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Título

Stroke or Seizure: A challenging case of prolonged Todd paresis

RESUMO

Case: A 32-y-old male with a history of remittent epilepsy without current use of antiepileptic drugs, traumatic brain injury with amaurosis in the left eye, smoking, and abstinence from cocaine presented to our ER with left-sided weakness, mild dysarthria and loss of nasolabial fold at the left with 30 min of onset. CT scan at the admission presented no signs of bleeding. His initial NIHSS was 21. He had no contraindications to thrombolysis and alteplase was administered without complications. After thrombolysis, NIHSS remained the same. On the next day, the patient remained with hemiparesis and a motor examination showed weakness on his left side (2/5, Medical Research Council [MRC] scale). Brain MRI was performed and showed no alterations. Transthoracic echocardiogram and doppler ultrasound imaging of the carotids and vertebral arteries were normal. Blood count, autoimmune disease biomarkers, and metabolic panel were without alterations. By day 5 of admission, the patient had an improvement in his symptoms but remained with weakness on his left side (4/5 on his left leg and 2/5 on his left arm). Prolonged Todd’s paresis was considered and an EEG showed disorganization, asymmetry, hyporeactivity, and slowing of background activity, compatible with mild-moderate toxic-metabolic encephalopathy, with a background asymmetry possibly related to a post-ictal seizure state. On day 11 of admission, the patient was asymptomatic and was started on valproic acid 250 mg t.i.d., discharged home, and referred to the Neurology outpatient clinic. Discussion: Todd paresis, also known as Todd paralysis or postictal hemiparesis, was initially described in 1849 and is associated with weakness or paralysis in part or all of the body after a seizure. Since stroke is the main differential diagnosis in patients presenting with weakness in the ER, this may lead to misdiagnosis and unnecessary treatments. In fact, in one series, this was the most common non-stroke cause of referral to a stroke unit. However, Todd paresis tends to be a regressive deficit with symptoms that do not exceed 36h, and only rarely do symptoms last beyond this period of time. Final Comments: In this way, this is a crucial differential diagnosis in the ER and a thorough evaluation involving medical history, physical examination, clinical parameters, neuroimaging, and EEG is often necessary to establish the diagnosis, particularly when atypical presentations such as prolonged Todd paresis take place.

Palavras Chave

Epilepsy. Todd paresis. Stroke.