Supernumerary phantom limb as a rare symptom of epileptic seizures--case report and literature review

Supernumerary phantom limbs

Silas Weir Mitchell (1829-1914), justly regarded as one of the founding fathers of neurology, published accounts of phantom limbs in the 1860s and 1870s,1 around the time that neurology was emerging as an independent clinical discipline (although earlier accounts of phantom limbs are recognised2). Phantom limbs are most often observed in the context of amputation, but reports of extra limbs occurring without amputation have also appeared. Two brief cases are presented here to illustrate the clinical heterogeneity of the supernumerary limb, the possible pathophysiology of which is briefly considered.

Effects of combined rTMS and visual feedback on the rehabilitation of supernumerary phantom limbs in a patient with spinal cord injury: A case report

BACKGROUND

Supernumerary phantom limb (SPL) caused by spinal cord injury (SCI) has previously been reported in several studies. However, the mechanisms and management of SPL in SCI patients are still not fully understood. Herein, we report a rare case of SPL in a patient with incomplete SCI.

CASE SUMMARY

A 46-year-old man complained of four hands 7 d after SCI. He was diagnosed with SPL complicated with actual limb neuropathic pain. Following a period of treatment with neurotrophic agents and Chinese traditional and analgesic medications, SPL symptoms and actual limb pain did not improve. However, his symptoms gradually lessened after combined treatment with high-frequency repetitive transcranial magnetic stimulation (rTMS), a promising neuromodulation technique, over the M1 cortex and visual feedback. After 7 wk of this treatment, SPL disappeared completely and actual limb pain was significantly relieved.

CONCLUSION

Cerebral plasticity changes may be a mechanism underlying the occurrence of non-painful SPL in SCI patients, and high-frequency rTMS applied to the M1 cortex could be a promising treatment method for SPL.

Birth and death of a phantom

Patients with supernumerary phantom limb report experiencing an additional limb duplicating its physical counterpart, usually following a stroke with sensorimotor disturbances. Here, we report a short‐lasting case of a right upper supernumerary phantom limb with unusual visuomotor features in a healthy participant during a pure Jacksonian motor seizure unexpectedly induced by continuous Theta‐Burst Stimulation over the left primary motor cortex. Electromyographic correlates of the event followed the phenomenological pattern of sudden appearance and brutal dissolution of the phantom, adding credit to the hypothesis that supernumerary phantom limb results from a dynamic resolution of conflictual multimodal information.

Supernumerary phantom limb in a patient with basal ganglia hemorrhage - a case report and review of the literature

Background

Supernumerary phantom limb (SPL) is a rare neurologic phenomenon, in which a patient misperceives an extra limb in addition to the original set of limbs. We report a case of SPL in a patient with a right basal ganglia hemorrhage and review the previous literature about this peculiar phenomenon.

Case presentation

Two days after the event of a right basal ganglia hemorrhage, a 78-year-old male reported a phantom arm protruding from his left shoulder. He could not see or touch the phantom arm but he felt the presence of an addition arm lateral to his paretic arm. Pain or sensory discomfort were absent in either the paretic arm or the phantom arm. He stated that he could intentionally move the phantom arm independent of his paretic arm. The examination showed that the passive movement of his paretic arm did not elicit any movement of his phantom arm. We diagnosed the SPL as a complication of the hypertensive basal ganglia hemorrhage and treated him with anti-hypertensive medications. His phantom arm persisted for 3 weeks, and it gradually faded away.

Conclusion

SPL had been reported as a rare complication of various types of cerebral lesions. Right hemispheric lesions were most frequently associated with the SPL. Considering the intentional movement of the phantom arm, we deduced that the SPL might result from the impairment of the sensory feedback system for both internal body image and motor movement.

Cortico-thalamic disconnection in a patient with supernumerary phantom limb

Supernumerary phantom limb (SPL) designates the experience of an illusory additional limb occurring after brain damage. Functional neuroimaging during SPL movements documented increased response in the ipsilesional supplementary motor area (SMA), premotor cortex (PMC), thalamus and caudate. This suggested that motor circuits are important for bodily related cognition, but anatomical evidence is sparse. Here, we tested this hypothesis by studying an extremely rare patient with chronic SPL, still present 3 years after a vascular stroke affecting cortical and subcortical right-hemisphere structures. Anatomical analysis included an advanced in vivo reconstruction of white matter tracts using diffusion-based spherical deconvolution. This reconstruction demonstrated a massive and relatively selective disconnection between anatomically preserved SMA/PMC and the thalamus. Our results provide strong anatomical support for the hypothesis that cortico-thalamic loops involving motor-related circuits are crucial to integrate sensorimotor processing with bodily self-awareness.

Post-traumatic Visualized Supernumerary Phantom Limbs: A Case Presentation

The experience of supernumerary phantom limbs (SPLs) is a rare phenomenon known to occur following a variety of neurological ailments. This case report details visualized supernumerary phantom arms and legs in a polytrauma patient with suspicion of seizure as the primary contributing factor. Fewer than 30 cases of SPLs have been previously described. SPLs are usually confined to the phantom proprioception/sensation of the limb, with only 6 prior cases reporting visualized SPLs, all of which occurred in the setting of isolated stroke. This case presentation is notable because it is the first to describe visualized SPLs in a polytrauma patient.

LEVEL OF EVIDENCE

V.

Supernumerary phantom limbs in ICU patients with acute inflammatory demyelinating polyneuropathy

OBJECTIVE

To explore the previously undescribed phenomenon of phantom limb generation in patients with severe acute inflammatory demyelinating polyradiculoneuropathy (AIDP).

METHODS

Between April 2011 and January 2014, we encountered 3 patients with AIDP in our intensive care unit who experienced features of self-limited supernumerary phantom limbs (SPLs) during their course.

RESULTS

The following case series describes the phenomenon of SPLs in AIDP.

CONCLUSIONS

This report aims to raise awareness of the possibility of SPLs in the course of AIDP. The pathophysiology and management strategies for this clinical phenomenon are unknown.

Third International Congress on Epilepsy, Brain, and Mind: Part 2

Epilepsy is both a disease of the brain and the mind. Here, we present the second of two papers with extended summaries of selected presentations of the Third International Congress on Epilepsy, Brain and Mind (April 3-5, 2014; Brno, Czech Republic). Humanistic, biologic, and therapeutic aspects of epilepsy, particularly those related to the mind, were discussed. The extended summaries provide current overviews of epilepsy, cognitive impairment, and treatment, including brain functional connectivity and functional organization; juvenile myoclonic epilepsy; cognitive problems in newly diagnosed epilepsy; SUDEP including studies on prevention and involvement of the serotoninergic system; aggression and antiepileptic drugs; body, mind, and brain, including pain, orientation, the "self-location", Gourmand syndrome, and obesity; euphoria, obsessions, and compulsions; and circumstantiality and psychiatric comorbidities.

The effect of virtual visual feedback on supernumerary phantom limb pain in a patient with high cervical cord injury: a single-case design study

We characterized the effect of virtual visual feedback (VVF) on supernumerary phantom limb pain (SPLP) in a patient with high cervical cord injury. The subject was a 22-year-old man diagnosed with complete spinal cord injury (level C2) approximately 5 years ago. We applied the ABA'B' single-case design and set phases B and B' as intervention phases for comparison. SPLP significantly improved in comparison of phase A with phase B and phase A with phase B'. We suggest that VVF reduces SPLP and the effect lasts after VVF.