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Agraphia and Acalculia After a Left Prefrontal (F1, F2) Infarction

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Agraphia and Acalculia After a Left Prefrontal (F1, F2) Infarction 3'ournal ofNeurology, Neurosurgery, and Psychiatry 1995;58:629-632 629 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.5.629 on 1 May 1995. Downloaded from SHORT REPORT Agraphia and acalculia after a left prefrontal (F1, F2) infarction Hideo Tohgi, Kou Saitoh, Satoshi Takahashi, Hiroaki Takahashi, Kimiaki Utsugisawa, Hisashi Yonezawa, Kentaro Hatano, Toshiaki Sasaki Abstract been working in a construction company. His A patient presented with agraphia and job was mainly to procure building materials. acalculia associated with a left frontal For six years before admission he had dia- (Fl, F2) infarction. He made mainly betes and hypertension, which were being phonological but also lexical errors in treated but he had been in normal health. writing (syllabograms), but his ability to Two days before admission, when he was write kanji (morphograms) was relatively talking with a carpenter, he suddenly became preserved. Although he could add and unable to respond with even a single word. subtract numbers, he could neither mul- On admission, he was alert and well ori- tiply nor divide them because of a diffi- ented for both time and space. Neuro- culty in retrieving the multiplication logically, he had a mild right hemiparesis and tables and calculation procedures. a mild stocking type sensory disturbance due Positron emission tomography showed to diabetic neuropathy. Computed tomogra- decreased cerebral blood flow and phy and MRI showed a haemorrhagic infarc- metabolism limited to the infarct site. tion in the left frontal lobe; the high intensity These findings suggest that agraphia and area on T2 weighted MRI involved mainly acalculia may occur associated with a left the middle frontal gyrus, the upper part of the prefrontal lesion, and that the retrieval inferior frontal gyrus, and part of the precen- of arithmetic processes is modality spe- tral gyrus (figure, A, B). In other areas, only a cific. few lacunes were found. Brain PET studies showed a severe (- 70%) reduction in (7 Neurol Neurosurg Psychiatry 1995;58:629-632) regional cerebral blood flow (CBF) and meta- bolic rate of oxygen (CMRo2) in the left pre- frontal area (figure, C). CBF and CMRo2 http://jnnp.bmj.com/ Keywords: agraphia; acalculia; prefrontal cortex were some 20% less than controls in the supramargical and angular gyri, and the Pure agraphia was first ascribed to lesions in reductions were symmetric (figure, C). the premotor cortex (Brodmann's area 6) by Exner in 1881, and this view was supported LANGUAGE by early researchers.' 2 Many later studies, The Japanese writing system consists of kana however, reported agraphia associated with and kanji. Kana are syllabograms represent- on September 24, 2021 by guest. Protected copyright. Department of parietal lesions,37 implicating the angular ing vowels (a, i, u, e, o) or combinations of Neurology, Iwate consonants m, with vow- Medical University, gyrus as a graphic centre,89 or to interruption (k, s, t, n, h, y, r, w) Morioka, Japan of the transfer of writing information between els (ka, ki, etc) and most kana are ortho- H Tohgi the parietal and frontal cortices.10 More graphically regular. Kanji are morphograms, K Saitoh or from Chinese char- S Takahashi recently there have again been reports of ideographs, developed H Takahashi some patients with pure agraphia due to acters, and are read using the original K Utsugisawa frontal lesions. 11-14 An isolated acalculia Chinese sound or the Japanese sound-for H Yonezawa (anarithmia) has been also ascribed to a instance, a kanji meaning "east" is read as Nishina MemorWial parieto-occipital lesion in most cases,'5-"7 but [tou] (original sound) or as [higashi] Cyclotron Center to a one 18 on the context. (Japan Radioisotope frontal lesion in patient. Some (Japanese sound) depending Association) and patients with agraphia or acalculia showed All Japanese sentences can be written with Cyclotron Research dissociations between different orthographic'4 kana only, but are usually written with both Center, Iwate Medical 19-21 22-24 University, Morioka, or arithmetical operations,'6 suggest- kanji (for nouns and roots of verbs, adjec- Japan ing domain specificity of individual processes tives, and adverbs) and kana (for inflexions, K Hatano in the writing and calculation system. We conjunctions, and propositions). T Sasaki describe a patient with pure agraphia and A week after onset, his auditory and read- Correspondence to: Dr Hideo Tohgi, acalculia associated with a left frontal lobe ing comprehension of words and sentences Department of Neurology, (Fl, F2) infarction. were normal (28/30, 93% for each), but his Iwate Medical University, 19-1, Uchimaru, Morioka, ability to carry out oral and written com- 020 Japan. mands (such as to place a coin and a foun- Received 2 August 1994 Case report tainpen on a handkerchief) was severely and in revised form 17 October 1994. The patient, a 59 year old, right handed man impaired (3/19, 30% for each). He could cor- Accepted 27 October 1994 had had 11 years of formal education and had rectly choose a kana that corresponded to a 630 Tohgi, Saitoh, Takahashi, Takahashi, Utsugisawa, Yonezawa, Hatano, Sasaki J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.5.629 on 1 May 1995. Downloaded from (A) T2 weighted MRI of horizontal planes (TR = 2500, TE = 110) at level of corpus callosum; (B) at level ofcentrum semiovale; the infarct area includes mainly Brodmann's areas 6 and 8, and a posterior part of area 9, but spares area 44; (C) PET images of cerebral bloodflow (CBF), and cerebral metabolic rate ofoxygen (CMRo,) in the horizontal planes 60 and 70 mm above and parallel to the orbitofrontal (om) line (8 weeks after onset using Headtome IV, Shimadzu, _Japan, with thefull width at half maximum of 4-5 mm). The CBF and CMRo, were determined using C'502 inhalation methods and 1502 respectively. The right side of the head is on the left in allfigures. The CBF and CMRo2 are profoundly decreased in the left prefrontal areas (arrowheads). Quantitative data are as follows (mlllOO mllmin): prefrontal area, CBF 33-8 and CMRo2 2-42 on the right, and CBF 12 2 and CMRo2 0-79 on the left; supramargznal gyrus, CBF 33-6 and CMRo2 2-51 on the right, and CBF 32-8 and 2-42 on the left; angular gyrus, CBF 29-8 and CMRo2 2-45 on the right, and CBF 31 7 and CMRo2 2 58 on the left; and control values, CBFG 40 and CMRo2 - 3 0. phoneme pronounced by the examiner included (table) (a) omission of phonetic (20/20, 100%), could name objects (18/20, marks (two dots on the right upper corner of 90%), and could repeat words orally that a kana) to convert voiceless consonants to http://jnnp.bmj.com/ were spoken by the examiner (10/10, 100%). voiced ones (for example, h to b, k to g, s to He could describe what a person was doing z, and t to d), or of those to convert h to a on single action pictures (7/10, 70%), but voiceless bilabial sound p (a small circle on could not narrate a story for composite pic- the right upper corner of a kana) (60%); (b) tures. He could read aloud and comprehend difficulty in writing kana that are used to perfectly single kana words written in kanji denote double vowels, or to prolong the and kana and sentences composed of both precedent kana's sound (kya, kyo, kyo, or kana and kanji (25/25, 100% for each). If he hou, kou) (14%); (c) confusion with a graphi- on September 24, 2021 by guest. Protected copyright. was asked to say as many words as possible cally similar kana (4%); (d) confusion with (word naming), he said only two words (con- phonetically similar kana (2%); (e) confusion trol > 12). His writing ability was severely with orthographically irregular kana (8%); impaired: the correct responses were far less and U) failure to complete a word (12%). He frequent for spontaneous writing (1/25, 4%) also made similar errors in writing non- than for dictation (7/25, 28%; x2 = 5-4, words. Although Japanese kana are in most p < 0 025). cases orthographically regular, there are a few His linguistic abilities gradually recovered exceptions: the subject of a sentence is indi- after admission. Seven weeks after onset, he cated by a kana postposition "ha" which is made almost no errors in speaking, listening, pronounced as [wa]; the object of a sentence and reading, but made many errors in writ- is indicated by a postposition written by a ing. His writing errors for kana (24/62 words, kana used for "wo" in ancient times which in 39%) were significantly more frequent than modern Japanese is pronounced simply as for kanji (4/65 words, 6%) (P < 0 001). His "o". He almost always wrote kana "wa" oral responses to 60 pictures of the Boston instead of "ha" as the postposition for the naming test (40-55 for the average Japanese) subject, and kana [o] instead of "wo" for the were correct for 45 pictures (75%), but his object, which was inconsistent with his 11 graphic responses were correct for 31 pictures year educational history. He could correctly (52%)-that is, he made errors in writing in copy words both in kanji and kana. The kanji 14 out of 45 words (31 %) that he could character is composed of a radical that is express orally. His writing errors for kana related to its meaning (semantic component) Agraphia and acalculia after a left prefrontal (Fl, F2) infarction 631 Examples ofwriting errors of the patientfor kana (footnote 1 to 6) and kanji (footnote 7 and 8) The writing is generated by semantic or J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.58.5.629 on 1 May 1995.
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