How is Todd's paralysis managed?

Management of Todd's Paralysis

Todd's paralysis should be managed with supportive care and close monitoring until symptoms resolve, while ensuring proper differential diagnosis to rule out acute stroke. 1

Definition and Clinical Presentation

• Todd's paralysis consists of acute focal neurological deficits following an epileptic seizure, occurring after 6-13% of seizures with symptoms lasting from minutes up to 36 hours 1
• Clinical presentation may include paralysis, paresthesia, aphasia, hemianopsia, and altered consciousness 2
• In rare cases, symptoms can last up to 70 hours and may present as unusual variants including ideomotor limb apraxia or severe hemineglect syndrome 3

Diagnostic Approach

• Advanced neuroimaging is essential to differentiate Todd's paralysis from acute stroke, as they can be clinically indistinguishable 1
• Recommended imaging includes cerebral CT and MRI with angiography to rule out stroke and other structural causes 1, 2
• Diffusion-weighted MRI may show transient diffusion restriction that resolves on follow-up imaging, distinguishing it from true stroke 2
• EEG may be helpful to document seizure activity, especially in cases where the seizure was not witnessed 1

Management Protocol

1. Acute Management:

   • Ensure patient safety during and after seizure activity 4
   • Maintain airway, breathing, and circulation 4
   • Position patient to prevent aspiration 4

2. Neurological Monitoring:

   • Perform frequent neurological assessments to track resolution of deficits 1
   • Document progression and resolution of symptoms 2

3. Seizure Management:

   • Administer antiepileptic medications if seizures are ongoing 4
   • Consider levetiracetam (10 mg/kg, up to 500 mg per dose) every 12 hours as it has minimal drug interactions 4
   • Avoid antiseizure medications with unfavorable cardiotoxicity profiles (such as lacosamide and phenytoin) when possible 4

4. Supportive Care:

   • Provide adequate hydration and nutrition 4
   • Implement physical therapy for patients with prolonged deficits 4
   • Consider neurology consultation for specialized assessment 4

Risk Factors and Special Considerations

• Patients with pre-existing structural brain lesions, particularly old stroke, have significantly higher risk (19.7%) of developing Todd's paralysis 5
• Older age, longer duration of convulsion, and convulsive status epilepticus are associated with increased risk of Todd's paralysis 5
• Todd's paralysis can occur in special circumstances such as after carotid endarterectomy due to cerebral hyperperfusion syndrome, mimicking postoperative stroke 6

Follow-up Care

• Schedule follow-up neurological assessment after resolution of symptoms 1
• Consider long-term seizure management and prevention strategies 1
• Evaluate for underlying causes of seizures if not previously identified 5

Important Clinical Pitfalls

• Misdiagnosis as acute stroke can lead to unnecessary thrombolytic therapy with potential complications 2
• Failure to recognize Todd's paralysis as a stroke mimic may result in delayed appropriate epilepsy management 5
• Overlooking underlying structural brain lesions that predispose to Todd's paralysis can miss important etiologies requiring treatment 5
• Not considering Todd's paralysis in patients with seizures after procedures like carotid endarterectomy may lead to inappropriate management 6