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Art, Constructional Apraxia, and the Brain
ART, CONSTRUCTIONAL APRAXIA, AND THE BRAIN
Louis Caplan Harvard Medical School, Best Israel Deaconess Medical Center Boston, Massachusetts 02215, USA
I. II. III. IV.
Introduction Constructional Apraxia What Attributes are Customarily Needed to Make a Painting or Sculpture? The Frontal Lobes and Their Projections A. Nature of the Deficits B. Anatomy C. Testing at the Bedside V. The Parietal Lobes and Their Projections A. Left Parietal Lobe B. Right Parietal Lobe References
I. Introduction
Art is diverse. Painters, sculptors, and architects use diVerent media and often pursue their art in very diVerent ways. Painters can be as diVerent as Rembrandt, Turner, Mondrian, Klee, Miro, and Rothko, yet all share important attributes. In this volume, the various contributors also have very diVerent backgrounds, being engaged in diVerent artistic and medical disciplines. My perspective is that of a doctor, a neurologist who cares for individuals with brain diseases, mostly strokes and will comment on the dysfunction, labeled constructional apraxia, from a practicing physician’s viewpoint. After describing and defining the term, I reflect on important attributes needed to complete successful art. I then will turn to the regions of the brain that usually show lesions in patients with constructional apraxia and comment on bedside testing of the various disorders that contribute to this disorder, emphasizing my own approach.
II. Constructional Apraxia
Art is performed using many parts of the brain. Children love to build with blocks, make castles and bridges in the sand, draw and finger paint, and mold INTERNATIONAL REVIEW OF NEUROBIOLOGY, VOL. 74 DOI: 10.1016/S0074-7742(06)74015-6
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clay into objects. The brain regions involved in these functions are active early in life, very widespread, and distributed within much of the brain. Neurologists coined the term ‘‘constructional apraxia’’ to describe diYculties with functions that relate to art. The early definitions are diYcult to decipher. Macdonald Critchley (1969) wrote ‘‘constructional apraxia can be defined in simplest form as a diYculty in putting together one-dimensional units as to form two-dimensional figures or patterns.’’ Karl Kleist wrote that constructional apraxia describes ‘‘a disturbance in formative activities (arranging, building, drawing) in which the spatial part of the task is missed, although there is no apraxia of single movements’’ (Critchley, 1969). I find it easier to think of constructional apraxia simply as diYculty in drawing, copying, and arranging when elementary neurological functions, such as seeing, speaking, and using the limbs, are well preserved. After Critchley (1969) and his famous monograph on The Parietal Lobe, neurologists have tended to emphasize the parietal lobe, especially the inferior portion of the right parietal lobe, as being the epicenter in which lesions cause constructional apraxia. However, many brain lesions can result in constructional apraxia—each with very diVerent signatures and mechanisms. Herein, I analyze the three most common brain regions that relate to art—to drawing and copying, realizing at the same time that much of the rest of the brain is also involved in creative art.
III. What Attributes are Customarily Needed to Make a Painting or Sculpture?
An artist must have the initiative to begin the task. He or she must be motivated and energized in order to start preparing for the task. They then must consider what to depict in their work of art. This decision depends on weighing a number of factors, such as their own abilities, strengths, past successes and failures, the available tools and equipment (paints, colors, easels, canvas, and so on), and societal issues such as what might fit with the present norms of art, what patrons might support, what consumers might buy, and what galleries might display. Next, the artist must plan the work. Once the task has been decided and planned, the artist must be able to switch from one function to another and back to another during performance of the task. The artist must have the perseverance to complete the task and to do so timely enough to meet prespecified targets. The functions described so far are generally attributed to the frontal lobes of the brain and their aVerent and eVerent projections. The work of the artist diVers considerably, depending on whether the artist is creating the work without a model from their own memory, and must be able to revisualize and imagine the art that they will create or whether a picture is made by
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copying in some fashion a scene, a landscape, actual objects, people, or animal life. Creating an image without a present object requires conceptualization of the object, a function usually assigned to the left cerebral parasylvian speech cortex, especially portions of the left inferior parietal lobe—the supramarginal and angular gyri. Revisualization of objects is attributed mostly to the inferior banks of the calcarine sulci—the lingual and fusiform gyri (lesions of which almost invariable are accompanied by a visual field defect); revisualization of directions is usually assigned to the visual tracts that course from the upper banks of the calcarine sulci—the cuneus— through the superior parietal lobes and are also mostly accompanied by visual field defects or with features of the Balint syndrome (Barton and Caplan, 2001). Copying and depiction of size, shape, proportions, and relationships of visual percepts are functions most often localized to the right inferior parietal lobe. Since the designation constructional apraxia is by definition limited to those individuals who have normal visual and limb functions, the usual distribution of lesions associated with constructional apraxia are the frontal lobes and their projections and the left and right parietal lobes, mostly their inferior portions. In the remainder of this chapter, I will discuss the anatomy of the lesions that are most often responsible for constructional apraxia and their clinical testing.
IV. The Frontal Lobes and Their Projections
A. NATURE
OF THE
DEFICITS
Individuals with frontal lobe lesions have a number of dysfunctions that limit their creative artistic abilities (Table I). Some relate to the quantity and timing of actions and behavior; the two most important of which in relation to art are abulia and motor impersistence. Abulic individuals have a paucity of spontaneous behavior, speech, and action. They tend to sit for long periods without taking the initiative to begin to draw or paint. When they are asked questions or given directions they often delay their replies. Often they must be asked or told something repeatedly before a response is forthcoming. They have diYculty in persevering with tasks, often performing one appropriate action or giving several responses when many are requested or required. Abulic artists would have diYculty initiating a work of art and would be quite unable to persist to complete the work. Individuals with motor impersistence often respond quickly to commands and queries, although they just as quickly terminate the activity or response (Fisher, 1956). When asked to hold their arms outstretched in front of them, they assume this posture quickly but then drop their arms failing to persist with the task. Miller Fisher was accustomed to define deficits operationally by describing the tests and responses that he meant (Fisher, 1956). Impersistence is translated in life into impulsivity and
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ABNORMALITIES
IN
TABLE I PATIENTS WITH FRONTAL LOBE LESIONS
Abnormal quantity and timing of behavior Abulia Slowness Motor impersistence (impulsivity and diYculty persevering with tasks) Hyperactivity ‘‘Executive Dysfunctions’’ Loss of planning capabilities DiYculty performing concurrent and sequential acts Perseveration DiYculty switching ideas and actions Loss of working memory Ignoring of lessons from past personal experiences, society norms, and mores in making decisions and actions
diYculty persisting with activities; these individuals often answer queries even before the question is finished and make rather hasty, impulsive decisions that are not appropriate because they were not thought through before action. They also leave tasks prematurely and cannot persist with tasks that were planned. The other important capabilities loosely attributed to the frontal lobe are usually bundled under the designation of ‘‘executive functions.’’ These include the initial planning of a task or project. In order to appropriately plan, an individual must be aware of their own past experiences and capabilities as well as a multitude of practical issues—money, salability, society norms and mores, and what is ‘‘en courant.’’ After planning the task, the artist needs to frequently switch activities during the actual task of creating the art work. This involves switching diVerent colors, diVerent techniques, and diVerent parts of the work. Patients with executive dysfunctions often have diYculty switching tasks and performing concurrent and sequential tasks. They often perseverate, continuing the same activity with delays in switching to a new direction.
B. ANATOMY The deficits described are noted most often in patients with rather large frontal lobe lesions, often tumors. The precise anatomy within the frontal lobes, even left versus right versus bilaterality has not been well worked out. Most frontal lobe lesions that cause abulia and executive dysfunctions involve the lateral frontal convexal structures or areas near the frontal poles. Patients with strokes involving the caudate nucleus and the adjacent anterior limb of the internal capsule also show abulia, usually for a period that lasts up to
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FIG. 1. An MRI that shows an acute medial thalamic infarct (white arrow). The patient acutely became abulic.
6 months (Caplan et al., 1990). These areas have strong projection to the frontal lobes. The other main lesion that causes abulia and some executive dysfunction involves the medial thalamus on either side (Bogousslavsky and Caplan, 1993; Bogousslavsky et al., 1986). Infarcts within the territory of the thalamo-tubular arteries (also called the polar arteries) are most often responsible (Bogousslavsky and Caplan, 1993; Bogousslavsky et al., 1986). These arteries are usually branches of the posterior communicating arteries but occasionally branch from the thalamo-perforating arteries. Figure 1 shows an MRI of a medial thalamic infarct in an abulic patient. Like caudate lesions, the abulia that develops in medial thalamic infarct patients usually abates within the first 6 months after the stroke. C. TESTING
AT THE
BEDSIDE
The most important but oft-neglected first step is simple observation of the individual, noticing spontaneous behavior and conversation patterns. Abulic persons usually do not initiate conversations, reply belatedly or not at all to
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queries or directions, and speak in brief phrases or sentences. I recommend three tests: counting 20–0, cross oV all the A’s on a page, and name 10 articles of clothing. Ask the person to count quickly from 1–20, and then, if that task is performed accurately, to count backward from 20–1 without stopping. Abulic individuals can count forward indicating their understanding of the task and of the numbers involved. They, however, have great diYculty counting in reverse. They characteristically begin well and then pause, slow down, stop, or sometimes reverse directions and count forward. A typical example would be: 20–19–18– 17. . .. . .. . .16. . .. . .. . .15 (and then after they stop and you encourage) . . .14 . . .. . .13 . . .. . .. . .12 . . .. . .13 . . .14, and so on. Many never reach 0 or do so very slowly and only with encouragement and cues to continue. Next show the individual a text in a newspaper, magazine, or page of print. Ask them to cross oV with a pencil all of one letter, for example A. Abulic individuals usually cross oV a few As correctly and then become distracted and quit. The fact that they do the initial identification correctly shows that they understand the nature of the task and can recognize the letter A; their problem is an inability to persevere with the task. Another strategy for testing is to ask the individual to make a list (either verbally or on paper) of common items, for example, articles of clothing, colors, fruits, cities, means of conveyance, and so on. Ask them to give you 10 names. Abulics usually get 2 or 3 items in the category and then stop and rarely persist until 10 are named. Testing for impersistence again begins with behavioral observation, since these individuals are often restless and easily distracted, they answer questions very quickly, often before the query is finished; they perform tasks quickly but just as quickly discontinue, even when directed to continue. Directions to the patient might include: hold up your hands in front of you and keep them there or hold your tongue out until I say to withdraw it. Table II lists Miller Fisher’s (1956) criteria for motor impersistence; note that he defines the term operationally by their response to the tests enumerated. Executive functions can be tested in several ways. I often test planning by asking the individual to draw a floor plan of the first floor of a house in which they would like to live. This task requires thought. How many bedrooms? Where to
TABLE II MOTOR IMPERSISTENCE (FISHER, 1956) Inability to maintain conjugate gaze steadily Inability to keep mouth open or tongue protruded Inability to maintain fixation on examiner’s nose during visual field testing Inability keeping eyes shut during sensory testing-peeking DiYculty holding breath or maintaining an ‘‘ah’’ sound DiYculty maintaining steady pressure during a hand grip
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place the dining room, kitchen, pantry, doors, hallway, entrance, bathrooms, and so on. The location, size, and relationship of the rooms must be considered. Usually this task requires considerable thought and planning. I also use the Porteus Mazes test—which involves the ability to plan a strategy for route finding using a paper—and pencil maze test (Mesulam, 2000; Porteus, 1965). Another rather good test is the Tower of London puzzle test which is shown in Fig. 2 (Mesulam, 2000; Shallice, 1982). Patients with frontal lobe lesions often have diYculty switching from one subject or task to another. There are a number of bedside tests useful in testing this ability and seeking preservations. I give the individual a pencil and paper and ask them to make repeatedly a series of two squares, one circle, two squares, one circle, two squares, and one circle; patients with frontal lobe disease may have diYculty in switching from square to circle and will write more than two squares. A similar task involves tapping with palm down twice, alternating with palm up once. The patient can be asked to alternate positions using one hand. The patient is told to hit the top of the desk, first with a fisted hand, then with the palm, then with the side of the hand; these alternate hand postures are continued for 20 s or more. Patients who perseverate will have diYculty inhibiting repetition of postures. Another test involves alternating actions of the two hands such as palm down with the left hand followed by palm up with the right hand then palm up with the left hand and palm down with the right hand. The Go–No-Go test is another rather simple investigation of the ability of the individual to switch that can be performed at the bedside. The directions for this test are: place your hand palm down on table then raise your index finger if I tap once (Go signal) but do not raise the index finger if I tap twice (No-Go signal). Individuals with executive dysfunctions have diYculty with sequential or concurrent performance and frequently perseverate the last response (Drewe, 1975; Mesulam, 2000).
FIG. 2. The tower of London puzzle (from Mesulam, 2000 with permission).
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V. The Parietal Lobes and Their Projections
A. LEFT PARIETAL LOBE 1. Nature of the Deficits The left parasylvian area is most well known for a specialization in language. Language in its simplest sense means words, but more complex is the issue of concepts, for example, what is a chair. There are innumerable examples of chairs all configured, constructed, and modeled diVerently (Fig. 3). Similarly the concept of a table is complex; an individual can picture a specific table, but the concept of what really defines or makes a table is quite diVerent (Fig. 4). Patients with left parietal lobe lesions have diYculty in revisualizing the nature of objects and their appearances (Barton and Caplan, 2001; DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). Patients with left parietal damage often draw very simple rudimentary figures but do not omit one side of the drawing and generally estimate size, angles, and proportions well. They are able to copy well, greatly improving their spontaneous performance. Their problem is conceptualization of the abstract idea of the object, while patients with right parietal lobe damage have a normal concept of the object, they cannot
FIG. 3. A selection of various chairs taken from catalogue.
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FIG. 4. A selection of various tables taken from catalogues.
construct the visuospatial components of that percept (DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). 2. Anatomy The major region that correlates with constructional dyspraxia is the inferior parietal lobe, the supramarginal and angular gyri. Individuals with lesions in this area also may have a number of other deficits that are listed in Table III. The most common language disorders involve written language. Patients act as if they are illiterate, that is, they become unable to read, write, and spell. They may also make speech sound-alike and mean-alike errors and have diYculty repeating spoken language associated with some diYculty in understanding spoken speech. They also may show some of the various components of the Gerstmann syndrome (agraphia, right–left confusion, finger agnosia, and constructional apraxia) (Critchley, 1969). Some patients with superior parietal lobe lesions, the precuneus and gyri posterior to the postcentral gyrus, may have diYculty drawing living things, especially people. They seem to have diYculty with body parts and with conceptualization of the human and animal forms. 3. Testing The major testing for constructional apraxia associated with left parietal lobe lesions is to ask the patient to draw a complex figure from memory. Familiar
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TABLE III LEFT INFERIOR PARIETAL LOBE CLINICAL DEFICITS Alexia Agraphia DiYculty spelling Conduction aphasia Acalculia Right–left confusion Finger agnosia Constructional apraxia
FIG. 5. Shows examples of spontaneous drawing and copying of houses by patients with left parietal lobe damage (from Piercy, 1960 with permission).
figures, such as a house, bicycle, daisy, or church, are requested, and patients with left parietal lesions usually draw very simple figures that are not elaborate. The sizes, proportions, angles, and relationships are usually drawn appropriately, and they are able to copy complex figures rather well, indicating that the main problem is conceptual with diYculty in the concept of the object drawn. Once a model is available, they can copy and imitate it well. Figure 5 shows examples of spontaneous drawing and copying of houses by patients with left parietal lobe damage. The spontaneous drawings are rudimentary, but the copies are improved over the spontaneous performance. I usually also ask them to copy complex objects, such as the Rey-Osterrieth Figure (Osterrieth, 1944; Rey, 1941) (Fig. 6), which they usually do quite well.
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FIG. 6. The Rey-Osterrieth figure.
Ancillary testing of reading, writing, spelling, finger naming, and arithmetic functions is often useful in localizing the lesion to the left inferior parietal lobe. Asking the patient to draw a person is also useful.
B. RIGHT PARIETAL LOBE While the left cerebral hemisphere is thought to be dominant for language and recall of language-related semantic information, the right cerebral hemisphere is considered dominant for visuospatial functions and recall of visual data (Barton and Caplan, 2001; Caplan and Bogousslavsky, 1995; Hier et al., 1983). Patients with right parietal damage usually copy very poorly. In their spontaneous figures, they often omit objects on the left. Size, angles, and proportions are often misjudged (DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). Figure 7 shows examples of houses drawn by patients with right parietal lobe damage; copying does not improve their performance. They may also have diYculty in revisualizing the arrangements of things in their rooms at home, the relationships of one room to another, and directions within the city or town in which they live. Their deficits involve the visuospatial attributes of objects and places and involve revisualization, drawing, copying, and arranging. 1. Anatomy Most lesions that cause constructional apraxia are located within the inferior parietal lobe region—the supramarginal and angular gyri. Infarcts in this region are most often embolic, the donor source being the heart, aorta, or the ipsilateral
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FIG. 7. Shows examples of houses drawn by patients with right parietal lobe damage (from Piercy, 1960 with permission).
carotid artery. An agitated hyperactive state and a left superior quadrantanopia often accompany the constructional apraxia (Caplan et al., 1986). Large lesions that undercut these gyri, for example, large right posterior cerebral artery distribution infarcts, and posterior temporal–occipital hemorrhages can also aVect the function of the right inferior parietal lobe. 2. Testing The most common way to test for constructional apraxia is to ask the patient to draw objects such as a clock, house, daisy, bicycle, and so forth. Next, draw an abstract figure and ask the patient to copy it as exactly as possible. I suggest using a modern-art type figure that the patient cannot easily describe in words. If one asks the patient to copy a commonly recognized object, they will often see the object, give it a name (e.g., clock) and then draw a clock instead of slavishly copying the clock that you have asked them to reproduce. Visuospatial abnormalities can be further checked by having the patient copy the Rey-Osterrieth figure (Osterrieth, 1944; Rey, 1941) (Fig. 6). This can be done with the figure present to copy, or the figure can be removed and the patient asked to reproduce as much of the figure as they recall; this delayed reproduction tests visual memory ability. An alternate method of testing visuospatial functions is to ask patients to copy arrangements. Tongue blades, Q-tips (cotton topped sticks) with cotton removed (Fig. 8), or childrens’ building blocks (Fig. 9) can be
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FIG. 8. Sticks arrangements and their copies (from Critchley, 1969 with permission).
FIG. 9. Child building block arrangement and a patient’s copy (from Critchley, 1969 with permission).
arranged by the examiner in various patterns and the patient asked to reproduce the arrangement using a stack of the same materials. Drawing and then copying clocks, houses, daisies, and so on are the most important tests. Visuospatial capabilities are also readily tested at the bedside by asking the patient to construct mosaic patterns using Koh’s blocks (Fig. 10). Koh’s blocks are
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FIG. 10. Koh’s blocks.
small cubes that have surfaces that are red, blue, and white; red and white; blue and white; and red and blue. Diagrams of models of mosaics to be copied are available in WAIS-R testing kits, since testing with red and white Koh’s blocks is a standard part of this IQ test (Wechsler, 1981). Figure 11 shows some sample mosaics and attempts at copying by patients with right parietal lobe lesions. This subtest of the WAIS is easily administered in the oYce or at the bedside and is very useful in quantifying the severity of constructional, visuospatial deficits. Reading and writing can also show signs of left visual neglect. If patients are asked to read a paragraph, they may omit the most leftward words or phrases and have diYculty directing their gaze and attention to the left border of the page. Figure 12 shows an example of writing on the right side of a page ignoring the paper on the left side. Visual functions can be tested by showing pictures of scenes and individuals, specially those cut out from magazines such as the National Geographic or advertisements. The pictures chosen should have multiple persons or objects scattered on the left and right sides. Hold the picture in front of the patient for about 10 s. If the patient has poor visual acuity, give the picture to the patient to examine. After withdrawing the picture, ask the patient what they saw. After their general description, ask for specific details. When and where did the scene take place? How old are the individuals? How are they dressed, and so on? Much can be learned from the patient’s performance. Watch the patient’s eyes as they scan the picture. Do they search symmetrically? Have they seen the whole picture? Have they grasped the general gestalt of the picture or instead focused on a minor peripheral aspect? Patients with right cerebral hemisphere lesions often neglect
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FIG. 11. Sample mosaics and attempts at copying by patients with right parietal lobe lesions. (from Critchley, 1969 with permission).
figures on the left. Left visual neglect is often but not always accompanied by constructional apraxia (Osterrieth, 1944). Patients with frontal lobe disease often scan poorly and are satisfied with telling about the first feature that catches their eye and do not extract further information from the scene. DeRenzi and colleagues performed a series of three tests that illuminates the nature of the comparison of deficits between left and right parietal lobe damaged patients (DeRenzi et al., 1969). In the first test, patients were asked to match photographs that showed individuals’ faces in a frontal view with the same individuals shown in a profile or side view (Fig. 13); in the second test, patients were given an overlapping figure that contained various fruits (Fig. 14). The task was to select those fruits from the drawings of various fruits on the side of the overlapping figure that were contained within the overlapping figure. In the third test, patients were shown photographs of various objects and asked to match the photographs with actual objects, but the objects were not exactly the same as the pictures (Fig. 15). The actual objects diVered in form and color from the pictures.
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FIG. 12. Shows an example of writing on the right of a page ignoring the paper on the left side. (from Critchley, 1969 with permission).
FIG. 13. Matching of front-view photographs with side views. (from DeRenzi et al., 1969 with permission).
Patients with left parietal damage had no diYculty matching photographs of individuals (test 1) or identifying the fruits in the overlapping figure (test 2) but did poorly on test 3 matching nonidentical stimuli. The first two tests are purely visual; one does not need to know the names or identities of the people or fruits. These tests are visual matching tests and left parietal lobe damaged patients have no diYculty with visuospatial functions. The third test relates to categorization
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FIG. 14. The Ghent overlapping figures test. (from DeRenzi et al., 1969 with permission).
FIG. 15. An example of nonidentical matching of objects. (from DeRenzi et al., 1969 with permission).
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and left parietal lobe damaged patients have diYculty with this function, doing less well than right parietal damaged patients. In contrast, patients with right parietal lobe damage did poorly on the first two tests of visuospatial matching and did well on the third test of categorization (DeRenzi et al., 1969).
References
Barton, J. S., and Caplan, L. R. (2001). In ‘‘Cerebral Visual Dysfunction in Stroke Syndromes’’ (J. Bogousslavsky and L. R. Caplan, Eds.), 2nd ed., pp. 87–110. Cambridge University press, Cambridge, UK. Bogousslavsky, J., and Caplan, L. R. (1993). Vertebrobasilar occlusive disease: Review of selected aspects. Lll. Thalamic infarcts. Cerebrovasc. Dis. 3, 193–205. Bogousslavsky, J., Regli, F., and Assal, G. (1986). The syndrome of tuberothalamic artery territory infarcts. Stroke 17, 434–441. Caplan, L. R., and Bogousslavsky, J. (1995). Abnormalities of the right cerebral hemisphere. In ‘‘Stroke Syndromes’’ ( J. Bogousslavsky and L. R. Caplan, Eds.), pp. 162–168. Cambridge University press, Cambridge. Caplan, L. R., Kelly, M., Kase, C. S., Hier, D. B., White, J. L., Tatemichi, T., Mohr, J. P., Price, T., and Wolf, P. (1986). Infarcts of the inferior division of the right middle cerebral artery: Mirror image of Wernicke’s aphasia. Neurology 36, 1015–1020. Caplan, L. R., Schmahmann, J. D., Kase, C. S., Feldmann, E., Baguis, G., Greenberg, J. P., Gorelick, P. B., Helgason, C., and Hier, D. B. (1990). Caudate infarcts. Arch. Neurol. 47, 133–143. Critchley, M. (1969). ‘‘The Parietal Lobes.’’ Hafner Pub Co., New York. DeRenzi, E., Scotti, C., and Spinnler, H. (1969). Perceptual and associated disorders of visual recognition: Relationship to the side of the cerebral lesion. Neurology 19, 634–642. Drewe, E. A. (1975). Go No-go learning after frontal lobe lesions in humans. Cortex 11, 8–16. Fisher, C. M. (1956). Left hemiplegia and motor impersistence. J. Nerv. Ment. Dis. 123, 201–218. Gainotti, G. (1985). Constructional apraxia. In ‘‘Handbook of Clinical Neurology’’ (P. Vinken, G. Bruyn, and H. Klawans, Eds.), Vol. 45, pp. 491–506. Elsevier Science Publishers, Amsterdam. He´caen, H., and Assal, G. (1970). A comparison of construction deficits following right and left hemisphere lesions. Neuropsychologia 8, 289–304. Hier, D., Mondlock, J. J., and Caplan, L. R. (1983). Behavioral defects after right hemisphere stroke. Neurology 33, 337–344. Mesulam, M.-M. (2000). In ‘‘Principles of Behavioral and Cognitive Neurology,’’ 2nd ed., pp. 121–173. Oxford University press, Oxford. Osterrieth, P. A. (1944). Le test de copie d’une figure complex. Archives de Psychologie 30, 206–356. Piercy, M., Hecaen, H., and De Ajuriaguera, J. (1960). Constructional apraxia associated with unilateral cerebral lesions, left and right sided cases compared. Brain 83, 225–242. Porteus, S. D. (1965). ‘‘Porteus Mazes Tests: Fifty Years Applications.’’ The Psychological Corporation, San Antonio Texas. Rey, A. (1941). L’examen psychologique dans les cas d’encephalopathie traumatique. Arch de Psychologie 28, 286–340. Shallice, T. (1982). Specific impairments of planning. Philos. Trans. R. Soc. London Biol. 298, 199–209. Wechsler, D. (1981). ‘‘WAIS-R. Wechsler adult intelligence scale – Revised.’’ Psychological Corporation, New York.
Louis Caplan Harvard Medical School, Best Israel Deaconess Medical Center Boston, Massachusetts 02215, USA
I. II. III. IV.
Introduction Constructional Apraxia What Attributes are Customarily Needed to Make a Painting or Sculpture? The Frontal Lobes and Their Projections A. Nature of the Deficits B. Anatomy C. Testing at the Bedside V. The Parietal Lobes and Their Projections A. Left Parietal Lobe B. Right Parietal Lobe References
I. Introduction
Art is diverse. Painters, sculptors, and architects use diVerent media and often pursue their art in very diVerent ways. Painters can be as diVerent as Rembrandt, Turner, Mondrian, Klee, Miro, and Rothko, yet all share important attributes. In this volume, the various contributors also have very diVerent backgrounds, being engaged in diVerent artistic and medical disciplines. My perspective is that of a doctor, a neurologist who cares for individuals with brain diseases, mostly strokes and will comment on the dysfunction, labeled constructional apraxia, from a practicing physician’s viewpoint. After describing and defining the term, I reflect on important attributes needed to complete successful art. I then will turn to the regions of the brain that usually show lesions in patients with constructional apraxia and comment on bedside testing of the various disorders that contribute to this disorder, emphasizing my own approach.
II. Constructional Apraxia
Art is performed using many parts of the brain. Children love to build with blocks, make castles and bridges in the sand, draw and finger paint, and mold INTERNATIONAL REVIEW OF NEUROBIOLOGY, VOL. 74 DOI: 10.1016/S0074-7742(06)74015-6
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clay into objects. The brain regions involved in these functions are active early in life, very widespread, and distributed within much of the brain. Neurologists coined the term ‘‘constructional apraxia’’ to describe diYculties with functions that relate to art. The early definitions are diYcult to decipher. Macdonald Critchley (1969) wrote ‘‘constructional apraxia can be defined in simplest form as a diYculty in putting together one-dimensional units as to form two-dimensional figures or patterns.’’ Karl Kleist wrote that constructional apraxia describes ‘‘a disturbance in formative activities (arranging, building, drawing) in which the spatial part of the task is missed, although there is no apraxia of single movements’’ (Critchley, 1969). I find it easier to think of constructional apraxia simply as diYculty in drawing, copying, and arranging when elementary neurological functions, such as seeing, speaking, and using the limbs, are well preserved. After Critchley (1969) and his famous monograph on The Parietal Lobe, neurologists have tended to emphasize the parietal lobe, especially the inferior portion of the right parietal lobe, as being the epicenter in which lesions cause constructional apraxia. However, many brain lesions can result in constructional apraxia—each with very diVerent signatures and mechanisms. Herein, I analyze the three most common brain regions that relate to art—to drawing and copying, realizing at the same time that much of the rest of the brain is also involved in creative art.
III. What Attributes are Customarily Needed to Make a Painting or Sculpture?
An artist must have the initiative to begin the task. He or she must be motivated and energized in order to start preparing for the task. They then must consider what to depict in their work of art. This decision depends on weighing a number of factors, such as their own abilities, strengths, past successes and failures, the available tools and equipment (paints, colors, easels, canvas, and so on), and societal issues such as what might fit with the present norms of art, what patrons might support, what consumers might buy, and what galleries might display. Next, the artist must plan the work. Once the task has been decided and planned, the artist must be able to switch from one function to another and back to another during performance of the task. The artist must have the perseverance to complete the task and to do so timely enough to meet prespecified targets. The functions described so far are generally attributed to the frontal lobes of the brain and their aVerent and eVerent projections. The work of the artist diVers considerably, depending on whether the artist is creating the work without a model from their own memory, and must be able to revisualize and imagine the art that they will create or whether a picture is made by
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copying in some fashion a scene, a landscape, actual objects, people, or animal life. Creating an image without a present object requires conceptualization of the object, a function usually assigned to the left cerebral parasylvian speech cortex, especially portions of the left inferior parietal lobe—the supramarginal and angular gyri. Revisualization of objects is attributed mostly to the inferior banks of the calcarine sulci—the lingual and fusiform gyri (lesions of which almost invariable are accompanied by a visual field defect); revisualization of directions is usually assigned to the visual tracts that course from the upper banks of the calcarine sulci—the cuneus— through the superior parietal lobes and are also mostly accompanied by visual field defects or with features of the Balint syndrome (Barton and Caplan, 2001). Copying and depiction of size, shape, proportions, and relationships of visual percepts are functions most often localized to the right inferior parietal lobe. Since the designation constructional apraxia is by definition limited to those individuals who have normal visual and limb functions, the usual distribution of lesions associated with constructional apraxia are the frontal lobes and their projections and the left and right parietal lobes, mostly their inferior portions. In the remainder of this chapter, I will discuss the anatomy of the lesions that are most often responsible for constructional apraxia and their clinical testing.
IV. The Frontal Lobes and Their Projections
A. NATURE
OF THE
DEFICITS
Individuals with frontal lobe lesions have a number of dysfunctions that limit their creative artistic abilities (Table I). Some relate to the quantity and timing of actions and behavior; the two most important of which in relation to art are abulia and motor impersistence. Abulic individuals have a paucity of spontaneous behavior, speech, and action. They tend to sit for long periods without taking the initiative to begin to draw or paint. When they are asked questions or given directions they often delay their replies. Often they must be asked or told something repeatedly before a response is forthcoming. They have diYculty in persevering with tasks, often performing one appropriate action or giving several responses when many are requested or required. Abulic artists would have diYculty initiating a work of art and would be quite unable to persist to complete the work. Individuals with motor impersistence often respond quickly to commands and queries, although they just as quickly terminate the activity or response (Fisher, 1956). When asked to hold their arms outstretched in front of them, they assume this posture quickly but then drop their arms failing to persist with the task. Miller Fisher was accustomed to define deficits operationally by describing the tests and responses that he meant (Fisher, 1956). Impersistence is translated in life into impulsivity and
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ABNORMALITIES
IN
TABLE I PATIENTS WITH FRONTAL LOBE LESIONS
Abnormal quantity and timing of behavior Abulia Slowness Motor impersistence (impulsivity and diYculty persevering with tasks) Hyperactivity ‘‘Executive Dysfunctions’’ Loss of planning capabilities DiYculty performing concurrent and sequential acts Perseveration DiYculty switching ideas and actions Loss of working memory Ignoring of lessons from past personal experiences, society norms, and mores in making decisions and actions
diYculty persisting with activities; these individuals often answer queries even before the question is finished and make rather hasty, impulsive decisions that are not appropriate because they were not thought through before action. They also leave tasks prematurely and cannot persist with tasks that were planned. The other important capabilities loosely attributed to the frontal lobe are usually bundled under the designation of ‘‘executive functions.’’ These include the initial planning of a task or project. In order to appropriately plan, an individual must be aware of their own past experiences and capabilities as well as a multitude of practical issues—money, salability, society norms and mores, and what is ‘‘en courant.’’ After planning the task, the artist needs to frequently switch activities during the actual task of creating the art work. This involves switching diVerent colors, diVerent techniques, and diVerent parts of the work. Patients with executive dysfunctions often have diYculty switching tasks and performing concurrent and sequential tasks. They often perseverate, continuing the same activity with delays in switching to a new direction.
B. ANATOMY The deficits described are noted most often in patients with rather large frontal lobe lesions, often tumors. The precise anatomy within the frontal lobes, even left versus right versus bilaterality has not been well worked out. Most frontal lobe lesions that cause abulia and executive dysfunctions involve the lateral frontal convexal structures or areas near the frontal poles. Patients with strokes involving the caudate nucleus and the adjacent anterior limb of the internal capsule also show abulia, usually for a period that lasts up to
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FIG. 1. An MRI that shows an acute medial thalamic infarct (white arrow). The patient acutely became abulic.
6 months (Caplan et al., 1990). These areas have strong projection to the frontal lobes. The other main lesion that causes abulia and some executive dysfunction involves the medial thalamus on either side (Bogousslavsky and Caplan, 1993; Bogousslavsky et al., 1986). Infarcts within the territory of the thalamo-tubular arteries (also called the polar arteries) are most often responsible (Bogousslavsky and Caplan, 1993; Bogousslavsky et al., 1986). These arteries are usually branches of the posterior communicating arteries but occasionally branch from the thalamo-perforating arteries. Figure 1 shows an MRI of a medial thalamic infarct in an abulic patient. Like caudate lesions, the abulia that develops in medial thalamic infarct patients usually abates within the first 6 months after the stroke. C. TESTING
AT THE
BEDSIDE
The most important but oft-neglected first step is simple observation of the individual, noticing spontaneous behavior and conversation patterns. Abulic persons usually do not initiate conversations, reply belatedly or not at all to
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queries or directions, and speak in brief phrases or sentences. I recommend three tests: counting 20–0, cross oV all the A’s on a page, and name 10 articles of clothing. Ask the person to count quickly from 1–20, and then, if that task is performed accurately, to count backward from 20–1 without stopping. Abulic individuals can count forward indicating their understanding of the task and of the numbers involved. They, however, have great diYculty counting in reverse. They characteristically begin well and then pause, slow down, stop, or sometimes reverse directions and count forward. A typical example would be: 20–19–18– 17. . .. . .. . .16. . .. . .. . .15 (and then after they stop and you encourage) . . .14 . . .. . .13 . . .. . .. . .12 . . .. . .13 . . .14, and so on. Many never reach 0 or do so very slowly and only with encouragement and cues to continue. Next show the individual a text in a newspaper, magazine, or page of print. Ask them to cross oV with a pencil all of one letter, for example A. Abulic individuals usually cross oV a few As correctly and then become distracted and quit. The fact that they do the initial identification correctly shows that they understand the nature of the task and can recognize the letter A; their problem is an inability to persevere with the task. Another strategy for testing is to ask the individual to make a list (either verbally or on paper) of common items, for example, articles of clothing, colors, fruits, cities, means of conveyance, and so on. Ask them to give you 10 names. Abulics usually get 2 or 3 items in the category and then stop and rarely persist until 10 are named. Testing for impersistence again begins with behavioral observation, since these individuals are often restless and easily distracted, they answer questions very quickly, often before the query is finished; they perform tasks quickly but just as quickly discontinue, even when directed to continue. Directions to the patient might include: hold up your hands in front of you and keep them there or hold your tongue out until I say to withdraw it. Table II lists Miller Fisher’s (1956) criteria for motor impersistence; note that he defines the term operationally by their response to the tests enumerated. Executive functions can be tested in several ways. I often test planning by asking the individual to draw a floor plan of the first floor of a house in which they would like to live. This task requires thought. How many bedrooms? Where to
TABLE II MOTOR IMPERSISTENCE (FISHER, 1956) Inability to maintain conjugate gaze steadily Inability to keep mouth open or tongue protruded Inability to maintain fixation on examiner’s nose during visual field testing Inability keeping eyes shut during sensory testing-peeking DiYculty holding breath or maintaining an ‘‘ah’’ sound DiYculty maintaining steady pressure during a hand grip
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place the dining room, kitchen, pantry, doors, hallway, entrance, bathrooms, and so on. The location, size, and relationship of the rooms must be considered. Usually this task requires considerable thought and planning. I also use the Porteus Mazes test—which involves the ability to plan a strategy for route finding using a paper—and pencil maze test (Mesulam, 2000; Porteus, 1965). Another rather good test is the Tower of London puzzle test which is shown in Fig. 2 (Mesulam, 2000; Shallice, 1982). Patients with frontal lobe lesions often have diYculty switching from one subject or task to another. There are a number of bedside tests useful in testing this ability and seeking preservations. I give the individual a pencil and paper and ask them to make repeatedly a series of two squares, one circle, two squares, one circle, two squares, and one circle; patients with frontal lobe disease may have diYculty in switching from square to circle and will write more than two squares. A similar task involves tapping with palm down twice, alternating with palm up once. The patient can be asked to alternate positions using one hand. The patient is told to hit the top of the desk, first with a fisted hand, then with the palm, then with the side of the hand; these alternate hand postures are continued for 20 s or more. Patients who perseverate will have diYculty inhibiting repetition of postures. Another test involves alternating actions of the two hands such as palm down with the left hand followed by palm up with the right hand then palm up with the left hand and palm down with the right hand. The Go–No-Go test is another rather simple investigation of the ability of the individual to switch that can be performed at the bedside. The directions for this test are: place your hand palm down on table then raise your index finger if I tap once (Go signal) but do not raise the index finger if I tap twice (No-Go signal). Individuals with executive dysfunctions have diYculty with sequential or concurrent performance and frequently perseverate the last response (Drewe, 1975; Mesulam, 2000).
FIG. 2. The tower of London puzzle (from Mesulam, 2000 with permission).
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V. The Parietal Lobes and Their Projections
A. LEFT PARIETAL LOBE 1. Nature of the Deficits The left parasylvian area is most well known for a specialization in language. Language in its simplest sense means words, but more complex is the issue of concepts, for example, what is a chair. There are innumerable examples of chairs all configured, constructed, and modeled diVerently (Fig. 3). Similarly the concept of a table is complex; an individual can picture a specific table, but the concept of what really defines or makes a table is quite diVerent (Fig. 4). Patients with left parietal lobe lesions have diYculty in revisualizing the nature of objects and their appearances (Barton and Caplan, 2001; DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). Patients with left parietal damage often draw very simple rudimentary figures but do not omit one side of the drawing and generally estimate size, angles, and proportions well. They are able to copy well, greatly improving their spontaneous performance. Their problem is conceptualization of the abstract idea of the object, while patients with right parietal lobe damage have a normal concept of the object, they cannot
FIG. 3. A selection of various chairs taken from catalogue.
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FIG. 4. A selection of various tables taken from catalogues.
construct the visuospatial components of that percept (DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). 2. Anatomy The major region that correlates with constructional dyspraxia is the inferior parietal lobe, the supramarginal and angular gyri. Individuals with lesions in this area also may have a number of other deficits that are listed in Table III. The most common language disorders involve written language. Patients act as if they are illiterate, that is, they become unable to read, write, and spell. They may also make speech sound-alike and mean-alike errors and have diYculty repeating spoken language associated with some diYculty in understanding spoken speech. They also may show some of the various components of the Gerstmann syndrome (agraphia, right–left confusion, finger agnosia, and constructional apraxia) (Critchley, 1969). Some patients with superior parietal lobe lesions, the precuneus and gyri posterior to the postcentral gyrus, may have diYculty drawing living things, especially people. They seem to have diYculty with body parts and with conceptualization of the human and animal forms. 3. Testing The major testing for constructional apraxia associated with left parietal lobe lesions is to ask the patient to draw a complex figure from memory. Familiar
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TABLE III LEFT INFERIOR PARIETAL LOBE CLINICAL DEFICITS Alexia Agraphia DiYculty spelling Conduction aphasia Acalculia Right–left confusion Finger agnosia Constructional apraxia
FIG. 5. Shows examples of spontaneous drawing and copying of houses by patients with left parietal lobe damage (from Piercy, 1960 with permission).
figures, such as a house, bicycle, daisy, or church, are requested, and patients with left parietal lesions usually draw very simple figures that are not elaborate. The sizes, proportions, angles, and relationships are usually drawn appropriately, and they are able to copy complex figures rather well, indicating that the main problem is conceptual with diYculty in the concept of the object drawn. Once a model is available, they can copy and imitate it well. Figure 5 shows examples of spontaneous drawing and copying of houses by patients with left parietal lobe damage. The spontaneous drawings are rudimentary, but the copies are improved over the spontaneous performance. I usually also ask them to copy complex objects, such as the Rey-Osterrieth Figure (Osterrieth, 1944; Rey, 1941) (Fig. 6), which they usually do quite well.
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FIG. 6. The Rey-Osterrieth figure.
Ancillary testing of reading, writing, spelling, finger naming, and arithmetic functions is often useful in localizing the lesion to the left inferior parietal lobe. Asking the patient to draw a person is also useful.
B. RIGHT PARIETAL LOBE While the left cerebral hemisphere is thought to be dominant for language and recall of language-related semantic information, the right cerebral hemisphere is considered dominant for visuospatial functions and recall of visual data (Barton and Caplan, 2001; Caplan and Bogousslavsky, 1995; Hier et al., 1983). Patients with right parietal damage usually copy very poorly. In their spontaneous figures, they often omit objects on the left. Size, angles, and proportions are often misjudged (DeRenzi et al., 1969; Gainotti, 1985; He´caen and Assal, 1970; Piercy et al., 1960). Figure 7 shows examples of houses drawn by patients with right parietal lobe damage; copying does not improve their performance. They may also have diYculty in revisualizing the arrangements of things in their rooms at home, the relationships of one room to another, and directions within the city or town in which they live. Their deficits involve the visuospatial attributes of objects and places and involve revisualization, drawing, copying, and arranging. 1. Anatomy Most lesions that cause constructional apraxia are located within the inferior parietal lobe region—the supramarginal and angular gyri. Infarcts in this region are most often embolic, the donor source being the heart, aorta, or the ipsilateral
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FIG. 7. Shows examples of houses drawn by patients with right parietal lobe damage (from Piercy, 1960 with permission).
carotid artery. An agitated hyperactive state and a left superior quadrantanopia often accompany the constructional apraxia (Caplan et al., 1986). Large lesions that undercut these gyri, for example, large right posterior cerebral artery distribution infarcts, and posterior temporal–occipital hemorrhages can also aVect the function of the right inferior parietal lobe. 2. Testing The most common way to test for constructional apraxia is to ask the patient to draw objects such as a clock, house, daisy, bicycle, and so forth. Next, draw an abstract figure and ask the patient to copy it as exactly as possible. I suggest using a modern-art type figure that the patient cannot easily describe in words. If one asks the patient to copy a commonly recognized object, they will often see the object, give it a name (e.g., clock) and then draw a clock instead of slavishly copying the clock that you have asked them to reproduce. Visuospatial abnormalities can be further checked by having the patient copy the Rey-Osterrieth figure (Osterrieth, 1944; Rey, 1941) (Fig. 6). This can be done with the figure present to copy, or the figure can be removed and the patient asked to reproduce as much of the figure as they recall; this delayed reproduction tests visual memory ability. An alternate method of testing visuospatial functions is to ask patients to copy arrangements. Tongue blades, Q-tips (cotton topped sticks) with cotton removed (Fig. 8), or childrens’ building blocks (Fig. 9) can be
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FIG. 8. Sticks arrangements and their copies (from Critchley, 1969 with permission).
FIG. 9. Child building block arrangement and a patient’s copy (from Critchley, 1969 with permission).
arranged by the examiner in various patterns and the patient asked to reproduce the arrangement using a stack of the same materials. Drawing and then copying clocks, houses, daisies, and so on are the most important tests. Visuospatial capabilities are also readily tested at the bedside by asking the patient to construct mosaic patterns using Koh’s blocks (Fig. 10). Koh’s blocks are
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FIG. 10. Koh’s blocks.
small cubes that have surfaces that are red, blue, and white; red and white; blue and white; and red and blue. Diagrams of models of mosaics to be copied are available in WAIS-R testing kits, since testing with red and white Koh’s blocks is a standard part of this IQ test (Wechsler, 1981). Figure 11 shows some sample mosaics and attempts at copying by patients with right parietal lobe lesions. This subtest of the WAIS is easily administered in the oYce or at the bedside and is very useful in quantifying the severity of constructional, visuospatial deficits. Reading and writing can also show signs of left visual neglect. If patients are asked to read a paragraph, they may omit the most leftward words or phrases and have diYculty directing their gaze and attention to the left border of the page. Figure 12 shows an example of writing on the right side of a page ignoring the paper on the left side. Visual functions can be tested by showing pictures of scenes and individuals, specially those cut out from magazines such as the National Geographic or advertisements. The pictures chosen should have multiple persons or objects scattered on the left and right sides. Hold the picture in front of the patient for about 10 s. If the patient has poor visual acuity, give the picture to the patient to examine. After withdrawing the picture, ask the patient what they saw. After their general description, ask for specific details. When and where did the scene take place? How old are the individuals? How are they dressed, and so on? Much can be learned from the patient’s performance. Watch the patient’s eyes as they scan the picture. Do they search symmetrically? Have they seen the whole picture? Have they grasped the general gestalt of the picture or instead focused on a minor peripheral aspect? Patients with right cerebral hemisphere lesions often neglect
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FIG. 11. Sample mosaics and attempts at copying by patients with right parietal lobe lesions. (from Critchley, 1969 with permission).
figures on the left. Left visual neglect is often but not always accompanied by constructional apraxia (Osterrieth, 1944). Patients with frontal lobe disease often scan poorly and are satisfied with telling about the first feature that catches their eye and do not extract further information from the scene. DeRenzi and colleagues performed a series of three tests that illuminates the nature of the comparison of deficits between left and right parietal lobe damaged patients (DeRenzi et al., 1969). In the first test, patients were asked to match photographs that showed individuals’ faces in a frontal view with the same individuals shown in a profile or side view (Fig. 13); in the second test, patients were given an overlapping figure that contained various fruits (Fig. 14). The task was to select those fruits from the drawings of various fruits on the side of the overlapping figure that were contained within the overlapping figure. In the third test, patients were shown photographs of various objects and asked to match the photographs with actual objects, but the objects were not exactly the same as the pictures (Fig. 15). The actual objects diVered in form and color from the pictures.
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FIG. 12. Shows an example of writing on the right of a page ignoring the paper on the left side. (from Critchley, 1969 with permission).
FIG. 13. Matching of front-view photographs with side views. (from DeRenzi et al., 1969 with permission).
Patients with left parietal damage had no diYculty matching photographs of individuals (test 1) or identifying the fruits in the overlapping figure (test 2) but did poorly on test 3 matching nonidentical stimuli. The first two tests are purely visual; one does not need to know the names or identities of the people or fruits. These tests are visual matching tests and left parietal lobe damaged patients have no diYculty with visuospatial functions. The third test relates to categorization
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FIG. 14. The Ghent overlapping figures test. (from DeRenzi et al., 1969 with permission).
FIG. 15. An example of nonidentical matching of objects. (from DeRenzi et al., 1969 with permission).
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and left parietal lobe damaged patients have diYculty with this function, doing less well than right parietal damaged patients. In contrast, patients with right parietal lobe damage did poorly on the first two tests of visuospatial matching and did well on the third test of categorization (DeRenzi et al., 1969).
References
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