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Abstract—The authors retrospectively investigated the value of Todd’s palsy (TP) in lateralizing the hemisphere of
seizure onset in patients admitted for video-EEG monitoring in a tertiary epilepsy center. In 29 patients, a postictal
hemiparesis was observed. TP always occurred contralateral to the epileptogenic hemisphere in 27 patients (93%). In the
remaining two patients, the seizure onset could not be lateralized. In some patients, TP occurred after a seizure without
focal motor features or secondary generalization.
NEUROLOGY 2004;62:289 –291
It has been shown that information about the hemi- tion and distribution of the postictal lateralized weakness were
documented. Seizure types were classified according to the semio-
sphere of seizure onset in focal epilepsy can be reli- logic seizure classification.6 Lateralizing signs (focal motor sei-
ably derived from careful analysis of the seizure zure, focal somatosensory or lateralized visual aura, ictal speech,
semiology. In combination with EEG data and imag- dystonic hand posturing, forced head version, postictal aphasia)
ing findings, semiology may allow the evaluation of were also documented. The side of the epileptogenic zone was
determined based on all available clinical, neurophysiologic, and
possible resective surgery without the need of inva- imaging data. Data processing was performed using commercial
sive monitoring, or it may help guide the placement software (SPSS for Windows 11.0; SPSS, Chicago, IL).
of subdural or intracerebral electrodes. In a number
of ictal phenomena, the lateralizing value has been Results. Lateralized postictal weakness was documented
assessed.1,2 Comparable studies regarding postictal during video-EEG monitoring in 29 patients (table 1). The
phenomena, in particular Todd’s palsy (TP), are lateralization of the epileptogenic zone was confirmed on
scarce.3 In two small studies of patients with refrac- the basis of seizure freedom after epilepsy surgery in 6
tory focal epilepsy undergoing presurgical video-EEG (20%) of the 29 patients. In 15 patients (52%), the epilepto-
monitoring, the seizure onset was always contralat- genic zone was determined by interictal/ictal EEG find-
eral to the observed postictal weakness.4,5 However, ings, seizure semiology, and a structural lesion on MRI. In
these studies were performed in highly selective pa- four patients (14%), the MRI was normal, but functional
tient groups. Moreover, the occurrence of postictal imaging (fluorodeoxyglucose PET, ictal SPECT) showed an
weakness may have influenced the decision to oper- abnormality in concordance with EEG findings and seizure
ate, thus preventing patients with ipsilateral seizure semiology. In another two patients (7%) with normal MRI
findings, the lateralization of the epileptic zone was based
onset from inclusion into the study group.4 There-
on EEG and seizure semiology alone. In the remaining two
fore, the results are of limited value when the later-
patients (7%), the epileptogenic zone could not be
alization of the seizure onset has not yet been
lateralized.
established. In addition, it is not clear whether TP TP always occurred contralateral to the epileptogenic
also occurs in other epilepsies, besides focal epilepsy. zone in 27 patients (93%) (table 2). In one patient (3.5%)
We performed a retrospective analysis of all patients with seizure onset in both hemispheres, the EEG onset of
(regardless of the epilepsy classification) who have the seizure type resulting in postictal weakness was al-
undergone long-term video-EEG monitoring in a ter- ways contralateral to the involved body side. In the re-
tiary referral epilepsy center. maining patient (3.5%), the epileptogenic zone could not be
determined.
Methods. Medical records of approximately 4,500 consecutive In 20 (69%) of the patients, TP was confined to the arm
patients who underwent long-term (i.e., ⬎24 hours) video-EEG and face. In seven patients, it lasted ⬍10 minutes, and
monitoring at the Cleveland Clinic between 1990 and 2002 and
who had undergone cranial MRI were screened for the documen- ⬎12 hours in only one patient.
tation of transient lateralized postictal weakness during the eval- The seizure preceding TP started with an aura in 15
uation. The patient population consisted of approximately 75% patients, 6 of whom had a somatosensory aura in the body
with focal epilepsy, 5% with generalized epilepsy or multifocal parts involved in the TP (table 3). In 15 patients, TP was
epilepsy, and 20% with nonepileptic seizures. During the monitor-
ing, scalp electrodes were placed according to the 10 –20 Interna-
preceded by a focal clonic or tonic seizure involving the
tional System. The charts of the patients and, if possible, their body part that became paretic. A bilateral asymmetric
original video, EEG, and imaging data were reviewed. The dura- tonic seizure occurred in 10 patients, whereas a general-
From the Departments of Neurology, The Cleveland Clinic Foundation (Drs. Kellinghaus and Kotagal), Cleveland, OH; and University of Münster (Dr.
Kellinghaus), Germany.
Supported by Innovative Medizinische Forschung, University of Münster, Germany (KE 620201; C.K.).
Received May 16, 2003. Accepted in final form September 17, 2003.
Address correspondence and reprint requests to Dr. Christoph Kellinghaus, Department of Neurology, University of Münster, Albert-Schweitzer-Str. 33,
48129 Münster, Germany; e-mail: kelling@uni-muenster.de
Not lateralizable and not localizable 2 (7) Percentages do not add up because more than one feature could
Etiology of epilepsy, no. (%) be seen in a patient. Values are no. (%).
* Including automotor and hypermotor seizures.
Vascular 3 (10)
† Loss of consciousness without motor features.
Neoplasm 0
TP ⫽ Todd’s palsy.
Trauma 2 (7)
Inflammatory 4 (14)
Congenital malformation 7 (24) patients, TP occurred after a complex motor seizure that
Hippocampal sclerosis 0 was not preceded or followed by a simple motor seizure. In
one patient, TP was observed following a seizure without
Other 1 (3)
significant motor symptoms.
Unknown 12 (42)