The Alien Hand Syndrome
Clinical and Postmortem Findings
Gordon Banks, PhD, MD; Priscilla Short, MD; A. Julio Mart\l=i'\nez,MD; Richard Latchaw, MD;
Graham Ratcliff, DPhil; Fran\l=c;\oisBoller, MD, PhD

\s=b\ Two patients had automatonlike
movements of their left hands and arms
(alien hand syndrome) following damage
to the brain. Autopsy findings in one
patient demonstrated gunshot wound
damage to the medial frontal white matter
bilaterally, as well as the corpus callosum,
right basal ganglia, internal capsule, and
thalamus. The other patient had a ruptured anterior communicating aneurysm,
with subsequent resection of the right
frontal gyrus rectus. We postulate that
this syndrome is due to the combination
of a partial callosectomy and mesial frontal lesions.
(Arch Neurol 1989;46:456-459)

TVo patients had automatonlike

movements and uncooperative be¬
havior of the left arm and hand fol¬
lowing brain injury. Similar cases
have been referred to as the alien
hand syndrome. The cause of the
syndrome is uncertain, but it is con¬
sidered, at least partly, to be a discon¬
nection syndrome. Previously de¬
scribed cases have implicated the
medial frontal lobes and/or anterior
corpus callosum, but autopsy studies
have been lacking in evidence. We
describe herein the clinical and patho¬
logic features of these cases and try to
relate them to previously described
cases.

REPORT OF CASES
Case 1.—A 39-year-old (at the time of
injury), right-handed woman had attended
grade school and worked as manager of a

Accepted for publication Feb 15, 1988.
From the Departments of Neurology (Drs
Banks, Short, and Boller), Pathology (Dr Mart\l=i'\nez), Radiology (Dr Latchaw), Psychology (Dr
Ratcliff), and Psychiatry (Drs Ratcliff and Boller), University of Pittsburgh; and Harmarville
Rehabilitation Center, Pittsburgh (Dr Ratcliff).
Read before the 30th annual meeting of the
American Academy of Neurology, Boston, April
10, 1984.
Reprint requests to Department of Neurology,
University of Pittsburgh, 322 Scaife Hall, Pittsburgh, PA 15261 (Dr Banks).

snack bar until she suffered a gunshot
wound to the head in 1971. The bullet
entered the skull above the right orbit and
traversed the brain. Surgical findings
revealed destruction of the right orbital
plate of the frontal bone with periorbital
tissue pushing upward from the orbit. Both
proximal anterior cerebral arteries were
clipped to control bleeding. Postoperative¬
ly, the patient was blind in the right eye
and had left hemiparesis and left hemianesthesia. A few months later, she noticed
that her left arm began to move "on its
own." The left hand would tenaciously
grope for and grasp any nearby object, pick
and pull at her clothes, and even grasp her
throat during sleep. These autonomous left
arm and hand movements tended to occur
in bouts usually signaled when her hand
did "silly things" such as scratching her
knee. She slept with the arm tied to pre¬
vent nocturnal misbehavior. She never
denied that her left arm and hand belonged
to her, although she did refer to her limb
as if it were an autonomous entity. She
recovered her ability to walk, but the
arm movements persisted
unchanged until her death in 1983 due

autonomous

metastatic adenocarcinoma of the
breast.
We examined her for the first time in
October 1983. She was alert, sitting with
her left hand tucked into her right axilla.
She was oriented for time, place, and per¬
son and was slightly euphoric. She was
talkative and not aphasie, but she had a
mild dysarthria. She could name objects
and parts of objects presented visually,
and she could identify objects placed in her
right hand while her eyes were covered.
Tactile naming was much poorer (at
chance level) with her left hand. With her
eyes still covered, she was asked to identify
by touch a set of objects that had just been
put in her hand. She did well when the
objects were placed in her right hand but
poorly when they were placed in her left
hand. Auditory comprehension and calcu¬
lation were normal, but she showed rightleft confusion.
She performed gestures well, either
spontaneously or on command (eg, "sa¬
lute," "show how you would use a key"),
with her right arm but not with her left
one. Similarly, mirror movements were
to

impossible with the left arm.

Her memory was intact, but she had

difficulty recognizing familiar faces. Spon¬
taneous and copied drawings showed obvi¬
ous left-sided neglect. There was optic
atrophy on the right side with a Marcus
Gunn pupil and no vision, palsy of the right
trochlea, and decreased sensation over the
right ophthalmic trigeminal distribution.
She had a left hemianopia, weakness of the

lower facial muscles on the left side, and a
minimal to mild left hemiparesis.
Placed in the patient's lap, the left arm
often moved to her right axilla. The patient
claimed this movement was involuntary.
The left hand tenaciously grasped objects
and groped actively for objects to grasp,
such as clothing and bed rails. These grop¬
ing movements consisted of rapid opening
and closing of the fingers while the hand
crept forward.
The patient's legs were weak bilaterally.
Her reflexes were brisker on the left side,
with a left-sided Babinski's sign. She had
no grasp on the right side and no suck,
snout, or glabellar reflex. She had a left
hemianesthesia.
Bone scan and spine films, as well as
myelograms, revealed métastases in the
upper vertebral bodies, which were
thought to account for the right leg weak¬
ness. Chest x-ray films revealed metastatic
lung lesions. Electroencephalograms, both
awake and asleep, demonstrated groups of
high-amplitude theta waves in the right
frontal region. These slow waves were not
associated with her hand movements. A
head computed tomographic (CT) scan
revealed bifrontal encephalomalacia, more
pronounced on the right side, and lucency
in the anterior part of the corpus callosum
(Fig 1). A cerebrospinal fluid sample dem¬
onstrated the following values: leukocytes,
1 X 10VL (a lymphocyte); protein, 1.87 g/L;
and glucose, 4.7 mmol/L.
The patient was treated with radiation
and chemotherapy. She died of cardiopulmonary arrest during an admission for
chemotherapy 13 years after the gunshot
wound.
Case 2.—A 40-year-old right-handed,
male, college-educated draftsman had
complained of headaches, neck stiffness,
nausea, and vomiting for one month and
had been subsequently treated for "gastro-

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enteritis." In July 1986, following a sudden
increase in the severity of headache, he
rapidly became comatose. On arrival at the
medical center, he was unresponsive except
for grimace to painful stimuli. He had a
stiff neck, papilledema, and bilateral
Babinski's signs. The brain-stem reflexes
were intact. There was resistance to move¬
ment of all four extremities. Computed
tomographic scans showed subarachnoid
hemorrhage with blood in the lateral and
third ventricles but none in the brain
parenchyma. Angiograms revealed a large
aneurysm of the anterior communicating
artery at the junction of the right anterior
cerebral artery, with spasm of the left
anterior cerebral artery, middle cerebral
artery, and distal internal carotid arteries.
The following day, the aneurysm was
clipped in the chiasmatic cistern along the
right optic nerve. A "moderate amount"
of the right gyrus rectus was also re¬
sected.
Following surgery, the patient developed

in tasks requiring bimanual cooperation.
For example, while cutting meat at dinner,
he had difficulty getting the left hand to
relinquish the fork to the right hand. His
left hand would sometimes pick up a food
item and try to put it in his mouth while
the right hand was attempting the same
maneuver, resulting in a collision. Some¬
times the left hand would pick up a cup and
move it into the path of the right hand so
as to interfere with eating. While playing
checkers on one occasion, the left hand
made a move that he did not wish to make,

and he corrected the move with the right
hand; however, the left hand, to the
patient's frustration, repeated the false
move. On other occasions, he turned the
pages of a book with one hand while the
other one tried to close it; he shaved with
the right hand while the left one unzipped
his jacket; he tried to soap a washcloth
while the left hand kept putting the soap
back in the dish; and he tried to open a
closet with the right hand while the left
one closed it. He reported that usually he
could eventually make the left hand coop-

a progressively dilating right pupil; a right
temporal lobectomy was performed, in
which a piece of anterior temporal lobe,
measuring 4.5 X 3.2 X 1.5 cm, was removed.
By the next day, the patient was awake. He
was moving all four extremities spontane¬
ously, and he could follow simple com¬
mands with the right, but not the left,
hand. He was also mute. Only after two

weeks was he able to follow commands
with his left hand. One month after admis¬
sion, a ventriculoperitoneal shunt was
placed through a left approach to alleviate

progressive hydrocephalus.
He remained severely abulie, initiating
neither activities nor speech for two
months following admission. During the
next month he improved markedly. He
began to complain of difficulty getting his
left arm and hand to obey him, especially

Fig 1.—Computed tomographic scans of case 1. Note area of low density (path ot bullet) in
coronal (left) and horizontal (right) views.

Fig 2.—Left, Computed tomographic (CT) scan of axial section showing damage to frontal lobes and
corpus callosum (case 2). Dotted line indicates position of coronal section. Top right, CT scan of coronal
section showing damage to corpus callosum (case 2). Bottom right, CT scan of sagittal section 5 mm right
of midline showing damage to frontal lobe and corpus callosum (case 2).

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Fig 3.—Top left, Coronal section at level of genu of corpus callosum. Note extensive area of encephalomalacia, partially
cavitated and involving right subcortical white matter extending to left side and passing through genu of corpus callosum. Top
right, Coronal section at level of mamillary bodies. Note irregular cavity in right centrum semiovale with atrophy and
degeneration of corpus callosum, right thalamic nuclei, portions of adjacent pyramidal tract, and dilation of right lateral
ventricle. Bottom left, Coronal section at level of red nuclei. Area of encephalomalacia is evident in right thalamus. Corpus
callosum is very thin, and cavity extends through subcortical white matter. Bottom right, Coronal section passing through
splenium. Note extensive atrophy and degeneration of corpus callosum.

erate if he persisted with a task. It was

noted that often while he was doing a task
with the right hand, the left one grasped
and manipulated nearby objects, which
often hindered the work of the right hand.
To a lesser extent, the left leg was also
affected, once attempting to ascend while
the patient was descending stairs.
When we examined him, his affect was
flat, and he was inattentive and showed
some motor impersistence. He was ori¬
ented to time and place but not to day of
the week, and he could speak, name, under¬
stand, and read normally. He performed
simple commands well with his right hand
but had some difficulty showing how to use
scissors or how to turn a key with the left
hand; he could, however, show with some
delay how to salute and to brush his teeth.
When he was asked to put on a shirt held in
front of him, the left arm thrust into the
right sleeve. The patient said, "That is
wrong." Asked why, he replied, "It will be

on backwards."

However, he was unable to
make the left arm withdraw for several
moments. He did not have the feeling that
the left arm did not belong to him. It was
often easier for him to perform some tasks,
such as repetitive tapping, with the left
foot than with the left hand. There was no
grasp, snout, or suck reflex, although he
had a Myerson's sign. Visual fields and
cranial nerve functioning were normal. He
had no hemiparesis or spasticity. The
reflexes were brisk bilaterally, with bilat¬
eral Babinski's signs. There was extinction
to double simultaneous stimulation on the
left side, and he had more difficulty identi¬
fying objects placed in the left hand than
when placed in the right one, although he
often did it correctly. His gait was slow
and wide based.
A CT scan obtained four months follow¬
ing the hemorrhage showed radiolucent
areas in the medial frontal lobes bilateral¬
ly as well as damage to the genu and

anterior portion of the body of corpus
callosum (Fig 2).
PATHOLOGIC FINDINGS

The
case

general autopsy findings in

1 showed an infiltrating, well-

differentiated adenocarcinoma of the
left breast with métastases to the
lung, liver, kidneys, adrenal glands,
and lumbar vertebrae, as well as dis¬
semination through the subarachnoid
space.

Gross neuropathologic examination
of the formalin-fixed brain sections
revealed normal dura mater and blood
vessels and both thickened and
opaque basal leptomeninges. The vol¬
ume of the right frontal lobe was
reduced, and the right frontal pole
showed a brown-stained area of corti¬
cal encephalomalacia. The right orbi-

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tofrontal cortex, including the gyrus
rectus, was shrunken and retracted,
and it had a brownish discoloration
extending 3.2 X 2 cm. Coronal sections
demonstrated encephalomalacic cavi¬
ties primarily involving the right subcortical white matter and extending
into the left side through the genu of
the corpus callosum (Fig 3, top left).
The area of encephalomalacia became
cavitated and formed a tract extend¬
ing through the centrum semiovale,
affecting mainly the right side of the
corpus callosum and right thalamic
nuclei (Fig 3, top right and bottom
left), all the way to the subcortical
white matter of the right occipital
lobe (Fig 3, bottom right). The white
matter adjacent to this tract was soft¬
ened, but the nearby cortex appeared
intact. The right caudate nucleus and
internal capsule were largely de¬
stroyed with softening, brown discol¬
oration and microcavitation extend¬
ing into the region of the right pulvinar (Fig 3, top right and bottom left).
The ventricular system was dilated
more on the right than on the left
side. The entire corpus callosum
appeared shrunken and distorted,
particularly at the level of the spleni¬
um (Fig 3, bottom right). Sections of
the brain stem showed atrophy of the
right cerebral peduncle and the right

pyramidal tract.

The cerebral cortex

was

normal

except at the tip of the right frontal

pole where the entrance wound of the
bullet was located. Microscopic exami¬

nation revealed necrosis and cavitation in wide areas of subcortical white
matter of the orbitofrontal cortex,
portions of the right internal capsule,
the right caudate, and right subependymal and periventricular white mat¬
ter. The cingulate gyri were normal
bilaterally. The genu and the spleni¬
um of the corpus callosum were
infarcted and demyelinated, and the
remaining areas of the corpus callo¬
sum

were

markedly demyelinated.

The right superomedial thalamus was
infarcted. The right internal capsule
showed demyelination. The right
hypothalamus contained a lesion

characterized by necrosis, astrocytosis, axonal spheroids, and hemosiderin. The right optic nerve and the right

corticospinal tracts were demyelin¬
ated. Bullet fragments were found in
the head of the right caudate, puta¬
men, and

thalamus. Both anterior
cerebral arteries were occluded with
metallic clips. The leptomeninges con¬
tained widespread neoplastic cells
with the same histopathologic fea¬
tures as the primary adenocarcinoma
of the breast. This condition was

thought to result from propagation of
the neoplastic cells from vertebrae

and nonvertebral métastases1 and not
from an association with her neuro¬

logic symptomatology.
COMMENT

The involuntary movements of
these two patients resemble those
described in the North American lit¬
erature as alien hand syndrome. Alien
hand is a translation of the French la
main étrangère used by Brion and
Jedynak2 to describe a "feeling of
estrangement between the patient
and one of his hands." For example,
one of their patients (case 1), when
trying to put on his shirt, would
encounter his alien hand and try to
move it out of the way, exclaiming:
"Leave me alone, you prevent me from
dressing." Failure of recognition also
occurred when one hand was placed
into the other in front of the patient
with his eyes closed. After the patient
died, autopsy findings revealed a cal¬
losal tumor extending bilaterally into
the cerebral white matter. What was
impaired was not the tactile sensation
in the hand but "la reconnaissance de
son appartenance" (the recognition of
its belonging). No mention was made
of involuntary movements.
Subsequently, Goldberg et al3 used
the term alien hand syndrome to
describe two patients with left medial
frontal cortex infarction. These

patients' arms spontaneously grasped
and groped and could perform pur¬
poseful movements, but they seemed

not to be under conscious control of
the patients, who often used the left
hand to restrain the right one. These
investigators suggested that medial
frontal cortex damage and callosal
disconnection may contribute to the

syndrome.

Several years before the article by
Goldberg et al,3 Goldstein4 and Sweet5

described similar cases but had not
labeled the syndrome. A similar phe¬
nomenon occurs in some patients who
have undergone callosectomy, but in
the majority of cases it subsides with¬
in a few weeks, thus suggesting that
callosal damage alone is not sufficient
for the occurrence of the alien hand

phenomenon.6·7

In our first patient, autopsy find¬
ings confirmed the clinical impression
of bilateral frontal damage, more pro¬
nounced on the right side, and corpus
callosum damage, with additional
damage at the level of the right basal
ganglia and thalamus. In the second
patient, a CT scan showed bilateral
mesial frontal damage as well as

lesions of the corpus callosum.

The combination of lesions neces¬
sary to produce this syndrome is not
certain. In other syndromes, such as

alexia without agraphia, a unilateral
lesion plus callosal disconnection are
sufficient. Although both of our
patients had bilateral frontal lesions,
Goldberg et al3 reported patients who
had no evidence of bilateral lesions,
but there was no autopsy confirma¬
tion. Bilateral semiautomatous move¬
ments, which may mimic voluntary
movements, are observed in patients
with bilateral frontal lobe lesions. For
example, Lhermitte8 has described
"utilization behavior in patients with
frontal lobe lesions, in which the
patient compulsively grasps and pur¬
posefully uses objects placed in front
of him or her, performing complex
acts. Lhermitte thought this was an
extension of grasping behavior and
advanced an explanation involving
release of parietal lobe activity in
some respects reminiscent of DennyBrown's theory of motor control.9 Nei¬
ther of our patients demonstrated
utilization behavior as defined by
Lhermitte. It appears reasonable to
postulate that in our cases, as in oth¬
ers, the syndrome was produced by
the combination of partial callosecto¬
my and mesial frontal lesions.10
This investigation was supported in part by
Public Health Service grants AG03705-04 and
AG05133-01 (Dr Boiler, principal investigator)
and by National Library of Medicine grant
LM04431 (Dr Banks, principal investigator).
We thank Jason Brown, MD, who supplied
relevant literature references; Charles Kowal,
MD, and Lowell Lubic, MD, for letting us exam¬
ine their patients; and Margaret Forbes, Annette
Grechen, and Betsy Israel for their help in the
preparation of the manuscript.
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266.
3. Goldberg G, Mayer NJ, Toglia JU: Medial
frontal cortex infarction and the alien hand sign.
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283.
5. Sweet WH: Seeping intracranial aneurysm
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1941;45:86-104.
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1983;106:237-255.

9. Denny-Brown D: The nature of apraxia. J
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