Case Report
Cerebrovasc Dis 2000;10:70–72

Received: July 15, 1998
Accepted: March 16, 1999

Alien Hand Sign after a Right Parietal
Infarction
J. Martı́-Fàbregas a J. Kulisevsky a E. Baró b G. Mendoza a C. Valencia a
J.-L. Martı́-Vilalta a
a Neurology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, and
b Nephrology Department, Fundació Puigvert, Barcelona, Spain

Abstract
Involuntary movements are unusual during or after
acute stroke, and alien hand sign has not been reported
after single parietal infarction. We report on a woman
who presented with involuntary movements and a sense
of alienness of her left upper limb following a right parietal infarction. This combination, that can meet the criteria for the ‘alien hand syndrome’, is rarely seen after
acute lesions sparing the corpus callosum and the mesial
frontal areas.
Copyright © 2000 S. Karger AG, Basel

Introduction

Alien hand sign (AHS) is a term introduced by Brion
and Jedynak [1] to describe the sense of alienness of one
limb experienced by patients with callosal lesion. More
recently, this sign was revisited to include autonomous
and observable motor activity of the hand [2]. AHS is
usually considered a type of disconnection syndrome
resulting from a corpus callosum and mesial frontal
lesion, either alone or in combination [2–4], but its local-

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izing value is controversial as it has also been reported
after lesions sparing the corpus callosum [5–8]. We describe a patient who developed AHS and involuntary
movements afte a single right parietal infarction, a topography, to our knowledge, previously not reported.

Case Report
An 81-year-old right-handed woman was admitted to the emergency room because of the acute onset of disorientation. She had
arterial hypertension and long-standing type II diabetes mellitus,
complicated by chronic renal insufficiency and requiring peritoneal
dialysis during the last 2 years, and a right ductal carcinoma of the
breast, diagnosed 1 month before admission and staged as T4N2M0.
Previously unknown atrial fibrillation was detected. At admission
she was disorientated and unaware that she had had a stroke. She also
had left hemiasomatognosia, left spatial neglect, mild sensory deficit
for tactile and pain modalities, left Babinski sign and bilateral
Achilles tendon areflexia. Position and vibration sensations were
intact. She presented spontaneous movements in the left arm that
were repetitive and consisting on large amplitude wrist pronosupination and wrist and finger flexion-extension. These movements
seemed to explore repeatedly the left side, were sometimes combined
with grasping the railing of the bed or the drip pole, and often hit
these or other nearby objects. The left arm sometimes struck her face
or the wall. Although highly patterned, these movements did not
have any discernible objective. The patient scornfully considered
that this arm was ‘silly’ and that it ‘liked to dance’ by itself when
asked about. She many times denied it belonged to her. Optic ataxia
was not present. When performing the maneuver recommended to

Dr. Joan Martı́-Fàbregas
Servei de Neurologia, Hospital de la Santa Creu i Sant Pau
E–08025 Barcelona (Spain)
Tel. +34 93 291 90 49, Fax +34 93 291 92 75
E-Mail jmartif@meditex.es

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Key Words
Alien hand W Cerebral infarction W Stroke W Ischemic stroke

a

b

Fig. 1a, b. T2-weighted brain MRI showing

a single right parietal infarction.

Discussion

To our knowledge, this is the first reported patient in
whom an isolated nondominant parietal infarction without corpus callosum involvement caused a clinical picture
compatible with contralateral AHS. Recently, Doody and
Jankovic [2] suggested that the AHS should include the
presence of both the feeling of foreignness and involuntary movements. Patients with nondominant parietal infarction can exhibit asomatognosia, in the sense that he or
she denies being the owner of his or her limb and can
make scornful comments about this limb in accordance
with the first condition of the AHS, namely the feeling of
foreignness or alienness. However, in the typical case, the

Alien Hand Sign after a Right Parietal
Infarction

limb is not out of control and it does not carry out involuntary movements. This second condition for the AHS,
the autonomous and observable involuntary movement
of the left arm, was remarkable in our patient.
Hyperkinetic disorders during and after acute stroke
are uncommon [9, 10]. In recent series, 29 out of 2,500
patients (1%) [9] and 9 out of 1,099 patients (0.8%) [10]
presented a movements disorder, but AHS was not diagnosed in any of them. The hyperkinetic involuntary
movements presented by our patients did not fit the definition of chorea, ballismus, tics, or myoclonus. Although
stereotypes have been described after a cerebral infarction
[11, 12], our patient did not exhibit the repetitive and
almost identical movements typical of stereotypes.
AHS is usually secondary to a corpus callosum lesion
either alone or in combination with a lesion in left, right
or both medial frontal areas, sometimes extending to
neighboring cortical regions, thalamus or basal ganglia [2–
4]. However, it has also been reported after localized
lesions sparing the corpus callosum: right capsulothalamic
hemorrhage [5], right posterior cerebral artery territory
infarction [6, 13], bilateral parietal infarctions [7] and
border-zone frontoparietal infarction [8], as well as in diffuse degenerative diseases [2]. It is clear from these exceptions that a corpus callosum lesion is neither necessary
nor sufficient to explain all reported cases of AHS and
that AHS does not have a definite localizing value.
Moreoever, the etiology of AHS is also variable, and
includes degenerative diseases [2], cerebral ischemia (infarct in anterior cerebral artery territory [2], border zone

Cerebrovasc Dis 2000;10:70–72

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explore alienness [1], she confused her hand with the examiner’s
hand. The movements could not be diminished voluntarily and,
although almost continuous, did not seriously interfere with voluntary ones, and she could point, catch and manipulate objects without
obvious difficulty. Intermanual conflict, diagonistic dyspraxia and
mirror movements were not observed. Except for disorientation that
vanished, these neurologic abnormalities persisted unchanged on day
4 when a CT scan demonstrated a right inferior parietal infarction.
An MRI confirmed this lesion without disclosing other additional
lesions (fig. 1). Mainly affected cerebral areas were 39 and 40. No
lesions were detected in the corpus callosum or other cerebral
regions. She received antiaggregant therapy with ticlopidine.
During the following weeks, asomatognosia improved but abnormal movements and the sense of alienness of the hand persisted
unchanged. She was discharged 2 months after stroke onset and died
3 months after discharge. According to her family, the abnormal
hand movements persisted until shortly before death.

infarction [8], posterior cerebral artery territory [6, 13],
middle cerebral artery territory [7]), cerebral hemorrhage
(of corpus callosum [4], capsulothalamic [5], rupture of an
anterior communicating artery aneurysm [2, 4]), traumatic and surgical injuries (callosotomy) [2], tumors [4, 14],
encephalitis [4] and epilepsy [14]. AHS in these situations
is usually transient, but can persist for months [4].
AHS has never been reported after a single right parietal infarction. Dolado et al. [7] reported a patient with
AHS and with an old left parietal infarction and an acute
right parietal infarction. Levine and Rinn [6] described a
patient with a right posterior cerebral artery infarction
with AHS and interpreted the clinical manifestation as an
optic-sensory ataxia. Ay et al. [13] reported a patient with
AHS after a right posterior cerebral artery infarction
involving the splenium of the corpus callosum, in whom
PET scans showed a focally reduced uptake in right fronto-parietal-temporal regions and attributed the clinical
findings to a triple ataxia (sensory, cerebellar and optic)
and the PET findings to diaschisis. In one reported
patient with AHS after a right capsulothalamic hemorrhage, cortical hypometabolism was detected by PET and
was most pronounced in the sensorimotor area [5]. Leiguarda et al. [14] reported paroxysmal AHS after a right
parietal hematoma. All these cases argue about the existence of a sensory or posterior type of AHS that should be
distinguished from the more common motor or anterior
AHS [3, 13].
The prevailing explanation for AHS indicates a dysfunction of one or both supplementary motor areas or its
connections, with release of contralateral and/or ipsilateral movements [2, 4]. Parietal lobes carry motor function,

related to active movements of the contralateral hand and
arm, and receives cortical afferents from primary and secondary sensorimotor areas and has reciprocal cortical
connections with the premotor and prefrontal cortices
[14]. The right parietal infarction in our patient could
cause a loss of sensory integration and feedback interfering with motor function. The ‘isolated’ parietal lobe
would then release these exploratory movements in the
absence of appropriate stimuli. An alternative explanation is the combination of a neglect syndrome and loss of
visual guidance of the affected limb (optic ataxia) that
give rise to AHS [2, 6, 13], but our patient had neither a
clear optic ataxia nor an occipital lesion.
We agree with other authors who believe that AHS can
result from different anatomic lesions and pathological
processes and that the combination of lesions necessary to
produce this sign is not certain. A right parietal infarction
alone may be sufficient to produce AHS, a fact previously
predicted by Doody and Jankovic [2], and should be added to the list of rare lesions sparing the corpus callosum
and causing AHS. However, caution should be needed
when labeling lesions outside the corpus callosum as an
AHS. In the sense given by Doody and Jankovic [2], our
patient met the main criteria of ‘sense of alienness plus
involuntary movements’. Labeling these patients as true
AHS may be an oversimplification for a previous useful
(in the sense of localizing value) concept [1], as such
patients may lack other tyical accompanying manifestations of ‘callosal AHS’, such as dyspraxia, intermanual
conflict or mirror movements. The AHS concept needs a
re-evaluation.

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Martı́-Fàbregas/Kulisevsky/Baró/Mendoza/
Valencia/Martı́-Vilalta
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