Preston Padden, B.S. Biochemistry, West Virginia University
Medical Student
West Virginia University School of Medicine
Morgantown, West Virginia, United States
Disclosure information not submitted.
Levi Helmick, B.S. Biochemistry, B.S. Biology, West Virginia University
Medical Student
West Virginia University School of Medicine, United States
Disclosure information not submitted.
Bathmapriya Balakrishnan, M.D., B. Medical Science
Assistant Professor, Pulmonary & Critical Care Medicine
West Virginia University School of Medicine, United States
Disclosure information not submitted.
Title: Todd’s Paralysis: Masking of Seizures Due to Anesthesia and Sedation
Case Report Body:
Introduction: The most common cause of hemiparesis in patients age 18-50 is acute ischemic stroke. However, an expanded differential list includes postictal hemiparesis known as Todd’s paralysis, brain tumors, conversion disorder, and hemiplegic migraines. We report a case of left sided hemiparesis that was unmasked after weaning of sedation drips during mechanical ventilation.
Description: A 35-year-old man with a history of pulmonary embolism (PE), substance abuse, anxiety, and seizure disorder presented to the emergency department with complaints of agitation, dyspnea, and chest pain after calling off his wedding. He was normotensive, normocardic, and afebrile with normal respiratory rate of 14 breaths/min. He was agitated with variable oxygen saturation. Chest imaging ruled out pneumonia and PE. Laboratory results were significant for high serum lactate and a positive drug screen for ethanol, barbiturates, tricyclic antidepressants, and tetrahydrocannabinol (THC). He was given antibiotics, methylprednisolone, and lorazepam in the ED and was then intubated due to severe agitation. He was transferred to the intensive care unit for further management while sedated on propofol, lorazepam, etomidate, and succinylcholine.
During spontaneous awakening and breathing trial the following day, the patient was awake and alert to person, time and place, but his extremities were noted to be jerking after which he developed left-sided hemiparesis. Stroke protocol computed tomogram with angiography was performed and revealed no signs of stroke. The patient was subsequently extubated, and his hemiparesis resolved within several hours. An electroencephalogram (EEG) was ordered to determine the presence of subclinical seizure activity, but was not completed due to the patient’s request to leave the hospital against medical advice.
Discussion: Primary acute respiratory failure was suspected despite lack of conclusive evidence for pneumonia or exacerbation of obstructive airway disease. Paralyzation, mechanical ventilation, and use of sedative medication further delayed the recognition and treatment of seizures. A fast-acting benzodiazepine for symptomatic treatment and an EEG to confirm seizures would have been sufficient. The presence of seizures and Todd’s paralysis was unmasked following the weaning of sedative medications.