Post‑stroke disorders of ownership and agency, alien/anarchic hand syndrome: A longitudinal case analysis and systematic review.

Objective: Disorders of motor agency and ownership following stroke represent a complex clinical spectrum, ranging from transient phenomena to chronic syndromes. However, the prognostic factors that govern symptom persistence remain poorly defined.

Methods: We conducted a systematic review of post-stroke cases with uncontrollable hand actions and structural imaging data. Eligible reports were screened for lesion sites, awareness of limb ownership, and clinical courses. The time to the last reported assessment was documented to distinguish acute/subacute from chronic trajectories. Additionally, we present a longitudinal case study of a patient with a lesion extending from the genu to the splenium of the corpus callosum and into the right medial frontal area cortex, with follow-up imaging at both acute and chronic stages. A lesion-based disconnectome analysis was performed to characterize network disconnection.

Results: Agency disruption was universal, whereas ownership loss occurred selectively, typically associated with parietal, parieto-occipital, fronto-parietal, or combined callosal and medial frontal lesions. Patients with isolated callosal, fronto-parietal, or callosal plus cingulate lesions often achieved complete resolution in the early stages. In contrast, chronic persistence of symptoms was almost invariably linked to combined damage of the corpus callosum and frontal or fronto-parietal cortices. The index case exemplified this pattern, with sustained grasping behavior at long-term follow-up and disconnection of callosal fibers, the superior longitudinal fasciculus, the frontal aslant tract, and cingulum bandle confirmed by tract-based modelling.

Conclusions: Chronic anarchic hand phenomena primarily result from the combined breakdown of interhemispheric and premotor networks. Early imaging of callosal and frontal pathways is essential for prognosis and therapeutic planning.