Todd’s Paralysis disclosing neurocysticercosis

Todd’s Paralysis disclosing neurocysticercosis

 Trevisol-Bittencourt PC 1,2,3, Tomaselli PJ 1, Nahoum RG 1, Collares CF 4, Tournier MB 1, Pioner LM 1, Bittencourt FS 2
1 Federal University of Santa Catarina, Florianópolis/SC, Brazil
2 Hospital Santa Teresa, São Pedro de Alcântara/SC, Brazil
3 Epilepsy Centre of Santa Catarina, São Pedro de Alcântara/SC, Brazil
4 Intoxication Control Center of the Sao Paulo City Hospital, Brazil
www.neurologia.ufsc.br

 

Backgrounds: Transient neurological deficits are well-know after epileptic seizures. Robert Bentley Todd (1809–1860), an Irish physician, was the first to describe transient hemiparesis or hemiplegia that may follow some seizures. His remarkable observation was published in 1854 where he noticed it as a neurological state that recovers completely after a few time under the heading “epileptic hemiplegia”. He described a patient who developed hemiplegia after seizure;  with complete reversion of the deficit in the subsequent hours after the ictus. Since then many non motor equivalents of Todd’s paralysis (TP) have been described as well. Actually was Hughlings Jackson (1835-1911) who extended the limits of this definition including other transient neurological deficits as TP equivalents;  such as cognitive dysfunctions, dysphasia, riots of space construction and visual perception, etc.

 

Methods: To describe a young woman presenting TP secondary to partial status epilepticus due to neurocysticercosis.

 

Case report: DA, 26 years old, married, 2 children, peasant, portuguese roots, living in a rural area.  She went to a neurological centre due “stroke” that happened less than 24 hours. She presented complete left hemiplegia in the initial assessment. The previous diagnostic of “stroke” was questioned by her age, because she had a normal general clinical examination and due the absence of the classic risk factors for cerebral vascular disease. The clinical history provided other possibility – she was suffering from repetitive tremors in the  left arm two years before and as they usually had short duration time she had never complaint of this symptom. In fact she told she was adapted to live with her  “strange nervous attacks”.

 

Moreover the husband noticed  that in the day before of her “stroke”, she had presented repetitive tremor  episodes on the left arm and at the beginning of night a more intense episode was followed by an “epileptic convulsion”. He described well a secondary tonic-clonic seizure, and his contribution to better understanding the situation was excellent when he sad…doctor, my wife is going to be mad and me too, in the last weeks she was complaining to me from a lot of episodic and odd symptoms such as persecutory ideas; sudden and unexplained fear and very odd transient memory disturbances.  Clearly he described déjà vu and jamais vu seizures. He firmly  denied the usage of drugs or any type of medication, as well as febrile convulsive seizures during its infancy. And his contribution did not stop here, he was brilliant when suggested the diagnosis… we have old style swine farming at my area. DA gradually recovered and in 3 days she was completely normal. As she  presented positive epidemiology for cysticercosis, a TC scan was carried out and it showed many typical neurocysticercosis lesions (NC) in different evolutive stages, one of them close to the right motor area (Figures 1 to 4). A routine EEG showed a focus on the right temporal lobe (Figure 5).

 

Discussion: DA is suffering from symptomatic partial epilepsy due to NC and presented a classical picture of TP. We would like to pointed out that TP was the first major symptom of her  condition. If you have a look on contemporary neurological literature, this epileptic phenomenon would seems to be rare, however we believe this misconception is a result of poor clinical examination nowadays. TP rarely is proper recognized in people suffering from epilepsy,  resulting in repetitive, expensive and sometimes aggressive neurological investigations. The symptoms related to TP usually revert in 24 to 36 hours, although in few patients the recover time can take ten or more days.  This condition should be suspected in all patients who develop hemiplegia or another focal neurological deficit, presenting clinical history of epilepsy in the past. Unfortunately partial seizures are underestimates and doctors usually should no pay attention for this common presentation of epilepsy. Very interesting  to notice that TP, which had the fast recovery of the neurological deficit, frequently provoke among the health professionals an temptation to diagnose hysteria, and we know well  how these peculiar patients labeled as hysterics are treated… overdoses of insults prescribed by doctors and their “collaborators. As Rolak pointed out most of patients showing TP episodes will have structural cortical injuries.  We would like to remain that our patient has one NCC lesion close to the right motor area. Currently the hypothesis most accepted is that transient pos ictal neurological deficits are related with the injuries and its localization,  in this case there is a clear involvement of the motor cortex.  NCC as etiology for epilepsy must be considered in all patients coming from endemic areas, and DA was living in a region where this trouble is quite common.  Finally, NCC lesions are the main etiology of symptomatic epilepsy in Brazil,  however  its detection by CT would have to be followed by judicious clinical examination to define its clinical and electroencephalographic responsibility, if any.

 

References:

* Takayanagui, O.M. Jardim, E. Aspectos clínicos da Neurocisticercose: Análise de 500 casos. Arg Neuropsquiatr. 1983:41:50-63.

* Trevisol-Bittencourt, P. C., N. C. da Silva, et al. Prevalence of neurocysticercosis among epileptic in-patients in the west of Santa Catarina – southern Brazil. Arq Neuropsiquiatr 1998: 56(1): 53-8.

* Trevisol-Bittencourt, P.C. Eckeli A.L. Tournier, M.B. Neurocisticercose. Diagnóstico e Tratamento. www.neurologia.ufsc.br

* Garcia, H.H. Beutto, O.H. Nash, T.E. White, A.C. JR., Tsang, V.C.W. Gilman, R.H. New concepts in the diagnosis and management of neurocysticercosis (Taenia Solium) Am J Trop Med Hyg. 2005; 72: 3-9.

* Rolak LA, Rutecki P, Ashizawa T, Harati Y. Clinical features of Todd’s post-epileptic paralysis. J Neurol,Neurosurg and Psychiatry. 1992, (55); 63-64.

* Teive, H. A. G. ; Minguetti, G. Neurocisticercose: Artigo de Revisão. Revista Brasileira de Neurologia, 1997, 33(3), 147-153.

* Bergen DC, Rayman L, Heydemann P. Epilepsia; 1992, 33(6): 1101-1105.

* Morrell F. Memory loss as a Todd’s paralysis. Epilepsia; 1980, 21: 185.

* Savard G, Andermann F, Remillard GM, Oliver A. Post-ictal psyhosis following partial complex seizures is analogous to Todd’s paralysis. In: Wolf P, et al., Advances in epileptology, XVIth Epilepsy International Symposium, vol.16. New York: Raven, 1987: 603-605.
 
 
Endereço para correspondência:
Dr.Paulo César Trevisol Bittencourt
Neurologia/Departamento de Clínica Médica/UFSC
88040-970 – Florianópolis/Santa Catarina/Brasil
pcb@neurologia.ufsc.br
www.neurologia.ufsc.br