# Painful Todd’s: Post-ictal painful hemiparesis as an identifier of insular epilepsy

## TL;DR

This paper describes a case where painful post-seizure weakness helped identify the origin of seizures in the insula, a brain region often difficult to diagnose.

## Contribution

The paper introduces painful Todd’s paresis as a novel clinical marker for insular epilepsy.

## Key findings

- Painful Todd’s paresis localized seizure onset to the contralateral insula in a patient.
- Cortical stimulation confirmed the insula as the source of the post-ictal phenomenon.
- Radiofrequency thermocoagulation significantly reduced seizure frequency in the patient.

## Abstract

•Careful attention to seizure semiology can help to distinguish insular epilepsy.•Painful Todd’s paresis can localise seizure onset to the contralateral insula.•Cortical stimulation confirmed the anatomical origin of this post-ictal phenomenon.

Careful attention to seizure semiology can help to distinguish insular epilepsy.

Painful Todd’s paresis can localise seizure onset to the contralateral insula.

Cortical stimulation confirmed the anatomical origin of this post-ictal phenomenon.

The insula can generate seizures which mimic frontal, temporal and parietal epilepsies making electroclinical localization difficult. We report the case of a twenty-one-year-old woman who presented with seizure semiology of a left-sided painful somatosensory aura, progressing to bilateral tonic posturing and complex manual automatisms. She described a painful sensation and weakness affecting her left side following the offset of a seizure, with the pain consistenly outlasting the weakness. This would last from hours to days depending on the severity and duration of the seizure. Stereo-electroencephalography (SEEG) demonstrated seizure onset in the limen of the right insula. Extra-operative stimulation of the insula reproduced the clinical symptoms. She underwent radiofrequency thermocoagulation (RFTC) which has resulted in a significant reduction in seizure frequency. This case report describes a lateralized painful Todd’s phenomenon as a feature of insular epilepsy confirmed by SEEG and extra-operative stimulation.