Brain Imaging in a Patient with Hemimicropsia

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Brain Imaging in a Patient with Hemimicropsia View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Regensburg Publication Server Neuropsychologia 37 (1999) 1327±1334 www.elsevier.com/locate/neuropsychologia Brain imaging in a patient with hemimicropsia J. Kassubek*, M. Otte, T. Wolter, M.W. Greenlee, T. Mergner, C.H. LuÈ cking Neurologische UniversitaÈtsklinik, UniversitaÈt Freiburg, Freiburg, Germany Received 8 June 1998; accepted 2 March 1999 Abstract Hemimicropsia is an isolated misperception of the size of objects in one hemi®eld (objects appear smaller) which is, as a phenomenon of central origin, very infrequently reported in literature. We present a case of hemimicropsia as a selective de®cit of size and distance perception in the left hemi®eld without hemianopsia caused by a cavernous angioma with hemorrhage in the right occipitotemporal area. The symptom occurred only intermittently and was considered the consequence of a local irritation by the hemorrhage. Imaging data including a volume-rendering MR data set of the patient's brain were transformed to the 3-D stereotactic grid system by Talairach and warped to a novel digital 3-D brain atlas. Imaging analysis included functional MRI (fMRI) to analyse the patient's visual cortex areas (mainly V5) in relation to the localization of the hemangioma to establish physiological landmarks with respect to visual stimulation. The lesion was localized in the peripheral visual association cortex, Brodmann area (BA) 19, adjacent to BA 37, both of which are part of the occipitotemporal visual pathway. Additional psychophysical measurements revealed an elevated threshold for perceiving coherent motion. which we relate to a partial loss of function in V5, a region adjacent to the cavernoma. In our study, we localized for the ®rst time a cerebral lesion causing micropsia by digital mapping in Talairach space using a 3-D brain atlas and topologically related it to fMRI data for visual motion. The localization of the brain lesion aecting BA 19 and the occipitotemporal visual pathway is discussed with respect to experimental and case report ®ndings about the neural basis of object size perception. # 1999 Elsevier Science Ltd. All rights reserved. Keywords: Micropsia; Size constancy; Cavernoma; Brain atlas; Functional MRI 1. Introduction distortions in the size or the shape of the perceived object, respectively. In dysmetropsia, objects may Hemianopic defects in vision are frequent phenom- appear either reduced (micropsia) or enlarged (macrop- ena in the daily neuro-ophthalmological clinical rou- sia) relative to their normal size. Micropsia is more fre- tine. Less common are complaints about more quently reported than macropsia, but both are rather complex changes in visual perception following lesions infrequent phenomena, even more so if occurring as of the cerebral cortex. These de®cits are of interest isolated symptoms. More common is the combination since they can shed light on the functional role of the of these perceptual abnormalities with visual ®eld loss lesioned cortical area. Examples are dysmetropsia (also following extensive central lesions [11]). called dysmegalopsia) and metamorphopsia, which The phenomenon of metamorphopsia appears to be re¯ect disorders of visual processing causing subjective related to the perceptual mechanism of size constancy (phenomenologically, an object appears to retain its size despite substantial variations in viewing distance). * Corresponding author. Neurologische Klinik und Poliklinik der Normally, the perceived size of an image is scaled UniversitaÈ t Freiburg, Breisacher Str. 64 79106, Freiburg, Germany. Tel.: +49-761-2705001 (work); fax: +49-0761-5559588. according to its perceived distance, depending on a E-mail address: [email protected] (J. Kassubek) number of depth and distance cues. Errors of scaling 0028-3932/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved. PII: S0028-3932(99)00041-X 1328 J. Kassubek et al. / Neuropsychologia 37 (1999) 1327±1334 may occur with abnormalities in retinal image size, dis- 2. Clinical data turbances related to the binocular disparity and the central interpretation of the received aerent inputs. The patient was a 35-year-old right-handed male In cases where dysmetropsia occurs monocularly, it with no history of neurological disorders in his past. is likely to be due to retinal diseases which cause dis- As the ®rst clinical symptom, he reported an incident placement of the receptor cells, for instance excessive where he found himself lying on the ¯oor of his home separation of the photoreceptors by edematous ¯uid after falling down. Subsequently he suered from (like in central serous retinopathy; see [12]). severe occipital headache, but showed no focal neuro- Furthermore, dysmetropsia can result from a size re- logical de®cits. A cranial computed tomography duction of the retinal image due to an accommodation (CCT) in hospital showed a hyperdense lesion in his increase of the lens in¯uenced by the distances between right occipital lobe, suggestive of a hemangioma or the object plane and the pupil and the accommodation cavernoma. Since his headache disappeared within a level, which is a phenomenon called accommodative few days, the patient did not consent to further diag- micropsia [24]. A similar mechanism may underly the nostic measures. Six weeks later, a second episode of cases in which dysmetropsia occurs associated with acute headache occurred. This time the patient noticed muscular diseases such as ocular myasthenia [14]. In a change in visual perception, by experiencing transient cases of central origin, micropsia is mostly described episodes of dysmetropsia in the left hemi®eld; he saw as a transient phenomenon, occurring as prodroma of, objects on his left smaller, shrunk and compressed and or simultaneously with, temporal lobe epileptic seizures apparently farther away, though not distorted in or migraine [21]. It is then either accompanied by var- shape. Due to the hemimicropsia, he had diculties in ious symptoms of temporal lobe epilepsy, or it pre- perceiving proportions, symmetry, and depth, and, as sentsÐvery rarelyÐas a form of misperception a consequence, he collided with the left side of the gar- amongst others (metamorphopsia, dyschromatopsia) in age when parking his car. Interestingly, objects extend- purely visual seizures. Cases are reported in which ing into both hemi®elds appeared to be spatially micropsia was classi®ed as a psychopathological disparate, with the left half farther away. He had no phenomenon without evidence of neurological dysfunc- diculties in recognizing objects or persons and did tion (`psychogenic micropsia') [20], but these cases may not fail to comprehend the meaning of complex pic- possibly re¯ect undetected visual seizures. tures, as has been described in association with micro- There are only few reports in which micropsia (or psia [15]. Further episodes lasted from 30 min to 2 h hemimicropsia, i.e., apparent reduction of the size of in the following days, sometimes (but not always) ac- objects when presented in one hemi®eld) have been companied by headache. brought in association with a focal cerebral lesion, for In a conventional MRI investigation, the diagnosis instance a brain tumor, hemorrhage or ischaemic cavernous angioma was suggested by a peripheral low infarction. However, the lesions reported are rather signal ring (hemoglobin), 18 mm in diameter, and a scattered over extended regions of the brain, such as heterogeneous central signal (vascular malformation) the occipital lobe (micropsia associated with a homon- on T1-weighted images. The hemorrhage surrounding ymous loss of the visual ®eld) [12], the retrosplenial the cavernoma was accentuated at its superior and area [6], the chiasm [1] and visual association areas [3]. posterior parts, reaching well into the gray matter. It Wieser found micropsia/macropsia mainly when stimu- was diagnosed as a cavernous hemangioma with signs lating neocortical regions in the temporal-occipital bor- of a chronic bleeding (for details, see below). der zone [32]. A clearcut localization of a cortical area The frequency of micropsia episodes spontaneously for size constancy remains undetermined to date. The decreased to once or twice a week in the following results of work in monkeys suggest that size perception months, during which the patient did not seek out is mainly dependent on the occipito-temporal stream further medical treatment. Four months after the ®rst of visual information [19,28]. occurrence, the frequency and duration of the micro- We present here the case of a 35-year-old patient psia episodes increased anew and the patient was with recurrent hemimicropsia in the left hemi®eld admitted to our hospital. Clinical-neurological examin- resulting from a cavernous angioma in the right occipi- ation revealed no objective de®cit. A follow-up MRI tal lobe. After neurosurgical removal of the angioma, showed constant ®ndings with respect to the caver- the misperception no longer occurred. Exact localiz- noma. Both MR angiography and cerebral catheter ation data were gathered by magnetic resonance ima- angiography were normal, in line with the diagnosis ging and computer-guided reconstruction techniques cavernous angioma. Electroencephalography (EEG), and were related to the clinical and behavioural ®nd- consisting of a standard clinical protocol with 12 scalp ings. Functional MRI (fMRI) was employed to electrodes placed according to the International
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