NOTE
APRAXIA IN A PATIENT WITH LESION LOCATED
IN RIGHT SUB-CORTICAL AREA.
ANALYSIS OF ERRORS*
Maria Mozaz1•3 , J .F. Marti1.3, Edume Carrera1 , E. De Ia Puente1
('Dpto. de Procesos Psicol6gicos Basicos, Facultad de Ia Psicologia; 1Dpto. de Neurologia,
Hospital "Nuestra Sra. de Aranzazu"; 3Universidad del Pais Vasco, San Sebastian,
Guipuzcoa, Spain)

INTRODUcriON

Apraxia, an impairment of voluntary movements in the absence of paresis, sensory de­
ficits, language comprehension disturbance or problems in intellectual and cognitive per­
formance (Poeck, 1985), has generally been reported in patients with lesions in the cerebral
cortex.
Traditionally, apraxia has been associated with left-hemisphere lesions (Heilman and
Gonzalez, 1985; Goodglass and Kaplan, 1963). However, the participation of both hemis­
pheres in the organization of movements (Kimura and Humphrys, 1981) and the role of the
right hemisphere in controlling the limbs (Wyke, 1971; Heap and Wyke, 1972; Zaidel, Zaidel
and Sperry, 1975) has also been demonstrated. Byhernispheric representation ofpraxic func­
tions has been corroborated by De Renzi, Motti and Nichelli (1980), Poeck and Lehmkuhl
(1980), Haaland and Flaherty (1984). Furthermore, several authors (e.g. Agostoni et al.,
1983; Basso and Della Sala, 1986; De Renzi et al., 1986; Gonzalez Rothi et al., 1988) re­
ported patients who suffered subcortical lesions and who showed evidence of apraxia. Only
three of these patients (Agostoni et al., 1983) had lesions in the right sub-cortical areas; none
of them showed apraxia for the use of objects.
The present study reports an apraxic patient with a subcortical right hemisphere infarct
without cortical involvement. It describes her performance of different types of gestures and
the type of errors she displayed.
CASE REPORT

A.N. is a 74 year-old right-handed woman, who was admitted to the hospital with a 5 day
history of weakness in the left side of the body and falling when getting out of bed. Past clin­
ical history showed that she suffered from chronic gallbladder disease, peptic ulcer and hy­
pertension. On admission she was alert but apathetic, and complained of bifrontal hea­
dache. The head and eyes were deviated to the left and she had a left-sided hemianaesthesia
and hemiparesis. An BEG taken 2 days after admission showed moderate changes with slow­
ing on the right fronto-temporal area, isolated delta wave and frequent theta wave dis­
charges. On aCT scan taken 4 days after admission (Figure 1), there was decreased density
in the right subcortical fronto-temporal area which involved the corona radiata, the anterior
limb of the internal capsule, and the lenticular nucleus at the level of the head of the caudate.
A neuropsychological evaluation was performed 18 days after admission. The patient was
alert but depressed. She was cooperative and able to perform the examination. There was no
evidence of language impairment. She was able to follow simple and complex oral com­
mands, could point to different parts of her body, identify and name pictures of objects, and
there was no left-right disorientation. She was fairly well oriented for time, place and per­
son. She repeated 4 digits forwards and 3 backwards. There was no clinical evidence of de­
mentia or confusion.
Testing for apraxia was carried out on the right limb, which showed no paresis. The test

* Presented at the Annual Meeting of the International Neurological Society, Belgium, July 1989.
Cortex, (1990) 26, 651-655

652

M. Mozaz and Uthers

B

A

Fig. I (A and B) - CT scan demonstrating the right subcortical hypodense area.

followed roughly the plan proposed by De Renzi, Piezcuro and Vignolo (1966) and De Renzi
et al. (1986). The patient was asked to execute the following gestures:
(I) Ten symbolic common gestures (e.g. salute, thumb your nose, snap your fingers ...)
under verbal command and then on imitation.
(2) Imitation often meaningless postures (e.g. rest chin on fist, point to left eye with right
index, splay fingers palm down)
(3) Demonstrate the use of ten objects (e.g. brush teeth, hammer a nail, saw ...) first un­
der verbal command and then on imitation (both times without the objects). Finally, she was
asked to handle the real object.
(4) Ten oral gestures (e.g. stick out your tongue, whistle, yawn ... see De Renzi et al.,
1966). The patient had to perform these movements under verbal command and on imita­
tion.
Performance was scored on a scale from 0 to 2. Lack of response or obviously incorrect
response were scored 0. A score of I was given for a partial response, an almost correct res­
ponse, or if the patient used a body part as object. When the response was correct, a score
of 2 was given. The maximum score was 20 for each subtest.
Table I contains the scores obtained by the patient. The cut-off point for symbolic com­
mon gestures (17 out of 20 on imitation) chosen by De Renzi, Piezcuro and Vignolo (1968)
was used, because it has been confirmed in a Spanish control group (Mozaz, 1986). The items
of our test were identical to those us~d by De Renzi et al. (1968) with one exception ("make
TABLE!

Patient's Scores on Praxis Test
Oral command
Imitation .

1. .Meaningful
Movements
2. Meaningless
Movements
3. Object Use
4. Oral MOvements

14/20*

17/20

14/20
18/20

18/20
16/20
20/20

Object use

15/20

• The first number is the score obtained and the second the maximum score.
.
I. Maximum score: 20. Cut-off: 17 on imitation (De Renzi et al., 1968; Kertesz and Ferro, 1984; Agostoni et al., 1983).
2. Maximum score: 20. Cut-off: 17.
3. Maximum score: 20. Cut-off: 17 for verbal command and imitation, and 20 for real use of objects. (see Agostoni et
al., 1983; De Renzi et al., 1968; De Renzi et al., 1986).
4. Maximum score: 20. Cut-off: 16 (De Renzi et al., 1966; Agostoni et al., 1983).

Apraxia with a right sub-cortical lesion

653

the sign to come here" instead of "make the sign of the horns to designate a cuckold"). The
patient's behaviour on performing this test on verbal command was poor, with a score of 14
out of 20. She said: "I don't know" when asked to "salute", "thumb your nose" and "snap
your fingers". On imitation, she improved but her performance was not totally correct: on
"salute" she applied the palm to the lateral side of the face and did not recognize the gesture
when performed by the examiner; on "thumb your nose" she put her thumb in her mouth (this
was scQred as 1 point) while on "snap your fingers", she positioned her fingers correctly, but
could not perform the movement (scored also as 1 point). Failure to recognize gestures has
been described in some other reports (Heilman, Rothi and Valenstein, 1982; Gonzalez, Heil­
man and Watson, 1985; Ferro et al., 1983; Varney and Damasio, 1987) while the "raising in­
to position but not doing the movement" response has been reported by Geschwind and Da­
masio (1985). In spite of being asked to avoid verbal comments, the patient showed vocal ov­
erflow.
According to quantitative criteria, the patient was not apraxic on the imitation of sym­
bolic and meaningless postures. However, when demonstrating the use of objects, her per­
formance was defective (see De Renzi et al., 1968, and Agostoni et al., 1983). For intance,
she used body parts as objects (eg., used her hand as a saw or a hammer) both on command
and imitation. When using real objects the patient showed a type of error that has not been
reported before. This involved demonstrating the use of objects on her own body: for inst­
ance, she used a saw and a hammer on her thigh instead of an imaginary piece of wood or a
nail, respectively, as if the body represented the complementary object. When handling a
pencil and a tooth-brush, she took the objects and raised them into position but did not per­
form the gesture.
On oral gesture, the patient made only one error. She inhaled deeply in response to the
oral command of yawning (a "parapraxic error" described by Sabouraud, 1976). She was,
however, able to imitate all the movements correctly.
DISCUSSION

In this report we describe a patient with a right hemisphere subcortical lesion without
cortical involvement who was apraxic. This case corroborates other fmdings (see Agostoni
et al., 1983) and suggests that right subcortical structures may be associated with the organ­
ization of purposeful movements.
It has been suggested that subcortical apraxia might be secondary to other brain changes
not detectable by CT Scan such as a diaschisis or oedema. But the fact that apraxia persists
for several days or weeks after the stroke has been used as evidence to rule out this interpre­
tation (Agostoni et al., 1983). It is also conceivable that subcortical apraxia is the outcome
of interruptions of the cortico-subcortical connections. On the other hand, it has been shown
that there is an ipsilateral control of voluntary movements (Wyke, 1971; Kimura and Hum­
phrys, 1981) and also that deep neural structures can carry out functions which are normally
attributed to the corpus callosum, (Sergent, 1986). This suggests the possibility that sub­
cortical structures play a specific role in the organization of voluntary movements.
In examining the localization of the lesion in the II pure subcortical cases on which the
side of the lesion has been reported in detail (Kertesz and Ferro, 1984, 2 cases; Basso and
Della Sala, 1986, I case; De Renzi et al., 1986, 4 cases; Gonzalez Rothi et al., 1988, 3 cases,
and the present case), it is of interest to note that the internal capsule was the only structure
damaged in every case. However, it is not possible to specify which sector of the internal
capsule is crucial.
The type of errors made by the patient in performing meaningful and use of objects ges­
tures is remindful of an impairment of the "ideational component" of gestures, in Barbieri
and De Renzi's terms (1988). "Body parts as object" (BPO) responses permit the apraxic pa­
tients to reproduce a movement outside a concrete context (Goodglas and Kaplan, 1963).
According to Piaget (1950), the ability to demonstrate the use of implements is not present
in children during the early stages of sensorimotor coordination. BPO responses may thus be
interpreted as due to a loss of "symbolic formulation" (Ajuriaguerra, Muller and Tissot,
1960) or to a "defective propositional usage of objects" (Denny-Brown, 1958). The response
"demonstrating the use of objects on one's own body" (DOB) is possibly another manifes­

654

M. Mozaz and Others

tation of the same deficit. Ska and Nespoulos (1987) observed BPO responses in elderly nor­
mal subjects while Mozaz (in preparation) never found DOB responses in control subjects
(40). Hence it is possible to conclude that the patient displayed a pattern of errors more akin
to ideational apraxia. This reinforces the view (De Renzi et al., 1986) that subcortical regions
participate in the organisation of purposeful movements and suggests that certain types of
apraxic errors may be associated with subcortical structures.

ABSTRACT

This report describes a case of apraxia caused by a right sided sub-cortical lesion. Per­
formance on test for apraxia was impaired. A new type of error which involved demonstrat­
ing the use of objects on one's own body is reported. Some theoretical interpretations of the
findings are discussed.

Acknowledgments. The authors would like to thank Dr M.A. Wyke for her comments
on the paper, and Dr J. Dawson (Maudsley Hospital) for interpreting the CT Scan. We would
also to thank Universidad del Pais Vasco for their support.

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Maria Mozaz Garde, Facultad de Psicologia, Universidad del Pals Vasco, Apto. 1249, San Sebastian,
Guiplizcoa, Spain.