BRAIN INJURY, 1992, VOL. 6, NO. 6,529-542 Remediation of alexia without agraphia: a case study MICHAEL S . DANIELt, J O H N F. BOLTERS and CHARLES J . LONGS Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. tMemorial Rehabilitation Hospital, Long Beach, CA, $The NeuroMedical Center, Baton Rouge, LA and §Universityof Tennessee/Memphis State University (Received 15 September 1991; accepted 24 October, 1991) Following a left temporoparietal-occipital haemorrhage and surgery, a 43-year-old, right-handed male exhibited alexia without agraphia. A remediation programme consisted of training in head turning to compensate for a right visual field defect, letter-by-letter reading aloud and covcrtly, drill with flash-cards to improve word recognition and practice in naming objects to improve dysnomia. The patient’s readmg improved markedly over a 6-week period and he was able to resume work as a respiratory therapy supervisor. A post-morbid depression resolved concomitantly with the patient’s return to work. The training programme and the patient’s post-training approach to reading are discussed in terms of hemispheric functioning as well as ‘direct path’ and ‘indirect path’ readmg. The effectiveness of training is considered in the context of spontaneous recovery. Introduction Alexia without agraphia is a clinical syndrome in which reading impairment is the central feature and writing ability is relatively preserved [1-4]. Although readmg impairment is the most severe dysfunction, spehng and syntactic errors in writing are fairly common among the cases reported in the literature [4]. Right homonymous hemianopsia is almost always present. Impaired ability to copy and dyscalculia are 6equentiy associated with the syndrome, while mild dysnomia and colour anomia are less frequently reported [ 5 ] . Other cognitive abilities tend to be unaffected. Alexia without agraphia results from lesions which interrupt input from the occipital lobes to the left angular gyrus, thus ‘disconnecting’ cortical areas mediating visual perception of word images from the cortical area which decodes these images into meaningful language [2, 3, 6, 71. Understanding and developing treatment for acquired alexia is important because of the tremendous toll reading impairment takes on the individual’s functional and emotional life. Reading is required for many vocational activities as well as independent interaction with the environment. Loss of job or functional independence often leads to emotional distress such as depression and/or anxiety. This type of emotional response has been reported in some case studies of alexia [8-121. It may be that if the patient suffering alexia without agraphia could improve reading to functional levels, he/she could minimize disruption of work and independence and consequently avoid the type of emotional problems described above. Despite the severity of reading impairment in alexia without agraphia, most of the reported cases retained some residual reading ability. In some cases the individual was able to read only single letters [8, 13, 141, while others were able to read letters and some Address correspondence to: Dr Michael Daniel, 5762 Bolsa Ave. Suite 107, Huntington Beach, CA 92647, USA. 0269-9052/92 $3.00 0 1992 Taylor & Francis Ltd M . S . Daniel et al. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. 530 words [4, 7, 10, 15, 161. Individuals with the syndrome often are noted to employ a letter-by-letter reading strategy in which they spell the word aloud and are able to recognize the word from auditory spelling [13, 17, 181. A corresponding finding is that these individuals frequently are able to identifj words which they hear spelled aloud by others [2, 4, 8, 10, 141. Friedman and Albert [5] state that it is important to take into account residual reading abilities when planning remediation programmes for alexia. In most of the few reported cases of treatment for alexia without agraphia, intact reading skills, however minimal, were employed as a basis for treatment. Cases reported by Marks and DeVito [8], Will and Young 1141 and Moyer [9] each included motor rehearsal in the forni of tracing or copying, letter-by-letter reading and, in two of the three, flash-cards to practise visual recognition of letters, words or phrases. These approaches relied on the patient’s intact ability to read or kinaesthetically recognize letters and auditorially spelled words. The patients converted the auditorially spelled word into a spoken word. The spoken word served as a self-generated cue and was associated with the printed form of the word which the patient viewed simultaneously. After exposure to several pairings of the spoken and written word the patient eventually was able to recognize the word visually. In the case reported by Carmon ~1 al. [ l l ] , the same general approach was used, except the spoken word was provided by the therapist rather than self-generated by the patient because of the patient’s inability to read letters or profit from kinaesthctic mediation (it is not stated if the patient could recognize words from auditory spelling). Karanth’s [ 191 treatment approach for alexia without agraphia was distinct. Kinaesthetic mediation was discouraged. Printed words and narratives were paired with pictures and the pictures were faded out over time. The present case study describes treatment of reading impairment in a man who had alexia without agraphia. Residual reading capacity served as a basis for the intervention strategy. Prior to treatment he was developing depression due to inability to return to work. Case report KV was a 43-year-old, right-handed male with a high-school education and training as a respiratory therapist who was employed as a respiratory therapy supervisor at a large metropolitan hospital. He was hospitalized with a 1-week history of dificulty in carrying out routine functions on the job, particularly conipleting forms and work schedules. CT scan performed the day of admission revealed a left temporoparietal-occipital intraparenchymal haeniorrhage with rupture into the lateral left ventricle (Figure 1). A left parietal craniotomy was perfornied. An intracerebral clot was localized and removed through a small transcortical incision superior and posterior to the left angular gyms. No vascular abnormalities were found during the procedure. Once the clot was removed, an intracerebral teardrop-shaped cavity remained that was larger posteriorly than anteriorly and approximately 7 x 4 x 3 centimetres in size as estimated on post-operative CT scan (Figure 2 ) . KV’s post-operative course was uneventfd and he was discharged home within 2 weeks of surgery. Approximately 4-6 weeks following surgery KV attempted unsuccessfully to return to work, by his account, because he ‘could not do paper work’. H e indicated he was able to function in his job ordy by getting colleagues to coniplete many of his job responsibilities. After 1-2 weeks of working under these conditions, he saw his neurosurgeon again, by Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Remediation ofalexia without agraphia 53 1 Figure 1. Pre-operative CT scan showing lt$ temporopanetal-occipitalhaemowhage. now 2 months post-operatively. Formal visual fields by tangent screen revealed a right upper and partial right lower quadranopsia. KV was referred for neuropsychological evaluation. KV was evaluated with an abbreviated Halstead-Reitan Neuropsychological Battery, a prorated Wechsler Adult Intelligence Scale-Revised (WAIS-R), Wechsler Memory Scale (WMS) and selected tests fiom the Peabody Individual Achievement Test (PIAT) (Tables 1 and 2). Results of neuropsychological screening reflected average to low-average performance across most areas with a few exceptions. Performance on Trails B was slow and appeared due to problems with visual scanning, visual field deficit and/or recognition of the symbols as there were no errors, motor sk~Uwas average and performance on attention tasks was good. Memory was below average for Tactual Performance Test (TPT) blocks, as well as immediate recall of graphic figures (WMS) and word pairs (WMS). After a 1-hour delay KV recalled a low proportion of the figures and paragraphs (WMS) relative to immediate recall. Low-average performance on the WAIS-R appeared somewhat below what was predicted given his educational and vocational background. Figure 2 . Post-operative CT scan showing l$t temporoparietal lesion. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Remediation of alexia without agraphia 533 534 M . S . Daniel et al. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Table 1. 1%~arid post-treatiiietit rietrropsydiologicaldata. Motor Grip 0%) Tapping Sensory crrors Suppressions Tactile Auditory Visual Finger gnosis Graphaesthesia Stereognosis Form discrimination Pre-treatment Post-treatment R 50 59 L 42 52 K 52 63 1 44 54 0 0 7/9" 0 0 1/3 1/4 0 0 0 0 0 0 1/4 0 1/4 9/P 0 0 1/3 0 0 Trails A (Secs.) Trails B TPT R(mins) L B Memory Location Seashore Rhythm Test (errors) Thuntone Word Fluency: (S wds + C wds) Token Test (Errors) Aphasia Screening Test WMS Information Orientation Mental control Logcal memory (LM) D i g t span (Fwrdlbckwrd) Visual repro. (VR) Paired associates (PA) (Total easy/Total hard) Delay L M Delay V R Delay P A WAIS-Rd Information Comprehension Similarities Digit span Picture arrangement Block design Digit symbol VIQ' PIQ ~ ' left visual field cut was documented Russell, Nuringcr and Goldstein [20] scoring delay = 1 hour recall age-corrected scale scores prorated 0 0 0 1/20 0 0 48 211 51 120 5.9 3.6 4.9 2 1 5 21 (17+4) 1 9 5.0 3.0 4.5 5 1 4 34 (27+7) - 11 3 4 8 7 9/8 6 4 5 6 8 9/9 5 14/0 3.5 2 6/6 17/5 5 5 7/9 6 7 6 11 10 7 7 85 82 5 9 9 12 10 9 8 92 89 - 535 Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Remediation of alexia without agraphia Figure 3. Patient’s Aphasia Screening Test performance. Language screening revealed severe reading impairment with a mild dysnomia. KV was unable to read ‘He is a friendly dog. . .’ on the Aphasia Screening Test; he was also unable to name the picture of the baby and the drawing of the cross. Other than mild distortion in drawing the clock, the rest of the Aphasia Screening Test was performed M . S. Daniel et al. 536 Table 2 . Scores on reading, spelling and naming tests Pre-training Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. PIAT Word recognition Readmg comprehension Spelling Speech sounds perception Tat-errorsb Naming errorsn a Training Week 3 Week 6 1.4 6.4 0 1.6 8.4 7.9 10.0 11-4 4/10 9.8 11 1/10 2 0/10 scores are grade equivalents maximum errors = 60 patient unable to do test naming 10 common objects adequately (Figure 3 . ) KV was able to read digits, single letters and some two- and three-letter words (e.g. ‘cat’, ‘and’, ‘in’). H e could identift- longer printed words if he read each letter aloud. He obtained first-grade equivalents or lower on the Word Recognition, Reading Comprehension and Spelling subtests of the PIAT. KV was unable to d o the Speech Sounds Perception Test. He indicated that he understood the sounds but was unable to ‘read’ the choices. There were no other results which suggested that an auditory-perceptual deficit might account for this performance. O n confrontation naming, KV was unable to name four out of 10 common objects; his description of items he could not name suggested his performance was not due to visual agnosia (e.g. when shown keys he said ‘you know, you open the door with them and start the car with them’). Spontaneous word writing (Thurstone Word Fluency Test) and writing to dictation revealed some misspellings (Figures 4 and 5). Examination of preniorbid writing samples did not reveal this degree of spelling problem. However, this type of mild writing problem is frequently reported in cases of alexia without agraphia [4].The superiority of KV’s written spelling ability over his spelling scores on the PIAT provides some evidence of his alexia without agraphia. The spelling test on the PIAT relies heavily on word recognition skills; the patient is required to select the correct spelling of a word among three misspelled foils. KV performed poorly with this test format. In contrast, written spelling w h c h requires no word recognition was much better, although not flawless. KV’s test results indicate: (1) visual-perceptual abilities were generally intact despite a right field cut as evidenced by WAIS-R performance subtests, Aphasia Screening drawings and accurate letter and digit reading; (2) his lexicon was mostly intact, subtle dysnomia notwithstanding; (3) writing and other neuropsychological abilities were minimally affected; yet he was virtually unable to read. KV’s pattern of performance in conjunction with CT scan and surgery findings were consistent with the syndrome of alexia without agraphia as it is described in the literature. At the time of evaluation, KV described himself as moderately anxious and depressed due to his inability to return to work. He reported diminished interests, decreased energy, social withdrawal and hypersomnia. He spent most of his time in passive pursuits such as watching television. Although reading was crucial in his work and a hobby, he was not attempting to read because of the degree of impairment and frustration attendant to his alexia. H e expressed great concern about the implication of his reading impairment for return to work and the impact that failing to resume employment would have on his life. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Remediation of alexia without agraphia Figure 4 . Sample ofpatient's spontaneous wn'ting obtained in the Thurstone Word Fluency Test. Figure 5 . Patient's wn'ting to dictation. M . S. Dunid et al. 538 Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Treatment and results Treatment occurred during the second, third and fourth months post-onset. The primary goal of treatment was to provide KV with a reliable strategy which would allow him to read at a functional level in his work environment. Three factors appeared to most interfere with reading: (1) KV was unable to recognize most words visually; (2) a right visual field cut prevented visual perception of words appearing on the right side of the page; (3) mild dysnomia made it difficult for KV to discuss material read. KV’s strengths were: (1) he visually recognized letters; (2) he recognized words he spelled aloud; (3) other neuropsychologcal functions were not greatly affected. The visual field defect was addressed by training KV to turn his head slightly to the right to take full advantage of his intact visual field. He learned this technique quickly and significantly reduced the number of omission errors he made when attempting to read. To improve dysnomia, KV was instructed to nanie objects in his home rapidly for 5 minutes, three times daily. Training to improve KV’s reading deficit incorporated his residual reading abilities. When presented with a printed word he first was to read each letter aloud and then say the word aloud (which he recognized from the auditory spelling). This strategy proved effective after only a few practice trials. KV was then given 260 index cards each with a printed word; the words included items from the Dolsch Sight Word Reading List [21] as well as words KV commonly encountered in occupational activities. He was instructed to review as many cards as possible within 13 minutes, three titnes daily. When viewing a card he employed the following strategy: (1) attempt to recognize the word immediately; (2) if unable to do so, verbalize each letter of the word in sequence and attempt to recognize the word from spelling; (3) if the word was still not recognized, ask for assistance. Initially, direct supervisio~~ by the therapist was required to assure KV adhered to the strategy and was able to derive meaning from the words. Once the strategy was established, KV assunied responsibility for his own training with the therapist serving a consultant role. As KV mastered the orignal group of words on the index cards, new words were added. After 2 weeks of practice, KV was able to substitute covert spelling of words for spelling aloud. By the end of the third week, he was reading phrases and sentences. Three and 6 weeks after initiation of training, retesting on the I’IAT, Speech Sounds Perception Test and naming the same 10 conimon objects showed progressive improvement over baseline levels (Table 2). After 3 weeks of training, KV felt confident enough to resume full-time work. At first his duties were extremely curtailed, but over a number of weeks he resumed all his former responsibilities. KV described his return to work as very satisfactory and helpful in improving his depressed mood. He reported revi\d of former interests, increased levels of energy, increased social involvement and normalized sleep. Repeat neuropsychological evaluation 4 months post-onset following completion of treatment showed little change over baseline levels (Table 1). Improvement was noted on Trails B, presumably because the symbols were decoded more rapidly and visual field defect was compensated for. Verbal fluency improved, as did performance on some niemory measures. Performance on intelligence tasks also improved. All of these iniprovements (with the possible exception of verbal intelligence subtests) may be accounted for to some degree by practice effects, and standard error or measure must also be considered in this context. Nonetheless, improvement in reading and naming, skills which were the focus of training, was of a substantially greater magnitude than Remediation of alexia without agrapkia 539 improvements in other neuropsychological measures. However, some dysnomia and reading difficulty persisted; KV was unable to name the pictures of a baby and a cross and read M-G-W as ‘4-G-W’ on the Aphasia Screening Test. At 1-year follow-up, KV was still functioning effectively in his job, however, reading was still labonous and he no longer read for pleasure. Unless carefully attending, he remained likely to make reading errors. KV continued to employ the covert spelling strategy when he encountered reading difficulty. Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Discussion Normal reading involves initial perception of a word followed by identification of letters 1221. Subsequent to letter identification, reading may proceed along a ‘direct’ or an ‘indirect’ path [5, 231. In the ‘direct’ path, following letter identification, the written word is matched to a visual memory of the word and the word is recognized. Once the word is recognized, the meaning can be retrieved directly from the lexicon; the spoken form of the word (i.e. its pronunciation) need not be elicited to derive the word’s meaning in the direct path. It appears that the direct path is typically used in reading [23]. In alexia without agraphia, orthographic perception of words and the lexicon are intact. Direct path reading is impaired because the transmission of visual information to the lexicon is disrupted (i.e. disconnected). In the ‘indirect’ path, a written word is transformed into a spoken word. The spoken word is comprehended in the same manner as speech. The treatment for KV and similar cases reported in the literature [8, 9, 141 made use of the indirect reading path. A written word was transformed into a spoken word through oral reading of single letters and recognition of the auditory spelling of the word. The spoken form of the word was then associated with the written form of the word when the patient said the word aloud and simultaneously viewed the printed word. After practising this procedure, KV was eventually able to recognize the word immediately without the intermediate steps of spelling and saying aloud. What was the nature of KV’s reading process when a letter-by-letter approach was no longer necessary? We feel some light can be shed 011 this question by contrasting direct path reading mediated by the left hemisphere with direct path reading mediated by the right hemisphere. Direct path reading mediated by each hemisphere is different in (at least) two ways: ability to decode (vs. merely recognize) words and ability to generalize to various graphic forms (such as alternative founts, or plurals). We compare our patient with the case reported by Carmon et al. 1111 in this context. Carmon et al. [ll] conceptualized treatment of their patient to involve training in a ‘right hemisphere strategy’ in which an association between the spoken word and its orthographic representation were memorized. Their hypothesis is supported by the fact that when the orthographic representation was slightly altered (e.g. the word was made plural or the fount was changed), their patient no longer recognized the word. Their patient appeared unable to access the left hemisphere indirect reading path by letter recognition or employing grapheme to phoneme rules (suggesting their patient had a more severe lesion than KV). She was completely limited to a strict orthographic mediation. While KV’s treatment was similar to that of Carmon et al.’s patient [ll], there are important differences that suggest that the cognitive process involved in each patient’s training and the manner in which reading was eventually mediated were different. In KV’s Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. 540 M . S. Daniel et al. training, words were decoded using a letter-by-letter approach to transform the written word to the spoken word. The spoken word served as the self-generated auditory component of a spoken word-written word pair. KV’s training, therefore, involved two processes: (1) decoding words via the left hemisphere mediated indirect path; and (2) pairing of the spoken and written forms of the word. In contrast, Carmon et al’s patient [ I l l was completely unable to decode words and could not self-generate the auditory component of the spoken word-written word pair; the spoken word was provided by the therapist. The training for their patient involved only the pairing of the spoken and written form of the word. Their patient used a right hemisphere mediated direct path approach in training. In addition, KV had no problem generalizing recognition of words he leamcd to their plural forms or to different founts as described for Carmon et al.’s patient [ll]. In fact, his job required reading a number of different people’s handwriting. These observations suggest that left hemisphere, direct path reading was reinstituted to some degree for KV. However, he did not recover direct path reading fully up to 1 year post-onset and had to fall back o n the indirect path, letter-by-letter strategy when he encountered difficulty. Therefore, while it appears that Carmon et al.’s patient employed a right hemisphere, direct path reading approach, our patient employed a somewhat limited left hemisphere, direct path reading approach. By what process or mechanism does training influence eventual improvement in reading ability? The relationship between the training of Carmon et al.’s patient and her eventual reading capacity appears straightforward. She practised and eventually ‘read’ by using the same technique, often referred to as ‘sight word reading’. The relationship between KV’s training and his eventual reading capacity is less straightforward. It is not possible to delineate clearly how practice with indirect path reading and pairing spoken and written word forms may have influenced partial restitution of direct path, left henlisphere mediated reading that we presume KV used. However, concepts posited by Luria (241 and elaborated by Sohlberg and Mateer [25] have relevance. Luria felt that direct retraining of cognitive processes can result in reorganization of higher-level thinking capacity. Sohlberg and Mateer emphasize extensive repetition through multiple trials as an important aspect of training that provides the stimulation and activation of the target process required to achieve neurologcal reorganization. The notion is that repeated taxing of the same neurologcal system facilitates and guides the reorganization of function. As such, repetitive exercises within a planned programme place demands on the patient to perform an impaired slull; Sohlberg and Mateer describe this as a ‘process-specific approach’ to cognitive training. Certainly a number of other factors in addition to treatment influenced KV’s reading recovery. Age, education, sex, cerebral dominance, premorbid reading skill, and lesion characteristics such as location, nature, and extent are important determinants of recovery. So-called spontaneous recovery must also be considered in this context. KV was treated in the second through fourth months following onset, a period when rapid spontaneous improvement of deficits typically occurs. O n e way of attempting to determine the extent to which treatment may have contributed to recovery of reading above and beyond the effects of spontaneous recovery is to examine the long-term outcome of untreated patients. T w o untreated cases of alexia without agraphia secondary to cerebral haemorrhage are reported in the literature which include some information about rcading ability 6 or more months post-onset. Ajax [12] reported that a 46-year-old miner was able to read only short words 5 years post-onset. Johansson and Fahlgren [26] described a 53-year-old carpenter who ‘could slowly read headlines in newspapers but was not able to read books’ 6 months post-onset. While these cases suggest spontaneous Brain Inj Downloaded from informahealthcare.com by Queen's University on 12/29/14 For personal use only. Remediation of aiexia without agraphia 541 recovery from alexia without agraphia can be minimal, caution must be used in drawing definite conclusions about differentiation of spontaneous recovery from treatment effects in KV’s case. There are important demographic differences in the cases and it is unclear to what extent the lesions are comparable. Furthermore, although there are reports of treated cases with successful outcome, it is not known how many alexia without agraphia patients may have been unsuccessfully treated. Thus, there is a paucity of evidence regarding how frequently the syndrome may be recalcitrant. None the less, two of the cases reviewed earlier [8, 91 which used treatment techniques similar to ours documented continued reading improvement beyond one year post-onset suggesting this approach can result in gains beyond a time when the majority of spontaneous recovery is presumed to have occurred. Logically, it seems that spontaneous recovery accounts for at least some of the improvement noted in KV’s reading ability. It may be that the treatment interacted with spontaneous improvements in reading potential by providing structure and guided stimulation to maximize gains and allow a more rapid course of improvement. The concomitant improvement in KV’s emotional status was notable. While it is conceivable that his depression began to remit spontaneously and improvement in reading ability was a corollary, this is not our impression. KV’s depression was related primarily to his impaired work capacity. We had the strong clinical impression, and KV’s self-report concurred, that improvement in mood was related to return to work. A related point is that prior to treatment, the degree of reading impainnent led to failure and frustration. As a result, KV was not attempting to read and actually appeared to be developing anxiety related to reading attempts. The training programme allowed him to use intact skills and experience some success in reading, thus avoiding emotional reaction to repeated failure. Clinically, one of the important factors in the success of the treatment was the patient’s motivation and capacity to practice independently. It appears that the intervention focused KV’s energies in a goal-directed fashion allowing the development of compensatory strategies. An important benefit of treatment was providing KV with a strategy to use when he encountered difficulty in reading. References 1. DEJERINE, J.: Sur un cas de c6citC verbal avec agraphie suivi d‘autopsie. Memoires de la SociPtt de Biologic, 3: 197-201, 1891. 2. GESCHWIND, N.: Disconnexion syndromes in animals and man, I and 11. Brain, 88: 237-294, 585-644, 1965. 3. GREENBLATT, S. H.: Subangular alexia without agraphia or hemianopsia. Brain and Language, 3: 229-245, 1976. 4. FRIEDMAN, R. B.: Mechanisms of reading and spelling in a case of alexia without agraphia. Neuropsyrhologia, 20: 533-545, 1982. 5. FRIEDMAN, R. B. and ALBERT,M. L.: Alexia. In: K. Heilman and E. Valenstien (editors). Clinical Neuropsychology. (Oxford University Press, New York) pp. 49-74, 1985. 6. DAMASIO, A. R. and DAMASIO, H.: The anatomic basis of pure alexia. Neurology, 33: 1573-1583,1983. 7. HENDERSON, V., FRIEDMAN, R., TENG,E. et a/.: Left hemisphere pathways in readmg: inferences from pure alexia without hemianopia. hreurology, 35: 962-968, 1985. 8. MARKS,R. and DEVITO, T.: Alexia without agraphia and associated disorders: importance of recognition in the rehabilitation setting. 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F.: Rccovery from alcxia with transient agraphia: a case study. C l i i i i ~ d!TeiircJpsyrlrol[~.cy, 4: 155-159, 1982. 15. GROSSI,D., FKA(;A\SI,N., OK\INI, A. f t a / . : Residual reading capability in a patient with alexia without agraphia. Br’7Iti turd Lnrgirage, 23: 337-348, 1984. 16. VINCENT,F . . S A I ) ~ W S Kc., Y . S,4VNI~El\S,I<. cf a / . : N e x l a without agraphia, hcniianopia, or color-naming dcfcct: a disconnection syndrome. iVerirolyy, 27: 689-69 I , 1977. 17. S P E E ~ I L. E ,J.. ROTHI, L. J. and HEILMAN, K. M.: Spelling dyslexia: a form of cross-cuing. BrnirL nrrd Lirigiin,qe, 15: 34k352, 1982. 18. WAIIIIIN(;~TON.E. K . and SHALLICE, T.: Word-form dyslexia. B r i t / , 103: 99-1 12, 1980. I>.: Pure alcxia in a Kannada-English bilingual. Cortex, 17: 187-198, 1981. 19. KARANTH, 20. KUSSFI I , E., NEUKIN(;EI<,c. and GOL~STEIN, (;.: Asscssrrretrf (f Brnirr h i i i r y : A 1%4ropsycho~ogica/ Keys ,4pproaih. (Wilcy. New York), 1970. 21. ZINTZ.M. V.: CorrcL-fk Keadiriy. (William C . Brown, I>ubuquc, Iowa), 1972. 22. M C C L ~ L L A N J. IL.: ) . I’rcliminary letter identification in the perception of words and nonwords. J w r i o l of Esyerinreirral Psyrholoyy: Hiittinti Perqtiorr mid Pe$wmurie. 2: 80-91, 1976. 23. BARON, J.: Mechanisms of pronouncing printed words: use and acquisition. In: I). LaBerge and S. Samuck (editors). Bnsii Prorexscs irr Rcndirfg: Perrfptiorr mid Corriprf/rciisiori.(Lawrence Erlbcaum Associates, Hillsdale. NJ), 1977. 24. LUIUA.A.: Resrornfiorr of‘Frtrrrfiotr &er Brnirr h j i i r y . (Basic Books, Ncw York), 1963. 25. SOHLUEKG, M. arid MATEEK,C.: Itrtrodiirtiorr to Copiiriiv Rc/iobi/itntiorr: Theory and Prnrtice. (Guiiford l’rcss, Nciv York). 1989. - O N , T. and FAHLGKEN, H.: Alexia without agaphia: lateral and medial infarction of left occipital lobe. S c r i r o l ~ y y 29: , 390-393, 1979.