Hemispheric hypoperfusion in postictal paresis mimics early brain ischemia

The clinical differentiation between stroke and seizure is usually straightforward but postictal neurological deficits can be mistaken for stroke in case no detailed medical history is available. Up to now, the imaging findings of Todd's paresis are not well described. This case report demonstrates that postictal paresis can be accompanied by a reversible global hemispheric hypoperfusion as measured with perfusion MRI indicating transient but profound cerebrovascular dysfunction in postictal paresis. Extensive postictal perfusion changes must be discriminated from emerging stroke to avoid potentially harmful therapy like thrombolysis. Further investigations are warranted to clarify the role of cerebrovascular dysfunction in the pathophysiology of postictal paresis.