Neuroradiology (2002) 44: 921–923
DOI 10.1007/s00234-002-0839-2

S. Rohde
S. Weidauer
H. Lanfermann
F. Zanella

Received: 17 June 2002
Accepted: 26 June 2002
Published online: 28 September 2002
Ó Springer-Verlag 2002

S. Rohde (&) Æ S. Weidauer
H. Lanfermann Æ F. Zanella
Institute of Neuroradiology, Johann
Wolfgang Goethe University, Schleusenweg
2–16, 60528 Frankfurt am Main, Germany
E-mail: Stefan.Rohde@kgu.de
Tel.: +49-69-63015462
Fax: +49-69-63017176

DIAGNOSTIC NEURORADIOLOGY

Posterior alien hand syndrome: case report

Abstract The alien hand syndrome
(AHS) is involuntary uncontrolled
movement of an arm with a sense of
estrangement from the limb itself.
AHS was initially used to describe
interhemispheric disconnection phenomena in patients with lesions in
the anterior corpus callosum, but it
has been found in patients with
posterior cerebral lesions without
involvement of the corpus callosum,
for example parietal infarcts or
corticobasal degeneration. The
posterior alien hand syndrome is less

Introduction
The alien hand syndrome (AHS) is defined as involuntary uncontrolled but partly purposive movement of an
arm or hand with a feeling of foreignness or personification concerning the affected limb. The complex
autonomous motor activity can be differentiated from
other movement disorders [1]. The main features are
persistent groping of the affected hand, compulsive
manipulation of tools, intermanual conflict and aggressive actions, such as hitting or touching the face and
body. Patients perceive these movements as aggressive
and hostile; they often feel threatened and terrified by
the affected limb [2].
Goldstein [3] first described the syndrome in a discussion of apraxias in 1908. The term AHS was introduced in 1972 by Brion and Jedynak [4] to describe a
feeling of alienness of an arm in patients with lesions of
the corpus callosum. Initially the term was restricted to
those with disturbed interhemispheric communication
due to lesions of the anterior corpus callosum alone.
Since 1982 acceptable usage has broadened considerably,
defining AHS more generally as a cluster of clinical

frequent and presents with nonpurposive behaviour like lifting the arm
or writhing fingers. We report an
80-year-old woman with a posterior
AHS of the dominant right hand.
MRI showed atrophy of the pre- and
postcentral gyri without involvement
of the corpus callosum. We discuss
the aetiology of the posterior AHS
and the differences from the anterior
varieties.
Keywords Posterior alien hand
syndrome Æ Cerebral infarct

features without specific neuroanatomical correlation
[5,6]. One reason for was due the finding, that AHS can
result from lesions in different sites [7]. At present, three
subtypes are recognised: two frontal and one parietal,
with different underlying lesions and clinical presentations. In the frontal varieties, AHS with associated
lesions in the language-dominant medial frontal cortex
and anterior corpus callosum is differentiated from AHS
caused by a lesion in the anterior corpus callosum alone.
The term posterior AHS is used for patients with lesions
of the parietal and occipital cortex and subcortical areas,
excluding the corpus callosum [1, 8, 9]. While frontal
and frontomedial AHS is more likely to present with
exploratory grasping, compulsive manipulation and
intermanual conflict, these specific and seemingly purposive movements are less distinct in posterior AHS [6].

Case report
An 80-year-old woman complained of slowly progressive immobility of her right arm over 3 years. Apart from arterial hypertension she was well until the age of 77 years when she first noticed
impairment of controlled movement of her right hand, that became

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progressive. She felt as if her right hand did not belong to her and
had a ‘‘mind of its own’’, complaining that her right arm ‘‘doesn’t
do what it’s supposed to’’. The involuntary movement consisted
primarily of uncontrolled elevation of the right arm, sometimes
provoked by a sudden noise or cough.
On examination, the patient was alert and orientated. Cranial
nerves were intact. Extension of the right hand and fingers was
markedly reduced, but flexion was nearly normal. Muscular tone
of the right arm and right-handed reflexes were slightly increased,
but no pyramidal signs were observed. Although not paretic,
movements of her right shoulder and upper arm were markedly
delayed. She was unable to imitate with her right hand postures
adopted by the left and showed her left hand when asked to
show the right.
MRI showed marked atrophy of the left pre- and postcentral
gyri (Fig. 1) and white-matter lesions of their subcortical areas
without involvement of the corpus callosum (Fig. 2). Cervical MRI
was normal.

Fig. 1a, b. Axial MRI. a
T1-weighted image showing
marked atrophy of the left preand postcentral gyri with
enlargement of the central
sulcus. b A T2-weighted image
reveals high signal in the
subcortical white matter

Fig. 2a, b. Sagittal T2-weighted
images. a A midline image
showing no circumscribed lesion
in the corpus callosum. b A left
paramedian image shows extensive high signal in subcortical
and deep white matter,
especially parietal

Discussion
Isolated cases of AHS without involvement of the corpus callosum have been reported [8, 9, 10, 11,12]. The
patients had lesions in the parietal cortex and subcortical
areas, mainly caused by parietal infarcts or corticobasal
degeneration. AHS-like symptoms have been described
in one patient with epileptic seizures [13].
In the posterior AHS movement disorders are less
specific. The affected arm often shows undirected nonpurposive movements and there is no intermanual
conflict. In contrast to their classical frontal counterparts, sensory phenomena are described [1]. Disrupted
cortico-striato-thalamic function which leads to poor

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proprioception and sensory ataxia is a possible underlying pathology AHS [6]. In one report there was
abnormal basal ganglia blood flow in a patient with
hemidystonia while CT, angiography and electroencephalography (EEG) were normal [14].
Our patient fulfils the criteria for posterior AHS. She
described strong feeling of estrangement from the affected limb. The distinct feeling of foreignness goes beyond
the common apraxic disorder or absent perception of a
limb in the sense of anosognosia or asomatognosia.
Early on, a sudden noise or cough provoked uncontrolled lifting of the arm. To our knowledge, this has not
previously been described the AHS.
MRI showed left central/parietal cortical and subcortical lesions and extensive atrophy of the pre- and
postcentral gyri. We think these changes to be most
likely of vascular origin, because of the subacute onset of
the symptoms. Pathognomonic symptoms for corticobasal degeneration, such as extrapyramidal symptoms or
dementia were absent. There was no signal change in the
corpus callosum, thalamus or basal ganglia.

We think the sensation of estrangement is due to a
distortion of the body image secondary to the postcentral cortical lesions, even though this phenomenon
is usually observed in the nondominant hemisphere.
The progressive involvement of the left pyramidal
tract by a vascular process could have hindered the
development of further involuntary movements. Bundick and Spinella [6] reported a posterior AHS caused
by an infarct in the middle cerebral artery territory
with motor symptoms disappearing while the patient
was in hospital, while the proprioceptive disorder
persisted.
The intensity of symptoms and subjective perception
of the movements may differ between individuals
because of the multifocal underlying pathology in posterior AHS. Moreover, they may follow a more dynamic
course than their frontal counterparts. Some symptoms
of posterior AHS may appear only for a limited time
while others persist or progress with the underlying
process.

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