93

Behavioural Neurology 19 (2008) 93–106
IOS Press

Agraphia for kanji resulting from a left
posterior middle temporal gyrus lesion
Yasuhisa Sakurai ∗ , Imari Mimura and Toru Mannen
Department of Neurology, Mitsui Memorial Hospital, Tokyo, Japan

Abstract. Objective: To clarify whether agraphia or alexia occurs in lesions of the left posterior middle temporal gyrus.
Methods: We assessed the reading and writing abilities of two patients with this lesion using kanji (Japanese morphograms) and
kana (Japanese syllabograms).
Results: Patient 1 first presented with pure alexia more impaired for kana after an infarction in the left middle and inferior occipital
gyri and right basal occipital cortex, and after a second infarction in the left posterior middle temporal gyrus adjoining the first
lesion he showed alexia with agraphia for kanji and worsened alexia for kana; kanji alexia recovered over the following six to 10
months. Patient 2 presented with alexia with agraphia for kanji following a hemorrhage in the left posterior middle and inferior
temporal gyri, which resolved to agraphia for kanji at two months after onset. Kana nonword reading was also slightly impaired,
but became normal by six months post-onset. In both patients, kanji agraphia was mostly due to impaired character recall.
Conclusion: The present patients demonstrate that damage to the left posterior middle temporal gyrus alone can cause agraphia
for kanji. If the adjacent mid fusiform/inferior temporal gyri (Area 37) are spared, the kanji alexia is transient.
Keywords: Pure agraphia, kanji, kana, alexia with agraphia, posterior middle temporal gyrus, fusiform gyrus, visual word form
area

1. Introduction
Agraphia, particularly for kanji, arises from lesions
in the posterior inferior temporal cortex [13,16,31,
34], angular gyrus [12,14,20,32], superior parietal lobule [14,18,30] and posterior middle frontal gyrus [28].
A characteristic feature common to all these lesions
is impaired character recall or failure to retrieve lexical representations. Since kanji have many irregular
readings (described below), agraphia for kanji is comparable to lexical or orthographic agraphia in Western
countries [3,34].
Lexical agraphia is due to lesions of the posterior inferior temporal cortex [7,24], angular gyrus [25]
and precentral gyrus [23]. Among these lesions, the
posterior inferior temporal cortex (more precisely, mid
∗ Corresponding author:

Yasuhisa Sakurai, MD, PhD., Department of Neurology, Mitsui Memorial Hospital, 1 Kanda-Izumi-cho,
Chiyoda-ku, Tokyo 101-8643, Japan. Tel.: +81 3 3862 9111; Fax:
+81 3 5687 9765; E-mail: ysakurai-tky@umin.ac.jp.

fusiform/inferior temporal gyri, Area 37) is assumed to
be the site for an orthographic lexicon [24] or visual
word form area (VWFA [5]), where word orthography
is accessed. It was suggested that damage to VWFA or
the occipitotemporal cortex yields pure alexia [6,22]. It
should be noted, however, that a lesion in this area per
se does not cause pure alexia, but alexia with agraphia
for irregular words and letter-by-letter reading [24] or
its Japanese equivalent alexia with agraphia for kanji [26]. In support of this view, a study on patients
with acute ischemic stroke revealed that VWFA dysfunction was associated with impairment on all reading, naming and writing tasks that required lexical output [11]. On the other hand, pure alexia occurred in a
circumscribed lesion located more medially in the mid
fusiform gyrus [33].
We here describe the kanji and kana writing systems
briefly. The Japanese language has two distinct writing systems; i.e. kanji (morphograms, originally adopted from Chinese characters) and kana (Japanese phonetic writing or syllabograms, originally taken from

ISSN 0953-4180/08/$17.00  2008 – IOS Press and the authors. All rights reserved

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Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion
Table 1
The WAB test scores
Patient
Time
(after onset, mo.)
Spontaneous speech
Information content
Fluency
Naming total
Object naming
Repetition
Comprehension total
Reading total
Comprehension of sentences
Recognition of orally spelled kanji
Oral spelling of kanji characters
Writing total
Copying
Kanji writing from dictation
Kana writing from dictation

Patient 1
June 2005
July 2005
5a
1b
10/10
10/10
9.5/10
58/60
10/10
9.15/10∗
10/10
40/40
6/6
6/6
10/10
10/10
6/6
6/6

9/10
10/10
8.6/10
55/60
10/10
9.1/10∗
8.4/10
34/40
2/6
0/6∗
9.7/10
10/10
4.5/6
6/6

Patient 2
Mar 2007
2
10/10
10/10
9.9/10
60/60
10/10
10/10
10/10
40/40
6/6
6/6
9.5/10
10/10
5/6
6/6

a Five months after the first infarction in the bilateral occipital lobe.
b Actually eight days after the second infarction in the posterior middle temporal

gyrus.

∗ More than 2SD below the normal mean [35].

kanji characters). Kana are further divided into hiragana (a cursive form of kana that is used for grammatical formatives), e.g.
([shikashi], however), and
katakana (a square form of kana that is used primarily for representing loan words), e.g.
([kamera],
camera). One feature that differentiates Japanese from
English is that reading and writing errors occur at a
single character level (for phonological and visual errors) as well as at a word level (for semantic errors;
see the footnote to Table 3 for error examples). Kanji
are graphically complicated and have meanings with
two ways of being read: the on-reading that conveys
the phonetic value and the kun-reading that conveys the
meaning. Each kanji character has a few on-readings
and a few kun-readings. Kanji words comprise from
one to five kanji characters and usually have one reading attached to the meaning. As there are many homophones, particularly in the on-reading of kanji characters or words, errors in writing contain homophone
errors (see the legend for Fig. 3) that may also be observed in Western countries. Two-character kanji account for the majority of kanji words. There are many
more two-character words with on-reading than with
kun-reading. Therefore, normal Japanese readers try to
pronounce an unknown two-character kanji word with
a typical on-reading of the constituent kanji characters. Although how a kanji character is pronounced
is thus statistically predicted [10], there is actually no
rule for pronouncing a kanji character in a word. This
multiplicity in reading makes a number of kanji words

comparable to irregular or inconsistent words in Western countries, and causes on-kun confusion errors in
which words are, similar to English regularization errors, incorrectly but legitimately pronounced, e.g.
([soushu], incorrect on-reading) for
([aite], correct
kun-reading, partner). In contrast, kana are graphically simple and have one definite phonetic value and no
intrinsic meaning. A kana character represents a mora of spoken Japanese (a single vowel or consonantvowel combination), which always has the same pronunciation regardless of the position in a word. A kanji
word can be transcribed into kana character sequences
(kana word) that represent the pronunciation, e.g.
→
([aite], partner).
Due to the use of these dual writing systems, reading
and writing impairments in Japan can present as dissociative disturbances between kanji and kana. Agraphia,
particularly for kanji as described above, is one example. On the basis of the case studies, some cognitive models of reading and writing in the Japanese language [13,15,26,28] have been proposed in line with
the dual-route hypothesis in English. We developed
an anatomically constrained dual-route model of writing (Fig. 1) in which orthographic information of a
word goes from the posterior inferior temporal cortex
(a site for the orthographic lexicon) and proceeds upward under the angular gyrus and superior parietal lobule to travel to the frontal motor and premotor area
(orthographic route) whereas phonological information
of a word goes from the posterior superior temporal

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

gyrus (a site for the phonological lexicon) to the angular and supramarginal gyri and joins the arcuate fasciculus to travel to the motor and premotor area (phonological route) [28,30]. The orthographic lexicon and
the phonological lexicon have a reciprocal connection.
According to this hypothesis, kanji characters that are
graphically complex depend more on the orthographic
route; thus, kanji agraphia results from damage to any
part of the orthographic route [30]. In contrast, kana
characters that are graphically simple and are directly
linked to phonemes depend less on the orthographic
route; hence, kana agraphia (impaired kana character
recall) occurs less frequently in lesions of the orthographic route. Instead, kana paragraphia (substitution
of other kana characters) results from some parts of the
phonological route [28,37].
An unsolved problem is whether pure agraphia (without alexia) occurs in a lesion at or around VWFA. In
fact, some investigators reported pure agraphia for kanji resulting from nearly the same lesion [34,39]. However, it remains unknown whether there is an anatomical difference that causes alexia with agraphia and pure
agraphia for kanji. Here, we report two patients who
showed agraphia for kanji after damage to the left posterior middle temporal gyrus and discuss the role of this
area in writing.

2. Materials and methods
2.1. Patient profiles
2.1.1. Patient 1
A 75-year-old right-handed man, university graduate and company executive, became aware of blurred
vision and felt difficulty reading newspapers in January, 2005. He consulted the department of medicine
at our hospital and was diagnosed with a cerebral infarction in the left lateral occipital gyri and the right
basal occipital cortex on MRI (Fig. 2a). There were
also high intensity areas in the white matter above the
two lesions (Fig. 2a–F). Neurological and neuropsychological examinations revealed right homonymous
hemianopia (later confirmed by Goldmann perimetry)
and alexia, particularly for kana. The patient’s clinical data will be included in our research paper on pure
alexia for kana. The Western Aphasia Battery (WAB;
Japanese edition) administered five months after onset
showed a minimal impairment in auditory comprehension (Table 1). Reading and comprehension of sentences were perfect, although he misread some hiragana

95

Fig. 1. Diagram of an anatomically constrained dual-route model of
writing in response to dictation. a. phonological route, b. orthographic route, c. interaction between phonology and orthography, d.
interaction between parietal graphemic area and frontal hand area. P.
phonological lexicon, O. orthographic lexicon, S. semantic storage
site, AG. angular gyrus, G. graphemic area, H. premotor hand area.
Orthographic information of a word goes from the posterior inferior
temporal cortex (a site for the orthographic lexicon, O; Area 37) and
proceeds upward under the angular gyrus and the superior parietal
lobule to travel to the premotor hand area (H; Areas 44/45 and 6).
This orthographic route (b) goes directly or indirectly to the hand
area via the parietal graphemic area (G), where visuokinesthetic and
sequential motor engrams for letters and words are stored. Phonological information of a word goes from the primary auditory cortex (Heschl’s gyri) and the posterior superior temporal gyrus (a site
for the phonological lexicon, P; Area 22) to the angular and supramarginal gyri and joins the arcuate fasciculus to travel to the frontal
motor and premotor areas (a, phonological route). The orthographic lexicon (O) and phonological lexicon (P) have a reciprocal connection (c). Lexico-semantic information (S) is stored in extensive
areas in the left temporal lobe, and can be accessed either through
the posterior superior temporal gyrus during listening or through the
posterior inferior temporal cortex during reading (illustrated by dotted lines). The parietal graphemic area and the frontal hand area
(H) have a reciprocal connection (d). Putative damaged routes for
kanji agraphia from the posterior middle temporal gyrus lesion are
illustrated with “x.” Revised from Sakurai et al. [30].

characters. In July (six months after onset), when reading ability had recovered to within the normal range
so that he could read newspapers, he felt faint during
writing and could not fill in an invoice. The next day,
he found he could not recall or write kanji characters
or his son’s name. A neuropsychological examination
showed alexia with agraphia, particularly for kanji and
anomia. He could read two of three two-character kanji
words, but could not write the same three kanji words
at all. He named correctly only one of six objects visually presented. The patient was admitted to our hospital with a diagnosis of cerebral infarction in the left
posterior middle temporal gyrus on MRI. WAB eight
days after onset showed slight impairments in auditory comprehension, reading and writing (Table 1). He
read sentences slowly and phrase by phrase, sometimes

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Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

(a)

(b)
Fig. 2. a. MRI images at five months after the first infarction in patient 1. A high intensity area with marginal low intensity on T2-weighted
axial (A-D) and coronal (E-H) images (1.5 Tesla, time of repetition [TR]/time of echo [TE] = 4000/81), suggesting a hemorrhagic infarction,
was noted in the left middle and inferior occipital gyri. Another high intensity area was observed in the right basal occipital cortex (A, E). b.
MRI images at eight days after the second infarction in patient 1. A high intensity area on T2-weighted axial (A-D) and coronal (E-H) images
(1.5T, TR/TE = 4000/82 in axial images, 3500/81 in coronal images) was evident in the left posterior middle temporal gyrus that was located just
anterior to the old lesion.

with paralexia of both kanji and kana. Recognition
of orally spelled kanji characters and oral spelling of
kanji characters were very poor, indicating character
imagery deficits (impaired character recall). In spontaneous writing, literal paragraphia of kanji, a kind of
homophone error, and substitution of kanji for the kana
transcription were observed (Fig. 3). In all, his language profile was rated as alexia with agraphia for kanji
(orthographic alexia with agraphia [26]) and minimal
anomia mixed with the preceding pure alexia for kana.
MRI administered eight days after onset showed a high
intensity area on T2-weighted images in the left posterior middle temporal gyrus that extended deep to the

posterior horn of the lateral ventricle (Fig. 2b). Adjacent to this lesion, a high intensity area with marginal
low intensity was located posteriorly in the middle and
inferior occipital gyri, suggesting the first stroke of a
hemorrhagic infarction (Fig. 2b–A, B).
2.1.2. Patient 2
A 60-year-old right-handed man, senior high school
graduate and public official, noticed that he had difficulty reading kanji characters in a newspaper and recalling kanji characters when writing in January, 2007.
Two weeks later, he consulted the department of neurosurgery at our hospital and was diagnosed as having

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

a cerebral hemorrhage on MRI. He could read newspapers without difficulty by six weeks after onset. However, he noticed that he sometimes first read the second
character in a kana character sequence. Because of persistent hypertension, he was introduced to our department. Neurological and neuropsychological examinations six weeks after onset showed agraphia for kanji
due to impaired character recall. WAB two months
post-onset revealed a slight writing impairment (Table 1). In spontaneous writing, he could not recall some
kanji characters and omitted or added a kana character in some words. MRI administered 23 days after
onset revealed a high intensity area on both T1- and
T2-weighted images, suggesting a hemorrhage and surrounding edema, in the left posterior middle and inferior temporal gyri that extended subcortically to the
posterior horn of the lateral ventricle (Fig. 4).

97

(A)

2.2. Special neuropsychological tests
Patient 1 underwent the following special neuropsychological tests (1), (2) and (3) [33] 23 days to four
months after the first stroke and 10 to 11 days after the
second stroke. Follow-up studies were conducted at
six to 10 months and one year after the second stroke.
He was also given Test (4) 22 days after the second
stroke. Patient 2 was given these tests two to three
months after onset. Reexamination was performed five
to six months post-onset.
2.2.1. Test 1 (reading and writing test)
Reading of 100 single-character kanji and the kana
transcription of kanji characters, and writing of the
same 100 dictated kanji and kana [31]. Most of the kanji
characters had two or more readings, i.e. on-readings
and kun-readings. We read aloud the kun-reading of a
kanji character, and the patient wrote it down in kanji
or kana. All of the kanji characters are taught in the
first three years of primary school in Japan.
2.2.2. Test 2 (100 word reading test)
Reading of 100 two-character kanji words, the corresponding 100 three-character hiragana words (high
familiarity, described below) that were transcribed
from the above kanji words, another set of 100 threecharacter hiragana words (low familiarity), and two sets
of 100 three-character hiragana nonwords. The kana
words were chosen from those with higher (hf) or lower (lf) familiarity based on how often the subject had
seen, heard or used the word [17]. Mean familiarity
values in auditory presentation assessed in a more re-

(B)

Fig. 3. Written output in the WAB test in patient 1. A. Five months
after the first stroke. B. Eight days after the second troke. The
patient was presented with a picture card and asked to write a story
about what was going on in the picture within three minutes. Writing
was normal in the first trial (A). In the second trial (B) after the left
middle temporal gyrus infarction, there were fewer kanji characters
and some kanji words were substituted for kana characters. a, a’: A
kanji word was substituted for the hiragana (a cursive form of kana
that is used for grammatical formatives) transcription after the second
stroke. b, b’: A kanji word was substituted for the katakana (a square
form of kana that is used primarily for representing loan words)
transcription. c, c’: A kanji character in a three-character kanji word
was substituted for another character that was phonologically the
same, but orthographically different (homophone error), i.e.
([jidousha], car) →
([jidousha], nonword).

cent study [2] were 5.98 for high familiarity words and
4.20 for low familiarity words on a seven-point rating
scale. Two sets of kana nonwords were provided as follows: (a) (low association character) those combining
kana symbols that had no association with each other [1] and (b) (changed character order) those changing
the sequential order of characters in the above higher
familiarity kana words.
2.2.3. Test 3 (multiple character reading test)
Reading of single-character kana symbols, fivecharacter kana words and nonwords, and the total or

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Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

Fig. 4. MRI images at 23 days after onset in patient 2. A high intensity area on both T2-weighted axial (A-D) and T1-weighted coronal (E-H)
images (1.5 T, TR/TE = 4000/81 in axial images, 600/14 in coronal images), suggesting a hemorrhage and surrounding edema, was localized in
the left posterior middle and inferior temporal gyri.

partial kanji transcription of the five-character kana
words (mixture of one to three kanji words and one to
[otouthree kana characters untranscribed, e.g.
san], father). The five-character kana words were selected from those with higher familiarity based on how
often the subject had seen, heard or used the word [9].
Five-character kana nonwords were made by changing
the sequential order of characters in the above fivecharacter kana words.
2.2.4. Test 4 (visual discrimination test) [27]
The materials were two sets of line drawings of
slightly different lengths, sizes, shapes, spatial locations, and angles. The patient was asked whether the
two stimuli drawn on a card were the same or different
and, if different, to explain the difference.

3. Results
Figure 5 summarizes the % correct responses for
each item in Tests 1 (reading and writing test), 2 (100
word reading test) and 3 (multiple character reading
test).
3.1. Patient 1
At one to four months after the first infarction in the
occipital lobe, the patient showed deficits in reading
single-character kana, five-character kana words and
nonwords (Table 2). Letter-by-letter reading was noted in the five-character kana word and nonword read-

ing tests. No word length effect was clearly observed
(single-character, 1.56 sec/character; three-character
word (hf), 4.30 sec/word; five-character word, 4.04
sec/word), probably because the reading test of fivecharacter words was performed a week after the singlecharacter kana and three-character kana word (hf) reading, so alexia had recovered to some extent. Kanji reading was also slightly impaired in the kanji-transcription
of five-character kana words (III in Table 2). However,
it took patient 1 more than twice as long to read kana
words as to read kanji words in all the test items, which
is not the case with normal controls [26]. This fact
implies that alexia was more profound for kana.
In the second examination conducted 10 to 11 days
after the second infarction in the posterior middle temporal gyrus (July 2005 in Table 2), an impairment in
kanji writing was evident. Most of the error types were
non- and partial responses that were due to impaired
character recall (Table 3-B). Noteworthy is that the patient did rehearsals, moving the pencil over the paper
before writing down a character, subsequently succeeding in recalling in six of 26 trials. To determine the
effects of visual complexity, concreteness, familiarity (how often a person has seen or used a word) and
frequency of writing single-character kanji, we divided the test characters into two groups (above or under
a median) nearly equal in number: a more complex
(more writing stroke sequences), concrete, familiar or
frequent group and a less complex, concrete, familiar or
frequent group [33]. Correct scores for the two groups
were significantly different in complexity (p < 0.0001
by Fisher’s exact method), frequency (p = 0.0048 by

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

(A1)

(A2)

(B1)

(B2)

99

Fig. 5. Percent correct responses in Test 1 (reading and writing test) (A1, Patient 1; A2, Patient 2) and in Tests 2 (100 word reading test) and
3 (multiple character reading test) (B1, Patient 1; B2, Patient 2). Abbreviations. Kanji 2, 2-character kanji words; Kana 3hf, 3-character kana
words (high familiarity); Kana 3lf, 3-character kana words (low familiarity); Kana 3a, 3-character kana nonwords (a) (low character association);
Kana 3b, 3-character kana nonwords (b) (changed character order); Kana 1, single-character kana; Kana 5, 5-character kana words; Kanji 1–3,
kanji transcription of 5-character kana words; Kana 5nw, 5-character kana nonwords.

Fisher’s exact method) and familiarity (p < 0.0001 by
Fisher’s exact method), i.e. less complex, more frequent
and more familiar characters were written more easily.
Two-character kanji reading and three-character kana
word and nonword reading were also disturbed. Kana
reading errors consisted of phonological and phonological/visual (one or more characters in a word were substituted for another character that was visually similar
to the correct answer) responses (Table 3-A). A word

length effect became evident (single-character, 1.63
sec/character; three-character word (hf), 5.11 sec/word;
five-character word, 5.74 sec/word). High-familiarity
kana words were read better than low-familiarity kana
words (p = 0.0006 by Fisher’s exact method; familiarity effect), and kana words (hf) were read better than
kana nonwords (a) (low association character) and (b)
(changed character order) (p < 0.0005 by Fisher’s exact method; lexicality effect). In Test 4 (visual discrim-

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Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion
Table 2
Reading and writing test results
Patient
Patient 1
Patient 2
Time
Jan-May 2005
July 2005
Jan-May 2006
Mar-Apr 2007
June–July 2007
1b
6–10c
2–3
5–6
(after onset, mo.)
1–4a
I. Reading and writing (100 single-character kanji and kana transcription), % correct (time)
Kanji reading
100 (1 min)
98 (2 min)d
100 (2 min)
99 (1 min)
100 (1 min)
Kana reading
100 (1 min)
99 (5* min)e
98 (5* min)
99 (1 min)
100 (1 min)
Kanji writing
97 (8 min)
51* (30* min)
76* (13 min)
65* (7 min)
83* (7 min)
Kana writing
100 (6 min)
100 (7 min)
99 (7 min)
99 (5 min)
99 (5 min)
II. Reading (100 two-character kanji words, three-character kana words and three-character kana nonwords), % correct (time)
Kanji words
100 (3* min)
81* (5* min)
99 (4* min)
98 (1 min)
98 (1 min)
Kana words (hf)f
98 (7* min)
84* (8* min)
84* (7* min)
98 (1 min)
97 (1 min)
Kana words (lf)f
97 (4 min)
60* (5* min)
71* (7* min)
96 (2 min)
94 (2 min)
95 (4 min)
49* (7* min)
58* (8* min)
88 (2 min)
95 (2 min)
Kana nonwords (a)f
Kana nonwords (b)f
97 (4* min)
61* (6* min)
68* (7* min)
94* (2 min)
100 (2 min)
III. Reading (46 single-character kana, 50 five-character kana words and five-character kana nonwords), % correct (time)
Single-character (/46)
93* (1* min)
89* (1* min)
98 (1* min)
100 (1 min)
100 (1 min)
Five-character words (/50)
96* (3* min)
100 (4* min)
100 (5* min)
98 (1 min)
100 (1 min)
Kanji transcription (/50)
94* (1* min)
92* (2* min)
96* (2* min)
98 (1 min)
100 (1 min)
Five-character nonwords (/50)
82* (3 min)
68* (5* min)
58* (7* min)
86 (1 min)
92 (1 min)
IV. Visual discrimination test, % correct
Line length (/12)
Circle size (/12)
Parallel line or no (/12)
Circle-oval (/12)
Square-rectangle (/12)
Point location (/12)
Distortion of a square (/12)
Angle (/12)

92
92
92*
67*
92
100
58*
83*

100
100
100
83*
92
100
100
100

a Test I was performed in May, 2005 (four months post-onset) and Tests II and III were performed from January to February,

2005 (one to two months post-onset). In Tests II and III, reading of kana words (lf), kana nonwords (a) (low association
character) and (b) (changed character order), five-character kana words and nonwords, and kanji transcription of five-character
kana words were conducted a week after single-character kana, kanji word and kana word (hf) reading.
b Ten to 11 days after the second infarction in the posterior middle temporal gyrus.
c Test I was performed in January, 2006 (six months after the second infarction) and Tests II and III were performed in March
through May, 2006 (eight to ten months after the second infarction).
d Errors consisted of one visual (changing the kanji reading to the reading of another kanji with a visual resemblance to the
correct answer) and one unrelated (changing a kanji to another kanji that has no visual or semantic similarity to the correct
answer) response.
e The error was a phonological response (one or more characters in a kana word were substituted for other kana, i.e. phonemic
paralexia).
f Kana words consisted of higher (hf) and lower (lf) familiarity words. Kana nonwords were made by combining kana symbols
that had no association with each other (a) (low association character) and by changing the sequential order of characters in
the above higher familiarity kana words (b) (changed character order).
∗ More than 2SD above (for time) or below (for score) the normal mean [27,32,33].

ination test), he achieved low scores when discriminating the following visual stimuli (more than 2SD below
the normal mean [27]): parallel line or not, circle or
oval, distorted square or not, and angle difference (IV
in Table 2).
In a follow-up study conducted six to ten months
after the second infarction (Jan-May 2006 in Table 2),
kanji reading recovered to within the normal range
and kanji writing was considerably improved, although
kanji character recall remained impaired. Reading of
single-character kana, three-character kana words (lf),
and three-character kana nonwords (a) (low associa-

tion character) and (b) (changed character order) were
generally improved, but reading of five-character nonwords was somewhat worse. Also, a word length effect
was still observed (single-character, 1.30 sec/character;
three-character word (hf), 4.47 sec/word; five-character
word, 6.24 sec/word).
A reexamination one year after the second stroke revealed an improvement in three-character kana reading (kana words (hf), from 84 to 96; kana nonwords
(a) (low association character), from 58 to 71) but no
change in five-character kana (kana words, from 50 to
46; kana nonwords, from 29 to 31). Conversely, kanji

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

101

Table 3A
Types of reading error in two-character kanji word, three-character kana
word (hf) and three-character kana nonword (a) (low association character)
test (values are the number of errors)
Patient
Patient 1
Patient 2
Time
Jan-May 2005
July 2005
Mar 2007
(after onset, mo.)
1–4
1
2
Two-character kanji word (n = 100)
Non-response
0
6
0
Partiala
0
8
2
Unrelateda
0
5
0
Total errors
0
19
2
Three-character kana word (high familiarity) (n = 100)
Phonologicalb
2
13
1
0
3
1
Phonological/visualb
Total errors
2
16
2
Three-character kana nonword (a) (low association character) (n = 100)
Phonologicalb
3
35c
9c
b
Phonological/visual
2
16
3
Total errors
5
51
12
a Partial response:

one symbol of a two-character kanji word could not
be read. Unrelated response: changing the reading of a kanji word to the
reading of another kanji word that has no visual or semantic similarity to
the correct answer, e.g.
([shihai], control) →
([hansoku], foul).
Two of five errors in patient 1 (July 2005, 11 days after the second stroke)
were perseveration responses.
b Phonological response: one or more characters in a kana word or nonword were substituted for other kana (phonemic paralexia), e.g.
([tokai], city) →
([tooi], far). Phonological/visual response:
changing one character in a word to another visually similar to the target character, e.g.
([mohan], example) →
([mohon], nonword).
c Five of 35 errors in patient 1 and Five of nine errors in patient 2 occurred
at the level of vowel conversion in a consonant-vowel mora, e.g.
[tsu-ro-mo] →
[tsu-ro-mu].
Table 3B
Types of writing error in the 100 single-character kanji test (values
are the number of errors)
Patient
Patient 1
Time
Jan-May 2005
July 2005
(after onset, mo.)
1–4
1
Single-character kanji (n = 100)
Non-response
1
42
Partial*
0
4
Constructional*
1
0
Visual*
1
0
Unrelated*
0
3
Total errors
3
49

Patient 2
Mar 2007
2
34
1
0
0
0
35

*Partial response: the patient wrote a component of a character
correctly, but did not write the other components. Constructional
response: the omission or addition of a component of a kanji, e.g.
([ushi], cow) → ([go], noon). Visual response: substitution of
another kanji visually similar to the target character, e.g. ([karui],
light) →
([korogaru], roll). Unrelated response: substitution of
another kanji that has no visual or phonological similarity to the
correct answer, e.g. ([kuru], come) → ([ima], now).

writing was somewhat worse (correct response, from
76 to 69). At this time, naming was normal in the WAB
test (object naming, 60/60).

3.2. Patient 2
In Test 1 (reading and writing test), agraphia of kanji
was prominent (Mar-Apr 2007 in Table 2). Nearly all
the writing errors were non-responses due to impaired
character recall (Table 3-B). The writing impairment
was influenced by complexity (p = 0.0001 by Fisher’s exact method), frequency (p = 0.035 by Fisher’s
exact method) and familiarity (p = 0.037 by Fisher’s
exact method). Patient 2 read kanji and kana in Tests 2
(100 word reading test) and 3 (multiple character reading test) as fast as normal controls, but misread kana
nonwords (phonemic paralexia). Kana reading errors
consisted of phonological and phonological/visual responses (Table 3-A). Five of nine phonological responses in kana nonword errors occurred at the level of vowel
conversion in a consonant-vowel mora (see the footnote
to Table 3-A). Kana words (hf) were read better than
kana nonwords (a) (low association character) (p =
0.0055 by Fisher’s exact method). He did not exhibit
letter-by-letter reading or a word-length effect (single-

102

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

character, 0.47 sec/character; three-character word (hf),
1.16 sec/word; five-character word, 1.54 sec/word). In
Test 4 (visual discrimination test), he achieved a lower
score in circle-oval discrimination.
In a reexamination five to six months after onset,
kanji writing improved but was still slightly impaired,
whereas kana nonword reading recovered to within the
normal range (June–July 2007 in Table 2).
3.3. Neuroimaging study
Patient 1 underwent single photon emission computed tomography with a 99m Tc-ethylcysteinate dimer
(ECD-SPECT) five months after the first infarction and
24 days after the second infarction, and patient 2 was
given the scans 10 weeks after onset. SPECT data were
transformed into the Analyze format and were normalized, smoothed and corrected for inter-laboratory differences with a three-dimensional conversion map with
the easy Z-score Imaging System (eZIS) version 2 [19].
In this system, realignment, spatial normalization and
smoothing were essentially the same as those of Statistical Parametric Mapping (SPM [8]) Version 1999,
and the statistical significance was determined with a
two-sample t-test after adjusting the global blood flow
to 50 ml/min/dl for one patient vs. group (normal control) analysis. The data were compared with those of
a normal subject database of the same generation and
gender at the National Center of Neurology and Psychiatry, Tokyo (n = 20 for over 70 year-old men and
n = 18 for 60–69 year-old men). Areas showing a
significant decrease in cerebral blood flow (uncorrected p < 0.001) were rendered on standard brain surface
images (Fig. 6). In patient 1, the first scan revealed
significantly reduced blood flow in the left middle and
inferior occipital gyri and the right posterior fusiform
gyrus (Area 18/19). In the second scan, hypoperfusion
of the left middle and inferior occipital gyri extended to
the posterior middle temporal gyrus. The angular gyrus
(Area 39) and the mid fusiform/inferior temporal gyri
(Area 37) were spared. In patient 2, blood flow reduction was restricted to the left posterior middle temporal
gyrus and the cerebellar vermis.

4. Discussion
Patient 1 first presented with alexia more impaired
for kana and right hemianopia after an infarction in the
left middle and inferior occipital gyri and the right basal
occipital cortex. Six months later when alexia recov-

ered to within the normal range, he suffered a second
infarction in the left posterior middle temporal gyrus
that was continuous to the first lesion. This time alexia
with agraphia for kanji occurred, mixed with worsened
alexia for kana. Over the following six months, kanji
reading recovered while agraphia for kanji remained,
together with alexia for kana. On the other hand, patient 2 showed alexia with agraphia for kanji in the
acute phase and agraphia for kanji remained, together
with minor alexia, particularly for kana nonwords. At
six months after onset kana reading became normal,
whereas kanji agraphia persisted. Therefore, we can
designate the condition at this stage as pure agraphia
for kanji.
The clinical profiles of these patients raise two important points. First, alexia with agraphia for kanji that
resolved to agraphia for kanji occurred in a focal lesion
in the left posterior middle and inferior temporal gyri.
Patient 1 had damage to the right basal occipital cortex from the first stroke and it is conceivable that this
lesion affected his reading performance. However, a
left occipital gyri lesion is enough to give rise to pure
alexia for kana [27].
Second, alexia for kana became evident or worse in
a lesion of the posterior middle and inferior temporal
gyri. In patient 1 both kana words and kana nonwords
were affected, whereas in patient 2 alexia was limited
to kana nonwords.
4.1. Agraphia for kanji
Concerning the first point, the common lesion of the
posterior middle temporal gyrus was close to the posterior inferior temporal cortex (mid fusiform/inferior
temporal gyri, Area 37) or VWFA [5], damage to which
results in alexia with agraphia for kanji or orthographic
alexia with agraphia [26]. Probably, because the mid
fusiform/inferior temporal gyri were functionally affected by the middle temporal gyrus lesion, the patient
showed “alexia” in addition to agraphia for kanji in
the acute phase. The characteristics of agraphia were
impaired recall of kanji orthography, which was influenced by character complexity, frequency and familiarity. These features are similar to those of the writing
impairment in alexia with agraphia for kanji from a
posterior inferior temporal cortex lesion: a patient with
alexia with agraphia for kanji we previously reported [26,31,32] showed severe impairment of kanji writing (correct response, kanji 12/100; kana 77/100), characterized by a familiarity effect (p = 0.0139 by Fisher’s
exact method) and a trend towards a complexity effect

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

103

Fig. 6. 99m Tc-ECD-SPECT images in patient 1 at five months after the first infarction in the occipital lobe and 24 days after the second infarction
in the posterior middle temporal gyrus, and in patient 2 at two months after onset. Patient data were compared with those of normal volunteers of
the same generation and gender with a two-sample t-test of SPM 99. Coronal planes are at the level of the calcarine sulcus and lateral occipital
gyri (upper two, y = −90, −80 mm), the angular gyrus (middle, y = −70 mm in patient 1 and −64 mm in patient 2), and the mid fusiform and
temporal gyri (lower two, y = −50, −40 mm). A vertical line denotes the z-axis (x = 0) and the horizontal line denotes the x-axis (z = 0) in
the Montreal Neurological Institute (MNI) coordinate space. In patient 1, reduced blood flow was noted in the left middle and inferior occipital
gyri and the right posterior fusiform gyrus (Area 18/19) after the first stroke. After the second stroke, the area of hypoperfusion extended from
the lateral occipital gyri to the posterior middle temporal gyrus. In patient 2, a restricted area of hypoperfusion was observed in the left posterior
middle temporal gyrus (arrow).

(p = 0.0689 by Fisher’s exact method) at 15 months
after onset of the disease (unpublished data). One of
the main differences is that alexia of kanji in a posterior middle temporal gyrus lesion is transient, whereas
that in a mid fusiform/inferior temporal gyri lesion is
persistent [32]. This fact implies that in agraphia for

kanji in a posterior middle temporal gyrus lesion, visual images of words are intact, but access to the images
or output from the image storage is interrupted.
Previous reports on lexical agraphia or its Japanese
equivalent, pure agraphia for kanji, also involved the
left middle temporal gyrus [7,34], but there have been

104

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

few reported patients with an isolated lesion in the middle temporal gyrus. Only one patient reported by Yokota et al. [39] had a relatively limited area of hemorrhage
in the posterior middle temporal gyrus that extended
deep to the lateral ventricle, but this patient had angular gyrus involvement in the acute phase. Our patients
reveal that a lesion of the posterior middle temporal
gyrus alone can cause agraphia for kanji.
Functional imaging studies on writing revealed activation of the left posterior inferior temporal cortex (Area 37) in writing English words (x = −42,
y = −54, z = −12 in the Montreal Neurological Institute [MNI] coordinate space [4]) and kanji words
(x = −50, y = −56, z = −12 [38]; x = −43,
y = −58, z = −9 [21]). It should be noted, however,
that the peak activation locus was a little higher than
when reading European words (x = −42, y = −63,
z = −15 [6]; x = −46, y = −56, z = −22 [36])
and kanji words (x = −44, y = −54, z = −22 [29]),
and was identified more in the inferior temporal gyrus
than in the mid fusiform/inferior temporal gyri or VWFA. This difference in peak activation may reflect the
fact that agraphia (without alexia) for kanji results from
damage to the posterior middle/inferior temporal gyri,
whereas alexia with agraphia for kanji results from
damage to the mid fusiform/posterior inferior temporal
gyri.
We previously hypothesized that visual images of
words and letters (orthographic lexicon) are stored in
the posterior inferior temporal cortex and go upward
via the subcortical area in the angular gyrus to the superior parietal lobule, and then travel further to the frontal
motor and premotor area (orthographic route in writing, described in the Introduction; Fig. 1) [28,30]. According to this hypothesis, damage to the posterior middle/inferior temporal gyri interferes with the phonological access from the phonological lexicon (posterior
superior temporal gyrus) to the orthographic lexicon
(illustrated with “x” on “c; P→ O” route in Fig. 1), or
interrupts visual image transfer along the orthographic route from the posterior inferior temporal cortex to
the parietal lobe (illustrated with “x” on “b; O → AG”
route in Fig. 1), which may result in agraphia for kanji
or lexical agraphia.
4.2. Alexia for kana
In patient 1, kanji reading was also slightly impaired
after the first infarction. Thus, we can safely state that
the patient had pure alexia that affected kana more than
kanji (pure alexia more impaired for kana). We as-

sumed that pure alexia for kana became more profound
as the lesion involved extensive areas in the ventral and
dorsal side of the occipital lobe [27,33]. Since the lesion extended continuously from the middle and inferior occipital gyri to the middle temporal gyrus, it is
conceivable that kana alexia worsened. On the other hand, patient 2 showed that kana nonword reading
was minimally disturbed in an isolated lesion in the left
posterior middle and inferior temporal gyri, although
single-character kana reading was preserved and letterby-letter reading was not observed. In addition, more
than half of the reading errors were due to inappropriate vowel conversion in a consonant-vowel mora.
These findings suggest that the deficit lay in the stage
of grapheme-to-phoneme conversion, rather than in the
stage of letter identification.
The combination of agraphia for kanji and alexia for
kana was reported in a temporo-parietal area lesion [20]
and inferior occipital cortex lesions [27,33], as in our
patient 1. In the case of the temporo-parietal area lesion, unlike our patient 2, kana alexia was evident in
kana “real words.” Damage to the inferior occipital
cortex causes pure alexia for kana sometimes accompanied by minimal kanji agraphia, although patient 1
with the inferior occipital cortex lesion did not develop
kanji agraphia after the first stroke. Since patient 2
did not show letter-by-letter reading or a word-length
effect, he did not sustain pure alexia. Patient 2 is more
similar to the original case of lexical agraphia in European counties that was accompanied by phonological
alexia (selective impairment of nonword reading) in a
parieto-occipital region injury [3], although the kana
nonword reading impairment in patient 2 was too slight
to call this symptom phonological alexia.
It is yet to be determined whether kana nonword
alexia results from damage to the posterior middle temporal gyrus or reflects the involvement of the surrounding angular and lateral occipital gyri. According to our
hypothesis [26,29], sequential processing from letter
identification to grapheme-phoneme conversion is performed in a putative route from the medial to lateral occipital gyri to the posterior superior temporal gyrus via
the temporo-parietal junction (deep perisylvian cortex,
Area 40/22). This phonological processing route in
reading (see Fig. 3 in Sakurai [26]) may be influenced
by a posterior middle temporal gyrus lesion.
5. Conclusion
Damage to the posterior inferior temporal cortex or
VWFA does not yield pure alexia or pure agraphia, but

Y. Sakurai et al. / Agraphia for kanji resulting from a left posterior middle temporal gyrus lesion

rather alexia with agraphia for kanji or orthographic
alexia with agraphia [26]. If afferent access via visual
input to this area is interrupted more medially in the
mid fusiform gyrus, pure alexia for words [33] may
occur. If afferent access via auditory input to this area
or efferent output from the area is interrupted in the
posterior middle/inferior temporal gyri, agraphia for
kanji or lexical agraphia may occur.
The present study demonstrates that agraphia for
kanji arises from an isolated lesion in the left posterior middle temporal gyrus. If the adjacent mid
fusiform/inferior temporal gyri (Area 37) are spared,
alexia for kanji is transient. A remaining problem is
whether damage to the posterior middle temporal gyrus
causes pure agraphia for kanji or agraphia for kanji with
alexia for kana. Although patient 2 had pure agraphia
for kanji six months after onset, it is unknown whether
accompanying kana paralexia was caused by the posterior middle temporal gyrus lesion or the surrounding
area. Further study is required to solve this problem.

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