Management of Todd's Paralysis
Todd's paralysis should be managed with supportive care while focusing on differential diagnosis to rule out stroke, as it is a transient neurological deficit that typically resolves spontaneously within minutes to 36 hours after a seizure.
Understanding Todd's Paralysis
Todd's paralysis is a clinical entity consisting of acute focal neurological deficits following an epileptic seizure. It occurs after approximately 6-13% of seizures 1, with symptoms that may last from minutes to up to 36 hours. The condition presents as temporary limb weakness or hemiplegia without enduring consequences 2.
Diagnostic Approach
Initial Assessment
- Neuroimaging: Advanced imaging such as cerebral CT and MRI with angiography is recommended to differentiate Todd's paralysis from stroke 1. This is critical as stroke with seizure at symptom onset can be difficult to differentiate clinically from Todd's paralysis.
- Clinical Features: Todd's paralysis is more commonly observed after:
- Partial seizures or generalized tonic-clonic seizures
- In patients with old age or stroke history
- In patients with remote seizure etiologies (19.7% of cases) 3
Risk Factors
- Older age
- Longer duration of convulsion
- Convulsive status epilepticus
- Remote etiologies including old stroke (independent significant risk factor) 3
Management Protocol
Immediate Post-Seizure Care:
- Ensure airway, breathing, and circulation are stable
- Position patient safely to prevent injury
- Monitor vital signs
Neurological Monitoring:
- Perform serial neurological examinations to track resolution of deficits
- Document the progression and resolution of symptoms
Diagnostic Testing:
- Obtain brain imaging (CT/MRI) to rule out stroke, especially in patients without known seizure disorder
- Consider EEG to evaluate for ongoing seizure activity if deficits persist
Supportive Care:
- Maintain hydration
- Provide comfort measures
- Ensure patient safety during the period of neurological deficit
Management of Underlying Seizure Disorder:
- Review and optimize antiepileptic medication regimen
- Consider neurology consultation for patients with new-onset seizures
Special Considerations
Stroke vs. Todd's Paralysis
- The positive likelihood ratio of Todd's paralysis is 11.2 for remote seizure etiologies 3
- Todd's paralysis may be accompanied by cytotoxic edema on diffusion MRI, which can mimic acute stroke 4
- Resolution of neurological deficits and diffusion restriction on follow-up MRI helps differentiate Todd's paralysis from stroke 4
Unusual Presentations
- Todd's paralysis can occur in special populations such as pregnant patients 4
- It can also present after other conditions causing seizures, such as cerebral hyperperfusion syndrome following carotid endarterectomy 5
Follow-Up Care
- Ensure complete resolution of neurological deficits
- Schedule follow-up with neurology for patients with new-onset seizures or changes in seizure pattern
- Consider long-term seizure management strategies to prevent recurrence
Prevention
- Optimal seizure control through appropriate antiepileptic medication
- Identification and management of seizure triggers
- Regular follow-up with neurology for patients with epilepsy
Todd's paralysis is a transient condition that requires careful differentiation from stroke. While supportive care is the mainstay of management, proper diagnostic evaluation is essential to rule out other serious neurological conditions that may require specific interventions.