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Lingual and Fusiform Gyriin Visual Processing J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.5.607 on 1 May 1987. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1987;50:607-614 Lingual and fusiform gyri in visual processing: a clinico-pathologic study of superior altitudinal hemianopia JULIEN BOGOUSSLAVSKY, JUDIT MIKLOSSY, JEAN-PIERRE DERUAZ, GIL ASSAL, FRANCO REGLI From the Department ofNeurology, Division ofNeuropathology and Centre ofNeuropsychology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland SUMMARY A macular-sparing superior altitudinal hemianopia with no visuo-psychic disturbance, except impaired visual learning, was associated with bilateral ischaemic necrosis of the lingual gyrus and only partial involvement of the fusiform gyrus on the left side. It is suggested that bilateral destruction of the lingual gyrus alone is not sufficient to affect complex visual processing. The fusiform gyrus probably has a critical role in colour integration, visuo-spatial processing, facial recognition and corresponding visual imagery. Involvement of the occipitotemporal projection Protected by copyright. system deep to the lingual gyri probably explained visual memory dysfunction, by a visuo-limbic disconnection. Impaired verbal memory may have been due to posterior involvement of the parahippocampal gyrus and underlying white matter, which may have disconnected the intact speech areas from the left medial temporal structures. Altitudinal hemianopia due to occipital lobe damage deductions concerning the cortical representation of is rare. Pathological verification has been reported the superior visual field in man, our case provides only in three cases, which all showed inferior alti- further insight in the understanding of the role of tudinal hemianopia.`- In fact, both vascular cases2 3 the lingual and fusiform gyri in complex visual also showed a partial quadrantanopia in the superior processing. hemifield and cannot be considered as pure cases of altitudinal hemianopia. No case of superior alti- Case report tudinal hemianopia with pathological study could be 73 old man with chronic arterial hypertension, atrial found in the literature, but complete defects of the A year http://jnnp.bmj.com/ in fibrillation and insulin-independent diabetes was admitted superior hemifield have been sometimes reported after he had an episode of bilateral leg weakness associated bilateral occipital stroke diagnosed clinically.4- l with rotatory vertigo and nausea which lasted 30 minutes. Bilateral involvement of the infero-medial part of the Three days before, he had experienced throbbing bilateral occipital lobe (lingual and fusiform gyri) has been temporal headaches associated with lightning phenomena in demonstrated by CT in four patients. 12 - 15 In a series the left visual hemifield, followed by intermittent blindness of 39 patients with visual field defects due to occipital in the upper visual field on both sides. infarction shown by CT, only one had a superior alti- On admission, he was well-oriented and collaborated well tudinal hemianopia.'2 with the examiner. Blood pressure was 160/100 mm Hg, with on September 30, 2021 by guest. We present the first case of superior altitudinal an irregular pulse suggesting atrial fibrillation (60/min). with a There were no carotid or subclavian bruits and no heart hemianopia from occipital lobe damage murmur. The ophthalmological and visual findings are pathological study. Apart from confirming previous described below. The remainder of the cranial nerves did not show any abnormality. The tendon reflexes were normally brisk and symmetrical. The abdominal reflexes were absent Address for reprint requests: Dr J Bogousslavsky, Department of In the Switzerland. bilaterally. The plantar reflexes were downgoing. Neurology, CHUV, 101 I Lausanne, limbs, no abnormality of tone, strength and coordination Received 25 February 1986 and in revised form 9 May 1986. was found. Tactile, pain, temperature, posture and vibration Accepted 15 May 1986 senses were normal. The gait was unremarkable. 607 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.5.607 on 1 May 1987. Downloaded from 608 Bogousslavsky, Miklossy, Deruaz, Assal, Regli Fig 1 Goldmann perimetry: test target 1-59 mm at 100 apostilbs intensity. Macular-sparing congruent superior altitudinal Protected by copyright. hemianopia with complete sparing ofthe inferiorfield. A..04- . _ http://jnnp.bmj.com/ - .,.J.; s.. ;, ^>.: > V ..';;-.g =;.'' '' 5 5 Xw 1| F" ' 'T _Ea on September 30, 2021 by guest. f fw. .X ' '' 't ^:w. X .;.,/. i.E ._. | | -] - - R li F lE |NE. ° -Av t l | .F'. ''f;'4 is :. ::.;. sS :.O :' j Fig 2 CTscan,five days after admission. Slice levels are labelled after Matsui and Hirano.25 (A) level 10 (<50), (B) same level, with contrast, (C) level 9 ( < 50), (D) same level, with contrast, (E) level 8 ( < 50) (F) same level, with contrast. A bilateral medial occipital infarct is visible in (A)-(D) but not in (E) and (F), suggesting that only the regions ventral to the calcarine sulcus are involved. | . *. gB:| R| I _. ._ . F ',,. 1*: ..l* 53 R [- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.5.607 on 1 May 1987. Downloaded from Lingual andfusiform gyri in visual processing 609 Ophthalmological and visual examination Visual acuity was Visually-guided reaching with each upper limb into each 1 25 on both sides. The pupils reacted symmetrically to light hemifield was normal. Mental imagery and verbal descrip- and accommodation, optic fundi were normal. The retinal tion of famous streets in town were unimpaired. Ocular artery pressure was 70/30 mm Hg on both sides. No visual movements were full in all directions, without nystagmus. perception was present in the upper hemifield for light or They were recorded on AC ENG (time constant: 5 s). Pur- motion. On Goldmann perimetry (fig 1), a congruent suit eye movements were normal when tested as the patient macular-sparing superior altitudinal hemianopia was followed a spot of light projected on a circular screen placed shown. Vision in the inferior field was normal, including I m infront of him (50 and 10°/s). Optokinetic nystagmus recognition of objects, faces and colours. There was no inat- was induced by projecting alternating black and white tention to double simultaneous visual stimulation. On the stripes on the screen (20° and 40°/s) and showed a normal Ishihara plates,'6 no error was made and the patient had no (gain = 09) and symmetrical response, with a normal difficulty sorting the Holmgren coloured wools. Hue dis- optokinetic after-nystagmus. crimination (ordering of 12 variations of the four primary Reading of a printed text was normal, spelling and reverse colours) was normal. Mental colour imagery was preserved spelling of words and non-words did not show any abnor- and the patient could state the colours of 10 different fruits. mality. Spontaneous speech, naming, repetition (words, The flight of colours was present and normal in both eyes. non-words, sentences up to 15 words) and comprehension of The patient had no difficulty describing and interpreting simple and complex (Pierre Marie's three papers) orders complex pictures like the Cookie Theft picture. 7 were normal. Writing on dictation was unimpaired. Sponta- Identification of the faces of famous people on photographs neous drawing of a cube was normal. There was no bucco- was normal and the patient had excellent results on Benton's linguo-facial apraxia and limb praxias did not show any dis- facial recognition test (51/54). 8 When asked, the patient turbance (4/4 on symbolic gestures, 5/5 on imitation could readily imagine faces of members of his family and gestures). There was no apparent difficulty on evocation of animals, with an accurate description. Visuo-spatial gnosias recent and ancient events but there were significant were normal: Ghent" 35/36, Poppelreuter20 4/4, and pre- difficulties in verbal and visual learning: Rey Auditory served orientation on a geographic map of Switzerland. learning2' (26/75, recognition: 8/15, delayed evocation: Protected by copyright. 1 2 3 .. .. 11 r L; I!; -, .4..", I *> .-- .,. \-...4. ;-5 -- ... t t 1-11 ./ I --: iA I I'' s --. 1: I .... , -. --.7 I .....S _~~ ~ ~~~~~~*, I 1...' . ,, -.- 0 1 A, , 'N 4 5 < --6 .... .. 11 ., ... , .'. :. { . _; ........... / http://jnnp.bmj.com/ .)\. *0 , ........ 8 9 10 on September 30, 2021 by guest. 77 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. :f1 Fig 3 Schematic representation ofbrain sections illustrating the bilateral occipito-temporal involvement (hatched area corresponds to spared calcarine cortex). J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.50.5.607 on 1 May 1987. Downloaded from 610 Bogousslavsky, Miklossy, Deruaz, Assal, Regli 0/15), Hebb's recurring digits22 (maximal span of 7, failure cystic spaces, crossed by a few small vessels. Groups of of span + 1 learning), Learning of 15 signs23 (21/75, recog- macrophages staining strongly with Prussian blue were nition 13/15, delayed evocation 4/15), Corsi's block- present. Sections stained for myelin showed a well-defined tapping24 (maximal span of 6, failure of span + 1 learning). margin of the infarct bordered by few protoplasmic as well The CT (fig 2) showed bilateral areas of infarction as many fibrillary astrocytes. In summary, the histological involving the inferior occipito-temporal region. An arch findings corresponded with those of an infarct several angiography and bilateral carotid angiography showed a months old. stenosis of the right internal carotid artery reducing the lumen by 50% of the diameter. The left internal carotid Discussion artery showed a subtotal stenosis at the sinus and was com- pletely occluded at the siphon. The left subclavian artery was stenosed by more than 50% of the lumen diameter just Our patient showed a purely superior congruent before the origin of the vertebral artery, which also showed hemianopia with macular sparing associated with ver- a 75% stenosis. The right vertebral artery was occluded at its bal and visual memory dysfunction, but without the origin. The left middle cerebral artery territory was supplied visuo-psychic disturbances classically produced by by the right internal carotid artery.
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