INTERMANUAL REFERRAL OF
SENSATION (IMRS) AND EXTINCTION OF
PAIN AND PARTIAL RELIEF OF
MOTOR / SENSORY DEFICIT
IN STROKE
A.V. Srinivasan *, Rogers Ramachandran** &
V.S. Ramachandran**
*Institute of Neurology
Madras Medical College & Research Institute,
Chennai, India
**Center for brain and cognition,
University of California at San Diego
U.S.A
BACKGROUND
• ALLESTHESIA AND EXTINCTION
OF REFERRAL SENSATION IN BRACHIAL
PLEXUS LESIONS
A.V. Srinivasan and V.S. Ramachandran et al (1998)
• INTERMANUAL REFERRAL OF
SENSATIONS AFTER CENTRAL LESIONS
OF THE SOMATO SENSORY SYSTEM
K. Sathian et al (2000)
METHODS
• FIVE PATIENTS WITH HEMIPARESIS AND
HEMISENSORY DEFICIT FOLLOWING STROKE
ANALYSED (9-61 YEARS)
THALAMUS
: TWO
TEMPERO PARIETAL : TWO
BRAIN STEM
: ONE
• PATIENTS WERE VIDEO FILMED IN THE
MOVEMENT DISORDER CLINIC.PINPRICK, COLD,
VIBRATION AND KINESTHESIS WERE TESTED
• MRI & ENMG IN ALL CASES
STROKE
• Thalamus
- Two
• Temparo parietal
- Two
• Brain stem
- One
• Three to four months later
• In one temperoparietal patient
IMRS occurred within three weeks
• Ipsilateral arm to leg - no referral
Case vignette 1
• Lt. Hemiplegia 2 hrs denied of illness
• His left foot resembled - dead friend leg
• Accepted the disease but ignored the left
side
• Decreased the sensation on Lt. side
excluding face
• Poorly localized - Early IMRS
Case vignette 1
• V.S. Ramachandran examined – IMRS
confirmed
• Pain & temperature not felt referred
but felt as touch
• Lt. side face touched radiated to neck
• Extinction phenomenon – sixth day
Video segment
Case vignette 1
• Third week – topographically
organized Intermanual referral of
touch and vibration but not pain
or temperature from normal (right)
to mirror symmetric locations on
the affected side.
Case vignette 1
• Sixth week
IMRS decreased substantially
Intensive pressure on the normal arm
seemed to partially decrease the sensory
and possibly even the motor deficit in the
paralyzed
hand
Case Vignette 2
• Intense pressure on the normal
hand resulted in extinction of pain in
the stroke side
• Pain returned within one minute of
the pressure
• Intense pressure improved sensory
and motor phenomenon
Case Vignette 3
• Nine years boy
• Rt. Hemiplegia with Hemisensory
deficit and with IMRS
• Developed Lt. Hemipareisis with
hemisensory deficit
• Disappearance of IMRS
DISCUSSION
Anatomical facts
1. Primary somato sensory area 3b
2. A. Primary somato sensory area 1 & 2
B. Second somato sensory cortex and
parietal operculum
In 2A & 2B The receptive fields are larger
bilateral and callosal connection are
abundant
DISCUSSION
• Contralateral referral of sensations was
not found in normal subjects or in
hemiparietic patients without hemi
sensory loss
• Neural mechanisms for perceptual
alteration not clear
DISCUSSION
 It appears that a decrease in somatosensory
input to one cerebral hemisphere from the
contralateral hand allows responsiveness of
neurons in this hemisphere to moderately intense
tactile stimuli on the ipsilateral hand to exceed
perceptual threshold (which does not normally
occur).
INTERMANUAL REFERAL AND
EXTINCTION OF PAIN SENSATION
HEMIPARESIS WITH
HEMISENSORY
DEFICIT
AMPUTATION
BRACHIAL
PLEXUS
SPATIAL ORGANISATION
EXCELLENT
POOR
EXCELLENT
LOCALI-SATION
GOOD
POOR
EXCELLENT
TIME OF
OCCURANCE
AFTER 3 TO 4
MONTHS
IMMEDIATE
WITH IN 7 DAYS
IMMEDIATE
WITH IN 7DAYS
PAIN
EXTINCTION
AFTER A DELAY OF
3 - 5 SECONDS
IMMEDIATE
IMMEDIATE
CONCLUSION
• Intermanual Referral & Extinction of
Pain Occurred after a delay in
stroke.
• Intermanual Referral of Sensation
Occurred Topographically in a
Organized Manner in stroke
patients.
WE GRATEFULLY ACKNOWLEDGE
Mr. G. Kakuthan
Mr. R. Sasikumar
And
Stanley Videos, Chennai, India