INTRODUCTION: Todd paralysis (TP) is a rare postictal condition characterized by weakness following an epileptic seizure. TP includes both motor and non-motor entities including altered cognition, psychiatric symptoms, automatic behavior, and aphasia. The etiology is unknown. The reported duration of TP varies between half-an-hour to 36 hours. METHODS: A 33-year-old G6P5005 at 37 weeks with past medical history of epilepsy controlled with Levetiracetam, presented with right-sided weakness and elevated blood pressure following a generalized tonic-clonic seizure. Preeclampsia workup was performed and negative. Secondary to post-ictal paralysis Neurology was consulted with the conditional diagnosis of acute stroke. Motor examination showed paralysis on her right side. Cranial Magnetic Resonance Imaging revealed significant diffusion restriction in the territory of the left Middle Cerebral Artery involving the distal branches and watershed segments. After reviewing the clinical manifestations and neuroimaging findings, the diagnosis was established as TP and antiepileptic therapy was initiated. Routine electroencephalography showed slowed left frontal-parietal activity. Patient's weakness gradually improved with recovery to her premorbid status after 48 hours. The cranial Magnetic Resonance Angiography subsequently showed no significant stenosis or occlusion of the intracranial cerebral arteries. CONCLUSION: The nature, duration, and severity of TP are not related to the duration or severity of the seizures nor the presence of lesions or changes on electroencephalogram. Although stroke is the leading differential diagnosis in patients with neurologic deficits; in pregnancy, TP should be included in the differential if convulsive activity is coupled with paralysis. A misdiagnosis of stroke can lead to unnecessary and potential harmful interventions.
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