797

PAPER

Changes in artistic style after minor posterior stroke
J M Annoni, G Devuyst, A Carota, L Bruggimann, J Bogousslavsky
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See end of article for
authors’ affiliations
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J Neurol Neurosurg Psychiatry 2005;76:797–803. doi: 10.1136/jnnp.2004.045492

Correspondence to:
Julien Bogousslavsky,
Department of Neurology,
Lausanne University
Hospital, CH 1011
Lausanne, Switzerland;
Julien.Bogousslavsky@
chuv.hospvd.ch

Background: Two professional painters experienced significant changes in their art as the main
consequence of minor stroke located in the left occipital lobe or thalamus.
Methods: The features of this artistic conversion were analysed on the basis of extensive neurological,
neuropsychological, and psychiatric evaluations.
Results: Both painters, initially unaware of the artistic changes, exhibited mild signs of executive
dysfunction, but no general cognitive decline. The first painter, who showed mild visual-perceptive
difficulties (dyschromatopsia and scotoma in his right upper visual field after left occipital stroke), together
with increased anxiety and difficulty in emotional control, switched to a more stylised and symbolic art. The
second painter, who also presented features of emotionalism related to his left latero-thalamic stroke,
switched from an impressionist style to a more joyous and geometric, but more simplistic, abstract art.
Conclusions: These findings show that mild cognitive and affective modifications due to focal posterior
brain lesions can have significant repercussions on artistic expression.

Received 12 May 2004
Revised version received
13 September 2004
Accepted
13 September 2004
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P

ainting is a very complex behaviour1 and its neural
correlates involve brain areas processing the perceptive,
cognitive, and emotional valences of stimuli; brain
damage, therefore, could modify artistic expression. The
effect of a major stroke on artistic changes as a function of
the lesion type has been the subject of several reports, which
have generally focused on the result of severe visuo-spatial
disturbances (that is, hemispatial neglect)2 3 and aphasic
disintegration.3 4 Right parieto-occipital damage resulting in
spatial neglect, constructional apraxia, or perceptual agnosia
can alter the spatial configuration of the whole painting or
individual parts,5–8 while extensive left hemisphere damage
may be responsible for simplification of detail of represented
objects.3
Another aspect to consider is that, in a limited number of
cases, brain disorders seem, paradoxically, to improve artistic
expression. Painters with fronto-temporal dementia and
predominant left hemisphere dysfunction generally lose their
capacities of abstraction and symbolic representation, but
their paintings may appear more emotional and creative.9–11
Alzheimer’s disease and Lewy body dementia, in which
visuo-spatial disturbances may be prominent, adversely affect
drawing ability, but, in certain cases, painting become more
intuitive and fluid.12–14 From published reports of painters
with dementia, we can draw some conclusions about the
relationships between brain disorders and painting. In some
cases, a surprising outburst of creativity corresponds with the
loss of inhibitory control, leading to a sort of artistic
disinhibition.15 16 For example, in patients with semantic
dementia and predominant left hemisphere atrophy, facilitation of creativity has been attributed to a mechanism called
‘‘paradoxical functional facilitation’’,17 corresponding to a
shift from a left to a right hemisphere mode of functioning.
The effect of lesions within fronto-subcortical networks
subserving executive functions might be more subtle.
Executive functions may intervene in painting in the process
of screening the figurative relevance of stimuli or in
expressing novel order relationships between concepts.18
Furthermore, lesions limited to the limbic and paralimbic
regions involved in the regulation of mood and emotional
states should also affect an artist’s work. Creativity in
painters has always been related to the emotional features

of the artist’s unique personality, and periods of intense
artistic activity have frequently been compared to hypomanic
states.16 19 Depression, anxiety, emotional dyscontrol, apathy,
indifference, mania, and psychosis, all of which are known
possible affective consequences of focal infarcts,20–22 can have
a major influence on art, even after only limited brain
damage. The possibility that focal and limited brain lesions
might specifically influence an artist’s style through executive or affective changes has been poorly investigated. Here,
we present two painters, both of whom had a limited stroke
in the area of the left posterior cerebral artery and recovered
from their sensory motor deficits, but whose artistic expression was modified.

CASE REPORTS
Patient 1
Patient 1 was a 57 year old right handed lithographer and
described himself as a self taught painter. The themes of his
paintings were principally simplified human representations
(fig 1A), semi-figurative scenes, and original geometric
shapes. His pictorial language was rather naive, influenced
by primitive expressive styles (explanations of artistic terms
can be found in appendix A).
He presented a sudden loss of vision in the superior right
visual field and an autoscopic phenomenon (he saw himself
lying on the floor with his head turned to the left). He also
noticed difficulty in perceiving complex objects in his upper
right visual field. The first neurological examination showed
a right superior quadrantopia sparing macular vision,
confirmed by a detailed ophthalmologic evaluation. An MRI
revealed an acute ischemic infarct in the occipital area
corresponding to parts of V1 and V2 (fig 2). Arterial
dissection was excluded by MR angiographic and Doppler
findings, ECG monitoring did not reveal intermittent atrial
fibrillation, and other causes, such as diabetes, vasculitis, or
procoagulant states, were ruled out. The presumptive cause
was a paradoxical embolism from a patent foramen ovale and
he was treated with oral anticoagulants. Within a few days,
the right superior quadrantopia reduced to a paracentral
Abbreviations: DEX, Dysexecutive Questionnaire; MMSE, Mini Mental
State Evaluation; PTSD, post-traumatic stress disorder

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Annoni, Devuyst, Carota, et al

Figure 1 Paintings by patient 1 some
months before (A) and 4 months after
(B) stroke. The scenes were chosen
because of their similarity to highlight
the small stylistic changes.

scotoma, but a dazzling flash or white lines and contours
(mimicking the ‘‘shapes of fish skin and burning paper’’)
would frequently appear in the upper right visual quadrant.
Neurological examination 2 months after stroke showed a
right superior paracentral scotoma at 30˚ degrees and a
dyschromatopsia in the spared right upper visual field.
Repeated EEGs did not reveal any epileptic discharges. At
the 5 month follow up, neuropsychological assessment
(table 1) showed minor changes, such as a tendency to
digress in his discourse, a slightly delayed response times in
both visual fields in a visual detection task, and a tendency to
perseveration in a figural fluency task, but a normal performance in go-nogo and Stroop-like tasks. There was no
general cognitive decline in the Mini Mental State Evaluation
(MMSE = 29/30). Oral and written language, constructional,
ideational, and ideomotor praxis, and episodic and short term
memory were normal. He denied any difficulty in recognising
familiar shapes when looking for someone in the street,
when reading magazines, or when looking at paintings.
According to his wife, he had no problems conducting his
professional life and was independent in terms of travelling
alone, organising his exhibitions, and taking care of his bills.
We diagnosed a mild dysexecutive syndrome. A psychiatric
interview showed no personality changes after stroke, but did
show increased impulsiveness, fluctuating depressive mood,
and increased anxiety and avoidance behaviour, suggestive
of a moderate post-traumatic stress disorder (PTSD). This
PTSD-like syndrome was confirmed by a pathological score—
particularly for the avoidance symptoms—in the Impact of
Event Scale.23 Moreover, some irrational ideas were found,

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but these related only to the cause of the stroke (for example,
family problems), and the diagnosis of a psychotic reaction
was excluded. The Dysexecutive Questionnaire (DEX)24 25
showed a relatively higher score in the items of emotional
dyscontrol and loss of motivation compared to other items.
Patient 1 did not report any change in his habits, taste,
eating, or aesthetic judgment.
He started drawing and painting 1 month after the stroke
and, after a few weeks, comments by relatives and clients
made him aware that some changes had occurred in his art.
Human limbs and hands were thinner, sharper, and more
stylised (fig 1B) and the details simplified. Compared to his

Figure 2 Patient 1’s occipital
stroke, as shown in an MRI
3 weeks after the acute event. Fast
spin echo T2 (TR: 3800 ms, TE:
90 ms, NEX: 2, FOV: 1736230,
matrix: 1906256, 30% gap)
5 mm thick transverse section.

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799

Table 1 Summary of neuropsychological data for
patients 1 and 2
Scores
Domains
Gnosia
Recognition of embedded figures (POP)
Hooper visual organisation test
(adapted version)
Recognition of celebrities (actors,
politicians, etc)
Recognition of facial emotions
Colour naming
Position discrimination (BORB)
Object recognition in non-canonical
views (BORB)
Stereognosia (objects, right hand)
Stereognosia (objects, left hand)
Semantic memory
Semantic memory: Columbia
Semantic memory: description of
visual features
Executive functions
Phonological fluency (1 min)
Categorical fluency (1 min)
Design fluency (repetitions)
Perseveration in Luria’s graphomotor
tasks
Clinical go/nogo task
Non-colour Stroop (interference/
naming phase)
Behaviour/emotional scales
Global DEX score
Occasional emotional signs (reported
in the DEX)
Other artistic/diet changes
Psychiatric scales
HAD Depression
HAD Anxiety
IES scale

Patient 1

Patient 2

9/9

8/8

15/20
5/5

14/20
5/5

12/12
10/10
33/40
25/25

12/12
10/10
NA
6/6

5/5
5/5

6/7
5/7

11/12
6/6

9/12
8/12*

16
17
41 (6*)
3/20*

5*
15
38 (6*)
2/20*

10/10 (N) 10/10 (N)
,2 (N)
,2 (N)

5/80*

10/80*

Apathy
None

Impulsiveness
None

4/21
16/21*
.30

7/21
6/21
NA

*Normal: ,18.
N, normal; NA, not assessed. Impaired performances are indicated by
an asterisk. Abbreviations for the tests42: BORB, Birmingham Object
Recognition Battery; Columbia, Columbia Association Test; POP,
Poppelreuter’s figures; RAVLT, Rey’s Auditory Verbal Learning test.
43
Recognition of facial emotions is part of a prosopagnosia battery. The
adapted Hooper and Stroop-like tests were developed in Lausanne.44
Mood alterations were evaluated using the French version of the Hospital
45
Anxiety and Depression Scale (HAD) and PTSD-like symptoms were
assessed using the Impact of Event Scale (IES).46

first came to our attention because of sudden right
hypoesthesia-hemiataxia-hemiparesis, from which he recovered completely within 24 h. An MRI showed a small lesion
in the area of the thalamo-perforant branches (fig 3).
Intermittent atrial fibrillation was noted and treatment with
oral anticoagulants started.
A standardised neuropsychological evaluation 1 year after
the stroke (table 1) revealed a slight impairment in executive
functions, as demonstrated by a moderate tendency to
perseveration in verbal (phonological) and figural fluency
tasks and by some lack of precision in semantic and mental
imagery tasks (for example, in a word definition task, he
said, ‘‘An elephant, this is the largest animal on earth, with
tusks… I am not sure about its colour; does it have
hooves?’’). The MMSE showed no cognitive decline (28/30).
Oral and written language, constructional, ideational, and
ideomotor praxis, and episodic and short term memory were
normal, as were auditory and somesthetic tasks of interhemispheric transfer. According to his wife, he had no problems
carrying out social activities. In a self administered DEX
questionnaire, the patient only scored high on two items,
impulsiveness and lack of interest in social rules. We
diagnosed a mild to moderate dysexecutive syndrome. A
psychiatric interview led to the diagnosis of an absence of any
clinically relevant personality change, but the appearance of
mild emotional dyscontrol. Moreover, the consultant did not
suggest any psychiatric disorder. The painter’s wife completed a questionnaire on personality changes (the Iowa Scale
of Personality Change, ISPC26), comparing his personality
before and after the stroke, which confirmed that the only
change was the development of this slight emotional
dyscontrol.
He started to paint again 2 weeks after stroke, initially with
his left hand, then alternating between the left and right
hands, a method he had never used before the stroke. Even
though the strength and motility of the right hand had
completely recovered, he intended to train his left hand in
case his right hand was again paralysed. He sold his new
paintings with the same success as before. It was not until
several months later that comments by clients and critics
made him realise that his art had changed.

previous paintings, there was an overall simplification as a
result of the increased use of monochromic colour choices,
more stylised figures, and unreferenced background spaces.
He also introduced the luminous features that appeared in
his scotoma (fig 1B, top picture, bottom left corner; bottom
picture, top left corner). He showed us six examples from
before the stroke and four from after the stroke, which
confirmed these changes. Four of these (two from before and
two from after the stroke) were shown to two independent
judges who concluded there was simplification and increased
abstraction, symbolism, and role of luminosity (see appendix
B). His method of painting itself was also altered; as he said,
‘‘Previously, I would lie down and visualise a canvas for an
hour before starting to paint. Now, the flash prevents me
from doing this. My inspiration comes a little at a time while
painting, rather than before I start’’.
Patient 2
Patient 2, a 71 year old ambidextrous retired bank clerk,
developed a great interest in painting from the age of 50 and
exhibited locally and nationally. His favourite themes were
Swiss landscapes and he avoided purely abstract representation. Critics defined his art as ‘‘figurative-impressionist’’. He

Figure 3 Patient 2’s left paramedian thalamic stroke, as shown in an
MRI 6 weeks after the acute event. Fast spin echo T2 (TR: 3800 ms, TE:
90 ms, NEX: 2, FOV: 1736230, matrix: 1906256, 30% gap) 5 mm
thick transverse section.

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800

Patient 2 switched from a ‘‘figurative’’ to a more ‘‘realistic’’
art, in which colour intensity, a search for more realistic
shape consistency, a focus on detail, and a more structured
organisation of space were the most important features
(fig 4). He showed us three examples from before and three
from after the stroke, which confirmed these changes. Two
independent judges concluded that, after stroke, there was
more geometric organisation and use of bolder colours
and a greater relevance of each detail of the painting (see
appendix B).
He reported that he was ‘‘more sensitive to the hidden
beauty of nature’’ and that he ‘‘wanted to live and paint
spontaneously, explore the world, and represent it in its raw
strength’’. He also indicated a loss of interest in ‘‘impressionists’’, whom he had preferred for the previous 21 years.
Impressionism was now no longer sufficiently real or
representative of his creative strength. Intriguingly, he said
that it was the use of the left hand that led him into this new
artistic dimension. In fact, he discovered that figures
executed with his left hand had more emotional strength
and bolder colours, whereas, in those painted with the right
hand, the lines, contours, and perspectives were clearer. He
realised that his creativity was increased by the use of his left
hand. Patient 2 showed us three canvases representing the
same subject, painted with the left, right, or both hands,
respectively, which demonstrated that the painting produced
using the left hand employed more vivid colours (fig 5).
Apart from painting, patient 2 did not notice any changes
in his previous habits. His relatives and friends did not report
any change in his behaviour or personality after stroke. At the
1 year follow up, patient 2’s artistic productivity remained
high.

DISCUSSION
Our two patients were talented painters who experienced
qualitative artistic changes as the main consequence of a
stroke in the area of the left posterior cerebral artery. Other
behavioural consequences included moderate executive
dysfunction and features of emotional dyscontrol, but no
general cognitive impairment. The possibility that the artistic
changes were due to a conscious personal choice following a
life threatening medical event was initially considered;
however, both patients were initially unaware of the changes
to their art, suggesting that the change was due not to
personal choice, but was neurological in origin. Reduced
insight into a cognitive or behavioural modification is often a
direct consequence of brain dysfunction.27 Patient 2 evolved
initially towards bimanual painting. However, we did not
consider that the artistic changes were related to bimanual
painting, since the subjective feeling of the painter in parallel

Annoni, Devuyst, Carota, et al

was of a more general creative freedom, regardless of the
hand used. The fact that, in both painters, the changes only
involved painting, and not other habits or activities, also led
us to discount an effect on creativity related to general
effects, such as novelty seeking. Moreover, modification of
novelty seeking is generally related to frontal lesions,28 while
our patients had stroke in the posterior circulation.
The artistic changes may have been associated with a direct
effect of the infarct. Since the posterior brain regions seem to
play a specific role in creative thinking,29 it is not surprising
that a minor lesion in these regions might alter an artist’s
creative thought and thus his style of painting.18 Besides, the
fact that patients 1 and 2 had left hemispheric dysfunction
may provide some support for the theory of ‘‘right hemisphere functional release’’.17 Different possible cognitive
mechanisms may be considered.
Firstly, given that artistic modifications after posterior
strokes are often due to alterations in perceptual7 or spatial
and visuo-constructive30 31 activity or mental imagery,8 such
neuropsychological alterations may be the cause of the
artistic changes. However, we found no evidence of spatial
deficit or constructional apraxia.31 Patient 2 showed mild
signs of semantic impairment in verbally describing characteristics of animals or objects, but the fact that, after stroke,
his painting was more structured and detailed suggests that
mental imagery was well preserved.
Secondly, creativity is also modulated by evaluative
judgements32 and executive functions.16 The role of the
thalamus and posterior brain structures in executive functions has been reported33–35 and is supported by data from
functional imaging studies.36 Simplification of drawing and
attention to detail have both been described in some patients
with frontal dementia.15 Therefore, moderate executive
dysfunction in both painters could be partly associated with
their artistic changes. This hypothesis is strengthened by both
patients’ modified performances in verbal or visual fluency
tasks, which are executive tasks, but have also been used as a
short test of divergent thinking and creativity.37
However, fact that the artistic changes were different in
patients 1 and 2 suggested that executive dysfunction was
not the only mechanism. Both painters also showed poststroke emotional changes, which may also be considered.22 38
In the case of patient 1, the main artistic change was the way
he drew human figures. He also used a less structured
background in his paintings, and the relationship between
light and shapes appeared less developed than before. A
general simplification of his art developed after his stroke.
Increased anxiety and avoidance behaviour could have played
a role in this general simplification.39 In the case of patient 2,
the main pictorial changes were a conversion to a more

Figure 4 Paintings by patient 2 before
and after stroke. Note the use of more
vivid colours after stroke.

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Changes in artistic style

801

Figure 5 Pictures painted by patient 2
some weeks after his cerebrovascular
accident, using his left hand, right
hand, or both hands. Note the tendency
to use more colours when using the left
hand.

structured organisation and bolder colours. On clinical
evaluation, patient 2 also showed increased emotionality,
which has been shown to influence creativity in other
painters.40 These observations suggest that the artistic
modifications in our patients might be due not only to mild
executive dysfunction, but also to a moderate loss of
emotional control.
In conclusion, we suggest that the new painting style
adopted by these painters may be attributed to mild changes
in executive functions, semantic capacities, and emotional
regulation. While the change in their artistic behaviour
seemed to exceed the sum of the emotional and cognitive
manifestations related to their stroke, our data strongly
suggest that these modifications can, at least partly, explain
the change in style. The lack of strict formal rules in artistic
creativity allows the development of new abilities after brain
dysfunction, which depend not only on the artist’s personality, but also on the lesion site and the ability of the brain to
reorganise.41 The effect of focal brain lesions on individuals
highly skilled in artistic expression provides a unique
opportunity to study neuro-aesthetics, the neuroscience
discipline dealing with the neurobiology of art, that is, the
relationship between the brain and the artistic mind.

APPENDIX A
TO STYLISE
to synthesise the essential elements of the shape and colours
of that which is to be represented by simplifying them and
subordinating the realisation of this portrayal to a particular
aesthetic purpose. The concept is thus suggested by small
elements (features, spots of colour, etc), rather than explicitly
detailed.

SYMBOLIC
in figurative art, the process of transmitting specific concepts
by means of the representation of images and elements
suggestive of these concepts, but which have a figurative
autonomy regarding the concrete reality.

ABSTRACT ART
artistic tendency that discards the representation of the
external world, the aim of which is the formal message and
visual perception itself. The pictorial language that ensues
from this tendency expresses itself through the simplification
and decomposition of shapes.

ACKNOWLEDGEMENTS
We would like to thank Valentina Palma and Jean Ott for their
analysis of the painters’ work, the patients for their paintings, and
Tom Barkas for reading the manuscript.
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FIGURATIVE ART
the representation of truth by figures. Artistic language that
resorts to the use of images and subjects which are present in
the real world and universally known.

Authors’ affiliations

J M Annoni, G Devuyst, A Carota, L Bruggimann, J Bogousslavsky,
Department of Neurology, Lausanne University Hospital, 1011
Lausanne, Switzerland
A Carota, Centro ricerche in neuropsicologia I.R.C.C.S, Fondatione
Santa Lucia, Via Ardeatina 307, 00172 Rome, Italy
This work was supported by the Swiss National Science Foundation
(grant nos. 3151AO-102271 to JM Annoni and 3200-061342.00 to J
Bogousslavsky) and by the Biaggi Foundation
Competing interests: none declared

GREATER ORGANISATION OF THE STRUCTURE
to produce a picture balanced in the construction of each
element, so that the composition is harmonious and well
proportioned in the final work.

GEOMETRIC ORGANISATION
to structure a portrayal in a linear, ordered, and rigorous way,
as if the arrangement of each element had to be measured.

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Annoni, Devuyst, Carota, et al

STRONG IMPORTANCE OF EVERY DETAIL

After stroke (fig 1B)

to express every element of the composition in its shading,
originality, and formal characteristics.

artistic language which is able to provoke strong emotional
feelings due to a particular use of colours, shapes, design, etc.

Similar stylisation of the same subject. The same representations are shown on a red background. The luminosity of the
sun permits no colour work, except for some minor
accentuation of pallor. (AC)
Simplified painting with abstract elements and symbolism.
Strong signs of violence represented by ‘‘emissions’’ coming
from one of the figures. Some allusions to Kandinsky. (PA)

APPENDIX B

Patient 2, fig 4

EMOTIONAL FORCE

Comments on the paintings of patients 1 and 2 paintings
before and after stroke by an art critic (AC) and a
professional artist (PA). The patients lent us ten (patient 1)
or six (patient 2) paintings of different sizes. Half of these
paintings were from the 4 years before the stroke and half
from the year following the stroke. A standard A4 reproduction of the paintings was sent to the judges, to avoid size
effects. The judges were told which paintings were executed
before, and which after, the stroke. AC is an art critic in Rome
and PA a professional painter and sculptor in Lausanne. They
did not know the patients and were not aware of the type of
stroke or the subsequent deficits. They had no neurological
knowledge and were only told that the patients had started to
paint again after a stroke. Their analysis included global
observation and general architecture, represented theme,
style and characteristic of drawing, importance of details,
colours, and aesthetic evaluation.
Patient 1, top pictures fig 1

Before stroke (fig 1A)
The picture shows a figurative representation. In the centre,
there are two people, in vivid colours, who seem to float in a
landscape, represented only by floral elements. The pictorial
language is naive, evoking a primitive expression. However,
there is an interesting difference in style in the representation
of the trees; it seems that more thought has been given to
these before starting painting. (AC)
The painting represents an idyllic Eden. Images taken from
a conventional, but joyous, set. Light (divine) is nearly out of
field. Space is organised around the horizon. (PA)

After stroke (fig 1B)
Simplification of the previous paintings. There is now an
almost pure monochromic choice. On this blue, there are
some light sources confined to the right half of the painting
(sun, moon?) and around the single figures. These figures are
now completely stylised (like slowly moving silhouettes) and
move in an unreferenced space. There are some randomly
situated geometric patterns, suggesting an elementary
graphic language. (AC)
Very simplified painting: the elements are now abstract
and the symbolic is present everywhere. Peripheral features
are also abstract and suggestive of contradictory forces. The
light/form relationship develops on its own. (PA)
Patient 1, bottom pictures fig 1

Before stroke (fig 1A)
In this painting appears a determination to abandon
figurative style in favour of colour, light, and abstraction.
The allusion to Matisse is obvious. The painter shows a
number of individuals completely independent of each other.
Each object is represented as a silhouette illuminated by an
internal light. (AC)
The painting represents an organised space, in which light
is the principal subject. Imagery is more abstract, but the
church, house, and cat are conventional representations.
Naive art. (PA)

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Before stroke
This work alludes to the French impressionist school,
particularly towards dissipation of form, as in Cezanne’s
work, which announces Cubism. The objects lose their
classical definition because of the use of patches of pure
colours, which tend to mix with one another. (AC)
Dissolving and superimposing figures, rejecting individual
autonomy in aid of the whole. Oblique elements suggest
violence and confusion. Weak contrasts. Abstract expressionism pattern. (PA)

After stroke
This work seems to search for shape consistency and to focus
more on details represented in the first work. The red tonality
allows a stronger relevance of each object, particularly due to
the use of white. In the construction of the painting, it is
possible to define lines structuring the spatial composition.
This is almost a regression in its wish to clarify what was
previously expressed only by colour. (AC)
More structured and geometric organisation, bolder
colours, and contrasts. Each shape is more independent.
Space organised around the horizon. Clear patterns suggest a
free and confident painter. (PA)

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