How is Todd's paralysis managed?

Management of Todd's Paralysis

Todd's paralysis should be managed with supportive care while ensuring proper diagnostic evaluation to rule out stroke, as it is a transient neurological deficit that typically resolves within minutes to 36 hours following a seizure.

Definition and Clinical Presentation

• Todd's paralysis is a clinical entity consisting of acute focal neurological deficits following an epileptic seizure
• Occurs after 6-13% of seizures 1
• Symptoms may last from minutes to 36 hours 1
• Presents with various neurological findings including:
  • Paralysis/weakness (most common)
  • Paresthesia
  • Aphasia
  • Hemianopsia
  • Altered state of consciousness 2

Diagnostic Approach

Initial Assessment

• Determine if there was a witnessed seizure preceding the neurological deficit
• Assess for history of epilepsy or previous seizures
• Evaluate for risk factors that increase likelihood of Todd's paralysis:
  • Advanced age
  • History of stroke (significant risk factor - positive likelihood ratio of 11.2) 3
  • Longer duration of convulsion
  • Convulsive status epilepticus 3

Imaging

• Advanced neuroimaging is recommended to differentiate Todd's paralysis from acute stroke 1:
  • Brain CT scan
  • MRI with diffusion-weighted imaging
  • CT or MR angiography if vascular etiology is suspected
• Note: Todd's paralysis may show diffusion restriction on MRI that resolves on follow-up imaging, mimicking stroke 2

Management Protocol

Acute Management

1. Ensure seizure termination:

   • If seizure activity continues, administer appropriate antiseizure medications
   • For status epilepticus, follow standard protocols with benzodiazepines as first-line treatment

2. Supportive care:

   • Monitor vital signs
   • Maintain airway, breathing, and circulation
   • Position patient safely to prevent aspiration and injury
   • Supplemental oxygen if needed

3. Neurological monitoring:

   • Perform serial neurological examinations to track resolution of deficits
   • Document progression and resolution of symptoms

Specific Interventions

Antiseizure Management

• If the patient has known epilepsy:
  • Review and optimize current antiseizure medication regimen
  • Consider temporary increase in dosage if breakthrough seizures are occurring
• If first seizure:
  • Consider starting antiseizure medication based on underlying etiology and risk of recurrence
  • Levetiracetam (10 mg/kg, up to 500 mg per dose) every 12 hours may be considered as it has minimal drug interactions 4

Prevention of Secondary Complications

• For patients with impaired mobility:
  • Early mobilization when safe
  • DVT prophylaxis if prolonged paralysis
• For patients with dysphagia:
  • Swallowing assessment
  • Dietary modifications as needed
  • Referral to specialist if swallowing difficulties persist beyond expected resolution of Todd's paralysis

Follow-up Care

• Arrange follow-up with neurology within 1-4 weeks
• Consider EEG to evaluate for epileptiform activity
• Assess for complete resolution of neurological deficits
• Evaluate need for long-term antiseizure medication

Special Considerations

Differential Diagnosis

• Acute ischemic stroke (primary differential)
• Hemorrhagic stroke
• Migraine with aura
• Cerebral hyperperfusion syndrome (after carotid procedures) 5
• Conversion disorder

Pitfalls to Avoid

• Misdiagnosing Todd's paralysis as acute stroke or vice versa
• Failing to obtain appropriate neuroimaging
• Overlooking underlying structural lesions that may have precipitated the seizure
• Assuming all post-seizure deficits are Todd's paralysis without proper evaluation

When to Consider Alternative Diagnoses

• When deficits persist beyond 36 hours
• When deficits evolve or fluctuate in an atypical pattern
• When neuroimaging shows persistent abnormalities
• When other stroke symptoms are present (e.g., visual field defects, sensory deficits)

Pathophysiology

• Associated with cerebral perfusion abnormalities after seizures 6
• May involve cortical spreading depression
• Possibly related to neurotransmitter depletion and metabolic exhaustion in affected brain regions
• More common with structural brain lesions, particularly old stroke 3

By following this management approach, clinicians can appropriately care for patients with Todd's paralysis while ensuring that more serious conditions like acute stroke are not missed.