CME Lateralizing value of Todd’s palsy

in patients with epilepsy

Christoph Kellinghaus, MD; and Prakash Kotagal, MD

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-
sphere of seizure onset in focal epilepsy can be reli-
ably derived from careful analysis of the seizure
semiology. In combination with EEG data and imag-
ing findings, semiology may allow the evaluation of
possible resective surgery without the need of inva-
sive monitoring, or it may help guide the placement
of subdural or intracerebral electrodes. In a number
of ictal phenomena, the lateralizing value has been
assessed.1,2 Comparable studies regarding postictal
phenomena, in particular Todd’s palsy (TP), are
scarce.3 In two small studies of patients with refrac-
tory focal epilepsy undergoing presurgical video-EEG
monitoring, the seizure onset was always contralat-
eral to the observed postictal weakness.4,5 However,
these studies were performed in highly selective pa-
tient groups. Moreover, the occurrence of postictal
weakness may have influenced the decision to oper-
ate, thus preventing patients with ipsilateral seizure
onset from inclusion into the study group.4 There-
fore, the results are of limited value when the later-
alization of the seizure onset has not yet been
established. In addition, it is not clear whether TP
also occurs in other epilepsies, besides focal epilepsy.
We performed a retrospective analysis of all patients
(regardless of the epilepsy classification) who have
undergone long-term video-EEG monitoring in a ter-
tiary referral epilepsy center.
Methods. Medical records of approximately 4,500 consecutive
patients who underwent long-term (i.e., ⬎24 hours) video-EEG
monitoring at the Cleveland Clinic between 1990 and 2002 and
who had undergone cranial MRI were screened for the documen-
tation of transient lateralized postictal weakness during the eval-
uation. The patient population consisted of approximately 75%
with focal epilepsy, 5% with generalized epilepsy or multifocal
epilepsy, and 20% with nonepileptic seizures. During the monitor-
ing, scalp electrodes were placed according to the 10 –20 Interna-
tional System. The charts of the patients and, if possible, their
original video, EEG, and imaging data were reviewed. The dura-
tion and distribution of the postictal lateralized weakness were
documented. Seizure types were classified according to the semio-
logic seizure classification.6 Lateralizing signs (focal motor sei-
zure, focal somatosensory or lateralized visual aura, ictal speech,
dystonic hand posturing, forced head version, postictal aphasia)
were also documented. The side of the epileptogenic zone was
determined based on all available clinical, neurophysiologic, and
imaging data. Data processing was performed using commercial
software (SPSS for Windows 11.0; SPSS, Chicago, IL).
Results. Lateralized postictal weakness was documented
during video-EEG monitoring in 29 patients (table 1). The
lateralization of the epileptogenic zone was confirmed on
the basis of seizure freedom after epilepsy surgery in 6
(20%) of the 29 patients. In 15 patients (52%), the epilepto-
genic zone was determined by interictal/ictal EEG find-
ings, seizure semiology, and a structural lesion on MRI. In
four patients (14%), the MRI was normal, but functional
imaging (fluorodeoxyglucose PET, ictal SPECT) showed an
abnormality in concordance with EEG findings and seizure
semiology. In another two patients (7%) with normal MRI
findings, the lateralization of the epileptic zone was based
on EEG and seizure semiology alone. In the remaining two
patients (7%), the epileptogenic zone could not be
lateralized.
TP always occurred contralateral to the epileptogenic
zone in 27 patients (93%) (table 2). In one patient (3.5%)
with seizure onset in both hemispheres, the EEG onset of
the seizure type resulting in postictal weakness was al-
ways contralateral to the involved body side. In the re-
maining patient (3.5%), the epileptogenic zone could not be
determined.
In 20 (69%) of the patients, TP was confined to the arm
and face. In seven patients, it lasted ⬍10 minutes, and
⬎12 hours in only one patient.
The seizure preceding TP started with an aura in 15
patients, 6 of whom had a somatosensory aura in the body
parts involved in the TP (table 3). In 15 patients, TP was
preceded by a focal clonic or tonic seizure involving the
body part that became paretic. A bilateral asymmetric
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

Copyright © 2004 by AAN Enterprises, Inc. 289

Table 1 Characteristics of the patients Table 3 Clinical features of the seizures preceding the postictal
weakness
TP observed during
evaluation, TP observed during
Variable n ⫽ 29 Features evaluation, n ⫽ 29

Age at admission, y; median (range) 17 (2–59) Aura 15 (52)

Duration of disease, y; median (range) 12 (0.3–52) Somatosensory aura 6 (21)
Gender, no. (%) female 9 (31) Simple motor activity (focal or 23 (79)
generalized)
Handedness, no. (%)
Focal clonic or tonic seizure 15 (52)
Right 27 (93)
Bilateral asymmetric tonic seizure 10 (34)
Ambidextrous/unknown 2 (7)
Versive seizure 4 (14)
Diagnosis, no. (%)
Generalized tonic or tonic-clonic 12 (41)
Focal epilepsy 29 (100)
seizure
Temporal lobe 4 (14)
Complex motor activity* 10 (34)
Frontal lobe 10 (34)
Without preceding or following 5 (17)
Perirolandic area 5 (18) simple motor activity
Parietal lobe 4 (14) With dystonic posturing of one arm/ 5 (17)
Occipital lobe 1 (3) hand

Only lateralizable 3 (10) No motor seizure† 1 (3.5)

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)

TP ⫽ Todd’s palsy. Discussion. In 29 of approximately 3,600 patients

(0.8%) undergoing long-term video-EEG monitoring
in a tertiary epilepsy center, lateralized postictal
ized tonic-clonic seizure occurred in 12 patients prior to a weakness could be documented during the evalua-
TP. An automotor seizure with dystonic hand posturing
tion. This incidence is comparable with the data of
ipsilateral to TP was observed in five patients. In five
another study investigating TP in a heterogeneous
patient cohort.7 In contrast, TP was found in 22
Table 2 Lateralization of the epileptogenic zone (14%) of 160 patients with refractory focal epilepsy
whose seizure videotapes were systematically re-
TP observed during
Epileptogenic zone determined by evaluation, n ⫽ 29
viewed for postictal symptoms.5 However, in our
study, the patients were identified by the description
Seizure freedom ⬎1 y after epilepsy surgery 6 (20) of postictal weakness in their chart data. Therefore,
EEG/semiology and structural imaging 15 (52) patients with subtle signs of postictal weakness that
EEG/semiology and functional imaging, 4 (14)
may have been overlooked during the evaluation
structural imaging normal could not have been identified in our study. In addi-
tion, their patient group consisted only of patients
EEG/semiology only 2 (7)
with refractory focal (predominantly temporal) epi-
Could not be determined 2 (7) lepsy,5 whereas our patients were recruited from a
Postictal weakness compared with heterogeneous group admitted for diagnostic evalua-
hemisphere of epileptogenic zone tion of spells with recent onset as well as epilepsy
Always contralateral 27 (93) surgery candidates. The only study prospectively an-
Epileptogenic zone could not be 2 (7) alyzing the occurrence of TP in a mixed patient pop-
determined or both hemispheres ulation8 found an incidence of 6%. However, only
epileptogenic patients presenting with generalized motor seizures
were included in this study. Therefore, as of yet,
Values are no. (%).
there are no valid data about the incidence of TP in a
TP ⫽ Todd’s palsy. representative group of epilepsy patients.
290 NEUROLOGY 62 January (2 of 2) 2004
 Theoretically, false lateralization of the epilepto-
genic zone could have occurred in some of our pa-
tients. However, most of the unsuccessful surgeries
in our series were among patients with epilepsy aris-
ing from the posterior frontal lobe near the primary
motor cortex, precluding complete resection of the
lesion. In some patients, the surgical or pathologic
report explicitly mentioned that not all anatomically
or neurophysiologically abnormal tissue could be re-
sected. This may explain the relatively low rate of
seizure freedom despite unequivocal determination
of the epileptogenic zone. Only two patients had no
abnormalities on neuroimaging, but each had EEG
and semiologic findings clearly indicating the hemi-
sphere of seizure onset. Therefore, false lateraliza-
tion of the epileptogenic zone is highly unlikely.
All 27 patients in whom the epileptogenic zone
could be lateralized to one hemisphere had TP in the
contralateral side of the body, regardless of the lobe
of seizure onset. Two studies evaluating focal epi-
lepsy had similar findings without any patients hav-
ing TP on the side of the body ipsilateral to the
epileptogenic zone.4,5 Other semiologic features, like
forced head deviation, dystonic limb posturing, and
postictal nose wiping, were found to lateralize cor-
rectly in only 85 to 95% of cases.2 Therefore, TP
seems to have a strong and consistent value without
any reports of paradoxical lateralization in patients
with a clearly defined epileptogenic zone. Owing to
the obvious limitations of retrospective studies, our
data should be confirmed by a prospective study,
including a wide variety of different epilepsies.
Three-quarters of the patients had a seizure with
tonic or clonic movements preceding TP, the majority
of which (at least in the beginning) were restricted to
the limb or side affected by TP. This underscores the
crucial role of the cortical motor centers in the gene-
sis of TP. However, in some patients, only bilateral
motor activity was seen, and one patient did not
have significant motor symptoms in the seizure pre-
ceding TP. Other authors also have observed postic-
tal weakness after sensory auras and in unaffected
limbs.9 In those patients, epileptic activation of the
contralateral primary motor cortex alone may not be
reaching the threshold of motor activity and still re-
sult in TP. In addition, the epileptic activation of
subcortical structures, in particular the basal gan-
glia,10 may contribute to TP. However, definite ex-
perimental or clinical evidence illuminating the
pathophysiology of TP is still lacking.
Acknowledgment
The authors thank Dr. Kevin Chapman for help in preparing the
manuscript.
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