Local cortical hypoperfusion imaged with CT perfusion during postictal Todd's paresis

Postictal ("Todd's") paralysis, or "epileptic hemiplegia," is a well-known complication of focal or generalized epileptic seizures. However, it is unclear whether the pathophysiology of Todd's paralysis is related to alterations in cerebral perfusion. We report CT perfusion findings in a patient presenting with postictal aphasia and right hemiparesis.

A 62-year-old woman with a history of alcohol abuse, closed head injury and posttraumatic epilepsy, presented with acute onset aphasia and right hemiparesis. A non-contrast head CT scan demonstrated no acute hemorrhage. Left hemispheric ischemia was suspected, and the patient was considered for acute thrombolytic therapy. MRI revealed a subtle increase in signal intensity involving the left medial temporal, hippocampal and parahippocampal regions on both T2-weighted FLAIR and diffusion-weighted sequences. CT angiography and CT perfusion study were performed. The CT perfusion study and CT angiography demonstrated a dramatic reduction in cerebral blood flow and blood volume involving the entire left hemisphere, but with relative symmetry of mean transit time, ruling out a large vessel occlusion.

Clinical resolution of the aphasia and hemiparesis occurred within a few hours, and correlated with normalization of perfusion to the left hemisphere (detected by MR perfusion).

This unique case is the first in which clinical evidence of Todd's paralysis has been correlated with reversible postictal hemispheric changes on CT and MR perfusion studies. This is important because CT perfusion study is being used more and more in the diagnosis of acute stroke, and one needs to be careful to not misinterpret the data.