The sign wasnt placed there By the Big Printer in the sky Prof. A.V. SRINIVASAN, MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON) F.A.A.N, F.I.AN.Emeritus Professor - The Tamilnadu DR MGR Medical University 11th MAY, 2012
Thomas Elbert Basic Principles•Cortical representation expands linearly with use.• Synchronous inputs lead to fusion of cortical zones• Asynchronous inputs lead to segregation of cortical zones.•Disuse or De-afferentation leads to invasion of unused cortical area by nearby neurons.
Sensory modulation in spatial neglect Novel Techniques• Peripheral somatosensory- Magnetic stimulation• Repetitive optokinetic stimulation• Neck Vibration training Drug Treatment is currently unsuccessful
Sensory modulation and StrokeRehabilitation aimed to increase use ofparetic handVirtual realityMotor imageryProf. V.S..Ramachandran’s virtual realitybox • Phantom limb phenomenon
Other techniquesCaloric tests for balance • Brings awareness of illness to patient. Kinesthetic, visual, and auditory cuesto improve Parkinsonian gait.
INTERMANUAL REFERRAL OFSENSATION AND EXTINCTION OFPAIN IN PERIPHERAL ANDCENTRAL LESIONS OF SOMATOSENSORY SYSTEM Whatever the Mind can conceive and Believe, the mind can Achieve Napoleon Hill
BACKGROUNDAllesthesia and extinction of referralsensation in brachial plexus lesionsA.V. Srinivasan and V.S. Ramachandran et al (1998)Intermanual referral of sensations aftercentral lesions of the somato sensorysystemK. Sathian et al (2000) Every discovery contains an irrational element or 4 creative intuition Khrl Popper
METHODS8 patients (19-51 years) Brachial plexus lesion – one Amputation – two Stroke – five Patients were video filmed in the movement disorder clinic. Pinprick, cold, vibration and kinesthesis were tested MRI & ENMG in all cases Science is below the mind; Spirituality is beyond the mind
CENTRAL LESIONStrokeThalamic stroke - threeTemparo parietal - twoThree to four months later Ipsilateral arm - no referral to leg When they tell you to grow up, they mean stop growing
STROKE Contd…Intense pressure on the normal handresulted in extinction of pain in the strokesidePain returned within oneminute of the pressureIntense pressure improvedsensory and motorphenomenonOne is the most independent, unconventional and individualistic of all numbers
AMPUTATIONBoth the patients (belowelbow & knee amputation)showed intermanual referralof sensation within 10 days.The referred sensations oftouch and vibration lackedspatial organization andpoor localization with arelatively high threshold The Truth is Fear & Immorality are two of the greatest inhibitors of Performance to progress
CASE VIGNETTE (BRACHIAL PLEXUS LESION)21 year old girl, after totalbrachial plexus lesion wasexamined 6 months, 1 ½ &2 ½ years after the lesionShe had sensationsintermanually referred in atopographically organizedmanner in the phantom limb “Social Isolation is in itself a pathogenic Factor for disease production”
INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATION Hemiparesis with Brachial hemisensory Amputation plexus deficitSpatial organi- Poor Poor Excellent sation Localisation Good Poor Excellent Time of After 3 to 4 Immediate Immediate occurance months with in 7 days with in 7days Pain After a delay of Immediate Immediate Extinction 3 - 5 seconds Reputation is made in a moment; character is built in a life time
DISCUSSIONAnatomical facts 1. Primary somato sensory area 3b 2. A. Primary somato sensory area 1 & 2 2. B. Second somato sensory cortex and parietal operculumIn 2a & 2b the receptive fields are largerbilateral and callosal connection areabundant Two is the most gentle of all numbers and represents, diplomacy and tact
DISCUSSION Contd…Contralateral referral of sensations wasnot found in normal subjects or inhemiparetic patients without hemisensory lossNeural mechanisms for perceptualalteration not clear “Anger Begins In Folly And Ends In Repentance”
DISCUSSION Contd…It appears that a decreasein somatosensory input toone cerebral hemispherefrom the contralateral handallows responsiveness ofneurons in this hemisphereto moderately intensetactile stimuli on theipsilateral hand to exceedperceptual threshold(which does not normallyoccur). “By Nature All Men/ Women are alike but by Education widely different” - Chinese
CONCLUSIONIntermanual referral & extinction of painoccurred immediately in amputation andbrachial plexus lesions and after a delay instrokeIntermanual referral of sensation occurredtopographicaly organised manner inbrachial plexus lesions but not inamputation and stroke Experience can be defined as yesterday’s answer to today’s problems
Dedicated to my family for making everything worthwhile
My sincere gratitude to myTeachers, Collegues,Residents,Patients and Madras Institute of Neurology,MEDISCAN SYSTEMS & Mr.Thudhimugan for their computer work
We thankProf. V.S.Ramachandran, M.D., Ph.D.,DirectorCentre for Brain and CognitiveSciencesUniversity of California, San Diego,USA
READ not to contradict or confuteNor to Believe and Take for Grantedbut TO WEIGH AND CONSIDERTHANK YOU
Can the mind believe what the eye sees ? On vision, visuospatial dysfunction and body image perception in right hemispherical dysfunction Dr.K.Bijoy Menon (Senior Resident) Dr.Sundar, Dr.Saravanan, Dr.Ramakrishnan Dr.Nithyanandan (Asst.Prof) , Prof. A.V.Srinivasan
Indrani. 50 year old femalePresents with sudden onset ofweakness of left upper and lower limbO/E.– Conscious, oriented to time, place and person– Mild left UMN facial paresis– Left hemiplegia– All peripheral pulses palpable “Serious, sincere, systematic study surely secures supreme success”
CT Brain – P – Shows a (R)Occipitotemporal infarct Nine is the most humanitarian of all numbers. It is effort and sacrifice without the need for reward.
Higher mental function evaluation MMSE : 28/30 She was very attentive and quite clear in her conversation with us, though she would be complaining of a vague left sided shoulder painOn lobar testing, she had Left visual neglect with (L) hemianopia No auditory neglect Absent sensory perception in (L) upper limb and (L) tactile neglect in the lower limb “The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress”
Of a burning and unremitting character - F.W.PAVY
In any field, find the strangest thing and explore it
On cold caloric tests and its effect on neglect Discipline Weighs ounces Regret weighs Tons
Video of Neglect“You have got to be before you can do and do before you can have”
Video of caloric test and Nystagmus A true commitment is a heart felt promise to yourself from which you will not back down - D.
Video of disappearance of neglectEvery discovery contains an irrational element or 4creative intuition - Khrl Popper
On ‘ Mirror Agnosia’Mirror Agnosia on the Right A good teacher is a perpetual learner
After caloric test, Mirror Agnosia on the LeftThree is the most playful of all numbers and also creative, inspirational and motivating
‘Mirror Agnosia’ to frontFive is the most dynamic of all numbers. It is persuasive, versatile and adaptable
On Anosognosia, Body neglect(Hemisomatognosia) andsomatoparaphreniaAnosognosia – our patient has itBody neglect by Bisiach’s test – ourpatient does not have itSomatoparaphrenia – our patient has it Knowledge without action is useless; Action without knowledge is foolish
SomatoparaphreniaNumber sixth is the most loving of all numbers and is harmonious with all other number
On the somatophrenic arm and mirrorsNumber seven is the most spiritual of all numbers.It is the seeker of truth.
On Allesthesia, tactile neglect and ‘blind touch’‘Touch your left arm’ Bisiach’s test of bodyneglect.Absent proprioception and touch in the left upperlimbPatient is still able to touch her left arm whateverposition the examiner keeps the arm in. We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts -R.B. Schmeck