LE JOURNAL CANADIEN DES SCIENCES NEUROLOG1QUES

Balint's Syndrome

CHANTAL O. HAUSSER, FRANQOISE ROBERT, and NORMAND GIARD

SUMMARY: Balint's syndrome is usually INTRODUCTION ELEMENTS OF BALINT'S attributed to bilateral parieto-occipital Balint (1909) described a syndrome SYNDROME lesions. In several reported cases involve­ characterized by hemispheric paralysis Hemispheric paralysis of visual ment of the frontal lobes was also docu­ of visual fixation, optic ataxia and fixation mented and could be responsible for the "spasmodic fixation" often recorded in disturbance of visual attention in a In his room, the patient stared in these patients. We report a case of Balint's patient with bilateral occipito-parietal front of him without looking at the syndrome in a patient with bilateral frontal softenings. In the seventeen cases interlocutor. He had the behavior of a and parieto-occipital metastases demon­ published since, bilateral lesions have blind man. When ordered to glance in strated by CTscan and confirmed by post­ been found mostly in the parieto­ the direction of a specific object he was mortem examination. occipital lobes, sometimes in associa­ unable to do so. Should an unexpected tion with frontal lesions. Post-mortem noise occur he would turn his head and studies have revealed these lesions to glance in the right direction. He was RfiSUMfi: Le syndrome de Balint carac- be softenings (Balint, 1909; Hecaen unable to follow a moving object. tirisi par la paralysie psychique du regard, and Ajuriaguera, 1954; Michel et al., Optokinetic nystagmus was absent. I'ataxie optique et un trouble de I'attention 1965), gun-shot wounds (Holmes, visuelle, est gineralement attribue a des 1918; Luria, 1959), Balo's leucoence- lisions parieto-occipitales bilaterales. Dans phalitis (Hecaen et al., 1950), tumor Optic Ataxia quelques cas, il y a igalement une atteinte (Hecaen and Ajuriaguerra, 1954) and He was unable to grasp objects des lobes frontaux qui serait responsable Creutzfeldt-Jakob's disease (Morita et under visual control. He misreached de la "fixation spasmodique" que pre- al., 1975). We report a typical case of targets. He explained he saw these sentent certains malades. [.'observation objects but was unable to reach them. d'un malade souffrant de ce syndrome nous Balint's syndrome where pathological a permis de demontrer par la tomodensi- examination showed bilateral parieto­ He had difficulty lacing his shoes when tomitrie (CT scan) et de confirmer par occipital and frontal metastases from a looking at them. His shirt was often I'examen pathologique des metastases bronchogenic carcinoma. inside out, but he knew how to dress frontales et parieto-occipitales bilaterales himself step by step. provenant d'un ipithelioma bronchique. Disturbance of visual attention was CASE REPORT more pronounced on his left side, but Our patient was a 56 year-old man was present everywhere outside the admitted on January 10th, 1977 foveal zone. He did not notice threat­ complaining of a progressive visual ening gestures. There was no blink disturbance and disorientation of reflex. He could orientate himself three weeks duration. His relatives had when walking straight along the noted that he frequently bumped into corridor, but was unable to find the doors and that he appeared clumsy. entrance to his room. When presented Past history was negative. He had been with several geometrical figures drawn a heavy smoker for 40 years. The on the same card he saw only one or general examination revealed a tall, two of these although he identified thin, somewhat dyspneic man. He was each of them if presented separately. euphoric, disorientated, easily dis- Confronted with a complex figure, tractible, but was able to follow composed of several subunits, he was commands. Physical examination was completely unable to recognize it. normal. Blood pressure was 120/80. In addition to these signs the patient Fundi, visual acuity, and pupillary felt sometimes as if his eyes were From the Divisions of Neurology and Neuropa­ reflexes were normal. Neurological locked in fixation and, indeed, the thology, Notre-Dame Hospital and University of examination was normal except for a Montreal, Montreal, Canada. examiner was able to notice a peculiar neuropsychological distur­ spasmodic fixation. When an object Reprint requests to Dr. F. Robert, Department of bance recognized as a Balint's syn­ entered his visual field, the patient Pathology, Notre-Dame Hospital, 1560 Sherbrooke drome. Street East, Montreal, Quebec, Canada, H2L 4K8. would stare at it for a long time.

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The rest of the neuropsychological Post-mortem examination examination revealed diminished and General autopsy revealed a bron­ hesitant speech. Writing was poor with chogenic carcinoma in the left inferior wide letters of different size and at lobe with metastases to the hilar and different levels, but the words were paratracheal lymph nodes and to both correct. He copied simple geometric adrenal glands. figures but only after repeated stimu­ The brain weighed 1450 g. There lation. was edema, but no herniation was seen. Seven metastases histologically Laboratory findings identical with the lung tumor were Visual fields were concentrically identified in the cerebrum. Six of these diminished bilaterally. Biological tests were grossly symmetrical on each side were normal. Sedimentation rate was of the midline. Two were superficial at 23 mm/hour. Pulmonary investiga­ the vertex, two were in the frontal tion revealed a bronchogenic carci­ lobes and measured 2 cm by 2 cm each noma in the left inferior lung extend­ (Fig. 2A). Two larger necrotic and ing to the hilar lymph nodes. A skull hemorrhagic metastases measuring 5 X-ray was normal. The EEG showed a cm by 4 cm by 5 cm each were seen in moderate disturbance characterized the parieto-occipital regions (Fig. 2B). by theta activity over both parieto­ The seventh lesion was small and /It*/'* ' ' occipital regions more marked on the located in the left corona radiata. left side. The Tc" brain scan and the Another metastasis was found in the Figure 2A — Horizontal section of the computerized tomography (C T) with left cerebellar white matter. brain, 3 cm from the convexity shows sodium and meglumine diatrizoated two frontal metastases, a small metas­ enhancement disclosed four lesions, tasis in the left corona radiata and a left two parieto-occipital and two frontal DISCUSSION parieto-occipital metastasis. bilaterally (Fig. 1). Balint (1909) described a patient suffering from bilateral parieto-occipital cerebral softening. The syndrome comprised: (I) hemisphere paralysis of visual fixation, the patient being unable to look toward a point within his peripheral visual fields despite absence of palsy of ocular movements or visual field defect. (2) optic ataxia or inability to execute coordinated volun­ tary movements in response to visual stimuli while movements under pro­ prioceptive control were correctly performed. (3) impairment of atten­ tion to all visual stimuli. The patient's attention remained intact for non- visual arousal. Following Balint's description, se­ venteen additional cases have been reported. They are presented in table 1. Holmes (1918) described five patients suffering from gun-shot wounds in the Figure I — C.T. with sodium and parieto-occipital regions bilaterally. meglumine diatrizoates enhancement These patients had disturbance of shows two large parieto-occipital le­ ocular movements and reflexes des­ sions and several frontal lesions. cribed as follows: a difficulty in fixing visual objects and in retaining the Evolution fixation when those objects were The patient improved with steroid moved, failure to converge and acco­ therapy and was able to recognize a modate for near objects and absence of greater number of objects in his visual the blink reflex. They also showed a fields. However, because of a psycho­ disturbance of orientation and loca­ Figure 2B — Horizontal section of the tic reaction steroids were disconti­ lization in space by sight and inability brain, 5 cm from the convexity, shows nued. He died in February 1977. to estimate absolute and relative two parieto-occipital metastases.

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TABLE 1 Balint's Syndrome. Review of the Literature

Post-Mortem Authors Age/Sex Localization of Lesions Nature of Lesions Examination

Balint (1909) -/M bilateral parieto-occipital softenings yes left rolandic gyrus Holmes (1918) 27/M bilateral supramarginal gyrus gun-shot wound no 33/ M right occipital lobe gun-shot wound yes left angular gyrus -/M right supramarginal gyrus right precentral gyrus gun-shot wound no left angular gyrus -/M left supramarginal gyrus extending to rolandic gyrus gun-shot wound yes right angular gyrus right calcarine fissure -/M bilateral parieto-occipital gun-shot wound no Hecaen et al (1950) 33/M bilateral parieto-occipital Balo's leucoence- yes bilateral F3, right F2 phalitis bilateral atrophy (1954) 28/F bilateral occipital post-partum ischemia no diffuse cortical atrophy 59/F bilateral parieto-occipital astrocytoma yes 55/M left occipital softening yes right occipital horn metastasis left centrum ovale softening bilateral frontal metastasis Luria (1959) 21/M bilateral parieto-occipital gun-shot wound yes Waltz (1961) 35/F bilateral diffuse cerebral post-partum no dysfunction venous thrombosis Saraux et al 15/M diffuse cortical dysfunction cardiac arrest no (1962) Michel et al 51/M left fronto-parieto-occipital softening (recent) yes (1965) bilateral fronto-parietal softenings (old) Godwin-Austen 32/F bilateral parieto-occipital post-partum (1965) venous thrombosis Morita et al 55/F bilateral temporo-occipital yes (1975) bilateral fronto-basal Creutzfeldt-Jakob's Damasio and* 42/F bilateral parieto-occipital Benton (1979) softenings

*In this patient Balint's syndrome was incomplete.

lengths and sizes. Like Balint's case, Hecaen and Ajuriaguerra (1954) des­ Michel et al., 1965; Godwin-Austen, Holmes' patients had no impairment cribed a minor Balint's syndrome in 1965; Morita et al., 1975) only 3 had of visual fields or visual acuity. With which the disturbance of visual atten­ post-mortem examination (Luria, 1959; the exception of his second case, in tion and optic ataxia were unimpor­ Michel et al., 1965; Morita et al., which the entrance wound was behind tant or temporary. They emphasized 1975). Two of them showed bilateral the parieto-occipital notch in the right the probable importance of frontal parieto-occipital lesion. The case des­ occipital lobe, the lesions of Holmes' lesions in addition to bilateral parieto­ cribed by Morita et al. (1975) had patients were either in the supramar­ occipital lesions to obtain a classical, bilateral and frontal lesions, but these, ginal gyrus bilaterally or in the supra­ persistent Balint's syndrome. Since caused by Creutzfeldt-Jakob's disease marginal gyrus on one side and in the then, among 7 additional cases (Luria, were not circumscribed. angular gyrus on the other side. 1959; Waltz, 1961; Saraux etal., 1962; Our patient, in addition to the three

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main elements of Balint's syndrome, bilateral optic ataxia in a 47 year-old a further disconnection between ante­ i.e. paralysis of visual fixation, optic man was related to ischemic lesions rior and posterior visual pathways ataxia, and disturbance of visual located in the right frontal and left further impairing oculomotor control. attention, had a spasmodic fixation. parietal lobes and in the posterior When the frontal lesions are present This finding is not always reported in corpus collosum. This patient pre­ the Balint's syndrome is better defined association with the other signs of the sented with impairment of oculomotor and more persistent. syndrome. Usually, this sign is related movements and behaved as a "blind to frontal lesions in addition to the man". In this case, similar to Balint's parieto-occipital lesions (Holmes, syndrome, the visual pathways were 1938). 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In human cases with fur Psychiatrie und Neurologie, 25, 51-81. frontal lesions in Balint's syndrome. this finding Heilman and Valenstein BOLLER, F., MONROE, C, YOUNGJAI, K., Frontal regions are responsible for the (1978) showed that the lesions were MACK, J.L. and PATAWARAN, C. voluntary ocular movements and exert either parietal, fronto-parietal or (1975). Optic ataxia: clinical-radiological an inhibitive effect on the occipital correlations with the EMIscan. Journal of fronto-temporo-parietal, and induced Neurology, Neurosurgery and Psychiatry, centers. Thus, in the case of frontal a contralateral spatial agnosia. In the 38, 954-958. lesions, spasmodic fixation might monkey experimental lesions of the CASTAIGNE, P., PERTUISET, B., RONDOT, occur through a loss of inhibition of dorsolateral frontal lobe and reticular P. and RECONDO, J. (1971). 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