The sign wasn't placed thereThe sign wasn't placed thereBy the Big Printer in the skyBy the Big Printer in the sky

1111thth MAY, 2012 MAY, 2012

Prof. A.V. SRINIVASANProf. A.V. SRINIVASAN,,

MD, DM, Ph.D, DSc(hon)MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON)F.R.C.P(LONDON)

F.A.A.N, F.I.ANF.A.A.N, F.I.AN..

Emeritus Professor - The Tamilnadu DR MGR Emeritus Professor - The Tamilnadu DR MGR Medical UniversitMedical Universityy

Prof. A.V. SRINIVASANProf. A.V. SRINIVASAN,,

MD, DM, Ph.D, DSc(hon)MD, DM, Ph.D, DSc(hon) F.R.C.P(LONDON)F.R.C.P(LONDON)

F.A.A.N, F.I.ANF.A.A.N, F.I.AN..

Emeritus Professor - The Tamilnadu DR MGR Emeritus Professor - The Tamilnadu DR MGR Medical UniversitMedical Universityy

Thomas Elbert

•Cortical representation expands linearly with use.

• Synchronous inputs lead to fusion of cortical zones

• Asynchronous inputs lead to segregation of cortical zones.

•Disuse or De-afferentation leads to invasion of unused cortical area by nearby neurons.

Basic PrinciplesBasic Principles

Sensory modulation in spatial neglect

• Peripheral somatosensory- Magnetic stimulation

• Repetitive optokinetic stimulation

• Neck Vibration training

Drug Treatment is currently unsuccessfulDrug Treatment is currently unsuccessful

Novel TechniquesNovel Techniques

Sensory modulation and Stroke

Rehabilitation aimed to increase use of

paretic hand

Virtual reality

Motor imagery

Prof. V.S..Ramachandran’s virtual reality

box

• Phantom limb phenomenon

Other techniques

Caloric tests for balance

• Brings awareness of illness to patient.

Kinesthetic, visual, and auditory cues to improve Parkinsonian gait.

INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO SENSORY SYSTEM

INTERMANUAL REFERRAL OF SENSATION AND EXTINCTION OF PAIN IN PERIPHERAL AND CENTRAL LESIONS OF SOMATO SENSORY SYSTEM

Whatever the Mind can conceive and Believe, Whatever the Mind can conceive and Believe, the mind can Achievethe mind can Achieve

Napoleon Hill Napoleon Hill

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)

Every discovery contains an irrational element or 4 creative intuitionEvery discovery contains an irrational element or 4 creative intuition Khrl Popper Khrl Popper

METHODS

8 patients (19-51 years)

Brachial plexus lesion – one

Amputation – two

Stroke – five

Patients were video filmed in the movement disorder clinic. Pinprick, cold, vibration and kinesthesis were tested

MRI & ENMG in all cases

Science is below the mind; Science is below the mind; Spirituality is beyond the mindSpirituality is beyond the mind

CENTRAL LESION

StrokeThalamic stroke - three

Temparo parietal - two

Three to four months later

Ipsilateral arm - no referral

to leg

When they tell you to grow up, they mean stop growingWhen they tell you to grow up, they mean stop growing

STROKE Contd…

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

One is the most independent, unconventional and individualistic of all numbersOne is the most independent, unconventional and individualistic of all numbers

AMPUTATION

Both the patients (below

elbow & knee amputation)

showed intermanual referral

of sensation within 10 days.

The referred sensations of

touch and vibration lacked

spatial organization and

poor localization with a

relatively high threshold

The Truth is Fear & Immorality are two of the greatest inhibitors of The Truth is Fear & Immorality are two of the greatest inhibitors of Performance to progressPerformance to progress

CASE VIGNETTE (BRACHIAL PLEXUS LESION)

21 year old girl, after total

brachial plexus lesion was

examined 6 months, 1 ½ &

2 ½ years after the lesion

She had sensations

intermanually referred in a

topographically organized

manner in the phantom limb

““Social Isolation is in itself a pathogenicSocial Isolation is in itself a pathogenicFactor for disease production”Factor for disease production”

DR V S RAMACHANDRAN

INTERMANUAL REFERAL AND EXTINCTION OF PAIN SENSATION

Hemiparesis with hemisensory

deficitAmputation

Brachial plexus

Spatial organi-sation

Poor Poor Excellent

Localisation Good Poor Excellent

Time of occurance

After 3 to 4 months

Immediate with in 7 days

Immediate with in 7days

PainExtinction

After a delay of

3 - 5 seconds

Immediate Immediate

Reputation is made in a moment;Reputation is made in a moment;

character is built in a life timecharacter is built in a life time

DISCUSSIONAnatomical facts

1. Primary somato sensory area 3b

2. A. Primary somato sensory area 1 & 22. B. Second somato sensory cortex and

parietal operculum

In 2a & 2b the receptive fields are largerbilateral and callosal connection areabundant

Two is the most gentle of all numbers and represents, diplomacy and tactTwo is the most gentle of all numbers and represents, diplomacy and tact

DISCUSSION Contd…

Contralateral referral of sensations was

not found in normal subjects or in

hemiparetic patients without hemi

sensory loss

Neural mechanisms for perceptual

alteration not clear

““Anger Begins In Folly And Ends In Repentance”Anger Begins In Folly And Ends In Repentance”

DISCUSSION Contd…

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).

““By Nature All Men/ Women are alike butBy Nature All Men/ Women are alike butby Education widely different” - Chineseby Education widely different” - Chinese

CONCLUSION

Intermanual referral & extinction of pain occurred immediately in amputation and brachial plexus lesions and after a delay in stroke

Intermanual referral of sensation occurred topographicaly organised manner in brachial plexus lesions but not in amputation and stroke

Experience can be defined as Experience can be defined as

yesterday’s answer to today’s problemsyesterday’s answer to today’s problems

Dedicated to my family for

making everything worthwhile

My sincere gratitude to my

Teachers, Collegues,Residents,Patients and

Madras Institute of Neurology,

MEDISCAN SYSTEMS & Mr.Thudhimugan for

their computer work

My sincere gratitude to my

Teachers, Collegues,Residents,Patients and

Madras Institute of Neurology,

MEDISCAN SYSTEMS & Mr.Thudhimugan for

their computer work

We thank

Prof. V.S.Ramachandran, M.D., Ph.D., Director

Centre for Brain and Cognitive Sciences

University of California, San Diego, USA

READ READ not to contradict or confutenot to contradict or confute

Nor to Believe and Take for GrantedNor to Believe and Take for Granted

butbut TOTO WEIGH AND CONSIDERWEIGH AND CONSIDER

THANK YOUTHANK YOU

Can the mind believe what the eye sees ?

On vision, visuospatial dysfunction and

body image perception in right

hemispherical dysfunction

Dr.K.Bijoy Menon (Senior Resident)

Dr.Sundar, Dr.Saravanan, Dr.Ramakrishnan

Dr.Nithyanandan (Asst.Prof) ,

Prof. A.V.Srinivasan

Indrani. 50 year old female

Presents with sudden onset of weakness of left upper and lower limb

O/E.

– Conscious, oriented to time, place and person

– Mild left UMN facial paresis

– Left hemiplegia

– All peripheral pulses palpable

““Serious, sincere, systematic study surely secures supreme success”Serious, sincere, systematic study surely secures supreme success”

CT Brain – P – Shows a (R) Occipitotemporal infarct

Nine is the most humanitarian of all numbers. It is Nine is the most humanitarian of all numbers. It is effort and sacrifice without the need for reward.effort and sacrifice without the need for reward.

Higher mental function evaluation

MMSE : 28/30

She was very attentive and quite clear in her conversation with us, though she would be complaining of a vague left sided shoulder pain

On lobar testing, she had

Left visual neglect with (L) hemianopia

No auditory neglect

Absent sensory perception in (L) upper limb and (L) tactile neglect in the lower limb

““The Truth is fear and immorality are two of the greatest The Truth is fear and immorality are two of the greatest inhibitors of Performance to progress”inhibitors of Performance to progress”

Of a burning and unremitting character - F.W.PAVYOf a burning and unremitting character - F.W.PAVY

In any field, find the strangest thing and explore itIn any field, find the strangest thing and explore it

On cold caloric tests and its effect on neglect

Discipline Weighs ounces Discipline Weighs ounces Regret weighs TonsRegret weighs Tons

Video of Neglect

““You have got to be before you can You have got to be before you can do and do before you can have”do and do before you can have”

Video of caloric test and Nystagmus

A true commitment is a heart felt promise to A true commitment is a heart felt promise to yourself from which you will not back down - yourself from which you will not back down -

D. Mcnally D. Mcnally

Video of disappearance of neglect

Every discovery contains an irrational element or 4 Every discovery contains an irrational element or 4 creative intuition creative intuition - Khrl Popper - Khrl Popper

On ‘ Mirror Agnosia’Mirror Agnosia on the Right

A good teacher is a perpetual learnerA good teacher is a perpetual learner

After caloric test, Mirror Agnosia on the Left

Three is the most playful of all numbers and also creative, inspirational and motivatingThree is the most playful of all numbers and also creative, inspirational and motivating

‘Mirror Agnosia’ to front

Five is the most dynamic of all numbers. It is persuasive, Five is the most dynamic of all numbers. It is persuasive, versatile and adaptableversatile and adaptable

On Anosognosia, Body neglect (Hemisomatognosia) and somatoparaphrenia

Anosognosia – our patient has it

Body neglect by Bisiach’s test – our patient does not have it

Somatoparaphrenia – our patient has it

Knowledge without action is useless;Knowledge without action is useless;Action without knowledge is foolishAction without knowledge is foolish

Somatoparaphrenia

Number sixth is the most loving of all numbers and is Number sixth is the most loving of all numbers and is harmonious with all other numberharmonious with all other number

On the somatophrenic arm and mirrors

Number seven is the most spiritual of all numbers. Number seven is the most spiritual of all numbers. It is the seeker of truth.It is the seeker of truth.

On Allesthesia, tactile neglect and ‘blind touch’

‘Touch your left arm’ Bisiach’s test of body

neglect.

Absent proprioception and touch in the left upper

limb

Patient is still able to touch her left arm whatever

position the examiner keeps the arm in.

We learn by thinking and the quality of the learning outcome is We learn by thinking and the quality of the learning outcome is determined by the quality of our thoughts -R.B. Schmeckdetermined by the quality of our thoughts -R.B. Schmeck

Blind Sight Vs Blind Touch

On visual imagery, neglect and caloric tests

Visual imagery

Bisiach’s test

Our test

Eight is the most result-oriented of all numbers and represents a balanced worldEight is the most result-oriented of all numbers and represents a balanced world

Results

The True Art of Memory is The Art of Attention The True Art of Memory is The Art of Attention - S.Johnson - S.Johnson

Unconscious awareness in a person with

Blind Sight

And

Blind Touch

Conscious mind and unconscious mind

Theories of consciousness and the soul.NATURE, TIME AND PATIENCE NATURE, TIME AND PATIENCE

are the 3 great physiciansare the 3 great physicians

My sincere gratitude to my

Teachers, Patients and

Madras Institute of Neurology,

MEDISCAN SYSTEMS & Mr.Thudhimugan

for their computer work

My sincere gratitude to my

Teachers, Patients and

Madras Institute of Neurology,

MEDISCAN SYSTEMS & Mr.Thudhimugan

for their computer work

Dedicated to my family for

making everything worthwhile

READ READ not to contradict or confutenot to contradict or confute

Nor to Believe and Take for GrantedNor to Believe and Take for Granted

butbut TOTO WEIGH AND CONSIDERWEIGH AND CONSIDER

THANK YOUTHANK YOU