Images in…

Clinical presentation of left angular gyrus ischaemic
lesion: finger agnosia, acalculia, agraphia, left–right
disorientation and episodic autoscopia
Paolo Ripellino,1,2 Emanuela Terazzi,2 Daniela Mittino,2 Roberto Cantello2
1

Department of Neurology,
University of Turin, Turin, Italy
2
Department of Neurology,
University of Eastern Piedmont,
AOU Maggiore della Carità,
Novara, Italy
Correspondence to
Dr Paolo Ripellino,
pao.ripe@hotmail.it

DESCRIPTION
A 57-year-old right-handed man (smoker, suffering
from severe gastro-oesophageal reflux disease and
operated 5 years earlier for left ear cholesteatoma)
while sleeping at home suddenly developed right
haemiparesis and aphasia associated with an
autoscopic phenomenon for 10 min (out-of-body
experience)1 because he was seeing his wife and his
own right arm from above (video 1).
After 6 h in stroke unit, haemiparesis was
improved, but a detailed neurological examination
evidenced left–right disorientation, acalculia, agraphia and finger agnosia.2 No sensory loss coexisted.
The MRI scan showed an ischaemic lesion in the

left inferior parietal lobe (figure 1). After 48 h, the
patient’s haemiparesis fully recovered and left–right
disorientation was clearly reduced, but other symptoms persisted (video 2).

Video 1 The patient giving details of his out-of-body
sensation.

To cite: Ripellino P,
Terazzi E, Mittino D, et al.
BMJ Case Rep Published
online: [ please include Day
Month Year] doi:10.1136/
bcr-2013-009332

Video 2 The patient performing various tests to
provide evidence of the selective neuropsychological
impairment due to left angular gyrus lesion.

Ripellino P, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009332

Figure 1 Ischemic stroke. The MRI scan performed in
the acute setting documented hyperintensity in (A) DWI
and (B) FLAIR sequences at the left temporo-parietal
junction (angular gyrus, supramarginal gyrus, superior
temporal gyrus).
1

Images in…

Learning points
▸ Selective lesions (brain tumour, stroke and trauma) in the
lower left parietal lobe area could lead to four cardinal
neuropsychological symptoms, that is, acalculia, left–right
confusion, agraphia, finger and toe agnosia. Very rarely, all
those symptoms appear together and usually other
neurological deficits (such as aphasia and haemiparesis)
coexist.
▸ Autoscopia is a rare condition usually reported by patients
of epilepsy when they see their body or part of their body
from another perspective. In the ‘out-of-body experience’,
usually people look at the ground from above.
▸ An infarct in the area of the left angular gyrus area is the
cause of finger agnosia, acalculia, agraphia, left–right
confusion and autoscopia in this patient.

Contributors PR was involved in the acquisition of data, video included; analysis
and interpretation of data; writing and editing of the manuscript and the video. ET
was involved in the analysis and interpretation of data. DM was involved in the
analysis and interpretation of data. RC was responsible for study supervision.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES
1
2

Blanke O. Multisensory brain mechanisms of bodily self-consciousness. Nat Rev
Neurosci 2012;13:556–71.
Rusconi E, Pinel P, Dehaene S, et al. The enigma of Gerstmann’s syndrome revisited:
a telling tale of the vicissitudes of neuropsychology. Brain 2010;133(Pt 2):320–32.

Copyright 2013 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit
http://group.bmj.com/group/rights-licensing/permissions.
BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission.
Become a Fellow of BMJ Case Reports today and you can:
▸ Submit as many cases as you like
▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles
▸ Access all the published articles
▸ Re-use any of the published material for personal use and teaching without further permission
For information on Institutional Fellowships contact consortiasales@bmjgroup.com
Visit casereports.bmj.com for more articles like this and to become a Fellow

2

Ripellino P, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2013-009332