Post-hemiplegic epilepsy in the elderly.
Authors: W. Fine
Journal: BMJ (1967)

The devastating effect of hemiplegia occurring after cerebral thrombosis presents to the physician such a vast problem of rehabilitation that some of the later sequelae have received relatively little attention in the literature.These sequelae include various types of epileptic phenomena.The effects of these epileptic attacks can at times be temporarily very severe and give rise to symptoms which may be mis- interpreted.During the past few years I have seen much epilepsy occurring in old age, especially in patients suffering from cerebro- vascular disease.The epileptic syndromes that follow hemiplegia are particularly interesting and fall into several groups, which can be divided into the following: (1) motor manifestations, (2) sensorimotor manifestations, and (3) mental manifestations (which I shall not consider here). Motor ManifestationsCase 1.-A woman of 54, who was transferred under my care on 30 July 1956, had been successfully treated for subacute bacterial endocarditis but then suffered a cerebral embolus and sustained a right hemiplegia.At the time of admission she had a complete hemiplegia with flexion contracture of the right upper limb and knee, was completely aphasic, and had developed a bedsore.With full rehabilitation in the geriatric unit she reached the stage of walking about with the aid of a stick, and her speech was improving.After having been in hospital for about four months she developed a severe Jacksonian convulsive attack associated with loss of con- sciousness, and her hemiplegia returned to its previous state and she once more became helpless.Her cerebrospinal fluid was normal and not under pressure.She subsequently improved, but had a further convulsion, again with deepening of the hemiplegia.Her convulsive attacks were eventually controlled with a combination of phenobarbitone and phenytoin.At the time of writing she was still attending the follow-up clinic, fully ambulant with the aid of a stick, and her speech was almost normal.The interesting point which I wish to emphasize about this patient is the fact that after each convulsive seizure the hemi- plegia was greatly deepened and could well have been diagnosed as a fresh cerebral thrombosis or fresh cerebral embolus.Case 2.-A woman aged 80, admitted on 16 September 1963, sus- tained a cerebral thrombosis causing a right hemiplegia and was rehabilitated to the extent of being able to walk slowly with the aid of a stick.A few months later she had a convulsive attack, Jacksonian in type, affecting the right side of her body, developed a complete right hemiplegia, and became comatose.She was sent to hospital with a diagnosis of cerebral haemorrhage.She was not hypertensive, her blood pressure being 130/80 mm.Hg.This complete right hemiplegia and aphasia cleared in a fortnight to the point of her being able to stand and limp, and a week later she was discharged.In each of the two above cases an epileptic attack was followed by a deepening of a previous hemiplegia, the deepening being sufficient to appear clinically to be a fresh cerebral thrombosis, embolism, or haemorrhage.These cases fit in somewhat with the concept of Todd's (1856) paralysis, the so-called epileptic hemiplegia first described by Biavais (1827).In these cases temporary hemiplegia followed a c-nvulsion but there was no evidence of pre-existing cerebral