Pericallosal Artery Infarction & Alien Hand Syndrome

1. Pericallosal Artery Infarction
Alien Hand Syndrome
Ade Wijaya, MD – December 2018

2. Introduction
 Cerebral infarction in the territory of the anterior cerebral artery (ACA) is
often found accompanying middle cerebral artery (MCA) infarctions
 Isolated ACA stroke accounts for only up to 3–5% of strokes
 Pericallosal artery infactions are even rarer
 Mostly caused by emboli
 MRI (DWI) is highly sensitive for diagnosis
Kazui S, Sawada T, Naritomi H, Kuriyama Y, Yamaguchi T (1993) Angiographic evaluation of brain infarction limited to the anterior cerebral artery territory. Stroke 24:549–553
Kumral E, Bayulkem G, Evyapan D, Yunten N (2002) Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings. Eur J Neurol 9:615–624
Suwanwela NC, Leelacheavasit N (2002) Isolated corpus callosal infarction secondary to pericallosal artery disease presenting as alien hand syndrome. J Neurol Neurosurg Psychiatry 72:533–536
Gass A, Ay H, Szabo K, Koroshetz WJ (2004) Diffusionweighted MRI for the ‘‘small stuff’’: the details of acute cerebral ischaemia. Lancet Neurol 3:39–45

3. Anatomy

4. Radiology
Alonso A, Gass A, Rossmanith C, Kern R, Griebe M, Binder J, Hennerici MG, Szabo K. Clinical and MRI patterns of pericallosal artery infarctions: the significance of supplementary motor area lesions. Journal of neurology. 2012 May
1;259(5):944-51.

5. Clinical Presentation
 Etiology: Embolism either from cardiac origin or due to arterioarterial
propagation of thrombotic material
 Contralateral hemiparesis with lower limb predominance to be a core
symptom
 Motor hemineglect
 Decreased verbal fluency and mutism
 Acute confusional state
 Apraxia
 “Alien Hand Syndrome”
Alonso A, Gass A, Rossmanith C, Kern R, Griebe M, Binder J, Hennerici MG, Szabo K. Clinical and MRI patterns of pericallosal artery infarctions: the significance of supplementary motor area lesions. Journal of neurology. 2012 May
1;259(5):944-51.

7. Introduction
 A higher-order, motor control disorder featuring involuntary, yet purposeful,
movements
 The affected limb is typically the hand, although leg (alien limb phenomena)
involvement has been reported
 A complex sense of limb foreignness, including misidentifying the limb as the
examiner's. Sometimes the limb is personified
 AHS arise from the disruption of interhemispheric connections, and/or of the
connections between the frontal areas and the parietal lobes
Park YW, Kim CH, Kim MO, Jeong HJ, Jung HY. Alien hand syndrome in stroke - case report & neurophysiologic study. Ann Rehabil Med. 2012;36:556–560.
Chan JL, Chen RS, Ng KK. Leg manifestation in alien hand syndrome. J Formos Med Assoc.1996;95:342–346.
Carrilho PE, Caramelli P, Cardoso F, Barbosa ER, Buchpiguel CA, Nitrini R. Involuntary hand levitation associated with parietal damage: Another alien hand syndrome. Arq Neuropsiquiatr. 2001;59:521–525. Doody RS, Jankovic J. The alien hand and related
signs. J Neurol Neurosurg Psychiatry. 1992;55:806–810.

8. Associated Symptoms
 Decreased motor spontaneity
 Speech hesitation
 Apraxia
 Tactile dysnomia
 Behaviors associated with frontal lobe dysfunction
Brainin M, Seiser A, Matz K. The mirror world of motor inhibition: The alien hand syndrome in chronic stroke. J Neurol Neurosurg Psychiatry. 2008;79:246–252.

9. Etiology
 Anterior cerebral artery strokes
 Midline tumors
 Nurodegenerative illnesses
 Rarer causes include spontaneous pneumocephalus, migraine
aura, seizure, and Parry–Romberg Syndrome, a presumed autoimmune
disorder with progressive facial hemiatrophy
Sarva H, Deik A, Severt WL. Pathophysiology and treatment of alien hand syndrome. Tremor and Other Hyperkinetic Movements. 2014;4.

10. Kumral E. Compulsive grasping hand syndrome: A variant of anarchic hand. Neurology. 2001;57:2143–2144.

11. Treatment
Sarva H, Deik A, Severt WL. Pathophysiology and treatment of alien hand syndrome. Tremor and Other Hyperkinetic Movements. 2014;4.

12. Summary
 Pericallosal artery infarction is a rare condition
 Mostly due to emboli
 Diagnosed by MRI
 One of the clinical presentation is the “Alien Hand Syndrome”
 AHS is a higher-order, motor control disorder featuring involuntary, yet
purposeful, movements
 AHS arise from the disruption of interhemispheric connections, and/or of the
connections between the frontal areas and the parietal lobes
 No approved or recommended therapies for AHS
 Functional imaging might help to study further about this entity

13. THANK YOU