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position-dependent levitation of the dominant arm that increased by tactile stimulation.

Position-Dependent Levitation of the Dominant
Arm After Left Parietal Stroke:
An Unreported Feature of Posterior
Alien Limb Syndrome?
F.A.A. Gondim, MD, MSc, PhD,1,2,4 G.R. Oliveira, MD,3
and S. Cruz-Flores, MD4*
1

Departamento de Fisiologia e Farmacologia, Universidade
Federal do Ceará, Fortaleza, Ceará, Brazil
2
Department of Neurology, Weill Medical College of Cornell
University, New York, New York, USA
3
Department of Neurology, Albert Einstein School of
Medicine, Bronx, New York, USA
4
Souers Stroke Institute, Department of Neurology, Saint
Louis University Hospital, St. Louis, Missouri, USA

Abstract: We describe a patient with an unreported feature of
posterior alien limb phenomenon characterized by positiondependent levitation of the dominant arm exacerbated by tactile
stimulation and associated with low-amplitude tremor of the
fingers of the right hand in addition to a sensation of strangeness in the arm, secondary to a left parietal stroke. © 2005
Movement Disorder Society
Key words: alien hand phenomenon; arm levitation; parietal
lobe ischemic stroke
Goldstein first reported alien hand symptoms in 1908, in a
patient who perceived her left hand as having a will of its own.1
The condition gained more attention when Brion and Jedynak2
described the denial of hand ownership and inability of interhemispheric exchange in patients with corpus callosum tumors.
Alien hand syndrome (AHS) is defined as a combination of
observable involuntary motor activity and feeling of strangeness or foreignness of one limb. Two AHS subtypes have been
described classically: one secondary to callosal and the other to
frontal lesions.3 An uncommon posterior variant was reported
more recently resulting from lesions in the nondominant hemisphere caused by stroke or corticobasal ganglionic degeneration.3–5 Sustained, nonpurposeful, nonconflictive movements
characterize this variant and include arm levitation and finger
writhing.3– 6
We describe a patient with posterior AHS secondary to a left
parietal lobe infarct with a previously unreported feature: a

This article includes Supplementary Video, available online at http://
interscience.wiley.com/jpages/0885-3185/suppmat.
*Correspondence to: Dr. Salvador Cruz-Flores, Department of Neurology, SLUH, 3635 Vista Avenue at Grand Blvd., St. Louis, MO
63110. E-mail: SALVADOR.Cruz-flores@tenethealth.com
Received 12 April 2004; Revised 25 August 2004; Accepted 21
September 2004
Published online 23 February 2005 in Wiley InterScience (www.
interscience.wiley.com). DOI: 10.1002/mds.20404

Movement Disorders, Vol. 20, No. 5, 2005

Case Report
A 63-year-old, right-handed woman with history of smoking
presented with right hemiparesis and dysarthria of sudden
onset. A computed tomography (CT) scan of the head documented an ischemic stroke in the territory of the left middle
cerebral artery. She was found to have 60% stenosis of the left
carotid artery with ulceration. During her recovery, her hemiparesis worsened and an urgent left carotid endarterectomy was
carried out. Her hemiparesis improved after few months but she
had residual paresthesias in the right upper extremity. She
subsequently noticed a sense of “strangeness” and some involuntary movements in the right arm associated with the paresthesias. A brain magnetic resonance imaging (MRI) revealed
scattered infarcts involving the highest portions of the left
parietal lobe, with minimal frontal extension and corpus callosum sparing (Fig. 1).
Her neurological exam demonstrated fluent speech with normal comprehension, repetition, and naming. Her cognitive
function was normal. She had no frontal release signs (grasping
or palmomental reflex), right-to-left disorientation, intermanual
conflict, gait, or limb apraxia. Cranial nerves were normal. She
had a right upper extremity paresis (proximally 5-/5 and distally 3/5). Her reflexes were brisk and her tone was increased
mildly in the right limbs. Plantar response was flexor bilaterally. She also had mild dysmetria in the right upper extremity.
Pinprick, vibration, and proprioception were decreased in the
right upper extremity. She demonstrated a slow levitation of her
right upper extremity while in supination that was increased
significantly by gentle pressure over the biceps tendon. Slow,
low-amplitude tremor involving the fingers of the right hand
was also noted during the arm levitation (see Video). Movements were decreased by assuming the pronator position but
were not stopped by distraction or during performance of
simultaneous complex movements involving multiple limbs.
No exploratory or self-mutilating behavior was reported. The
patient was perplexed but not angered or frightened by the
movements.

Discussion
Our patient exhibited a constellation of symptoms
consistent with the posterior variant of AHS. Similar to a
recently published case,5 she had involuntary movements
consisting of arm levitation. The exploratory behavior or
compulsive manipulation of objects that are common in
patients with frontal alien hand phenomenon were not
present. She did not exhibit intermanual conflict but had
a feeling of strangeness or foreignness of her right arm,
which combined with her involuntary movements, points
to the diagnosis of alien limb phenomenon.7
Her involuntary movements consisted mainly of right
arm levitation and mild slow, low-amplitude tremor of
the right fingers (see Video). To the best of our knowledge, her pattern of arm levitation was significantly
different from previous cases, firstly because her levitation was position-dependent as it was obvious in supina-

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633

FIG. 1. Fluid attenuated inversion recovery
(FLAIR) MRI carried out after left carotid endarterectomy. Depicts a predominant high left
parietal infarct with minimal left frontal lobe
involvement.

tion but absent in pronation. Secondly, her levitation was
enhanced markedly by gentle finger pressure over the
biceps tendon, suggesting facilitation by proprioceptive
stimulation. Moreover, the movements were not stopped
by distraction, because they were present during the
simultaneous performance of multiple complex commands. Interestingly, when we asked the patient to counteract the levitation movements, she was not able to
unless she voluntary moved her arm to the original
supine position after significant effort.
AHS encompasses a diverse combination of symptoms. Currently there is some disagreement about the
requirement of “denial of ownership” in the diagnostic
criteria, because isolated arm levitation was described
recently in patients with progressive supranuclear palsy.8
Arm levitation is also part of the parietal motor syndrome characterized by slow levitation or sideward deviation of the forearm when patients are asked to keep
both arms extended forward.9 Sensory AHS was described in about 25% of these patients.9
The etiology of the involuntary movements in the
posterior AHS is not clear. A distortion of body schema
secondary to an abnormal cortico-striato-thalamic circuit
was proposed as the explanation although the precise
neuroanatomical circuitry is yet to be understood.3,4
In our patient the clinical and MRI findings supported
the diagnosis of posterior AHS resulting from a lesion of
the left parietal lobe without the thalamic involvement
observed in most reported cases. In light of this case, it
seems that the posterior AHS variant is not restricted to
nondominant parietal lesions.
In summary, we report a case of posterior alien limb
syndrome secondary to a left parietal infarct with features not reported previously including a position-dependent, pressure-evoked levitation of the dominant arm.

Legend to the Video
Position-dependent right arm levitation is demonstrated during performance of neurological examination.
When the right arm is in supination, slow arm levitation
is observed and is associated with tremor of the righthand fingers. Gentle pressure over the right biceps tendon accelerates arm levitation and pronation of the arm
abolishes the movement. Distraction by talking or performance of complex tasks involving the other limbs
does not interfere with arm levitation. Arm levitation
cannot be slowed, but only stopped abruptly by opposing
strong volitional movements.
References
1. Goldstein K. Zur Lehre der motorischen Apraxie. Journal fur Psychologie und Neurologie 1908;11:169 –187.
2. Brion S, Jedynak CP. Troubles du transfert interhemispherique. A
propos de trois observations de tumeurs du corps calleux. Le signe
de la main étrangère. Rev Neurol (Paris)1972;126:257–266.
3. Scepkowski LA, Cronin-Golomb A. The alien hand: cases, categorizations, and anatomical correlates. Behav Cogn Neurosci Rev
2003;2:261–277.
4. Ay H, Buonanno FS, Price BH, Le DA, Koroshetz WJ. Sensory
alien hand syndrome: case report and review of the literature.
J Neurol Neurosurg Psychiatry 1998;65:306 –369.
5. Bundick T Jr, Spinella M. Subjective experience, involuntary movement, and posterior alien hand syndrome. J Neurol Neurosurg Psychiatry 2000;68:83– 85.
6. Carrilho PEM, Caramelli P, Cardoso F, Barbosa ER, Buchpiguel
CA, Nitrini R. Involuntary hand levitation associated with parietal
damage: another alien hand syndrome. Arq Neuropsiquiatr 2001;
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7. Doody RS, Jankovic J. The alien hand and related signs. J Neurol
Neurosurg Psychiatry 1992;55:806 – 810.
8. Barclay CL, Bergeron C, Lang AE. Arm levitation in progressive
supranuclear palsy. Neurology 1999;52:879 – 882.
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a clinical description in 32 patients in the acute phase of pure
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Movement Disorders, Vol. 20, No. 5, 2005