Dominant posterior-variant alien hand syndrome after acute left parietal infarction

The Alien Limb Phenomenon in Creutzfeldt-Jakob Disease: A Systematic Review of Case Reports

Alien limb phenomenon (ALP) is a clinical finding seen in numerous neurological disorders, including Creutzfeldt-Jakob disease (CJD). We aimed to conduct a systematic review to update advances in understanding the classification and pathophysiology of ALP in CJD. We used PubMed advanced-strategy searches and only included full-text observational studies and case reports conducted on humans and written in English. We used the PRISMA protocol for this systematic review and the Methodological Quality of Case Reports tool to assess the bias encountered in each study. After applying the inclusion/exclusion criteria, 10 case reports were reviewed. Two independent reviewers analyzed data and confirmed the phenotype of each case of the alien limb in CJD separately. Overall, the most prevalent ALP phenotype presenting in patients with CJD was the posterior phenotype, usually in the early stages of the disease. Our findings corroborate previous research in demonstrating the pathophysiology behind ALP in CJD. We suggest physicians suspect CJD whenever patients present with ALP as the initial symptom.

Posterior Alien Hand Syndrome from Acute Ischemic Left Parietal Lobe Infarction

Alien hand syndrome (AHS) is defined as an involuntary goal-directed movement of the hand as if acting on its own will, or as being under the control of someone else. Moreover, the affected hand typically does not show any signs of weakness or convulsive movement. The cause of AHS is associated with an insult to the brain from various conditions such as stroke, trauma, tumor, aneurysm, neurosurgical intervention, infection, and degenerative brain diseases. We hereby illustrate a case of a patient with chronic atrial dysrhythmia whose oral anticoagulation therapy was placed on hold by his gastroenterologist for a scheduled colonoscopy. The patient presented to the hospital with symptoms of right-hand paresthesia with uncontrolled movement. These symptoms were seen along ST-segment elevation in the inferior leads on a 12 lead electrocardiogram. The case report acknowledges an unusual presentation of acute ischemic stroke, which may be frightening and bewildering to patients, their families, and any healthcare providers, including neurologists, who may have encountered it for the first time. Also, our patient had posterior AHS, likely from infarction involving the left inferior parietal lobe, which is reported to have a low prevalence.

[Right parietal cerebral infarction with symptoms challenging to differentiate between alien hand sign and sensory ataxia: a case report]

We report the case of a 73-year-old right-handed female with a right parietal cerebral infarction and presented symptoms that were challenging to differentiate between alien hand sign (AHS) and sensory ataxia. She presented to our emergency department with chief complaints of abnormal involuntary movements and a feeling of foreignness on her left upper limb. The first neurological examination revealed left spatial neglect, left-side sensory impairment that included superficial and deep sensations, left limb-kinetic apraxia, and left limb ataxia. Furthermore, her symptoms and complaints had characteristics of AHS that includes a sensation that her left upper limb dose not belong to herself and an abnormal behavior of left hand that is contrary to her own intent. Brain MRI revealed an acute cerebral infarction confined to the right postcentral gyrus. This case highlights that sensory ataxia due to the disturbance of deep sensation might present symptoms similar to AHS. Previous studies suggested the involvement of the disturbance of somatosensory pathway in posterior-variant AHS. Therefore, a precise distinction between AHS and sensory ataxia, especially in posterior-variant AHS, is imperative to avoid confusion regarding the term "alien hand sign."

Alien hand syndrome and migraine with aura: A case report

BACKGROUND

Alien Hand Syndrome (AHS) is an uncontrollable, involuntary, but in appearance, purposeful motor control disorder of the upper extremity.

CASE REPORT

A 42-year-old male patient was admitted to our clinic complaining of involuntary motor activity in his right hand. He had a previous history of migraine with visual aura. The uncontrollable motor control disorder was compatible with Alien Hand Syndrome, which was appearing immediately after the visual aura and before the beginning of headache.

CONCLUSION

Alien Hand Syndrome is usually observed with anterior cerebral artery infarction, midline tumors, trauma and several neurodegenerative diseases, but is rarely seen in paroxysmal conditions such as migraine with aura.

Alien Hand Syndrome

Alien hand syndrome (AHS) is a rare disorder of involuntary limb movement together with a sense of loss of limb ownership. It most commonly affects the hand, but can occur in the leg. The anterior (frontal, callosal) and posterior variants are recognized, with distinguishing clinical features and anatomical lesions. Initial descriptions were attributed to stroke and neurosurgical operations, but neurodegenerative causes are now recognized as most common. Structural and functional imaging and clinical studies have implicated the supplementary motor area, pre-supplementary motor area, and their network connections in the frontal variant of AHS, and the inferior parietal lobule and connections in the posterior variant. Several theories are proposed to explain the pathophysiology. Herein, we review the literature to update advances in the understanding of the classification, pathophysiology, etiology, and treatment of AHS.

When Playing Is a Problem: An Atypical Case of Alien Hand Syndrome in a Professional Pianist

Alien hand syndrome (AHS) is a neurological illness characterized by limb movements which are carried out without being aware of it. Many patients describe these movements as aggressive and some perceive a strong feeling of estrangement and go so far as to deny ownership. The sense of body ownership is the perception that parts of one’s body pertain to oneself, despite it is moving or not and if movement is intentional or unintentional. These anomalous self-experiences may arise in patients with focal brain lesions and provide unique opportunities to disclose the neural components underlying self-body perception. The feeling of foreignness described in AHS is often observed in post-central cortical lesions in the non-dominant hemisphere and is typical of the “posterior alien hand variant”. We used Diffusion-Tensor magnetic resonance imaging (DT-MRI) in an unusual case of posterior AHS of the dominant hand in a professional pianist with corticobasal syndrome (CBS). The patient showed uncontrolled levitation with the right arm while playing the piano and perceived as if her hand had a “mind of its own” which prevented her from playing. MRI-scans show asymmetric brain atrophy, mainly involving left post-central regions and SPECT-Tc99m-ECD patterns of hypometabolism over the left parietal-occipital cortices. DT-MRI revealed extensive damage which comprised left fronto-temporal cortex and extends into the ipsilateral parietal cortex causing a disruption of corpus callosum (CC) projections from the rostrum to the splenium. Our case illustrates that posterior AHS may occur in the dominant hemisphere due to widespread damage, which exceed parietal cortex. The parietal lobe has been recognized as a multimodal association region that gets input from several networks and organizes motor output. We suggest that the disturbance to this pathway could result in disruption of motor output and associate an abnormal motor control and anomalous self-body perception.

Paroxysmal posterior variant alien hand syndrome associated with parietal lobe infarction: case presentation

Alien hand syndrome (AHS) is an involuntary and rare neurological disorder emerges at upper extremity. AHS is a disconnection syndrome with the symptoms of losing sense of agency and sense of ownership, and presence of involuntary autonomic motor activity. There are frontal, callosal and posterior types of AHS and each of them occurs depend on the lesions of different of the brain. Posterior variant is a rarely encountered AHS type compared to others. AHS, generally regarded as persistent, but rarely maybe observed as paroxysmal. In this article, we present 71 year old patient with right posterior parietal lobe infarction and developed posterior variant AHS on left arm 1 month after discharge from the hospital. To discriminate AHS from conditions such as extrapyramidal movement disorders and epileptic seizures that take part in differential diagnosis should be kept in mind by the clinicians. Wrong and unnecessary treatments could be prevented in this way.

Biparietal variant of Alzheimer's disease: a rare presentation of a common disease

Alzheimer's disease (AD) is a clinically heterogeneous disease that may have atypical presentations with focal cortical syndromes and relatively preserved episodic memory. The posterior variant of AD has two subtypes: occipitotemporal, presenting with visuoperceptive impairment, and biparietal, presenting with visuospatial dysfunction and apraxia. We report a case of a 51-year-old woman with progressive limb apraxia and choreiform movements. Her neuropsychological evaluation was compatible with dementia, and revealed ideomotor and ideational limb apraxia, severe visuoconstructive ability impairment, dyscalculia and posterior aphasia. Workup excluded metabolic, infectious, inflammatory or neoplastic causes, and hereditary conditions as Huntington's disease and familial AD. Cerebrospinal fluid biomarkers revealed β-amyloid reduction and τ protein increase. Brain imaging showed marked biparietal atrophy and hypoperfusion, and widespread cortical β-amyloid deposition. Biparietal variant of AD was diagnosed and acetylcholinesterase inhibitor treatment induced clinical stabilisation. AD may present with atypical features and a high clinical suspicion is necessary for an early diagnosis.

Pathophysiology and treatment of alien hand syndrome

Background

Alien hand syndrome (AHS) is a disorder of involuntary, yet purposeful, hand movements that may be accompanied by agnosia, aphasia, weakness, or sensory loss. We herein review the most reported cases, current understanding of the pathophysiology, and treatments.

Methods

We performed a PubMed search in July of 2014 using the phrases “alien hand syndrome,” “alien hand syndrome pathophysiology,” “alien hand syndrome treatment,” and “anarchic hand syndrome.” The search yielded 141 papers (reviews, case reports, case series, and clinical studies), of which we reviewed 109. Non-English reports without English abstracts were excluded.

Results

Accumulating evidence indicates that there are three AHS variants: frontal, callosal, and posterior. Patients may demonstrate symptoms of multiple types; there is a lack of correlation between phenomenology and neuroimaging findings. Most pathologic and functional imaging studies suggest network disruption causing loss of inhibition as the likely cause. Successful interventions include botulinum toxin injections, clonazepam, visuospatial coaching techniques, distracting the affected hand, and cognitive behavioral therapy.

Discussion

The available literature suggests that overlap between AHS subtypes is common. The evidence for effective treatments remains anecdotal, and, given the rarity of AHS, the possibility of performing randomized, placebo-controlled trials seems unlikely. As with many other interventions for movement disorders, identifying the specific functional impairments caused by AHS may provide the best guidance towards individualized supportive care.

Stroke syndromes and clinical management

The knowledge of brain syndromes is essential for stroke physicians and neurologists, particularly those that can be extremely difficult and challenging to diagnose due to the great variability of symptom presentation and yet of clinical significance in terms of potential devastating effect with poor outcome. The diagnosis and understanding of stroke syndromes has improved dramatically over the years with the advent of modern imaging, while the management is similar to general care as recommended by various guidelines in addition to care of such patients on specialized units with facilities for continuous monitoring of vital signs and dedicated stroke therapy. Such critical care can be provided either in the acute stroke unit, the medical intensive care unit or the neurological intensive care unit. There may be no definitive treatment at reversing stroke syndromes, but it is important to identify the signs and symptoms for an early diagnosis to prompt quick treatment, which can prevent further devastating complications following stroke. The aim of this article is to discuss some of the important clinical stroke syndromes encountered in clinical practice and discuss their management.

Sequelae of a left-sided parietal stroke: posterior alien hand syndrome

Posterior alien hand syndrome is a new addition to a poorly understood group of movement disorders. Historically, anatomical lesions causing uncontrolled limb movement and a feeling of foreignness were found to be located in the corpus callosum or frontal lobe. Recent case reports, however, demonstrate the typical symptoms of alien hand syndrome with lesions located in the parietal/occipital lobes. Disturbance of normal function in these regions tends to produce less complex motor activity, such as hand levitation, along with a sensory component characterized by feeling of estrangement. We discuss a patient who presented with unusual symptoms following an outpatient procedure and was found to have posterior alien hand syndrome.

Posterior alien hand in a left-handed person

Posterior alien hand syndrome usually involves the non-dominant hand with lesions usually in the right hemisphere. This is the first case in a left-handed person, involving the dominant hand.