Pseudo Todd’s palsy in a patient with medically intractable epilepsy

Abstract

Patients with epilepsy may also have non-epileptic seizures (pseudo seizures). One study showed that 1 out of 5 people presenting to a comprehensive epilepsy center with the diagnosis of medically intractable epilepsy actually had non-epileptic events when monitored. It is particularly difficult to diagnose non-epileptic seizures in patients who also suffer from real epileptic seizures. Various non-epileptic clinical presentations have been reported in the literature. Patients may present with predominantly non-epileptic convulsions characterized by out of phase thrashing movements of the limbs, pelvic thrusting and side to side movements of the head. At other times the non-epileptic manifestations are predominantly psychiatric in character with patients exhibiting bizarre behavior, reporting vivid visual and somatosensory hallucinations or directed vocalizations. We present here a patient with medically intractable epilepsy who presented with dense hemiplegia and hemisensory loss after reported seizures at home. Patient was considered an ideal candidate for intravenous tissue plasminogen activator (tPA) therapy so an acute stroke up was initiated at the time of presentation to the ER. CT scan and MRI brain with DWI was negative for acute stroke. Neurological examination was suggestive of psychogenic weakness. Patient made a full recovery over a course of 2 days. Pseudoparalysis or pseudo Todd’s palsy should be considered in the differential of a patient with epilepsy presenting with acute hemiplegia and other focal neurological deficits especially if they are young and lack traditional vascular risk factors for stroke.