J Neurol (1999) 246 : 312–313
© Steinkopff Verlag 1999

L E T T E R TO T H E E D I TO R S

Maria Caterina Silveri
Sandro Misciagna
Maria Giuseppa Leggio
Marco Molinari

Cerebellar spatial dysgraphia:
further evidence
Received: 30 March 1998
Received in revised form: 2 July 1998
Accepted: 18 August 1998

Sirs: In a recent report Silveri et al.
[10] described a patient with cerebellar atrophy who had the typical features of peripheral dysgraphia [3],
confirming that the cerebellum is involved in cognition [4, 5, 7, 9, 10].
This writing deficit, previously described only in subjects with right
supratentorial lesions, is characterized by omission and repetition of
strokes and letters and has been related to a deficit in visual and proprioceptive feedback, or in attention to
feedback, which allows the updating
of graphic motor patterns during sequential hand movement [2, 8] The
authors explained the patient’s deficit
by hypothesizing deficient coordination between hand movement planning and performance due to a lack
of the cerebellar integration between
supratentorial areas and proprioceptive afferent from the skeleton and
muscles.
We describe a 26-year-old righthanded woman who suffered from
the sudden onset of cerebellar symptoms. Magnetic resonance imaging
revealed hemorrhage involving the
vermis and extending into the right
cerebellar hemisphere, the IV ventricle, and to a lesser extent the left
cerebellar hemisphere (Fig. 1).
Her score on the Mini-Mental
State Examination was 24/30. Overall IQ was 77 (verbal 82, nonverbal
73). Neuropsychological examination revealed mild memory impairment associated with slight constructional apraxia and reduced word flu-

Fig. 1 Brain magnetic resonance imaging

ency. Signs of peripheral dysgraphia
were detected, such as a moderate
tendency toward downward sloping
lines and strokes, letter omissions,
and repetitions (Fig. 2). The patient
was requested to write 189 words
both in cursive and in print script
(Table 1) with her right hand. Writing was only slightly dysmetric, and
writing speed was normal (0.37 s per
cursive letter, 0.47 s per print letter;
three normal subjects with matched
age and education: 0.39 s per cursive
letter, 0.44 s per print letter). As in
other typical cases of peripheral dysgraphia, oral spelling was correct; in
other words, the patient was perfectly able to spell the letters forming
single words aloud. No significant
increase in errors was detected when
the patient was requested to write
with her eyes closed. Upper-case
print writing elicited more errors
than lower-case print writing. A few
months later no cerebellar sign was
detected, and results of the neuropsychological examination was fully
normal. Overall IQ was 103 (verbal
107, nonverbal 98).
The patient’s deficit was similar
to that described previously [10] in a
patient who had cerebellar atrophy.
Despite different cerebellar pathology (atrophic and diffuse versus vas-

Fig. 2 Samples of patient’s writing errors
(arrows)

cular and focal) the two cases presented very similar writing deficits,
confirming the role of the cerebellum
in “high-order” writing control.
Bower [1] hypothesized that
within motor function the cerebellum
does not interact with the motor system primarily to produce accurate
movements but as a means of controlling the acquisition of sensory
data. In this patient errors such as
omission and repetition of strokes
and letters during the handwriting

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Table 1 Quantitative analysis of patient’s writing errors
Kind of error

Print writing

Cursive writing

Eyes-open,
189 words

Eyes-closed,
11 words

Eyes-open,
189 words

Eyes-closed,
11 words

Stroke omission
Stroke repetition
Letter omission
Letter repetition

3
25
6
8

2
5
0
0

3
16
3
6

0
1
0
1

Total errors

42

7

28

2

process might be interpreted as
“dynamic state estimator” errors [6]
(for discussion see [7]) due to the
lack of coordination between motor
planning and sensory (proprioceptive) afferents from the muscles and
skeleton of the hand that follows the
disconnection between the motor and
premotor cortices (through the corticoponto-cerebellar pathway) and the
peripheral afferents (through the
spinocerebellar pathway).
In peripheral dysgraphia the eyesclosed condition typically produces a
significant worsening of the writing
deficit, suggesting that vision compensates for the proprioceptive deficit. In our patient the eyes-closed
condition did not produce any worsening of the writing performance,
suggesting that she had already lost
visual control of writing. This suggests that at least in some cases a
cerebellar lesion impairs not only the
proprioceptive but also visual control
probably by a limitation of the eye
movements.

References
1. Bower JM (1995) The cerebellum as
sensory acquisition controller. Hum
Brain Mapping 2 : 12–13
2. Ellis AW (1987) Normal writing
processes and peripheral dysgraphias.
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3. Lebrun Y (1976) Neurolinguistic models of language and speech. In:
Whitaker H, Whitaker HA (ed) Studies
in neurolinguistics. Academic, New
York, pp 1–30
4. Molinari M, Leggio MG, Silveri MC
(1997) Verbal fluency and agrammatism. In: Jeremy D. Schmahmann JD
(ed) The cerebellum and cognition.
Academic, New York, pp 325–339
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8. Silveri MC (1996) Peripheral aspects
of writing can be differentially affected
by sensorial and attentional defect:
evidence from a patient with afferent
dysgraphia and case dissociation. Cortex 32 : 155–172
9. Silveri MC, Leggio MG, Molinari M
(1994) The cerebellum contributes to
linguistic production: a case of agrammatic speech following a right hemicerebellar lesion. Neurology 44 : 2047–
2050
10. Silveri MC, Misciagna S, Leggio MG,
Molinari M (1997) Spatial dysgraphia
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Neurology 48 : 1529–1532
M. C. Silveri (쾷) · S. Misciagna
Institute of Neurology,
Catholic University, Largo A. Gemelli 8,
I-00168 Rome, Italy
e-mail: iclnp@unicatt.rm.it;
Tel.: +39-6-30154333;
Fax: +39-6-30501909
M. G. Leggio
Institute of Psychology,
University of Rome La Sapienza,
Via dei Marsi, 78, I-00185 Rome,
and Istituto di Ricovero e Cura
a Carattere Scientifico,
S. Lucia, Via Ardeatina, 306,
I-00179 Rome, Italy
M. Molinari
Istituto di Ricovero e Cura
a Carattere Scientifico,
S. Lucia, Via Ardeatina, 306,
I-00179 Rome, Italy