Numerous signs and symptoms may appear in a postictal state, with some variations depending on the underlying type of epilepsy. For example, the duration of symptoms is significantly shorter if seizures originate from the temporal and frontal lobes (about 90 seconds), while tonic-clonic seizures may be followed by a postictal state lasting for hours [1] [2]. Additionally, a prolonged duration of seizures, age extremes (elderly and children) and seizures of the dominant hemisphere are established risk factors for a prolonged postictal state [1] [3]. Regardless of the duration, the following symptoms are encountered [1] [2] [3] [4] [5] [6] [7]:

• Behavioral changes - Postictal psychosis is one of the most important behavioral manifestations of the postictal state, distinguished by auditory and visual hallucinations, delusions, paranoia, mood disorders, aggression and disorders of thought [1] [3]. A rapidly resolving delirium is another important feature, but a severe and prolonged form is seen in more than a third of cases, presenting as alterations in the sleep-wake cycle, attention deficits, and increased autonomic activity [3] [6].
• Alterations in motor function - Weakness and/or paralysis, usually unilateral and contralateral to the seizure focus, can last for minutes or even hours, depending on the extent of brain damage after seizures. Patients who suffer from structural lesions (caused by a tumor or stroke) seem to be most susceptible [1].
• Cognitive and visual symptoms - Dysphasia, homonymous hemianopias or blindness, respectively, are also encountered during the postictal state, and they seem to be more common during childhood and when seizures stem from the occipital or occipitotemporal lobes [1].

Severe, potentially recurrent headaches after seizures may also be reported by some individuals, and they are frequently misdiagnosed as migraines [3], while epilepsy occurring exclusively during sleep can induce confusion or sleepwalking, which could be the only symptoms of a postictal state in such circumstances [5].

• Epilepsy

  Epilepsy Behav. 2010 Oct;19(2):146-50. doi: 10.1016/j.yebeh.2010.06.022. Epub 2010 Aug 14. [ncbi.nlm.nih.gov]

  Numerous signs and symptoms may appear in a postictal state, with some variations depending on the underlying type of epilepsy. [symptoma.com]

• Fatigue

  He or she may be able to help you find out what's causing your fatigue and recommend ways to relieve it. Read more on MedlinePlus.gov. [treato.com]

  Postictal phase : Fatigue, lethargy, and exhaustion follow the pain phase for migraine and the seizure phase for and epilepsy. This is the stage that’s often called a migraine hangover. [theraspecs.com]

  Many people who have seizures may feel fatigued or sleepy for hours or even days after having a seizure. [verywellhealth.com]

  Related to Physical Agents 397 Injury and Poisoning 404 Care of Acute Lacerations 421 Selected Injuries 435 Care of the Athlete 444 Athletic Injuries 453 Common Clinical Problems 465 Care of the Patient with Dysequilibrium 471 Care of the Patient with Fatigue [books.google.ro]

  […] uttering of an “ ictal cry” Increased sympathetic tone: dilated, unresponsive pupils, ↑ HR and ↑ blood pressure Clonic phase (rhythmic muscle twitching) Bladder or bowel incontinence Tongue bite lacerations Unresponsiveness Confusion Amnesia Aphasia Fatigue [amboss.com]

• Turkish

  […] at brain level, Aviat Space Environ Med, 2000, vol. 71 (pg. 1167 - 8 ) Effects of acceleration in relation to. aviation, Fed Proc, 1946, vol. 5 (pg. 327 - 44 ) Visual symptoms and G-LOC in the operational environment and during centrifuge training of Turkish [academic.oup.com]

• Stroke

  The patient has a history of epilepsy secondary to his stroke. [statpearls.com]

  WEBSITES National Institute of Neurological Disorders and Stroke (NINDS). Todd's Paralysis Fact Sheet. Bethesda, MD: NINDS, 2003.. Rosalyn Carson-DeWitt, MD [encyclopedia.com]

  The symptoms are similar to those of a stroke, but the two conditions are vastly different. Both strokes and seizures impact the function of your brain. The symptoms of Todd’s paralysis resolve themselves within 48 hours. [healthline.com]

  Apoplexy: stroke, SAH, extradural, subdural, Ca, meningitis, encephalitis, cerebral abscess, etc. [lifeinthefastlane.com]

• Somnolence

  Excessive daytime somnolence - eg, due to a sleep apnoea or narcolepsy. Periodic limb movement disorder. Tardive dyskinesia. Panic attacks. [patient.info]

  Postictal patients may also be confused or combative, especially as they transition from somnolent to awake. The postictal phase may last a few minutes to several hours, but patients usually fully recover after 20 minutes. [ems1.com]

  somnolent? if so, for how long?). Physical Examination Vital signs and blood sugar should be obtained immediately on all patients. As discussed previously, empiric thiamine should be given when treating hypoglycemia. [unboundmedicine.com]

  Side effects: nystagmus, dizziness, somnolence, drowsiness. D. Promote physical and emotional health. Establish regular routines for eating, sleeping, and physical activity. Avoid alcohol, stress, and excessive fatigue. [brilliantnurse.com]

  There were some problems with adherence to medication i.e. the patient would reduce dosage on her own when there was worsening of psychotic symptoms, either because of somnolence or because the AED were "the Devil's medicine". [scielo.br]

• Stupor

  Stupor and "twitching" Case #5 A 56-year-old man who was previously well was admitted to the hospital in a stupor with clonic twitching of his left extremities and face. [dartmouth.edu]

  The stuporous type is characterized by stupor, mutism, posturing and negativism. A third type is lethal or malignant catatonia: an often acutely emerged state involving alterations in consciousness, fever, severe rigidity and autonomous instability. [bmcpsychiatry.biomedcentral.com]

  […] twitching or blinking or other eye movement signs and/or fluctuating mental status Patients in whom no other cause is available to explain the altered sensorium, especially in those who have a history of a previous seizure, even if remote Unexplained stupor [lifeinthefastlane.com]

  Clinical presentation varies from mild forms to stupor or coma and can easily be mistaken for catatonia. Patients seem apathetic and lethargic as they can still eat, drink, dress themselves, and follow simple commands [98]. [hindawi.com]

• Altered Mental Status

  If a patient remains confused for longer than 20 minutes after a seizure, consider another cause of altered mental status [4]. [ems1.com]

  Lumbar puncture LP should be considered for any patient with status epilepticus, severe headache, fever, persistent altered mental status, or immunocompromised state (especially HIV). [cdemcurriculum.com]

  […] epilepticus) Patients with altered sensorium who demonstrate subtle signs, such as twitching or blinking or other eye movement signs and/or fluctuating mental status Patients in whom no other cause is available to explain the altered sensorium, especially [lifeinthefastlane.com]

  Nonconvulsive seizure is a rare presentation of altered mental status (AMS) but should always be on the differential of the comatose patient. Electroencephalography (EEG) is the diagnostic modality of choice for identifying these patients. [emedicine.com]

  Altered mental status due to metabolic or endocrine disorders. Emerg Med Clin North Am. 2005;23:901–8. [PubMed] [Google Scholar] 6. Sheth RD, Drazkowski JF, Sirven JI, Gidal BE, Hermann BP. Protracted ictal confusion in elderly patients. [ncbi.nlm.nih.gov]

• Slurred Speech

  Symptoms of Todd’s paralysis include: weakness of a limb, such as your hand, arm, or leg numbness slurred speech disorientation Symptoms begin during the postictal state, which is a period of time after a seizure when you transition back to a normal state [healthline.com]

To confirm the diagnosis of a postictal state and to confirm its symptoms as being a consequence of epilepsy, a thorough patient history, and a detailed physical examination must be conducted, as various conditions may mimic the clinical presentation [3]. Firstly, details regarding prior treatment with antipsychotic medications, alcohol abuse, use of antiepileptic therapy that can exert side-effects, and recent exposure to illicit drugs must be noted, in order to exclude iatrogenic causes of delirium and psychosis [3] [6]. A complete neurological examination should follow, during which weakness, paralysis or other pathological phenomena can be encountered. If clinical evidence suggests that patients fall into a postictal state, further workup must include electroencephalography (EEG). A nonconvulsive status while symptoms are still present, is considered to be a diagnostic hallmark of the postictal state, but interictal spikes and spike-waves may be present as a remnant of a seizure [7]. Because imaging studies, such as computed tomography (CT) and magnetic resonance imaging (MRI) are of limited use, the diagnosis of a postictal state relies on excluding other causes through patient history, clinical criteria and EEG studies.

Treatment of postictal states requires recognition of underlying neurological and systemic disorders associated with seizures and delirium such as metabolic disorders and nonconvulsive seizures. [ncbi.nlm.nih.gov]

The final chapters discuss emerging topics in epilepsy: the treatment of the postictal state, technologies to predict and detect seizures, strategies for closing the treatment gap and sudden unexpected death in epilepsy. [books.google.com]

[…] recordings of 955 spasms in children with cryptogenic and symptomatic West syndrome (WS) were reviewed to define the relation between a clinical manifestation of a spasm and its EEG pattern, and to examine whether these features reflect the etiology and prognosis [moh-it.pure.elsevier.com]

Prognosis The prognosis of Todd's paralysis is excellent, with full recovery to be anticipated. Resources BOOKS Pedley, Timothy A. "The Epilepsies." Cecil Textbook of Internal Medicine, edited by Lee Goldman, et al. Philadelphia: W.B. [encyclopedia.com]

Implications of NCSE are poorly defined associated with poorer prognosis, however the underlying cause is typically the major determinant of mortality Patients with pre-existing epilepsy have a lower mortality (3%) than where NCSE is due to acute medical [lifeinthefastlane.com]

Discharge Regained full consciousness Provide clear management for any recurrences Provide education, support and follow up with GP Complications and Prognosis Prognosis of epilepsy 50% of childhood epilepsy have a favourable course 25% gradually improve [armandoh.org]

PROGNOSIS The long-term impact of seizures is small for most children, especially if there are no underlying abnormalities in the child's brain. Many children with epilepsy have normal development and a good chance for a normal life. [uptodate.com]

Although it was independent from the etiology of the spasms, persisting hypsarrhythmia during a cluster of spasms appeared to be an EEG pattern that correlated with a favorable outcome. [moh-it.pure.elsevier.com]

Etiology Epilepsy Although these seizures are referred to as unprovoked, they may be triggered by certain provocative factors! [amboss.com]

Adult first generalized seizure: etiology, biological tests, EEG, CT scan, in an ED. Am J Emerg Med. Jan 1995;13(1):1-5. [cdemcurriculum.com]

The results also suggest that the etiology of postictal psychosis in this patient was initiated by an ictal event and the behavior apparently depended on seizure propagation outside the hippocampus. [thejns.org]

Etiology Etiologies for seizures include those listed in Table 27-3. [unboundmedicine.com]

Causes of epilepsy: contributions of the Rochester epidemiology project. Mayo Clin Proc. 1996;71(6):570–5. PubMed CrossRef Google Scholar 2. Hildebrand J, Lecaille C, Perennes J, et al. [link.springer.com]

These epidemiological results were first reported and stressed by Verrotti et al. [ 15 – 17 ], which conducted in pediatric age. [thejournalofheadacheandpain.springeropen.com]

He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education. [lifeinthefastlane.com]

Definition References: [1] [2] [3] [4] [5] Epidemiology References: [6] Epidemiological data refers to the US, unless otherwise specified. [amboss.com]

Epidemiology Focal epilepsy is often of temporal lobe origin but the true prevalence of TLE is not known. Presentation [ 1 ] Aura occurs in the majority of temporal lobe seizures. [patient.info]

Just as the pathophysiology of seizures is complicated, so is that of the PS multifactorial. As a practical issue, it would be very useful to have medications that reduce the morbidity of the PS. [ncbi.nlm.nih.gov]

Definition and Pathophysiology of Epilepsy Seizures (sometimes called epileptic seizures) are the stereotypical clinical manifestations (signs and symptoms) of excessive synchronous, usually self-limited, abnormal electrical activity of neurons situated [pedsinreview.aappublications.org]

Abstract The neuroanatomical and pathophysiological basis of primary generalised absences is uncertain. Administration of endogenous opioids has been shown to result in absence-like seizures in animal models. [pubmedcentral.nih.gov]

The pathophysiologic mechanism of PIP is unknown. One hypothesis is that PIP represents a psychic Todd's paralysis [ 15, 18 ]. [annals-general-psychiatry.biomedcentral.com]

Pathophysiology PP is associated with relatively broadly and bilaterally distributed epileptogenic networks as well as genetic determinants of seizures and psychiatric disorders. [doi.org]

Some of these tests include: Treatment and Prevention The best way to prevent postictal paralysis is by preventing seizures from happening. Seizures can be prevented with anti-epilepsy medications and sometimes with epilepsy surgery. [verywellhealth.com]

Prevent infection. High risk of meningitis, abscess, osteomyelitis, particularly in presence of rhinorrhea, otorrhea. Maintain strict asepsis. I. Prevent complications of immobility. Continue range-of-motion activities. Prevent contractures. J. [brilliantnurse.com]

If this drug is to be withdrawn prior to pregnancy, it must be tapered off slowly (months) to prevent withdrawal seizures. [obgynkey.com]

Deterrence/prevention To date, there have been no data to indicate that any intervention other than medications effectively prevents seizures or SE. Therefore, medication compliance should always be emphasized to every patient. [emedicine.com]

[…] to prevent these from happening in the future. No ER visit. No seizure drugs. No EEG etc. To get the diagnosis wrong—either way—would be to treat the patient inappropriately and perhaps even to harm the patient. So, accurate diagnosis is paramount. [jailmedicine.com]

1. Theodore WH. Effects of age and underlying brain dysfunction on the postictal state. Epilepsy Behav. 2010;19(2):118-120.
2. Bromfield EB, Cavazos JE, Sirven JI, editors. An Introduction to Epilepsy [Internet]. West Hartford (CT): American Epilepsy Society; 2006. Chapter 2, Clinical Epilepsy.
3. Krauss G, Theodore WH. Treatment strategies in the postictal state. Epilepsy Behav. 2010;19(2):188-190.
4. Rémi J, Noachtar S. Clinical features of the postictal state: correlation with seizure variables. Epilepsy Behav. 2010;19(2):114-117.
5. Bazil CW. Effects of sleep on the postictal state. Epilepsy Behav. 2010 Oct;19(2):146-50
6. Devinsky O. Postictal Psychosis: Common, Dangerous, and Treatable. Epilepsy Currents. 2008;8(2):31-34.
7. Fisher RS, Engel JJ Jr. Definition of the postictal state: when does it start and end? Epilepsy Behav. 2010;19(2):100-104.