J7ournal ofNeurology, Neurosurgery, and Psychiatry 1994;57:609-613 609 Naming difficulties in alexia with agraphia for J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.5.609 on 1 May 1994. Downloaded from kanji after a left posterior inferior temporal lesion Yasuhisa Sakurai, Katsuyuki Sakai, Manabu Sakuta, Makoto Iwata Abstract patient, a 71-year-old right-handed man, was The case is described of a patient with educated to senior high school level. He had alexia and agraphia for kanji, and severe no history of serious illness. On 22 June 1991 anomia after a subcortical haemorrhage he suddenly felt a slight left-sided headache. in the left posterior inferior temporal He then noticed that he could not remember area. Magnetic resonance imaging at four the names of objects or his family and could months after onset showed a lesion in the not read newspapers or write anything but his inferior temporal and fusiform gyri, own name. He was admitted to the Japanese extending from the temporo-occipital Red Cross Medical Center on 22 June with a junction toward the anterior third of the diagnosis of cerebrovascular disease. temporal lobe. Comparison with other He was fully conscious on admission. reported cases of alexia with agraphia Cranial nerve function, motor system, cuta- and anomia made it clear that when neous and deep sensation, and coordination accompanied by severe anomia, the were all intact except for a mild hearing loss in lesions extended either forward to the both ears. There was no visual field defect. anterior part of the middle temporal Blood chemistry was normal. Audiometry gyrus or medially to the parahippocam- showed mild hearing loss in both ears for pal gyrus. It is suggested that the discon- speech discrimination (right ear, 75%; left nection of association fibres between the ear, 80%; 80-85 dB). parahippocampal, fusiform, middle, and inferior temporal gyri, especially between NEUROPSYCHOLOGICAL EXAMINATION the parahippocampal gyrus and the other The patient's verbal IQ with the Wechsler temporal gyri, or the cortical damage to adult intelligence scale-revised (WAIS-R) the posterior part ofthese gyri is essential was 80, and his perforrnance IQ was 86. for the production of anomia. The Western aphasia battery (WAB; Japanese edition'8 (table 1)) at two months (7 Neurol Neurosurg Psychiatry 1994;57:609-613) showed that his spontaneous speech was flu- ent with preserved prosody. He showed marked word finding difficulty and overused Since Iwatal first described a case of alexia demonstrative pronouns, but there were few http://jnnp.bmj.com/ with agraphia only for kanji (Japanese mor- paraphasias. He made three correct responses phograms) due to a left posterior inferior tem- out of 20 in object naming and, given pho- poral lesion, there have been many similar nemic cues, made another four correct case reports stressing the importance of this responses. Circumlocution was observed in area in the reading and writing of kanji.'-" most of the incorrect responses. He could Alexia with agraphia for kanji due to a left explain how to use objects and could point to posterior inferior temporal lesion has two main features. Firstly, it is often accompanied, on September 27, 2021 by guest. Protected copyright. Table 1 Scoresfor the Western aphasia battery Department of to a greater or lesser degree, by naming diffi- Neurology, Institute culties (anomia). Little is known as to why August 1991 October 1992 for Brain Research, anomia is caused by this lesion. in University ofTokyo Secondly, Spontaneous speech School ofMedicine, some patients kana reading is more impaired Information content 7/10 9/10 Tokyo, Japan than kanji reading, though kanji writing dis- Fluency 8/10 9/10 Naming total 2-4/10 5 7/10 Y Sakurai turbance is always worse and persists longer M Iwata Object naming 13/60 31/60 than kana writing. For this reason it is called Repetition 8-6/10 9-6/10 of Department pure for some Comprehension total 7/10 9-45/10 Neurology, Japanese agraphia kanji by workers.215 Yes/no questions 51/60 54/60 Red Cross Medical In this paper we describe a Japanese man Auditory word recognition 41/60 59/60 Center, Tokyo, Japan with alexia and agraphia for kanji accompa- Sequential commands 48/80 76/80 K Sakai Reading total 3-9/10 8-05/10 M Sakuta nied by severe naming difficulties due to a left Comprehension of sentences 4/40 40/40 posterior inferior temporal lesion, and discuss Reading commands 7-5/20 13/20 Correspondence to: Kanji to object matching 3/3 3/3 Dr Yasuhisa Sakurai, the mechanism underlying the production of Kana to object matching 3/3 3/3 Departnent of Neurology, anomia by comparing this patient with Kanji to picture matching 3/3 3/3 Institute for Brain Research, Kana to reported cases. picture matching 3/3 3/3 University of Tokyo School Writing total 6-55/10 7-5/10 of Medicine, 7-3-1, Hongo, Copying 10/10 10/10 Bunkyo-ku, Tokyo 113, Kanji writing to dictation 0/6 2/6 Japan. Kana writing to dictation 4/6 5/6 Received 28 January 1993 Case report Sentence writing to dictation 7/10 9/10 and in revised form Clinical details of the patient during the acute Praxis total 9-8/10 9-8/10 14 July 1993. Construction total 8/10 7 9/10 Accepted 28 September 1993 phase have been described elsewhere.'7 The 610 Sakurai, Sakai, Sakuta, Iwata objects on command fairly well (17/20). speech profile was rated as one of anomic J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.5.609 on 1 May 1994. Downloaded from Repetition was almost normal. Auditory com- aphasia and alexia with agraphia, relatively prehension was slightly impaired. Kanji read- selective for kanji. HIe did not show apraxia, a ing was poor, which resulted in a low score for construction disturbance, nor colour agnosia. comprehension of written language, whereas To evaluate the extent of the reading and kana reading was generally good, though with writing difficulties for kanji compared with a few phonemic paraphasias (this difference kana more precisely, at three months the was made clear in the reading of sentences patient was given reading aloud and writing to including both kanji and kana, but was not dictation tasks involving 100 kanji and the reflected in the WAB score). In kanji-to-object corresponding kana (readings of kanj), all of matching he could point to the appropriate which are taught in the first three years of pri- objects correctly, though he could only read mary school. The results showed that in both one of six kanji word items. This implies that reading (correct response in kanji, 20%; kana, semantics were preserved even when he could 75%; p < 0 001 on the two-tailed Fisher's not read kanji words, characteristic of deep exact method) and writing to dictation (cor- dyslexia.'9 Also, in writing to dictation, kanji rect response in kanji, 4%; kana, 59%; p < was inferior to kana. Agraphia of kanji due to 0 001 on the two-tailed Fisher's exact word recall difficulty and phonemic para- method), kana function was significantly graphias of kana were noted. The patient's superior to kanji function. Most of the errors Figure 1 CT scan on admission showing a large high density area in the left temporal subcortical structure extending to the anterior part ofthe temporal lobe. The left is the patient's left side. http://jnnp.bmj.com/ on September 27, 2021 by guest. Protected copyright. Naming difficulties in alexia with agraphia for kanji 61 comprised no response in kanji tasks and all kanji or kana he could write in the re- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.57.5.609 on 1 May 1994. Downloaded from phonemic paralexias or paragraphias in kana examination, though there were some kanji or tasks. A similar tendency was observed on kana which he could not read but could write, re-examination 15 months after onset with or vice versa, in the first test (number of items significant improvement (reading: correct with both correct reading and correct writing response in kanji, 46%, p < 0 005; kana, were two for kanji and 45 for kana). 91%, p < 0 05; writing to dictation: correct Severe naming difficulties and alexia with response in kanji, 12%, p < 0 005; kana, agraphia for kanji still persisted at 16 months, 77%, p < 0 005, on the McNemar test). On though there was some improvement (table the whole, he could read in kana more than 1). 90% of the items he read correctly in kanji, as CT on admission showed a high density well as in writing. He could also read almost area in the left temporal subcortical structure, thus the patient was diagnosed as having a cerebral haemorrhage (fig 1). There was also a Figure 2 MRI T2- low density area suggesting an old infarction weighted coronal view (0 5 in the anterolateral portion of the left puta- T; TR = 2500 ms; TE = 120 ms) through the men. MRI at the same time confirmed these atrium of the lateral lesions and there was no other change in ventricle (A) and intensity affecting the left thalamus. In MRI hippocampus (B, C) at at four months the four months. The right is lesion was evident in the the patient's left side. A cortico-subcortical tissue of the left inferior low intensity area temporal and fusiform gyri, probably affecting suggesting haemosiderin the inferior longitudinal fasciculus and deposition is present in the cortico-subcortical tissue of extending from the temporo-occipital junc- the leftfusiform, inferior tion toward the anterior third of the temporal temporal gyri from the lobe (fig 2).