Todd's Paralysis Simulating Acute Ischemic Stroke: A Case Report

Todd's paralysis is a transient focal neurological deficit following epileptic seizures that may closely mimic an acute ischemic stroke, posing a diagnostic challenge in the emergency department. We report the case of a 32-year-old woman with a history of epilepsy who presented with persistent expressive aphasia and right hemiparesis after experiencing multiple generalized tonic-clonic seizures. On admission, her National Institutes of Health Stroke Scale (NIHSS) score was 6, initially raising strong suspicion for an acute ischemic cerebrovascular event. Noncontrast cranial computed tomography (CT) showed no intracranial hemorrhage or early ischemic changes. Due to the persistence of focal deficits, brain magnetic resonance imaging (MRI) was performed, which demonstrated no evidence of acute cerebral infarction or structural abnormalities. Electroencephalography (EEG) demonstrated focal epileptiform activity with secondary generalization. Following optimization of her antiseizure regimen with the addition of valproate, the patient achieved complete seizure control and full resolution of all neurological deficits, establishing the diagnosis of Todd's paralysis with postictal aphasia. This case underscores the importance of considering Todd's paralysis in the differential diagnosis of acute focal neurological deficits, particularly in patients with a history of epilepsy and prolonged postictal symptoms. In resource-limited settings where advanced perfusion imaging may be unavailable, integrating clinical findings, conventional neuroimaging, and electroencephalographic evaluation can provide sufficient diagnostic confidence to distinguish severe postictal deficits from acute ischemic stroke and avoid unnecessary or potentially hazardous interventions.