Phantom touch: how to unmask sensory unawareness after stroke

Comprehending the nature of tactile disorders following brain damage is crucial to understand how the brain constructs sensory awareness. Stroke patients may be unaware of being touched on the affected hand if, simultaneously, they are touched on the unaffected hand (i.e. tactile extinction). More rarely, they feel touches on the two hands, when they are solely touched on the unaffected hand (i.e. synchiria). Using a novel assessment tool, we investigated whether in stroke patients with apparent intact tactile awareness on standard evaluation, tactile extinction might be possibly masked by phantom (synchiric) sensations (i.e. elicited by ipsilesional stimulation) arising exclusively during Double Simultaneous Stimulation (DSS). Patients with right (n=17) and left (n=8) hemisphere lesions and age-matched healthy controls (n=13) were tested with the Tactile Quadrant Stimulation test, consisting in delivering unilateral or bilateral touches to one of four quadrants, identified on the participants’ hands. In DSS trials, stimuli were applied to asymmetric quadrants. Participants reported the side(s) and then pointed to the site(s) of stimulation. We found that, with the exception of one patient who showed tactile extinction, about 50% of patients with overall intact tactile perception on classical evaluation, although reporting two stimuli in DSS, failed in pointing to the correct contralesional stimulated site. They reported the felt sensation in positions that corresponded to the ipsilesional stimulated sites. Thus apparent detections of contralesional touches in DSS were accounted for by ‘phantom’ sensations of ipsilesional stimulation that masked unawareness of contralesional touches when classic assessment was applied. Preliminary lesion analyses indicate that the symptom was associated with damage to structures often affected in tactile extinction. These findings, while unveiling important underestimation of the patients’ neurological condition, provide a framework for investigating bihemispheric contributions to altered tactile perception following stroke.