague case that has a "nebulopathy" that might fit the profile. This, I will readily admit, is partly that I got rewarded big, strait out of the gate, on diagnosing Addisonians. {Prepare for a little story.} Back when I was a senior vet student we had PBL - Problem-Based Learning - in which the professor presented the group - 6 to 8 students - with a case that had actually been seen at the University at some time in the past. They gave us the signalment parameters - like, 6 year old female spayed black standard poodle presents with dehydration, lethargy and vomiting of 3 days duration; previous history from the referring veterinarian was (blah blah blah); phyiscal exam findings are (blah blah blah); what tests do you want to run? The students would choose tests and the prof would give the reults - either the actual results, or what would have been seen if we ran the test. Then we had to diagnose the case and come up with a course of treatment and they told us if the animal got better on our plan, or worse, or died. Well, one day in PBL it happened that they gave us an Addisonian. I had spent the previous evening studying while watching PBS and they happened to have had a thing on JFK, which discussed his Addison's disease. With that fresh in my mind, when poor Dr. Grauer asked us what tests we wanted to run, I said "I think we should test it for Addison's disease. JFK had that, you know." (much like I said it here, only a bit brattier). Dr. Grauer gave me this LOOK - which I didn't understand until after the case was done and it turned out to BE an Addisonian. He was irked because it's supposed to be a tough diagnosis - and it IS, really - and I wasn't supposed to jump right to it before running any other tests. In all honesty, had I not just seen the JFK thing the night before, I would NOT have jumped right to it - but as it turns out, it's a good thing I DID see that, because due to the immediate reward (after he got over being irked, Dr. G said some very nice things to me in front of the other students), that disease has stuck in my head and I've saved some lives by looking for Addison's disease behind every bush and tree and vomiting, lethargic and vaguely ill dog. All because I got it spectacularly right, once, long ago when it didn't really matter because I was diagnosing a dog on paper who had long since recieved the treatment it needed. A lucky happenstance for several dogs that have crossed my trail since then.

 

So, that was a long tale to answer your question, and I apologise for that. I hope I DID asnwer your question, which raised a good point. I also hope Becca's dog is better, and thanks for keeping me updated!

[Denise Wall]

Thanks

 

Denise

[Rebecca, Irena Farm]

This has been simply fascinating. THough I wish the occaion for the discussion were not at Ben's expense, perhaps something may come of it for him or someone else.

 

Ben's back at the clinic doing a 24 hour observation. His pupil response returned to normal briefly, but now his right eye is unresponsive. He seems overall happier though. He was slightly dehydrated again but the runs are gone now.

 

I suspect my vet is leaning in the direction of a dx of stroke - and is just watching for another event to confirm it. If that's so, I'd like to know why my seven year old dog is having strokes - is it related to the chronic Lyme? This would be his first breakout in two years (that's why I almost forgot about it).

 

I'm so anxious - I just can't lose this dog - I even hate the thought of seeing him disabled.

 

Thanks for your support!

[Denise Wall]

Becca,

How is Ben today? I hope things are going better for him.

[Rebecca, Irena Farm]

Things are still very mysterious. He will be spending the weekend at the clinic for continued observation. His attitude continues to improve but the other symptoms are still the same (diarrhea, skin lesions, funky neurological stuff that comes and goes).

 

We've been playing phone tag through this process but Monday I'll definitely request that she consider both the Lyme and Addison's, if she is still stumped.

 

Normally if she can't figure something out, she'll do a referal to a specialist, but this is going in so many directions and is so vague I'm sure she's pulling her hair out to know where to go next.

 

She adores Ben too - I feel really bad that she's knocking her head against the wall over this one.

[Rebecca, Irena Farm]

Ben came home from the vet clinic today. The final conclusion is, believe it or not, that following the accident he got into some mushroom or fungus down in the woods.

 

Ben's on pred and something to help clean out his liver, plus antibiotics for the dermatitis - he's looking much better already.

 

He's retired as a fulltime chore dog but still has a career as my duck dog. Even the new dog Doug (Doug the Dog) is not useful on the ducks - he is too excited about them right now and only wants to bite them!

 

But as I discovered when Ben was gone, moving 15 ducks from day foraging to night pens wihtout a dog is just as frustrating as trying to work sheep without a dog. So he will be quite busy enough when he is fully recovered! And he can still work sheep in large open fields which he loves anyway.

 

Thanks for the support and advice. AK Dog Doc, if you ever get sheep I am your 24 hour support hotline! Denise, if you ever need help with worming, lamb chores, hoof trimming, shearing, fencing, putting up hay, whatever - give me a ring!

[AK dog doc]

Thanks, Becca - I may take you up on that someday! (right now it's just the occasional orphan, but maybe someday I'll live where I have enough room for a few... Finn would love that.) I'm very glad to hear that Ben is on the mend! That must be a load off your mind.

 

Did they say what kind of fungus they thought it was? We have amanita mushrooms up here, which are hepatotoxic, but we generally don't see neurotoxic signs with them.... just curious.

[Rebecca, Irena Farm]

It's just an educated guess - but coincidentally a yorkie owned by one of my flyball teammates came down with a mystery illness with some similiar symptoms, plus a slow heart rate. It happened this weekend and her vet came to the same conclusion as my vet.

 

What I figure is that the mild dryish weather that is alternating with cold wet weather, is favoring some particular species of yummy but dangerous fungus. My teammate's vet called it "hallucinigenic" - my vet, a child of the sixties, said Ben was having a "bad trip"!

 

The slight liver involvement didn't show up until just before he was released. The weird thing is, when she described what was happening to Ben - I realized that the same thing had happened to my husband about this time last year - he had a bad reaction to a drug he was taking for carpal tunnel.

[Denise Wall]

Becca,

 

Glad they found out what was wrong with Ben and that he's doing better.

 

Denise, if you ever need help with worming, lamb chores, hoof trimming, shearing, fencing, putting up hay, whatever - give me a ring!

 

Thanks, but...aren't you all, like, hobbling around still from your wreck?

 

I really would like to know where you're getting your meat for your dogs, though if you're willing to give up your sources. Even shopping for specials, seven dogs can get expensive buying retail from grocery stores like I have been for the last couple of years. If you get a chance, email me at cdwall@yadtel.net

 

Thanks,

 

Denise

[Rebecca, Irena Farm]

Lambs still have to be docked, vacced, tagged, and now wormed! Though I have to get someone to hold the lamb for me once I've caught it. I can turn and hold a smallish sheep but have to ask for help with my Polypay/Suffolk ladies!

 

I'll e-mail you.

[Denise Wall]

Sorry, that's cdwall1@yadtel.net.

 

Thanks!

[Rebecca, Irena Farm]

Well THAT would explain it. I thought earthlink was being refused entry again.

 

B