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A Right Anterior Parietotemporal Syndrome 431 42848ournal ofNeurology, Neurosurgery, and Psychiatry 1995;58:428-432 Acute hemiconcern: a right anterior J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.428 on 1 April 1995. Downloaded from parietotemporal syndrome J Bogousslavsky, E Kumral, F Regli, G Assal, J Ghika Abstract selective and profound interest in the opposite Three patients developed a striking visual side of the body in association with severe and motor behaviour in the acute phase sensory loss: the patients touched, manipu- of a stroke involving the territory of the lated, and looked at the left side of their body right anterior parietal artery (postcentral in a relentless and sometimes compulsive gyrus, parts or upper and middle tempo- manner. This activity lasted only a few days ral gyri, anterior part of inferior parietal and improved as sensation returned. For these gyrus, and supramarginal gyrus). The reasons, we called this behaviour "acute hemi- patients concentrated on the left side of concern". their bodies, looking at it for long periods and relentlessly rubbing, touching, pinching, pressing, lifting, and manipu- Patients lating parts ofthe left arm, trunk, and leg We identified three patients with acute "hemi- with their right hand or foot. They all had concern" for the side of the body opposite to severe loss ofelementary sensation on the infarction in one cerebral hemisphere. These left (touch, pain, temperature, vibration, patients were identified from more than 2500 position). The behaviour was not patients with first ever stroke who were admit- associated with overinterest in the left ted consecutively to our population based pri- hemispace apart from their own bodies. mary care centre, and were in the Lausanne It lasted no more than a few days, dis- Stroke Registry.8 Although selection was appearing when left sided sensation made retrospectively from the Registry data, improved. The findings suggest an asso- the three patients had been examined by at ciation between sensory dysfunction and least one senior author (JB or FR). this "acute hemiconcern". None of 13 All three patients showed the same type of patients with a mirror infarct in the left behaviour when admitted to hospital: they hemisphere and none of 38 patients with looked overinterested in and overconcerned acute hemisensory loss due to thalamic about the left side of their bodies, which had capsular or brainstem stroke showed moderate to severe sensory loss (involving hemiconcern behaviour. This behaviour light touch, vibration, and position sensation, may result from a feeling of strangeness and in two, also pain and temperature sensa- http://jnnp.bmj.com/ critically associated with hemisensory tion); they stared for several seconds at vari- loss without hemispatial neglect, due ous parts of their left side and rubbed, to involvement of the right anterior pressed, and manipulated their trunk, face, parietotemporal region. and limbs on the left with their right hand; sometimes, they also lifted and displaced their (7 Neurol Neurosurg Psychiatry 1995;58:428-432) left arm or leg with their right hand. It was difficult to distract them from this activity, on September 27, 2021 by guest. Protected copyright. which was relentless during the first hours of Keywords: acute hemiconcem; anterior parietotemporal admission. Although two patients complained syndrome of numbness, none had painful or itching Department of paraesthesiae to explain the rubbing activity. Neurology, University Several behavioural disturbances can be They could not give a satisfactory explanation Hospital, 1011 Lausanne, Switzerland found in acute stroke. The most common lat- for their concern, interest, and manipulation J Bogousslavsky eralised abnormality is hemineglect which of their left side, except that it felt "strange". E Kumral may encompass several distinct syndromes.'-' They showed no particular overinterest in the F Regli Hemineglect due to acute stroke may be left hemispace, their activity being concen- J Ghika associated with several localisations of lesion, trated on the left side of their own bodies. Division of Neuropsychology, most critically, the right inferior parietal lob- Neuropsychological testing in the acute phase University Hospital, ule.26 Another less well recognised abnormality and a few days later showed no appreciable 1011 Lausanne, is hyperkinetic motor behaviour contralateral dysfunction; in particular, no sign of visual Switzerland G Assal to hemiplegia, with limb stereotypes, such as hemineglect was found on line bisection or of or mobili- cancellation tests. One showed left ear Correspondence to: compulsive manipulation passive patient Dr J Bogousslavsky, sation of the paralysed limb in patients with a extinction on a dichotic listening test, which Department of Neurology, University Hospital, 101 1 large hemispheral infarct.7 resolved after three days. The hemiconcern Lausanne, Switzerland. We now report a particular motor and behaviour was transient, being limited to the Received 17 June visual behaviour that developed in the acute first two to six days after stroke. Its improve- and in revised form 23 September 1994 phase of stroke involving the anterior parietal ment and disappearance paralleled improve- Accepted 3 November 1994 region in the right hemisphere. It consisted in ment in left sided sensation. Acute hemiconcern: a right anterior panietotemporal syndrome 429 Brain MRI (two patients) or CT (one A J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.428 on 1 April 1995. Downloaded from patient) showed an acute infarct in the ante- rior parietal region (and upper parts of tempo- ral lobe) on the right in all three patients (figure), which corresponded to the territory of the anterior parietal artery.9-"2 From the registry, we identified two other patients with a right anterior parietal artery territory infarct of similar topography and size, in whom this behaviour was not reported. None of a total of 13 patients with an infarct in the territory of the left anterior parietal artery identified dur- ing the same period showed hemiconcem behaviour. It was also not reported in 38 patients with hemisensory loss due to right or left thalamic (32), brainstem (five), or capsular I stroke (one). PATIENT 1 A 66 year old man was admitted to hospital after he developed left sided numbness, pre- dominant in the hand. His history included high cholesterol concentrations, cigarette smoking (20 packs a year), and compensated heart failure. The day of admission, he had had an unpleasant numbness in his left hand B while driving his car. This spread to the left side of his body within a few minutes. He stopped and fell to his left when trying to get out of the car. On admission one hour later, the patient was anxious and slightly agitated. He relentlessly manipulated and touched his left hand and forearm, to a lesser extent his left leg and the left side of his trunk, less often his foot-with his right hand-in a rather stereotyped manner; he palpated, rubbed, pinched, and pressed on the skin, muscles, and bones at different spots on his left arm and leg, attentively looking at what he was doing. It was very difficult to distract him from this activity. When asked why he was behaving in that way, he was not able to give a http://jnnp.bmj.com/ clear explanation, but stated that his left side was numb and "felt strange", and that he had to take care of it. It was possible to examine him and to perform the usual bedside neuro- logical and neurophysiological tests, but this was always interrupted by his manipulating, touching, and looking at the left side of his body. On neurological examination, there was on September 27, 2021 by guest. Protected copyright. a moderate left lower facial weakness, with decreased light touch, pain, and temperature sensation on the left side of the face, mouth, tongue, and palate. The left corneal reflex was decreased. Visual fields and eye movements were normal. The patient did not move the limbs on the left spontaneously. Tone in the arm and leg on the left was decreased, with decreased tendon reflexes, and no plantar reflex on that side. There was a complete anaesthesia in the left side of the trunk, and left arm and leg, involving pain, light touch, temperature, vibration, and position. There was no abnormality on the line bisection test Templates ofinfarct shown by MRI (patients 1(A) and (line bisection at 14-5, 14-5, 15, 16, 15-5 cm 3(C)), or CT (patient 2(B)). from the right edge of lines 30 cm long on five trials) or cancellation test (20/20). There was no left extinction on simultaneous right and side was still present, but intermittently, and left auditory or visual stimulation. The next the patient could now move the limbs sponta- day, the manipulatory behaviour of the left neously. Sensation had improved, although 430 Bogousslavsky, Kumral, Regli, Assal, Ghika the patient stated that his left side still felt heel to knee tests with the eyes closed. Muscle J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.4.428 on 1 April 1995. Downloaded from numb and strange. He never complained of tone and tendon reflexes were normal. Light feeling a foreign body instead of his left body touch, pain, temperature, vibration, and posi- side or of a feeling of amputation. On neuro- tion sensations were abolished on the left side psychological examination with a standard of her trunk (with a sharp cut off point at the battery of tests (Assal G Batterie des examens midline), and left arm and leg. Neuro- neuropsychologiques du CHUV, Lausanne, psychological examination (the same day and Switzerland, 1985)-namely, tests for lan- two days later) with the same battery of tests guage (fluency, Boston naming test, token test, as in patient 1 showed no appreciable abnor- repetition, writing, reading), bucco-lingual- mality. In particular, the line bisection test facial and limb apraxias, gnosias (famous (the same test as in patient 1), cancellation faces, colours, objects, finger, right-left), test (20/20), and Gainotti's recognition test visuospatial and visuoconstructive tasks were normal.
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