A Case of Mirror-Image Crossed Thalamic Aphasia With Jargon Agraphia.

In right-handed individuals, aphasia resulting from right hemisphere damage is termed crossed aphasia and has a very low occurrence rate. Additionally, aphasia due to thalamic lesions often involves hemorrhage, with infarction cases less frequently reported. We present the case of an 81-year-old right-handed female who developed aphasia due to a right thalamic infarction. She exhibited characteristics typical of thalamic aphasia observed in left thalamic lesions. Furthermore, jargon agraphia manifested during writing tasks. This may suggest disinhibition of the left hemisphere writing motor memory by the right hemisphere language function.

Frontal allographic agraphia in a patient with behavioral variant frontotemporal dementia.

We report a patient with behavioral variant frontotemporal dementia who developed agraphia, irritability, perseverative and stereotyped behavior, and dietary changes. MRI revealed bilateral frontal convexity atrophy. Neuropsychological examination showed fluent aphasia with perseverative allographic agraphia, mild semantic impairment, and dysexecutive syndrome. Allographic agraphia featured unidirectional conversion from hiragana (cursive form of Japanese phonograms) and kanji (Japanese morphograms) to katakana (square form of Japanese phonograms), as opposed to mutual (bidirectional) conversion between hiragana and katakana in parieto-occipital gyri lesions. Furthermore, all letters of the word were converted and this whole-word conversion may be characteristic of perseverative behavior in frontotemporal dementia.

Reading and writing from right to left after anterior cerebral artery stroke.

This is the case report of a woman who started to write and read from right to left after anterior cerebral artery stroke, affecting the left supplementary motor area. No cases were found in the literature with exactly the same characteristics. She has been able to read and write faster after rehabilitation approach at Sarah Network of Rehabilitation Hospitals, in the Belo Horizonte city unit, Brazil, despite the maintenance of the inversion. She returned to her previous activities in an adaptive way. It was discussed how the dysfunction in this cerebral area and its connections may disturb the reading strategy and direction.

Relato do caso de uma mulher que passou a escrever e ler da direita para a esquerda após um acidente vascular encefálico isquêmico de artéria cerebral anterior, acometendo área motora suplementar esquerda. Não foram encontrados casos na literatura exatamente com as mesmas características. Durante a participação da paciente no programa de reabilitação neurológica da Rede Sarah de Hospitais de Reabilitação, unidade Belo Horizonte, foram observados ganhos na agilidade de leitura e escrita, ainda que mantendo a inversão, e retorno às suas atividades de forma adaptada. Realizou-se discussão de como o comprometimento dessa área e de suas conexões pode perturbar a estratégia de leitura e sua direção.

Reading and writing from right to left after anterior cerebral artery stroke / Escrita e leitura da direita para a esquerda após lesão cerebral

ABSTRACT. This is the case report of a woman who started to write and read from right to left after anterior cerebral artery stroke, affecting the left supplementary motor area. No cases were found in the literature with exactly the same characteristics. She has been able to read and write faster after rehabilitation approach at Sarah Network of Rehabilitation Hospitals, in the Belo Horizonte city unit, Brazil, despite the maintenance of the inversion. She returned to her previous activities in an adaptive way. It was discussed how the dysfunction in this cerebral area and its connections may disturb the reading strategy and direction.

RESUMO. Relato do caso de uma mulher que passou a escrever e ler da direita para a esquerda após um acidente vascular encefálico isquêmico de artéria cerebral anterior, acometendo área motora suplementar esquerda. Não foram encontrados casos na literatura exatamente com as mesmas características. Durante a participação da paciente no programa de reabilitação neurológica da Rede Sarah de Hospitais de Reabilitação, unidade Belo Horizonte, foram observados ganhos na agilidade de leitura e escrita, ainda que mantendo a inversão, e retorno às suas atividades de forma adaptada. Realizou-se discussão de como o comprometimento dessa área e de suas conexões pode perturbar a estratégia de leitura e sua direção.

Handwriting Changes in Alzheimer's Disease: A Systematic Review.

BACKGROUND: Handwriting is a complex process involving fine motor skills, kinesthetic components, and several cognitive domains, often impaired by Alzheimer's disease (AD). OBJECTIVE: Provide a systematic review of handwriting changes in AD, highlighting the effects on motor, visuospatial and linguistic features, and to identify new research topics. METHODS: A search was conducted on PubMed, Scopus, and Web of Science to identify studies on AD and handwriting. The review followed PRISMA norms and analyzed 91 articles after screening and final selection. RESULTS: Handwriting is impaired at all levels of the motor-cognitive hierarchy in AD, particularly in text, with higher preservation of signatures. Visuospatial and linguistic features were more affected. Established findings for motor features included higher variability in AD signatures, higher in-air/on-surface time ratio and longer duration in text, longer start time/reaction time, and lower fluency. There were conflicting findings for pressure and velocity in motor features, as well as size, legibility, and pen lifts in general features. For linguistic features, findings were contradictory for error patterns, as well as the association between agraphia and severity of cognitive deficits. CONCLUSIONS: Further re-evaluation studies are needed to clarify the divergent results on motor, general, and linguistic features. There is also a lack of research on the influence of AD on signatures and the effect of AD variants on handwriting. Such research would have an impact on clinical management (e.g., for early detection and patient follow-up using handwriting tasks), or forensic examination aimed at signatory identification.

Apraxia of speech with phonological alexia and agraphia following resection of the left middle precentral gyrus: illustrative case.

BACKGROUND: Apraxia of speech is a disorder of speech-motor planning in which articulation is effortful and error-prone despite normal strength of the articulators. Phonological alexia and agraphia are disorders of reading and writing disproportionately affecting unfamiliar words. These disorders are almost always accompanied by aphasia. OBSERVATIONS: A 36-year-old woman underwent resection of a grade IV astrocytoma based in the left middle precentral gyrus, including a cortical site associated with speech arrest during electrocortical stimulation mapping. Following surgery, she exhibited moderate apraxia of speech and difficulty with reading and spelling, both of which improved but persisted 6 months after surgery. A battery of speech and language assessments was administered, revealing preserved comprehension, naming, cognition, and orofacial praxis, with largely isolated deficits in speech-motor planning and the spelling and reading of nonwords. LESSONS: This case describes a specific constellation of speech-motor and written language symptoms-apraxia of speech, phonological agraphia, and phonological alexia in the absence of aphasia-which the authors theorize may be attributable to disruption of a single process of "motor-phonological sequencing." The middle precentral gyrus may play an important role in the planning of motorically complex phonological sequences for production, independent of output modality.

A case of aneurysmal subarchnoid haemorrhage and superficial siderosis complicated by prospagnosia, simultagnosia and alexia without agraphia.

A 42-year-old lady presented with acute aneurysmal subarachnoid haemorrhage and developed difficulty recognising faces (prosopagnosia), inability to process visual information in busy environments (simultagnosia) and difficulty to read (alexia). She was subsequently found to have superficial siderosis on MRI.

The effects of cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters: A case report.

INTRODUCTION: This report examines the effects of a multimodal rehabilitation program which includes cognitive, physical, and somatosensory rehabilitation after right temporo-parietal tumor resection on cognitive, motor, somatosensory, and electrophysiological parameters. CASE DESCRIPTION: A 22-year-old patient presented with sensory loss in the dominant left hand and reduced writing ability after right temporo-parietal lobe resection. Cognitive, motor, and sensory evaluations were carried out pre and post-treatment. The patient's spontaneous electroencephalo-gram (EEG) and an EEG during application of transcutaneous electrical nerve stimulation (TENS) (TENS EEG) were recorded. As a reference for the patient's electrophysiological values, EEGs of 4 healthy individuals were also taken. Over a period of 1 year, the patient received multimodal rehabilitation which includes cognitive, physical, and somato-sensory rehabilitation on 2 days each week. OUTCOMES: An improvement of the patient's cognitive capacities, motor strength, superficial, deep and cortical sensations was achieved. After rehabilitation, an increase in parietal and occipital alpha activity as well as in frontal and parietal beta activity was seen both in spontaneous EEG and in TENS EEG. With increasing TENS intensity, alpha and beta power increased as well. CONCLUSION: Our findings suggest that a multimodal rehabilitation program may improve cognitive, sensory, and motor effects after resection due to tumor surgery.

Two adult patients with moyamoya disease presenting with alexia with agraphia limited to kanji: can revascularization improve characteristic symptoms?

Patients with moyamoya disease (MMD) may exhibit higher brain dysfunction due to hypoperfusion, which may be ameliorated by revascularization. However, few studies have examined the relationship between cerebral perfusion and language function or the ameliorating effect of revascularization on language dysfunction. We present two cases with MMD who presented with alexia with agraphia, specifically for Japanese kanji. The patients had impaired perfusion in the left inferior temporal and lateral occipital lobes. Following superficial temporal artery-middle cerebral artery bypass, the symptoms improved dramatically. Thus, correction of hypoperfusion may be effective even in adult patients with MMD presenting with language dysfunction.

Capecitabine-related neurotoxicity presenting with agraphia.

INTRODUCTION: Capecitabine is a pre-metabolite of 5-fluorouracil and is used as a chemotherapeutic agent. Among the common side effects of capecitabine, there are gastrointestinal side effects including nausea, vomiting, and diarrhea, and dermatological side effects including hand-foot syndrome and skin pigmentation change. However, neurological side effects of capecitabine are very rare. We describe herein a patient who developed neurological side effects in the form of agraphia and dysarthria on the 7th day of capecitabine treatment. CASE REPORT: A 34-year-old male patient, who was being followed up with the diagnosis of colon cancer, presented with speech and writing disorder that developed while under capecitabine treatment. Dysarthria and agraphia were detected in his neurological examination. Diffusion-weighted magnetic resonance imaging (MRI) revealed acute diffusion restriction in the splenium of the corpus callosum and at the level of the bilateral centrum semiovale. Brain MRI revealed symmetrical T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) signal increases at the right temporoparietal medial, corpus callosum level, and bilateral white matter level. MANAGEMENT & OUTCOME: The capecitabine treatment was terminated, and methylprednisolone treatment was administered and plasmapheresis procedure was carried out. Subsequently, significant improvement was observed in the clinical findings and neuroimaging. DISCUSSION: Capecitabine is used as an oral agent; thus, it provides ease of use. Neurological side effects associated with the use of capecitabine reportedly occur very rarely. The findings of this case demonstrated that leukoencephalopathy can be seen during the use of capecitabine, imaging results are very important in the diagnosis of leukoencephalopathy, and improvement can be achieved with the termination of the capecitabine treatment.

Symptomatology and Neuropathology of patients presenting with focal cortical signs.

Here, we describe two patients who presented with focal cortical signs and underwent neuropathological examination. Case 1 was a 73-year-old woman with progressive speech disorder and abnormal behavior. She showed agraphia of the frontal lobe type, featured by the omission of kana letters when writing, other than pyramidal tract signs, pseudobulbar palsy, and frontal lobe dementia. Neuropathological examination, including TAR DNA-binding protein 43 (TDP-43) immunohistochemistry, revealed bilateral frontal and anterior temporal lobe lesions accentuated in the precentral gyrus and posterior part of the middle frontal gyrus. Both upper and lower motor neurons showed pathological changes compatible with amyotrophic lateral sclerosis. Case 2 was a 62-year-old man with progressive speech disorder and hand clumsiness. He had a motor speech disorder, compatible with apraxia of speech, and limb apraxia of the limb-kinetic and ideomotor type. Neuropathological examination revealed degeneration in the left frontal lobe, including the precentral gyrus, anterior temporal, and parietal lobe cortices. Moreover, numerous argyrophilic neuronal intracytoplasmic inclusions (Pick body) and ballooned neurons were observed in these lesions and the limbic system. The pathological diagnosis was Pick disease involving the peri-Rolandic area and parietal lobe. In these two cases, the distribution of neuropathological changes in the cerebral cortices correlated with the clinical symptoms observed.

Common predictors of spoken and written language performance in aphasia, alexia, and agraphia.

Language performance requires support from central cognitive/linguistic abilities as well as the more peripheral sensorimotor skills to plan and implement spoken and written communication. Both output modalities are vulnerable to impairment following damage to the language-dominant hemisphere, but much of the research to date has focused exclusively on spoken language. In this study we aimed to examine an integrated model of language processing that includes the common cognitive processes that support spoken and written language, as well as modality-specific skills. To do so, we evaluated spoken and written language performance from 87 individuals with acquired language impairment resulting from damage to left perisylvian cortical regions that collectively constitute the dorsal language pathway. Comprehensive behavioral assessment served to characterize the status of central and peripheral components of language processing in relation to neurotypical controls (n = 38). Performance data entered into principal components analyses (with or without control scores) consistently yielded a strong five-factor solution. In line with a primary systems framework, three central cognitive factors emerged: semantics, phonology, and orthography that were distinguished from peripheral processes supporting speech production and allographic skill for handwriting. The central phonology construct reflected performance on phonological awareness and manipulation tasks and showed the greatest deficit of all the derived factors. Importantly, this phonological construct was orthogonal to the speech production factor that reflected repetition of words/non-words. When entered into regression analyses, semantics and phonological skill were common predictors of language performance across spoken and written modalities. The speech production factor was also a strong, distinct predictor of spoken naming and oral reading, in contrast to allographic skills which only predicted written output. As expected, visual orthographic processing contributed more to written than spoken language tasks and reading/spelling performance was strongly reliant on phonological and semantic abilities. Despite the heterogeneity of this cohort regarding aphasia type and severity, the marked impairment of phonological skill was a unifying feature. These findings prompt greater attention to clinical assessment and potential treatment of underlying phonological skill in individuals with left perisylvian damage.

The making of a syndrome: Gerstmann's patients before Gerstmann syndrome.

When Gerstmann published the case report which later became known as the first case of Gerstmann syndrome, he did not claim the discovery of a new syndrome. It was only a few years later, after reporting on another two similar cases, that he isolated the famous tetrad of symptoms (finger agnosia, right-left disorientation, agraphia and acalculia) as a meaningful cluster with both localising and functional value. In this article, we provide the translation of key-excerpts of the second of Gerstmann's reports (Gerstmann, 1927) and a synoptic description of the symptoms as reported in the three original cases, which were later identified as cases of Gerstmann syndrome. The descriptions appear highly consistent across cases. Among symptoms, finger agnosia stands out for its pervasiveness, which may explain why Gerstmann considered this as the core symptom and speculated it could subtend all symptoms. However, no common functional denominator emerges from the original descriptions.

History of aphasia: A broad overview.

This chapter gives a broad overview of the description and theorizing of a wide range of language disorders resulting from brain damage, commonly classified under the umbrella term "aphasia." It covers works written in Antiquity up to the 20th century. Moreover, it looks at disturbances in various language modalities such as speech, language comprehension, reading, writing, and sign language. In addition, also forms of the more recently discovered primary progressive aphasia are discussed. Finally, important developments in the history of assessment and rehabilitation of language disorders are described. To properly characterize disorders of language, these developments are discussed from the perspectives of neurology, psychology, and linguistics.

Efeitos da Estimulação Transcraniana por Corrente Contínua na escrita: um relato de caso de agrafia profunda / Effects of Transcranial Direct Current Stimulation in writing: a case report of deep agraphia

RESUMO Apresentamos o relato de caso de um participante do sexo masculino, 61 anos, com afasia de condução crônica e agrafia profunda após acidente vascular cerebral isquêmico que recebeu treinamento de escrita sob ditado associado à estimulação transcraniana por corrente contínua. O tratamento consistiu em cinco sessões de 50 minutos de escrita sob ditado com aplicação de 2 mA de estimulação transcraniana por corrente contínua anódica durante 20 minutos sobre o córtex occipitotemporal esquerdo. O participante apresentou melhora na produção escrita de pseudopalavras e de palavras regulares de baixa frequência, via rota fonológica, além de uma pequena melhora na produção de palavras irregulares, via rota lexical. Após o treinamento, houve também pequena melhora da escrita de estímulos não treinados, sugerindo generalização. Na avaliação realizada 5 meses após o término do tratamento, o benefício foi mantido para estímulos processados via rota fonológica. Os resultados são promissores dada a gravidade e cronicidade do caso e sugerem que a estimulação transcraniana por corrente contínua associada à terapia de escrita representa possível alternativa clínica para pacientes com agrafia profunda.

ABSTRACT We present the case report of a 61-year-old male participant with chronic conduction aphasia and deep agraphia after ischemic stroke who received training on writing under dictation associated with transcranial direct current stimulation. The treatment consisted of five 50-minute dictation sessions with the application of 2 mA of anodal transcranial direct current stimulation for 20 minutes over the left occipitotemporal cortex. The participant improved his written production of pseudowords and regular low-frequency words, via the phonological route, in addition to a small improvement in the production of irregular words, via the lexical route. After training, there was also a small improvement in writing for untrained stimuli, suggesting generalization. In the assessment carried out 5 months after the end of the treatment, the benefit was maintained for stimuli processed via the phonological route. The results are promising given the severity and chronicity of the case and suggest that transcranial direct current stimulation associated with writing therapy represents a possible clinical alternative for patients with deep agraphia.

Handwriting in Alzheimer's Disease.

BACKGROUND: Agraphia is a typical feature in the clinical course of Alzheimer's disease (AD). OBJECTIVE: Assess the differences between AD and normal aging as regards kinematographic features of handwriting and elucidate writing deficits in AD. METHODS: The study included 23 patients with AD (78.09 years/SD = 7.12; MMSE 21.39/SD = 3.61) and 34 healthy controls (75.56 years/SD = 5.85; MMSE 29.06/SD = 0.78). Both groups performed alphabetical and non-alphabetical writing tasks. The kinematographic assessment included the average number of inversions per stroke (NIV; number of peaks in the velocity profile in a single up or down stroke), percentage of automated segments, frequency (average number of strokes per second), writing pressure, and writing velocity on paper. RESULTS: A total of 14 patients showed overt writing difficulties reflected by omissions or substitutions of letters. AD patients showed less automated movements (as measured by NIV), lower writing velocity, and lower frequency of up-and-down strokes in non-alphabetical as well as in alphabetical writing. In the patient group, Spearman correlation analysis between overt writing performance and NIV was significant. That means patients who had less errors in writing a sentence showed a higher automaticity in handwriting. The correctness of alphabetical writing and some kinematographic measures in writing non-alphabetical material reached excellent diagnostic values in ROC analyses. There was no difference in the application of pressure on the pen between patients and controls. CONCLUSION: Writing disorders are multi-componential in AD and not strictly limited to one processing level. The slow and poorly automated execution of motor programs is not bound to alphabetical material.

Could pure agraphia be the only sign of stroke? Lessons from two case reports.

Agraphia is defined as the disruption of the previously intact writing skills due to an acquired brain damage. Stroke remains the most common cause of language impairment; however, writing disorders, including agraphia, are underestimated in patients with stroke. In this regard, we report two patients presenting with pure agraphia as an early symptom of stroke. Both patients complained of at least two difficulties in visualizing letter formation beforehand, the frequent need for verbal cues, misuse of lines and margins, poorly legible signature, and writing and thinking at the same time (e.g., creative thinking and taking notes). They underwent brain magnetic resonance imaging which revealed a small lacunar infarction of the left insula and external capsule (patient 1) and a small hemorrhagic lesion in the posterior limb of the left internal capsule (patient 2). To our knowledge, this is the first report on pure agraphia as the presenting symptom of stroke. We suggest that all patients with acute agraphia, even when presenting as an isolated symptom, should be evaluated for stroke, in order to better facilitate its diagnosis and treatment.

Reading and alexia.

Alexia refers to a reading disorder caused by some form of acquired brain pathology, most commonly a stroke or tumor, in a previously literate subject. In neuropsychology, a distinction is made between central alexia (commonly seen in aphasia) and peripheral alexia (a perceptual or attentional deficit). The prototypical peripheral alexia is alexia without agraphia (pure alexia), where patients can write but are impaired in reading words and letters. Pure alexia is associated with damage to the left ventral occipitotemporal cortex (vOT) or its connections. Hemianopic alexia is associated with less extensive occipital damage and is caused by a visual field defect, which creates problems reading longer words and passages of text. Reading impairment can also arise due to attentional deficits, most commonly following right hemisphere or bilateral lesions. Studying patients with alexia, along with functional imaging studies of normal readers, has improved our understanding of the neurobiological processes involved in reading. A key question is whether an area in the left ventral occipitotemporal cortex is specialized for or selectively involved in word processing, or whether reading relies on tuning of more general purpose perceptual areas. Reading deficits may also be observed in dementia and traumatic brain injury, but often with less consistent deficit patterns than in patients with focal lesions.