ictal paresis or inhibitory motor seizures are a relatively rare nonconvulsive manifestation of epileptic seizures characterized by an inability to initiate or continue movements usually with preservation of muscle strength and consciousness , , , , , , , , . here , we report an elderly female patient with dementia who manifested with severe and prolonged left hemiplegia . an 84-year - old female had convulsive seizures for the first time in her life out of sleep ( day 1 ) . on arrival at our emergency room , she had left clonic hemiconvulsions including the neck in association with conjugate deviation of the eyes to the left . the convulsion , sustained for more than 45  min as witnessed by her family , stopped following injection of diazepam and phenytoin ( pht ) . prior to the convulsion , she did not speak voluntarily because of dementia and was bedridden most of the time , although she had no hemiparesis . laboratory examinations were unremarkable , only showing slight leukocytosis and slight elevation of lactate dehydrogenase and ammonia . cerebrospinal fluid examination was also unremarkable . at 10  h after the admission ( day 2 ) , her consciousness recovered to the previous level , and she could keep her eyes open visually pursue objects around around her bed . however , she had left flaccid hemiplegia , bilateral symmetrical brisk deep tendon reflexes , and babinski signs . cranial diffusion - weighted mri demonstrated slightly high intensity in the right posterior quadrant ( fig .  1 ) , which did not indicate cerebral infarction in terms of signal intensity and distribution . electroencephalography recorded while she had left hemiplegia demonstrated continuous epileptiform discharges located mainly in the right parieto - occipital areas and occasionally evolving to the right central area , indicative of focal non - convulsive status epilepticus ( fig .  2 ) . tc - hexamethylpropylene amine oxime - single photon emission computed tomography showed markedly high blood perfusion in the right parieto - temporo - occipital areas ( fig .  1 ) . on the basis of the diagnosis of nonconvulsive status epilepticus manifesting with ictal paresis , intravenous pht and oral sodium valproate were administered . her left hemiplegia improved gradually , although seven days were needed to obtain full voluntary movements . in the present elderly patient with dementia , the ictal paresis consisted of severe complete flaccid hemiplegia and lasted for a week , whereas , in previous reports , paresis is usually described as mild , , , , , , , , . reported an elderly male whose ictal paresis , though in mild degree , prolonged for a week similar to that of the present patient . patients with dementia are known to be at increased risk of developing seizures and epilepsy , which may also be in association with seizure severity . therefore , age and preexisting dementia , as in the present patient , can be possible factors associated manifestation of severe ictal paresis . there are two postulated pathophysiologies of ictal paresis : epileptic activities in negative motor areas which are located anterior to the face region of the primary or supplementary sensorimotor areas may affect voluntary movements , and epileptic activities in the sensorimotor area may activate an inhibitory system , . considering the distribution of eeg and spect findings , it is most likely that the ictal paresis of our patient was caused by the latter mechanism . in summary , ictal paresis can be as severe as complete flaccid hemiplegia and can last as long as for a week , especially in elderly patients with preexisting dementia . careful clinical consideration of the possibility of ictal paresis is needed , as this is potentially a treatable condition .
we report an 84-year - old female who showed a rare manifestation of epilepsy , ictal paresis , a type of simple partial seizure presenting with focal motor dysfunction . while the patient exhibited severe left hemiplegia which lasted for a week , cranial diffusion - weighted mri demonstrated slightly high intensity in the right posterior quadrant , and electroencephalography ( eeg ) showed continuous epileptiform discharges located mainly in the right parieto - occipital area , strongly suggesting that the patient was in an ictal state . 
 99mtc - hexamethylpropylene amine oxime - single photon emission computed tomography ( hmpao - spect ) showed markedly high blood perfusion in the right parieto - temporo - occipital areas . 
 considering the distribution of eeg epileptiform activities and hmpao - spect hyperperfusion , it is most likely that the ictal paresis of our patient was associated with epileptic activities at the sensorimotor area which caused either direct or indirect activation of an inhibitory system . 
 careful clinical consideration of the possibility of ictal paresis is needed in elderly patients , especially in those with preexisting dementia , because paresis can be as severe as complete flaccid hemiplegia and can last as long as for a week .