1. The document examines intermanual referral of sensation (IMRS) and extinction of pain in 5 stroke patients. 2. IMRS occurred in 3-4 months in thalamic and temporoparietal stroke patients, but within 3 weeks in one temporoparietal patient. Intense pressure on the normal hand partially reduced sensory and motor deficits in the affected hand. 3. Extinction of pain occurred when intense pressure was applied to the normal hand, disappearing within a minute of stopping pressure. IMRS disappeared in one patient after developing a second hemiparesis.

2. INTERMANUAL REFERRAL OF
SENSATION (IMRS) AND EXTINCTION OF
PAIN AND PARTIAL RELIEF OF
MOTOR / SENSORY DEFICIT
IN STROKE
A .V. Srinivasan * , Rogers Ramachandr an** &
V.S. Ramachandr an**
*Institute of Neur ology
Madr as Medical College & Resear ch Institute, Chennai,
India
**Center for br ain and cognition,
Univer sity of Califor nia at San Diego
U.S.A

3. BA CKGROUND
• 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)

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. Case Vignette 3
• Nine years boy
• Rt. Hemiplegia with Hemisensory
deficit and with IMRS
• Developed Lt. Hemipareisis with
hemisensory deficit
• Disappearance of IMRS

12. 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

13. 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

14. 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).

15. INTERMA NUA L REFERA L A ND EX TINCTION
OF PA IN SENSA TION
HEMIPARESIS WITH BRACHIAL
HEMISENSORY DEFICIT AMPUTATION PLEXUS
SPATIAL ORGANI-SATION EXCELLENT POOR EXCELLENT
LOCALI-SATION GOOD POOR EXCELLENT
TIME OF OCCURANCE AFTER 3 TO 4 MONTHS IMMEDIATE WITH IN IMMEDIATE WITH IN
7 DAYS 7DAYS
PAIN AFTER A DELAY OF IMMEDIATE IMMEDIATE
EXTINCTION 3 - 5 SECONDS

16. 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.

17. WE GRA TEFULLY A CKNOWLEDGE
Mr. G. Kakuthan
Mr. R. Sasikumar
And
Stanley Videos, Chennai, India