Arm levitation in progressive supranuclear palsy

To the Editor:

I enjoyed reading the article by Barclay et al.1 Their six patients had progressive supranuclear palsy (PSP) with abnormal upper limb levitation (ULL) in the absence of obvious apraxia or major alien hand syndrome. These patients were able to bring down the limb on command but when the attention was diverted it would resume to ULL posture. I have observed a similar physical sign in association with acute neurologic events. Although these two entities differ in clinical evolution both may require bilateral cerebral dysfunction to become manifest.

Five patients with an acute cerebral lesion demonstrated ipsilateral abnormal ULL. Four patients had left ULL that could be easily demonstrated by lifting both of the patient’s upper extremities by the physician. No verbal instruction is given. Upon slow release, the right upper extremity typically drops because of marked weakness, and left upper extremity remains in elevated position at least for a minute and occasionally up to several minutes. Most patients were drowsy and several even snored during this “Nazi-salute” position. If spontaneously awake with intact speech, no patient asked to lower the left upper extremity, but when the attention was brought to the levitated arm, the limb slowly dropped. Three patients had superimposed hyperkinetic finger movement in the levitated arm. Underlying acute cerebral lesions consisted of two left middle cerebral infarctions and two striatocapsular hemorrhages; one on each side and one left subdural hygroma with recent hemorrhage. MRIs showed bilateral lesions in three and in the remaining two patients, both stuporous, the lesions were large (one with left striatocapsular hemorrhage superimposed with separate old left frontal infarction and another with a single large left middle cerebral artery (MCA) infarction).

An ipsilateral ULL in the setting of an acute unilateral cerebral insult most likely represents a transient contralateral physiologic …