脳卒中後Alien hand syndromeに対する低頻度反復性磁気刺激療法と集中的作業療法

Combined Low-frequency Repetition Transcranial Magnetic Stimulation (rTMS) and Intensive Occupational Therapy for Alien Hand Syndrome after Stroke : A Case Report

はじめに

　Ailen hand syndrome（以下AHS）は主に前頭葉内側部，脳梁，前部帯状回，後部頭頂皮質などを中心とする損傷により生じる上肢の運動障害である^1）．症状として他人の手徴候，強迫的把握，道具の強制使用や両手間の対立が認められるとされており，これらは疾患や病巣により様々である^2）．またこれらの症状に対する明確なリハビリテーション（以下，リハ）方法は確立されていない．

　我々の施設では，2012年10月より脳卒中後の上肢麻痺患者を対象として，健側大脳への低頻度反復性磁気刺激療法と集中的作業療法の15日間プロトコール（NEURO-15）を実施し，過去の報告と同様に良好な改善効果が得られている^3）．今回，回復期リハを経た後にNEURO-15を行い上肢機能とAHS症状の改善が認められたAHS症例を経験した．その経過について報告する．

Abstract : Alien hand syndrome (AHS) is a rare neurologic disorder in which movements are performed without conscious will. Cognitive rehabilitation is usually first considered for treating AHS. However, we proposed different modalities for the treatment. This is the first case report showing therapeutic effects of the NEURO-15 program that consists of low-frequency repetitive transcranial magnetic stimulation and intensive occupational therapy on AHS symptoms and upper limb dysfunction caused by a stroke one year and three months before. A 68-year-old male developed right upper limb palsy secondary to cerebral infarction on the medial side of the left frontal lobe. On admission, he exhibited disturbed skilled motor behavior, compulsive grasping of the right upper limb, and dissociated behavior of the right hand independent from the left. The right hand interfered with the actions executed by the left hand. The left hand restricted the right hand in its actions by holding it. Six months after the onset, his Activities of Daily Living improved and he was discharged from hospital to home. However, his compulsive grasping of the right upper limb symptoms remained, and he underwent NEURO-15 one year and three months after the onset. His right upper limb function improved. Compulsive grasping of the right upper limb disappeared, and the contradictory action of the right upper limb was rarely seen. These results suggested that NEURO-15 influenced the neural network including the primary motor cortex and supplementary motor area.