Severe and prolonged ictal paresis in an elderly patient

Abstract

We report an 84-year-old female who showed a rare manifestation of epilepsy, ictal paresis, a type of simple partial seizure presenting with focal motor dysfunction. While the patient exhibited severe left hemiplegia which lasted for a week, cranial diffusion-weighted MRI demonstrated slightly high intensity in the right posterior quadrant, and electroencephalography (EEG) showed continuous epileptiform discharges located mainly in the right parieto-occipital area, strongly suggesting that the patient was in an ictal state. 99mTc-hexamethylpropylene amine oxime-single photon emission computed tomography (HMPAO-SPECT) showed markedly high blood perfusion in the right parieto-temporo-occipital areas. Considering the distribution of EEG epileptiform activities and HMPAO-SPECT hyperperfusion, it is most likely that the ictal paresis of our patient was associated with epileptic activities at the sensorimotor area which caused either direct or indirect activation of an inhibitory system. Careful clinical consideration of the possibility of ictal paresis is needed in elderly patients, especially in those with preexisting dementia, because paresis can be as severe as complete flaccid hemiplegia and can last as long as for a week.

Seizure semiology: ILAE glossary of terms and their significance

“…Ictal paresis is a rare phenomenon. It is characterized by weakness or paralysis of a part of one's body or hemibody [78][79][80]. Ictal paresis must be differentiated from ictal akinesia (see 7 • 463 patients with temporal lobe epilepsy [81], and postictal Todd's paresis (see 9.2).…”

Focal inhibitory seizure with prolonged deficit in adult Sturge‐Weber syndrome

“…Several authors have shown that ictal negative phenomenon can be due to lesions affecting the centro‐parietal lobe and not necessarily SWS‐related Bussière et al ., ; Murahara et al ., ; Oono et al ., ). Moreover, the stimulation of the secondary somatosensory area (Penfield and Rasmussen, ) or the supplementary motor area (Penfield and Jasper, ) could inhibit voluntary movements or induce paralysis In addition, Lüders et al .…”

“…However, the lack of motor fluctuation, the increased blood flow with SPECT, and the dramatic clinical, radiological and electrophysiological improvement after aggressive antiepileptic therapy support the hypothesis of a persistent occult epileptic activity. Several authors have shown that ictal negative phenomenon can be due to lesions affecting the centro-parietal lobe and not necessarily SWS-related Bussière et al, 2005;Murahara et al, 2013;Oono et al, 2014). Moreover, the stimulation of the secondary somatosensory area (Penfield and Rasmussen, 1950) or the supplementary motor area (Penfield and Jasper, 1954) could inhibit voluntary movements or induce paralysis In addition, Lüders et al (1995) postulated the existence of "negative motor areas" (NMAs) in certain dorsal or ventral premotor areas.…”

Epilepsy: Workup and Management in Adults

“…163 Postictal periods are also often prolonged in comparison to younger patients. 164 Additionally, other common clinical phenomena can mimic seizures (e.g. syncope, confusion), and an underlying seizure disorder can easily be misdiagnosed (e.g., dementia, delirium).…”