Seizure activity may be followed by a period of decreased function in regions controlled by the seizure focus and the surrounding brain. This period of decreased activity is the postictal period and usually lasts less than 48 hours. After status epilepticus, however, deficits may take several days to resolve.

A transient deficit that results from seizure activity is usually called a postictal state. Postictal phenomena might include transient blindness after an occipital seizure and loss of memory after a complex partial seizure that originates in one or both temporal lobes. Generalized convulsive seizures may be followed by minutes to hours of sleep, confusion, or unresponsiveness. A postictal state that is characterized by a motor weakness in the distribution of muscles controlled by seizing neurons is called Todd's paralysis.3

In the emergency department (ED), it is critical to determine whether a postictal neurologic deficit is due to a postictal state, which resolves spontaneously, or to another process that may require immediate treatment. This task is complicated by the fact that fever, headache, disorientation, and focal weakness may be normal sequelae of seizures.

Attribute abnormal postictal neurologic findings to a postictal state as a diagnosis of exclusion. This rule should be violated only when:

  • there is a clear history of identical postictal deficits after typical seizures
  • no other significant abnormalities are found on physical and laboratory examination
  • the patient can be discharged into the care of reliable individuals and will rapidly return to the ED if symptoms do not resolve typically or new symptoms emerge

Other causes of postictal neurologic deficits must be investigated, especially when any postictal state lasts for more than 24 hours. If there is any question about the nature of the patient's deficits, the patient should be admitted to the hospital, and an appropriate neuroimaging study, preferably a magnetic resonance imaging (MRI) scan with and without contrast, should be performed.

In the ED, investigate any fever in the postictal period as a new fever and assume that it is unrelated to the seizure until no other source is found. Send blood for CBC, electrolytes, and blood cultures from two independent sites.

Perform lumbar puncture whenever a central nervous system infection is suspected. It should be performed on most patients who present with a new-onset seizure, but may not be needed if the patient returns rapidly to normal baseline and the fever rapidly abates, as long as someone reliable can observe the patient. Lumbar puncture is strongly recommended, however. In competent hands, it is a relatively painless and low-morbidity procedure, and the consequences of missing a meningitis or encephalitis can be devastating.

If there is a postictal fever and the patient refuses lumbar puncture, the patient should be admitted for observation for at least 24 hours. Further studies should include urinalysis; urine culture, when appropriate; a thorough lung examination; and a chest x-ray, if indicated.

Patients who are febrile postictally and immunocompromised (e.g., patients on chemotherapy, chronic alcoholics, or individuals with HIV infection or chronic renal failure) or cognitively impaired (particularly those who cannot communicate well) should undergo aggressive, thorough evaluations, including lumbar puncture, unless there is a contraindication.

Adapted from: Kolb SJ and Litt B. Management of epilepsy and comorbid disorders in the emergency room and intensive care unit. In: Ettinger AB and Devinsky O, eds. Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002;515–535. With permission from Elsevier (www.elsevier.com).

Authored By: 
Steven J. Kolb Md PhD
Brian Litt MD
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Reviewed By: 
Steven C. Schachter MD
on: 
Saturday, May 1, 2004