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Table of Contents    
LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 5  |  Page : 1493-1494

Unilateral arm flapping gait as a manifestation of synkinesis following recurrent strokes


Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea

Date of Web Publication17-Sep-2018

Correspondence Address:
Dr. Byung Kun Kim
Department of Neurology, Nowon Eulji Medical Center, Eulji University, 68 Hangeulbiseok.-ro, Nowon.-gu, Seoul 01830
Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.241358

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How to cite this article:
Kang K, Lee WW, Kwon O, Kim BK. Unilateral arm flapping gait as a manifestation of synkinesis following recurrent strokes. Neurol India 2018;66:1493-4

How to cite this URL:
Kang K, Lee WW, Kwon O, Kim BK. Unilateral arm flapping gait as a manifestation of synkinesis following recurrent strokes. Neurol India [serial online] 2018 [cited 2018 Oct 23];66:1493-4. Available from: http://www.neurologyindia.com/text.asp?2018/66/5/1493/241358




Sir,

Movement disorders are well-known but uncommon complications of stroke.[1] Many different types of hyperkinetic movement disorders can be seen after ischemic stroke.[1] Dystonia, chorea, and rest tremor are involuntary movements that often appear in the arms during walking. However, poststroke synkinetic movements, manifesting as involuntary arm movements that appear during walking, have been rarely reported. We report a patient who had recurrent ischemic stroke and experienced unilateral arm flapping gait as a manifestation of synkinesis.

A 67-year old woman with a history of mitral valve replacement 11 years ago, and the development of left hemiparesis 5 years previously, was admitted to our hospital because of the development of mild right hemiparesis; the brain magnetic resonance imaging (MRI) revealed acute infarcts in the left frontoparietal lobes and encephalomalacia in the right frontotemporal area and left cerebellum. Five years later, she developed dysarthria, right facial paralysis, right hemiplegia, and right hypesthesia; the brain MRI showed acute infarcts in the left frontoparietal lobes including the left cingulate cortex [Figure 1]. Her right-sided hemiplegia gradually improved following her admission. She was subsequently able to walk independently and was discharged one month after admission.
Figure 1: Diffusion-weighted images obtained 2 months before the onset of involuntary movements show high signal intensities in the left frontoparietal area (a) and left paramedian frontal lobe (b). Fluid-attenuated inversion recovery images reveal encephalomalacia in the right frontotemporal area (c and d) and left cerebellum (e)

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One month after discharge, she developed involuntary movements in her right arm. She flapped her right arm like a wing when she walked. On examination, she had mild dysarthria, mild right hemiparesis, and right hypesthesia. Her limbs were not spastic and the deep tendon reflexes were symmetric. When she, in a recumbent position, flexed her thigh and lifted her leg, there was no involuntary movement of her right arm [Video 1]. Active dorsiflexion of her right ankle was followed by abduction of her right thumb; active plantar flexion of her right ankle was followed by adduction of her right thumb [Video 2]. There was no involuntary movement of the right arm when the left arm was actively abducted. Involuntary movements appeared in her right arm during walking [Video 3]. Her right arm abducted and extended as her right leg was advanced while walking; as her left leg was advanced while walking, her right arm adducted. Furthermore, she showed right forearm mirror movements during pronation/supination movements of the left forearm [Video 4]. The brain MRI revealed no acute infarct. As we misdiagnosed her as having poststroke hemiballism, she was placed on haloperidol 3 mg bid for 4 days, but to no effect. The unilateral arm flapping gait persisted until she became bedridden owing to recurrent right hemiparesis, 7 months after the appearance of the involuntary movements.






The term ‘synkinesis' refers to involuntary movements which accompany certain voluntary movements and are presumed to reflect aberrant growth of regenerating neurons after injuries.[2],[3],[4] Ipsilateral hand-foot synkinesis has been observed in Parkinson's disease,[5] thalamic hemorrhage,[6] and frontoparietal infarcts.[7] A patient with thalamic hemorrhage who exhibited an elevation of the paretic arm while moving the ipsilateral leg has been reported.[6] His involuntary movements were flexion and extension of the paretic arm at the shoulder rather than abduction and adduction of the arm.[6] The arm movement during walking was not described in the previous report.[6] Another case report described a patient with an acute right frontoparietal infarct who had left arm levitation whenever she tried to lift the weak left leg.[7] The location of the lesion in this patient was very similar to that of our patient.[7] However, the left arm of this patient levitated in supination with elbow flexion,[7] whereas our patient exhibited straight arm elevation. The authors of the case report hypothesized that the motor cortex representing the arm movements might have been activated instead of the motor cortex representing the leg movements; or, the activated motor cortex responsible for the leg movements might have been wrongly connected to the subcortical white matter tracts that originally served the arm movements due to neuronal misconnections in the cortico-striato-thalamic pathway after the development of stroke.[7] The delay in developing involuntary movements after the onset of the recent stroke was two months in our patient, which might have reflected the time required for the partial recovery of motor function and the occurrence of central motor reorganization.

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  References Top

1.
Handley A, Medcalf P, Hellier K, Dutta D. Movement disorders after stroke. Age Ageing 2009;38:260-6.  Back to cited text no. 1
    
2.
Messe SR, Shin RK, Liu GT, Galetta SL, Volpe NJ. Oculomotor synkinesis following a midbrain stroke. Neurology 2001;57:1106-7.  Back to cited text no. 2
    
3.
Lam L, Engstrom J. Teaching video neuroimages: The breathing arm: Respiratory brachial synkinesis. Neurology 2010;74:e69.  Back to cited text no. 3
    
4.
Valls-Sole J, Montero J. Movement disorders in patients with peripheral facial palsy. Mov Disord 2003;18:1424-35.  Back to cited text no. 4
    
5.
Salardini A, Narayanan NS, Arora J, Constable T, Jabbari B. Ipsilateral synkinesia involves the supplementary motor area. Neurosci Lett 2012;523:135-8.  Back to cited text no. 5
    
6.
Jung KH, Park SH, Chang GY. Imitative arm levitation from a recurrent right thalamic hemorrhage: A case report. Neurology 2003;61:718.  Back to cited text no. 6
    
7.
Alanazy MH, Menon BK, Demchuk AM. Arm levitation sign in acute right frontoparietal infarct. Neurosciences 2011;16:66-7.  Back to cited text no. 7
    


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