J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.66.2.233 on 1 February 1999. Downloaded from J Neurol Neurosurg Psychiatry 1999;66:233–237 233 SHORT REPORT Pure apraxic agraphia with abnormal writing stroke sequences: report of a Japanese patient with a left superior parietal haemorrhage Mika Otsuki, Yoshiaki Soma, Toshiko Arai, Atsuko Otsuka, Shoji Tsuji Abstract ted to Takeda General Hospital on 12 October A 67 year old Japanese male patient had 1993. He had been in good health without any pure agraphia after a haemorrhage in the relevant history of disease, but was subse- left superior parietal lobule. He developed quently found to have hypertension. On the diYculty in letter formation but showed evening of 12 October he noted sudden weak- no linguistic errors, consistent with the ness in his right arm while he was at his oYce. criteria of apraxic agraphia. He mani- His colleagues noted at that time that he fested a selective disorder of sequencing answered their questions irrelevantly and they writing strokes, although he was able to brought him to the hospital. A neurological orally state the correct sequences. The examination showed him to be alert, but diso- patient’s complete recovery after 1 month, riented as to time and place. The cranial nerves without new learning, showed that he had were all intact, and he showed no paresis in the manifested a selective disorder of writing limbs, and no pathological reflexes or sensory stroke sequences. These findings indicate deficits. By the next day he had become well that the final stage of the execution of oriented, but he became aware of an impair- writing according to acquired sequential ment in his writing. Brain MRI performed 22 memory shown as a stroke sequence can days after onset (fig 1) disclosed a circum- be selectively disturbed, and should be scribed haemorrhage in the left superior considered to be distinct from the ability parietal lobule. Seventeen days after onset, of character imagery and the knowledge of N-isopropyl-(123I)-p-iodoamphetamine single Cerebrovascular the writing stroke sequence itself. This photon emission computed tomography Division, Department case also indicates that the left superior (SPECT) disclosed decreased blood flow of Internal Medicine, parietal lobule plays an important part in corresponding to the region showing a haemor- National the execution of writing. rhage, as disclosed by MRI. http://jnnp.bmj.com/ Cardiovascular Center, (J Neurol Neurosurg Psychiatry 1999;66:233–237) Japan M Otsuki Keywords: pure apraxic agraphia; left superior parietal Neuropsychological assessment lobule; writing stroke sequences From the onset, the patient’s speech was fluent Department of Neurology, Brain and well articulated, and he showed no Research Institute, orofacial apraxia. The western aphasia Niigata University, Pure agraphia is an impairment in writing unac- battery,10 Japanese version11 was administered Japan companied by any other relevant language within 1 week after onset, and disclosed no on September 27, 2021 by guest. Protected copyright. Y Soma disorder,1 which occurs in association with aphasic findings or reading disability except for S Tsuji lesions in the frontal lobe,2 superior parietal a writing impairment. On the revised Wechsler lobule,3–5 temporal lobe,6 left caudate nucleus adult intelligence scale (WAIS-R), adminis- Department of Speech 7 89 Therapy, Takeda and internal capsule, and left thalamus. tered 13 days after onset, the patient showed a General Hospital, Regarding the type of pure agraphia and the verbal IQ of 109, performance IQ of 100, and Japan lesions, the parietal lobe is considered a full scale IQ of 105. Regarding the praxis T Arai candidate site of the causative lesion for examined during the first week after onset, he A Otsuka disorders of spatial and kinesthetic movements was able to make meaningful gestures such as of writing34; however, the relation between the Correspondence to: beckoning, waving goodbye, tooth brushing, Dr Mika Otsuki, type of agraphia and other lesions remains pretended tool use, and pantomime on verbal Cerebrovascular Division, uncertain. We herein report a case of pure command and on imitation; he was also able to Department of Internal agraphia after a haemorrhage in the left superior Medicine, National imitate meaningless gestures made by the Cardiovascular Center, 5-7-1 parietal lobule in a Japanese patient, who examiners, and he could use tools accurately, Fujishirodai, Suita, Osaka, showed a characteristic impairment of writing, which indicated that he had no impairment in 565-8565, Japan. Telephone and we discuss the symptoms and the mech- 0081 6 833 5012; fax 0081 6 praxis such as ideomotor apraxia or ideational 872 7486. anism of pure agraphia after a left parietal lesion. apraxia. He was able to imitate simple finger patterns using either hand, and he showed no Received 30 April 1998 and Case description clumsiness. He was able to copy cubic and in revised form 10 August 1998 A 67 year old, right handed, university Rey-Osterreith’s designs without any problem, Accepted 25 August 1998 educated Japanese male bank clerk was admit- with the normal strategy employed to copy, and J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.66.2.233 on 1 February 1999. Downloaded from 234 Otsuki, Soma, Arai, et al Figure 1 T2 weighted brain MR axial images (TR=3000, TE=90) of the patient obtained 22 days after onset. A circumscribed haemorrhage in the left superior parietal lobule is seen. Scattered white matter lesions indicate the ischaemia within the white matter after hypertension. obtained a normal score on the block design both Kanji and Kana, equally on spontaneous test (score of 11 on the WAIS-R), which writing, dictation, and transcription. He him- indicated that he had no constructional distur- self noticed that his stroke sequences were bance. There was no spatial disturbance, optic strange, and he was able to express orally with- ataxia, or visual agnosia. out any diYculty how the sequence of strokes We administered writing tests 18 days after should proceed and how he used to perform onset: the dictation and transcription of the sequence before the haemorrhage. There- educational Kanji (morphograms12), and the fore, his knowledge of the sequence of writing same words written in Kana (syllabograms12). strokes seemed to be preserved. He sometimes We used the easiest Kanji, selected at random succeeded in correcting his mistakes, but not from among educational samples for pupils at always. He showed no spelling errors in his elementary school level. writing, and he was perfectly able to select cor- rect Kanji or Kana from among the samples and make words and sentences. Results At the re-examination 1 month after onset, The results are summarised in the table and in the same writing tests administered earlier, writing samples by the patient are shown in fig- the patient was able to write correctly all of the ure 2. Before any further description, it is nec- Kanji and Kana tested with the correct essary to explain the Japanese writing system. sequence of writing strokes, without new There are two systems of writing in Japanese; learning, and he has never shown an unusual Kanji (morphograms12) and Kana stroke sequence in writing since then. In a (syllabograms12). Kanji often have very compli- cated shapes, achieved with as many as 10–20 Results of reading and writing examinations http://jnnp.bmj.com/ strokes, and many Kanji thus require a particular writing stroke sequence. Figure 2, A, Kanji Kana* B, and C are examples of Kanji. Thus it is a Reading (administered 17 days fundamental educational subject for Japanese after onset): Administered numbers 50 50 pupils to learn the stroke sequences of Kanji. Correct answers 50 (100%) 50 (100%) They learn them by practicing the sequences Writing (administered 18 days repeatedly, not only through knowledge but after onset): Administered numbers 50 50 on September 27, 2021 by guest. Protected copyright. also using sequential movement memory. Kana Correct answers are much simpler than most Kanji; Kana are A 38 (76%) 38 (76%) B 10 (20%) 9 (18%) generally two to four stroke symbols of mora C 1 (2%) 3 (6%) (in the Japanese language, the ultimate mini- D 1 (2%) 0 (0%) mum unit of a sound corresponds to a mora, (A) Correct shapes with a correct sequence of strokes; (B) cor- which can in turn correspond to one Kana let- rect shapes with an unusual sequence of strokes; (C) bad ter) such as “ro” or “bo” (fig 2, D shows two formation; (D) no recall Kana). Examples of both the correct sequences * Regarding the examinations of Kana, the administered num- bers are not the numbers of Kana letters but are Kana words, of strokes for Kanji or Kana, which were shown which consist of several Kana letters. We assessed the patient’s by the patient after his recovery, and the performance according to the existence of mistakes, which patient’s writing with unusual stroke sequences means that even if the patient showed an incorrect response in during his morbid period are shown in fig 2. one Kana letter, we assessed the entire word as an incorrect response, and the patient was assessed as giving a normal answer In addition to the ill shaped letter formation, only when he was able to complete whole words with completely the patient characteristically showed an unu- correct letter formation. We used Kana for the word sual sequence of strokes for forming Kanji or examinations because the number of Kana letters is limited, only 46 in all, compared with the standard elementary school Kana, although he was able to eventually arrive vocabulary level of 1000 Kanji. We also hoped to examine the at the correct formation. The patient com- patient’s ability to write sequential movements which demand a plained of his impairment of writing as follows: certain flow, so it seemed preferable to adopt words to each let- ter.