Transient Left Alien Hand Syndrome after Left Anterior Cerebral Artery Infarction.

Sir,

Alien hand syndrome is a movement disorder characterized by involuntary and autonomous movements. Alien hand syndrome may be transient in patients with partial loss of the corpus callosum genu and splenium. A 49-year-old right-handed woman presented with difficulty in speech and mild right-sided weakness. She had type 2 diabetes mellitus and hypertension for 15 years and had no addictions. She was on insulin for diabetes and amlodipine for hypertension. She had involuntary and purposeless movements of the left hand and abnormal feelings in the left upper limb and had intermanual conflict (e.g., the patient's left hand took off her clothing while she attempted to dress with the right hand), suggesting Alien hand syndrome. Her fluency and comprehension was reduced with preserved repetition. She had left-sided tactile anomia, ideomotor apraxia, left-hand agraphia, and alexia in left visual field. She had no delusions or hallucinations. Fundus showed nonproliferative diabetic retinopathy. She had mild right hemiparesis, and Babinski sign was positive on the right side. Frontal lobe release signs such as reflexive grasping, palmomental reflex, and snout reflex were absent. Biochemical parameters showed mild renal failure (serum creatinine −2.6 mg %) and glycated hemoglobin was 9.5%. Magnetic resonance imaging of brain showed hypointensity in the body of corpus callosum (left half more than the right half) extending to left cingulate gyrus, inferior aspect of paracentral lobule, and anterior aspect of precuneus on T1-weighted image and hyperintensity on T2-weighted and fluid-attenuated inversion recovery images in the same area. Diffusion-weighted imaging showed high signal intensity with the corresponding restricted diffusion on the apparent diffusion coefficient sequences. Magnetic resonance imaging (time of flight) showed narrowing and occlusion of A2 and A3 segments of the left anterior cerebral artery [Figure 1a–d]. She was treated with antiplatelets, atorvastatin, and insulin. When reviewed after a month, she had improvement in her symptoms, but the speech abnormality and alexia in the left visual field were persisting.

Figure 1

Magnetic resonance imaging of brain showing hyperintensity in the body of corpus callosum (left half more than the right half) extending to left cingulate gyrus, inferior aspect of paracentral lobule, and anterior aspect of precuneus on T2-weighted sagittal image (a). Diffusion-weighted imaging showing high signal intensity (b) with corresponding restricted diffusion on the apparent diffusion coefficient sequences (c). Magnetic resonance imaging (time of flight) showing narrowing and occlusion of A2 and A3 segments of left anterior cerebral artery (d)

Corpus callosum is by far the largest of the nerve fiber bundles that directly connect one cerebral hemisphere with the other. Infarcts involving the corpus callosum are not common, due to its rich blood supply from three main arterial systems, specifically the anterior cerebral, anterior communicating, and posterior cerebral arteries.[1] Alien hand syndrome has been reported to be associated with several abnormal involuntary movements when different regions of the brain, such as the corpus callosum, parietal region, or frontal region, are involved. Alien hand syndrome may be transient in patients with partial loss of the corpus callosum genu and splenium; in addition, patients with unilateral callosal lesions may regain connectivity between the two hemispheres if the remaining corpus callosum is functional.[23] Our patient had spontaneous recovery of symptoms following antiplatelet therapy suggesting that the remaining corpus callosum may have compensated for the infarcted area, and that connectivity between the bilateral cerebral hemispheres was re-established.

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