JNS-11886; No of Pages 2
Journal of the Neurological Sciences xxx (2011) xxx–xxx

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Journal of the Neurological Sciences
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Ipsilateral hyperschematia without spatial neglect after right frontal lesion☆
Arnaud Saj ⁎, Sabina Catalano Chiuvé, Camille Brugger, Marian van der Meulen, Frédéric Assal
Neuropsychology Unit, Neurology Department, University Hospital of Geneva and Faculty of Medicine, Switzerland

a r t i c l e

i n f o

Article history:
Received 9 May 2011
Received in revised form 14 June 2011
Accepted 21 June 2011
Available online xxxx
Keywords:
Hyperschematia
Frontal lesion
Space distortion

a b s t r a c t
The disorder is described as a size distortion involving the side of space. We report the case of a woman with
an ipsilateral hyperschematia without neglect after a right frontal lesion. The patient has exhibited a
disproportionate enlargement of the right-hand side of objects and added more left-sided petals to the drawn
daisy. This pathologic behavior is independent from spatial neglect and from classic frontal perseverations.
Our data support the presence of a spatial component to the perception of object size and a specific subcomponent of space distortion.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction
The term ‘hyperschematia’ was introduced in the neurological
literature in 1905 by Bonnier, to describe patients who overestimate
the size of the whole body or part of it [1,2]. Unilateral and particularly
left-sided hyperschematia now refers to a disproportionate left-sided
expansion in drawing tasks, which has been observed in patients with
right temporo-parieto-occipital lesions [3,4]. Here, we report the first
case of a patient presenting with ipsilateral hyperschematia after a
right frontal lesion.

2. Case report
A 65-year-old right-handed woman, with 20 years of education,
and no history of neurological or psychiatric disorders, was admitted
to the stroke unit for a sudden onset of confusion with temporospatial disorientation and nausea, secondary to a right frontal
hematoma (Fig. 1A). The lesion includes the dorsolateral prefrontal
cortex (BA9, BA46), the frontal eyefield (BA8), the inferior frontal
gyrus (BA44, BA45), the orbito-frontal cortex (BA47, BA11), the
frontopolar cortex (BA10), the premotor cortex (BA6), and the
anterior cingulea including its dorsal (BA32) and ventral regions
(BBA24). The patient signed an informed consent form following the
principles outlined in the Helsinki Declaration before taking part in
the study. On examination, she presented with anosognosia, apathy,
☆ Disclosure: The authors report no conflict of interest. All authors have full access to
all the data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis. This work was supported by the Swiss National
Foundation for AS (#3200B0-114014).
⁎ Corresponding author at: Dept of Neurology, HUG, Rue Gabrielle-Perret-Gentil 4,
CH-1211 GENEVA 14, Switzerland. Tel.: +41 22 379 5381; fax: +41 22 379 5402.
E-mail address: arnaud.saj@unige.ch (A. Saj).

emotional blunting, rightward deviation of head and trunk, reduced
spontaneous utilization of the left limbs (motor neglect), marked
psychomotor slowing with deficits in executive functions (letter
fluency, TMT part A and B) and working memory (verbal: 5; visuospatial: 3). Importantly, there was no evidence of neglect in
peripersonal space in a line cancelation task (7.8%; cut-off 11%), in a
bell cancelation task (left omission: 3; right omission: 2) and in the
copying of a complex scene (4/4), and no graphic or motor
perseverations were observed.
Next, the patient was asked to draw a flower from memory
(Fig. 1B) on a 21 × 29.7 cm sheet of paper that was aligned with the
midsagittal plane of her body. Using a similar evaluation method to
the one used by Rode et al. [3], we measured the number of petals on
the left and on the right side, after dividing the flower into two equal
halves, by drawing a vertical line passing through the center of its
pistil. Petals that fell onto both sides of the vertical line were not
considered. The number of petals drawn was 12 on the left side and 35
on the right side. When asked to draw a cube, the patient clearly
expanded the right part of it (Fig. 1C), and when drawing an unfolded
cube, she only stopped adding additional sides to the right when there
was no more paper left. (Fig. 1D).
3. Discussion
Bonnier described only briefly [5], his cases of hyperschematia,
which occurred in patients with peripheral disorders of the vestibular
system. In these cases, the phenomenon was not lateralized or global
(“he felt his head becoming huge, immense”). Other published cases
all disclosed left-sided (contralateral) hyperschematia, accompanied
by left-sided spatial neglect and associated with right posterior lesion
[3,4]. Moreover, size distortions in perceptual judgments have been
described only in patients with spatial neglect after right hemispheric
lesions [5]. As suggested by Rode et al. [3,4], hyperschematia can be

0022-510X/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.jns.2011.06.040

Please cite this article as: Saj A, et al, Ipsilateral hyperschematia without spatial neglect after right frontal lesion, J Neurol Sci (2011),
doi:10.1016/j.jns.2011.06.040

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A. Saj et al. / Journal of the Neurological Sciences xxx (2011) xxx–xxx

Fig. 1. A) Right hemispheric lesion (MRI axial); B) Draw a flower of memory; C) Copy the drawing of a cube; D) Draw a cube unfolded.

interpreted as a primarily spatial disorder rather than a purely visual
one. Indeed, the abnormal right-sided drawings of our patient suggest
an object-based disorder [6], but paradoxically ipsilaterally to the
lesion. Unlike in other reports, the phenomenon in our patient cannot
be explained by perseveration, since motor and particularly graphic
perseverations [7] and stimulus-bound behavior [8] were totally
absent. We hypothesized that our right side distortion could be due to
an ipsilateral relaxation of the spatial medium reflecting a compensatory attentional shift towards the ipsilesional side [1,3], that fit with
right hemisphere dominance in the attention network [9].
4. Conclusion
The occurrence of such a pure ipsilateral hyperschematia associated with a right frontal lesion confirms that this disorder is
independent from spatial neglect and from classic frontal perseverations. Rather, our results support the presence of a spatial component
to the perception of object size. This new subtype of hyperschematia
might be a specific sub-component of space distortion.

References
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Please cite this article as: Saj A, et al, Ipsilateral hyperschematia without spatial neglect after right frontal lesion, J Neurol Sci (2011),
doi:10.1016/j.jns.2011.06.040