A case of literal alexia: evidence for a disconnection syndrome

We describe a patient with literal alexia, agraphia, and only minimal aphasia, resulting from a left occipito-parietal ischemic infarction. Neither impaired visual processing nor impaired oral output could explain the patient's letter reading deficit, since he retained the ability to match letters of mixed case, and remained able to spell aloud and to pronounce and comprehend orally spelled words. His residual word reading was characterized by better performance for nouns and highly imageable words than for functors , poorly imageable words, and nonwords. We propose that this patient's letter reading deficit was due to a partial disconnection of his visual from his linguistic systems, with residual word reading accomplished by a semantically mediated compensatory mechanism. We suggest, further, that the dissociations between word and letter reading observed in some alexic individuals may be attributed, in part, to a difference in the relative contributions of dorsal and ventral occipital structures to the reading process.     

Varieties of alexia from fusiform, posterior inferior temporal and posterior occipital gyrus lesions

Reading impairments of three alexia patients, two pure alexia and one alexia with agraphia, due to different lesions were examined quantitatively, using Kanji (Japanese morphogram) words, Kana (Japanese phonetic writing) words and Kana nonwords. Kana nonword reading was impaired in all three patients, suggesting that widespread areas in the affected occipital and occipitotemporal cortices were recruited in reading Kana characters (corresponding to European syllables). In addition, the findings in patient 1 (pure alexia for Kanji and Kana from a fusiform and lateral occipital gyri lesion) and patient 2 (pure alexia for Kana from a posterior occipital gyri lesion) suggested that pure alexia could be divided into two types, i.e. ventromedial type in which whole-word reading, together with letter identification, is primarily impaired because of a disconnection of word-form images from early visual analysis, and posterior type in which letter identification is cardinally impaired. Another type of alexia, alexia with agraphia for Kanji from a posterior inferior temporal cortex lesion (patient 3), results from deficient whole-word images of words per se, and thus should be designated "orthographic alexia with agraphia". To account for these impairments, a weighted dual-route hypothesis for reading is suggested.     

Errors resembling semantic paralexias in Spanish-speaking aphasics.

Forty-one Spanish-speaking left-hemisphere-damaged patients were selected and divided into seven groups (transcortical, Broca's aphasia, conduction aphasia, Wernicke's aphasia, anomic aphasia, alexia without agraphia, and global aphasia). A reading battery composed of eight different subtests was given to each patient (reading of letters, reading of syllables, reading of pseudowords, reading of words, reading of sentences, understanding commands, reading and comprehension of texts, and logographic reading). Different types of reading errors were analyzed. Only in the logographic reading subtest were some word-recognition errors found, resembling semantic paralexias. It is proposed that semantic paralexias in English (and other languages) depend upon the partial logographic nature of the reading system. The importance of cross-linguistic analysis of reading errors, taking into account reading system idiosyncracies, is emphasized.     

Cognitive resource limitations during sentence comprehension in Parkinson's disease

We report a single-case study of peripherally acquired dyslexia that meets the clinical criteria of "alexia without agraphia." The patient, AA, has a large infarct involving the left posterior cerebral artery. The most striking feature is a severe impairment in recognizing single visually presented letters that precludes explicit or implicit access to reading, even in a letter-by-letter fashion. AA can, however, differentiate letters from similar nonsense characters and digits, and he is also able to identify alphanumeric signs when the visual channel is bypassed (through somesthesic or kinesthesic presentation). Spelling tasks are also well performed. Since there is a breakdown in mapping a visually presented letter to its abstract graphemic representation, we propose the term "visuographemic alexia" for this kind of reading disorder. The pattern of deficits is interpreted following theoretical models previously developed in cognitive neuropsychology. An alexia for arabic numerals with preserved comprehension lends additional support for the crucial processing of different notational systems (e.g., phonographic vs logographic). More general perceptive disorders do not seem to account for these patterns; they are material-specific. Finally, we attempt to specify functional correlations with the implied neural networks.     

Pure agraphia and Gerstmann's syndrome as a visuospatial-language dissociation: an experimental case study

A right-handed man suffered a left parieto-occipital cerebral infarction, causing agraphia with Gerstmann's syndrome but without major aphasia, alexia, or apraxia. Oral spelling was superior to written spelling. Experiments were performed involving (1) analysis of errors in writing, (2) tasks of visual imagery, and (3) identifying letters drawn without leaving a visual trace. The results suggest that the agraphia and Gerstmann's syndrome are due to a dissociation of language skills and visuospatial skills caused by a dominant parieto-occipital lesion.     

Alexia and agraphia with spared spelling and letter recognition abilities

A patient with alexia and agraphia had intact spelling and comprehension of spelled words and used a letter-naming strategy to read and write. We propose that there is a graphemic area important for distinguishing graphemic features and for programming movements used in writing. In this patient this area was not functioning or did not have access to the area of visual word imagés. Therefore, he used an ideographic letter-naming strategy to verbally circumvent his disability and gain access to the area of visual word images.     

Functional disconnection in pure alexia and color naming deficit demonstrated by facilitation methods.

The authors suggest that the possible combinations of pure alexia with concomitant neuropsychological symptoms form a continuum determined by the extent and severity of the brain lesion. The disconnection mechanism underlying these syndromes is demonstrated by the facilitating effect of unblocking methods (in the tactile, somesthetic, auditory, and visual modality) on the reading performance of a pertinent case. In the unblocking situation, other pathways than the one impaired by the brain lesion are used. It is proposed that the color naming deficit is associated with defective verbal identification of graphemic stimuli because of their common linguistic features. The delineation from aphasic color naming and reading deficit is discussed.     

Optic aphasia, optic apraxia, and loss of dreaming

A 47-year-old man with a left temporo-occipital infarct in the area of the posterior cerebral artery is presented. The neuropsychological examination did not reveal aphasia or gross mental deficits. The patient presented with alexia without agraphia, color agnosia, but few visual perceptual deficits. The main impairment was in confrontation naming; he was incapable of naming objects and pictures, not from lack of recognition (excluding visual agnosia) but from lack of access to the appropriate word (optic aphasia). The patient also exhibited a deficit in the evocation of gesture from the visual presentation of an object (optic apraxia) and a difficulty in "conjuring up" visual images of objects (impaired visual imagery) and loss of dreams. The fundamental deficit of this patient is tentatively explained in terms of visuoverbal and visuogestural disconnection and a deficit of mental imagery.     

Ideogram writing in a disconnection syndrome

A case of disconnection-type agraphia coupled with alexia was reported. The patient showed several asymmetrical manual capacities between the two hands, i.e., dissociated difficulty of Kanji (ideogram) writing between the two hands, left unilateral difficulty of Kana (phonogram) writing, right unilateral dyscopia of letters as well as geometrical figures, and right unilateral difficulty in drawing without a model. Anatomically, lesions involved most of the corpus callosum in its posterior portion including the splenium and the left medial occipital lobe. From these data, a possible liguistic capacity of the right hemisphere was suggested.     

Alexia with agraphia due to the left posterior inferior temporal lobe lesion--neuropsychological analysis and its pathogenetic mechanisms

We report three cases of alexia with agraphia due to the left posterior inferior temporal lesions. In Case 1, the reading disability was more prominent in the use of Kana than in the use of Kanji, which is similar to previously reported cases of alexia with agraphia due to angular gyrus lesion. In Cases 2 and 3, by contrast, the reading disability was more prominent in the use of Kanji than in the use of Kana. In spontaneous writing and dictation, the disability was more pronounced in the use of Kanji compared with the use of Kana. In each of the three cases, the CT scan and positron emission tomography showed a localized lesion in the lower part of the left posterior temporal lobe. A typical form of an alexia with agraphia could be caused not only by the left angular lesion but also by the left posterior inferior temporal lesion. We discuss the neuropsychological analysis and pathogenetic mechanisms of alexia with agraphia due to the left posterior inferior temporal lesion in the comparison of alexia with agraphia caused by the left angular lesion.     

Event-related potentials in neuropsychological studies of language

Experiments are described in which event-related potentials (ERPs) are employed to study the specialization of functions between and within the cerebral hemispheres during the performance of language and nonlanguage tasks by normal adults. Similar studies of deaf subjects suggest that the functional organization of the brain may be altered after different early language and sensory experiences. Studies of patients with alexia without agraphia suggest that the ERP may be a valuable tool with which to study cerebral reorganization after brain damage.     

Body image and comprehension of body part names

The relation between awareness of body topology and auditory comprehension of body part names was studied in 22 aphasic subjects. Two nonverbal tasks—human figure drawing and placement of individual body parts in relation to a drawn face—were compared with two auditory tests of body part comprehension. The two nonverbal and the two verbal tasks were closely correlated with each other, but there was no relation involving either of the verbal tests with either of the nonverbal tests. Selection errors in the auditory comprehension tasks were predominantly semantically based and equally distributed between functionally analogous parts and parts related by location on the body.Dr. Benedet's effort in this study was supported by a grant from the Hispano-North American Joint Committee for Cultural and Educational Cooperation.     

Verbal, perceptual and intellectual factors associated with reading achievement in adolescents with cerebral palsy

31 adolescents with cerebral palsy were administered measures of verbal production, speech perception, nonverbal auditory perception, visuospatial perception and verbal intelligence as well as measures of reading recognition and reading comprehension. Nonverbal auditory perception and verbal intelligence were most highly correlated with both reading measures despite the fact that most subjects were most severely impaired in visuospatial perception.     

Subangular alexia without agraphia or hemianopsia

A 40 year old right-handed woman underwent resection of an unruptured vascular malformation which was located just deep to the left posterior insula. Postoperatively she demonstrated a transient syndrome of alexia without agraphia or hemianopsia. Analysis of her postoperative findings, in conjunction all available anatomical data, let to the conclusion that the responsible lesion was in the white matter of the left occipitotemporal region, below the angular gyrus and lateral to the lateral ventricle. Hence the lesion in the present case was truly subangular, and is therefore distinctly differentiated from the classical lesion in alexia without agraphia, which may be described as splenio-occipital.     

Memory for verbal and nonverbal stimuli in learning disability subgroups: analysis by selective reminding

Memory for verbal and nonverbal stimuli was evaluated using selective reminding procedures in normal achieving children and four groups of disabled learners: (1) reading-spelling disabled (R-S); (2) reading-spelling-arithmetic disabled (R-S-A); (3) spelling-arithmetic disabled (S-A); and (4) arithmetic disabled (A). Each child received two analogous free-list memory tasks, one for verbal material (animal names) and the other for nonverbal material (random dot patterns). These tasks were administered using selective reminding procedures that permit separation of storage and retrieval aspects of memory by reminding children only of those words not recalled on previous trials. Results revealed that relative to controls, the A and S-A children had significantly lower storage and retrieval scores on the nonverbal task, but did not differ on the verbal task; the R-S children differed only on retrieval scores from the verbal task; and the R-S-A children on retrieval scores on the verbal task and storage and retrieval scores on the nonverbal task. Thus, results indicate that the memory performance of disabled learners varies according to (1) the type of learning problem (arithmetic vs reading), (2) the nature of the stimuli (verbal vs nonverbal), and (3) the aspect of memory being assessed (storage vs retrieval). This study provides external validation for the classification of disabled learners according to patterns of academic achievement, demonstrating a useful procedure for dealing with the intrasubject variability characteristic of disabled learners.     

I recognize your face but I can’t remember your name: Further evidence on the tip-of-the-tongue phenomenon

Fifty faces of “famous” persons were used as stimuli to precipitate the tip-of-the-tongue (TOT) experience. Results showed that Ss in TOT states searched for target’s name by locating first his profession, where he was most often seen, and how recently. Ss also had accurate knowledge of the initial letters of target names, initial letters of similar sounding names, and numbers of syllables in target names. It was concluded that TOT states for to-be-remembered names are retrieved from semantic and episodie memory systems on the basis of verbal and imaginal encodings.     

Letter-by-letter reading: natural recovery and response to treatment

The present investigation provides a longitudinal study of an individual (RB) with acquired alexia following left posterior cerebral artery stroke. At initial testing, RB exhibited acquired alexia characterized by letter-by-letter (LBL) reading, mild anomic aphasia, and acquired agraphia. Repeated measures of reading accuracy and rate were collected for single words and text over the course of one year, along with probes of naming and spelling abilities. Improvements associated with natural recovery (i.e., without treatment) were documented up to the fourth month post onset, when text reading appeared to be relatively stable. Multiple oral reading (MOR) treatment was initiated at 22 weeks post-stroke, and additional improvements in reading rate and accuracy for text were documented that were greater than those expected on the basis of spontaneous recovery alone. Over the course of one year, reading reaction times for single words improved, and the word-length effect that is the hallmark of LBL reading diminished. RB's response to treatment supports the therapeutic value of MOR treatment to in LBL readers. His residual impairment of reading and spelling one-year post stroke raised the question as to whether further progress was impeded by degraded orthographic knowledge.     

Hemispheric differences in stimulus identification

Subjects were presented with either verbal (letters) or nonverbal (outline forms) stimuli to their left or right cerebral hemispheres. Verbal items presented with a lateral masking stimulus were identified more quickly and accurately when presented to the right hemisphere rather than to the left. When the letters were presented without a masking stimulus, weak hemispheric effects were obtained. Nonverbal forms demonstrated faster reaction time and fewer errors for right-hemisphere presentations under both masked and unmasked conditions. Retinal locus of the display item was also varied and produced faster responding with fewer errors when the stimulus was presented foveally rather than peripherally under all display conditions. These effects were attributed to the use of a manual response procedure that effectively reduced the ability of subjects to employ names for the stimulus objects.     

Evasion, private events, and pragmatism: A Reply to Moore's response to my review of Conceptual Foundations of Radical Behaviorism

Moore's screed in response to my review of his book uses several rhetorical tricks to counter criticism without actually addressing it: he tries to preempt the transparency of his own orthodoxy by groundlessly accusing me of orthodoxy; he caricatures my criticisms to make them appear obviously wrong; he professes lack of understanding so as to dodge having to attempt a genuine response; and he engages in pejorative labeling to dismiss the criticisms without analysis. From a scientific and pragmatic point of view, private events are a mistake, precisely because they are private. They cannot serve as independent variables, as Moore suggests, because they cannot be measured; “private independent variable” is a contradiction in terms. When we carefully examine locutions like “observe” and “report on,” we discover that they entail only public verbal and nonverbal behavior, not objects and not private events as objects. A person in pain is not reporting on anything, is engaging in public verbal and nonverbal pain‐behavior, and an infant or a dog may be considered to be in pain. The public behavior is all that matters, because determining whether a person is really in pain privately is impossible. The same is true of any private event, and the control of the public behavior on which the verbal community comments lies in the public environment. We cannot have two sets of principles, one for verbal behavior and one for nonverbal behavior or one for humans and one for other animals.     

Anatomy of posterior pathways in reading: a reassessment

Contemporary accounts of the neurology of reading stem from Dejerine's original visual-verbal disconnection hypothesis of pure alexia. Reassessment of Dejerine's traditional formulations for posterior left hemisphere pathways in reading suggests that the occipital cortex-left angular gyrus-Wernicke's area scheme is undoubtedly oversimplified. The role of left angular gyrus cortex in reading is unsettled, and although clinically undefined, more inferior portions of the left temporal lobe may also contribute to the reading process. Nevertheless, to a surprising extent, the neuroanatomic edifice erected by Dejerine remains largely intact.