1404 - Recovery Reveals an Uncommon Presentation of Alien Hand Syndrome

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

Jessie P. Chan, MD (she/her/hers)

Resident Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States

Co-Author(s)

SJ

Stacey Jou, MD

Resident
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States
KH

Kristen A. Harris, MD

Attending Physician
JFK Johnson Rehabilitation Institute
Edison, New Jersey, United States

Case Diagnosis: Alien Hand Syndrome

Case Description: A 57 year-old male presented to inpatient rehabilitation (IPR) after a right parietal ischemic stroke with hemorrhagic conversion requiring hemicraniectomy, complicated by postoperative hematomas of right frontal lobe and thalamus seen on MRI brain. Evaluation during IPR noted left-sided spastic hemiplegia and neglect, severe apraxia, and language and attention deficits. After four weeks, the patient transitioned to a subacute facility (SAR) where significant physical assistance was still needed, but alertness and clarity of communication improved. He began identifying his left hand as his dog, asking staff to “get rid of it”. Cuing and mirror therapy allowed temporary re-orientation but there was persistent perseveration on the dissociation of the left hand. Alien Hand Syndrome (AHS) confounded by left spastic hemiplegia was deemed the most likely diagnosis.

Discussions: AHS typically presents as spontaneous and involuntary movements in the affected extremity that leads to a sensation of limb foreignness and personification. The frontal lobe, cingulate gyrus, corpus callosum, parieto-occipital lobe, and thalamus are frequently implicated, many of which are also associated with hemiparesis, hemineglect, and hand control. AHS has multiple variants with symptoms associated with localization of the lesion; anterior manifests with grasping, callosal involves interference of the affected limb with the unaffected one, and posterior is associated with abnormal limb posturing and sensory deficits. This case is atypical due to absence of the classic motor symptoms of AHS, likely masked by profound spastic hemiplegia in the extremity. Improvement of cognitive deficits and left hemineglect was required for the patient to begin expressing disconnect from his left hand, allowing for identification and management of AHS.

Conclusions: This case highlights a unique presentation of presumed AHS which limited participation in therapies. This case highlights the importance of ongoing clinical monitoring for emerging symptoms in patients with neurological diagnoses in SARs.