sensation referral of sensation (imrs) and extinction of pain and partial relief of
INTERMANUAL REFERRAL OFSENSATION (IMRS) AND EXTINCTION OF PAIN AND PARTIAL RELIEF OF MOTOR / SENSORY DEFICIT IN STROKE A .V. Srinivasan * , Rogers Ramachandr an** & V.S. Ramachandr an** *Institute of Neur ologyMadr as Medical College & Resear ch Institute, Chennai, India **Center for br ain and cognition, Univer sity of Califor nia at San Diego U.S.A
BA CKGROUND• ALLESTHESIA AND EXTINCTION OF REFERRAL SENSATION IN BRACHIAL PLEXUS LESIONS A.V. Srinivasan and V.S. Ramachandran et al (1998)• INTERMANUAL REFERRAL OF SENSATIONS AFTER CENTRAL LESIONS OF THE SOMATO SENSORY SYSTEM K. Sathian et al (2000)
METHODS• FIVE PATIENTS WITH HEMIPARESIS AND HEMISENSORY DEFICIT FOLLOWING STROKE ANALYSED (9-61 YEARS) THALAMUS : TWO TEMPERO PARIETAL : TWO BRAIN STEM : ONE• PATIENTS WERE VIDEO FILMED IN THE MOVEMENT DISORDER CLINIC.PINPRICK, COLD, VIBRATION AND KINESTHESIS WERE TESTED• MRI & ENMG IN ALL CASES
STROKE•Thalamus - Two•Temparo parietal - Two•Brain stem - One•Three to four months later•In one temperoparietal patient IMRS occurred within three weeks•Ipsilateral arm to leg - no referral
Case vignette 1• Lt. Hemiplegia 2 hrs denied of illness• His left foot resembled - dead friend leg• Accepted the disease but ignored the left side• Decreased the sensation on Lt. side excluding face• Poorly localized - Early IMRS
Case vignette 1• V.S. Ramachandran examined – IMRS confirmed• Pain & temperature not felt referred but felt as touch• Lt. side face touched radiated to neck• Extinction phenomenon – sixth day Video segment
Case vignette 1• Third week – topographically organized Intermanual referral of touch and vibration but not pain or temperature from normal (right) to mirror symmetric locations on the affected side.
Case vignette 1• Sixth week IMRS decreased substantially Intensive pressure on the normal arm seemed to partially decrease the sensory and possibly even the motor deficit in the paralyzed hand
Case Vignette 2• Intense pressure on the normal hand resulted in extinction of pain in the stroke side• Pain returned within one minute of the pressure• Intense pressure improved sensory and motor phenomenon
Case Vignette 3• Nine years boy• Rt. Hemiplegia with Hemisensory deficit and with IMRS• Developed Lt. Hemipareisis with hemisensory deficit• Disappearance of IMRS
DISCUSSIONAnatomical facts 1. Primary somato sensory area 3b 2. A. Primary somato sensory area 1 & 2 B. Second somato sensory cortex and parietal operculum In 2A & 2B The receptive fields are larger bilateral and callosal connection are abundant
DISCUSSION• Contralateral referral of sensations was not found in normal subjects or in hemiparietic patients without hemi sensory loss• Neural mechanisms for perceptual alteration not clear
DISCUSSION It appears that a decrease in somatosensory input to one cerebral hemisphere from the contralateral hand allows responsiveness of neurons in this hemisphere to moderately intense tactile stimuli on the ipsilateral hand to exceed perceptual threshold (which does not normally occur).
INTERMA NUA L REFERA L A ND EX TINCTION OF PA IN SENSA TION HEMIPARESIS WITH BRACHIAL HEMISENSORY DEFICIT AMPUTATION PLEXUSSPATIAL ORGANI-SATION EXCELLENT POOR EXCELLENT LOCALI-SATION GOOD POOR EXCELLENT TIME OF OCCURANCE AFTER 3 TO 4 MONTHS IMMEDIATE WITH IN IMMEDIATE WITH IN 7 DAYS 7DAYS PAIN AFTER A DELAY OF IMMEDIATE IMMEDIATE EXTINCTION 3 - 5 SECONDS
CONCLUSION• Intermanual Referral & Extinction of Pain Occurred after a delay in stroke.• Intermanual Referral of Sensation Occurred Topographically in a Organized Manner in stroke patients.
WE GRA TEFULLY A CKNOWLEDGE Mr. G. Kakuthan Mr. R. Sasikumar AndStanley Videos, Chennai, India