1422 - From Brain Surgery to Brief Paralysis: Todd's Tale of Temporary Trouble

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

KS

Kanwardeep Singh, MD

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States

Co-Author(s)

RC

Ricardo Cruz, MD

Attending Physician
Nassau University Medical Center
East Meadow, New York, United States
JL

Jack E. Leal, DO

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States
OA

Omar Alsheikh, DO

Medical Student
Nassau University Medical Center
East Meadow, New York, United States

Case Diagnosis: Todd’s Paralysis in Acute on Chronic Subdural hematoma status post-right craniotomy

Case Description: 85 year old male with new onset altered mental status (AMS) and left sided weakness with history of recurrent falls. CT scan revealed a right-sided subdural hematoma (SDH), patient underwent a right parietal craniotomy and had residual left upper extremity weakness. Patient completed a 7 day postoperative course of anti-epileptic medication (Keppra). Patient presented on post-op day 10 with AMS, progressive left upper and lower extremity flaccidity and urinary incontinence. Repeat head imaging ruled out stroke. Continuous EEG indicated seizure like activity and moderate nonspecific diffuse or multifocal cerebral dysfunction. Patient was started on anti-seizure medications. Over the next 48 hours the patient regained strength in both left upper and lower extremities and showed functional improvement in bedside physical therapy. Patient was diagnosed with Todd’s Paralysis and transient hemiparesis that resolved with time and anti-epileptic medication.

Discussions: In craniotomy patients, Todd's paralysis may result from a seizure that occurs during or after the surgery. Seizures can be triggered by various factors, including the surgical manipulation of the brain tissue, changes in brain electrolyte levels, or the presence of underlying neurological conditions.The prognosis for Todd's paralysis is generally favorable, as the weakness or paralysis is temporary and reversible. Once the effects of the seizure wear off, the individual typically regains full or near-full function in the affected body parts.

Conclusions: The development of Todd paralysis following a craniotomy for a chronic subdural hematoma is a rare but significant complication. One should consider Todd’s Paralysis if the patient shows signs of acute loss of motor strength, AMS, repetitive jerky movement, and urinary incontinence. After acute stroke can be ruled out, the patient should be evaluated with seizure work-up including but not limited to EEG.