BRAIN

AND

LANGUAGE

26, 63-71 (1985)

Optic Aphasia, Optic Apraxia, and Loss of Dreaming
JORDI PENA-CASANOVA,

AND TERESA ROIG-ROVIRA

Unitat de Neuropsicologia,
tnstitut
Hospital
General
de Ntra. Sra.

Neuroldgic
Municipal,
de1 Mar, Barcelona

AMALIA

BERMUDEZ

Montevideo,

Uruguay

AND
EDUARD TOLOSA-SARRO
Servei

de Neurologia,

Hospital

Clinic,

Barcelona

A 47-year-old man with a left temporo-occipital infarct in the area of the
posterior cerebral artery is presented. The neuropsychological examination did
not reveal aphasia or gross mental deficits. The patient presented with alexia
without agraphia, color agnosia, but few visual perceptual deficits. The main
impairment was in confrontation naming; he was incapable of naming objects
and pictures, not from lack of recognition (excluding visual agnosia) but from
lack of access to the appropriate word (optic aphasia). The patient also exhibited
a deficit in the evocation of gesture from the visual presentation of an object
(optic apraxia) and a difficulty in “conjuring up” visual images of objects (impaired
visual imagery) and loss of dreams. The fundamental deficit of this patient is
tentatively explained in terms of visuoverbal and visuogestural disconnection
and a deficit of mental imagery. 8 1985 Academic press, 1~.

INTRODUCTION
Several papers in the past have distinguished disorders of visual recognition from those of naming (Spreen, Benton, & Van Allen, 1966;
Lhermitte & Beauvois, 1973; Assal & Regli, 1980; McCormick & Levine,
1983). The term optic aphasia, introduced by Freund (1889), refers to a
The authors are grateful to Dr. Michel Paradis of McGill University and Robert Zatorre
of the Montreal Neurological Institute for valuable suggestions. Requests for reprints should
be sent to Dr. Jordi Petia-Casanova, Unitat de Neuropsicologia, Institut Neurologic Municipal,
Hospital General de Ntra. Sra. de1 Mar, Passeig Maritim s/n, Barcelona-08003, Spain.
63
0093-934X/85 $3.00
Copyright
0 1985 by Academic press, Inc.
All rights of reproduction
in any form reserved.

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disorder in naming which results neither from visual agnosia nor from
aphasia. The disorder in confrontation naming contrasts with otherwise
normal language and with a normal or near normal visual perception.
We report a case in part similar to those presented by Lhermitte and
Beauvois (1973) and Assal and Regli (1980) which is another illustration
of the syndrome of visuoverbal disconnection and adds new data, especially
with respect to visuogestural disconnection and a deficit of visual mental
imagery.
CASE REPORT
A 47-year-old right-handed male patient (A.R.)‘with 10 years of education was admitted
to the emergency clinic. He had a history of arterial hypertension and, until 6 years ago,
alcoholism. Four day before admission on 22 September, 1982, the patient complained of
a right hemiparesthesia with minimal loss of strength.

Neurologic Examination
The patient was conscious and cooperative. Eye movements were normal, as were
pupillary responses; fundi showed discrete artereosclerotic signs. Cranial nerves were
normal. There was a hemihypoesthesia on the right side along with a very slight hemiparesis.
A right homonymous hemianopsia was present with no macular sparing. A CT scan revealed
the existence of a marked hypodensity at the level of the internal surface of the left
temporal lobe with no sign of a mass effect and with no contrast enhancement, corresponding
to a left temporo-occipital infarct (see Fig. 1).

Neuropsychological

Examination

The following examinations were conducted during the last 2 weeks of November and
the first 2 weeks of December 1982.
Speech. Testing revealed normal melody, sentence length, articulation, and grammar.
No phonemic paraphasias or neologisms were present, although occasionally some semantic
vagueness and rare circumlocutions demonstrated the existence of a very mild word-finding
difficulty.
Automatized series (counting, days of the week, and months of the year) were normal,
both forward and backward.
The patient exhibited no impairment in the repetition of syllables, groups of two syllables,
pseudowords, minimal pairs, polysyllabic words, or sentences [Boston Diagnostic Aphasia
Examination (BDAE) maximum score].
The patient exhibited no difficulty in sentence comprenension or logicogrammatical
relations (in Luria’s sense).
Verbal comprehension, as assessed by the Boston Diagnostic Aphasia Examination,
yielded the following scores: word discrimination, 36/72; identification of parts of the body,
20/20; performance of commands, 15/U; and complex material, 502. It is worthy of note
that the patient’s global score is lowered by the slowness of execution in the picturepointing test, but that he made no error in that test (36/36). If his performance is scored
without taking time into account, his global score is within the norm.
The word-discrimination
test of the BDAE shows a low score because it is a timed
picture-pointing test. The patient did not make errors, but lost a point on each item because
of slowness (he lost 36 points). The comprehension subtest of the body-part identification
test is also timed but this did not affect the patient since no pictures are involved. The
commands subtest was also absolutely normal (but is not a timed test).

OPTIC APHASIA

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FIG. 1. CT scan (1 February, 1983).
Verbal fluency scores were 9 for animal names and 16 for words starting with P in 3
min (lower than the score for our controls of low sociocultural level, which was 21).
Sentence completion tasks and responsive naming tasks were performed completely
normally and with short latencies.
Writing.
Automatisms and mechanics of writing were normal. No neglect of graphic
space was observed, nor was there any impairment of narrative writing. Dictation of letters,
words, and sentences was normal. Copy was totally impossible during the first examinations
and eventually the patient managed only a servile copy with some small errors.
Reading.
In reading letters as well as words and sentences, the patient exhibited a gross
impairment. The patient attempted to spell out the words but totally failed. The patient
was unable to read the sentences that he had written, as is typical of pure alexia. Reading
of numbers was practically preserved (the patient inverted the order in one instance: 127

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was read as 721). If the patient traced the letters with his finger as he read, he was capable
of reading the word, but he made several errors with similar letters (e.g., R and A).
Visual perception.
The patient performed the Thurstone test of identical forms in 27
min with four errors. The test for neglect (Albert, 1973) was performed quickly and without
error. He performed a copy of Type I of the Rey figure in 10 min and scored 32. The
average time taken for the reproduction of the Rey complex figure in our group of normal
control subjects is 4 min.
Recognition
and naming
of pictures.
In naming 50 pictures the patient gave rapid and
correct responses for 37% of the items. The 63% errors consists of 35% delays, 14%
circumlocutions, and 6% errors without connection or lack of response. The patient rejected
the incorrect names suggested to him.
The following are typical examples of circumlocutory responses.
glass: it is something that you find in bars.
plate: it is something used to eat.
syringe:
something that nurses use . . . it’s about injections . . . I don’t know how to
say . . .
balloon:
something that children hold and that is full of air.
airplane:
I know what this is . . . but I don’t have the name . . . it is something that
you find at airports . . .
sled: it is something to ski with.
penknife:
it is something that you carry in your pocket . . . what is it called?
Recognition
and naming
of objects.
The results of recognition and naming of objects
(50 objects) in the visual modality showed the same basic characteristics observed with
pictures but with better results: 71.8% correct.
Typical examples of failures to name.
glass: is used to drink.
scissors:
something used to cut.
key: it is used to open the door.
fork:
it is something to eat with . . . to pick.
button:
yes . . . I know . . . by the holes . . . a button.

FIG. 2. The Rey figure produced 1 week after the first examination of the patient’s
writing.

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cigar: it is to smoke.
folder: it is to keep things . . . folder. How did you arrive at the name? By the elastic
band and the shape (correct description).
zipper: it is to open and close. . . . What? A dress for example
. zipper.
Tact& recognition and naming. The patient named all objects placed in either hand
quickly and correctly.
Pointing ofobjects. When asked to point to objects named by the examiner in a multiplechoice test of six items, the patient had only two errors (semantic) and one latency.
Written naming. The task consisted of writing the names of objects presented to him
by the examiner and was normal (25/25).
Grouping by category. The patient was required to group the objects presented into
categories previously stipulated by the examiner. The patient made many errors, all of
which were explainable by word-finding difliculties. The groupings performed were of the
functional type. (Examples: scissors with clothes; men of different races were classified
by their clothes; train was included in sea transport; and egg was included with fruits.)
Association of pictures of items of the same category but of different shapes was normal
(25/25).
Gestural praxis. The patient was capable of imitating, with the right as well as the left
hand, all of the arbitrary positions of the Berg&s and Lezine (1981) test. There was no
difficulty in performing verbal commands, symbolic gestures (military salute, threat, etc.),
mimicry of the use of objects (hammer, saw, etc.), or use of real objects (a candle and a
box of matches, etc.). However, when an object was presented and the patient was asked
to perform the gesture corresponding to the use of the object-without
touching the objectthe patient manifested the same problems as before: if he could not find the word, he was
incapable of performing the pantomime (e.g., scissors, spoon, glass, syringe, bicycle).
During the examination of picture and object naming the same phenomenon was repeatedly
observed: The patient was unable to perform the pantomime of the use of the object if
he could not correctly name the object. If, after a while, through circumlocutions, he
managed to recall the name (but not during the period of circumlocutions) he performed
the gesture correctly. If the patient retrieved the wrong name (which occurred in two
cases) the gesture performed corresponded to the (wrong) word retrieved (e.g., when
presented a fork, and he said it was a spoon, he performed the gesture corresponding to
the use of a spoon).
Face recognition. The patient was capable of recognizing photographs of current celebrities
of political life, artists, etc., but showed a clear difficulty in evoking the names of the
celebrities presented. He was capable of saying whether the face was that of a singer or
whether he saw him/her on television or if it was a known actress from Hollywood. To
a picture of the King of Spain he said: Right! it is the master of all . . . the king . .
(pause) His name is . . . Juan. Brigitte Bardot: a movie star . . . J. Manuel Serrat: a Catalan
singer. The patient was also capable of picking out the faces of famous people among
others.
Constructional praxis. There were no significant defects in copy with single figures (circle,
square, triangle) or with more complex figures (daisy in a flower pot, and a small house).
In drawing to verbal command there was slowness of performance and in several items a
defect of evocation of mental visual imagery was apparent. The patient produced a verbalization and a successive description of the characteriestics of the objects. He explained
his own defects as follows: “I can draw the object quickly only if I have the image when
I am given the name.” (Examples. for elephant: “I don’t know what it is
it is the
one with the trunk, right? . I don’t know if he has a tail . . .; palm tree: It’s a tree . .
but no . . now I don’t know what it is like . . .; have you seen some? yes, there are
many . . . in Alicante.)
Results on Bender’s gestalt visuomotor test showed only one inversion in the first figure
and a predominance of macrographia.

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Recognition and naming of noises. He did not exhibit any difficulty with the presented
items except when he had to match a sound with a picture in a multiple-choice format.
Somatognosia and right-left identification. No deficit was observed. The patient was
capable of performing quickly and correctly the items of the BDAE which involve parts
of the body, digital gnosis, and right-left orientation.
Colors. Color matching was normal. Performance on the Farnsworth test was normal.
Naming and pointing to colors showed clear deficits, constituting a color-naming defect.
The patient exhibited no difficulty in verboverbal associations involving colors (i.e., telling
the characteristic color of objects). In these tasks, responses were always quick and correct
(35/35).

Memory. The patient obtained an MQ of 77 on the Wechsler memory scale (WMS). His
scores on the WMS subtests were as follows: personal and current, S/6; orientation, 515;
mental control, 8/9; logical memory, l/23; digits, 8/17; visual reproduction, 9/15; and associative
learning, 7121. The reproduction of the Rey complex figure from memory was 18/36.
Intelligence. Scores on the Wechsler Adult Intelligence Scale (WAIS) were as follows:
verbal IQ 103; performance IQ 79; and full scale IQ 96. His low achievement on the
performance tasks were attributable to the figure completion and object assembly subtests
on which performance was very low.
Raven’s progressive matrices, [Series A and B (color)]. The result was 28/36.
Concrete and abstract words. The patient easily understood the meaning of very abstract
words (such as those in the vocabulary of the WAIS) but had difficulties when he referred
to concrete words pertaining to animals or to various items that call for concrete visual
images. Also, he could say that an elephant is an animal and that it is in the zoo, but he
had great difficulties when he had to describe the inherent characteristics of the animal
(it is big, has a trunk, a short tail, tusks, etc.). This contrastive phenomenon between the
concrete and the abstract represents a leitmotiv in all tasks. He was able to tell that a
rose and a carnation are flowers and that in Catalonia roses are offered on Saint Georges’
day, but it was very difficult for him to say what a rose looks like or what a carnation
looks like.
Dreams. The patient reported having had dreams almost every night before his illness
but no more since. Five months later, when naming was better, he reported having had
one dream, but no more since.

DISCUSSION
The patient presented with a deficit centered around the retrieval of
names of objects presented in the visual modality (producing circumlocutions and pauses), a deficit in the evocation of the gesture appropriate
to the use of objects when also presented in the visual modality, and a
deficit in the evocation of mental images of objects. The deficit in the
evocation of gesture was similar to the case described by Assal and Regli
(1980) and represents a form of visuogestural disconnection (called optic
apraxia by these authors). The patient was incapable of going from the
image of the object to the “gesteme,”
defined by Signoret and North
(1979) as the mental representation of the gesture, and which also corresponds to “the overall memory image of the gesture” mentioned by
De Renzi, Faglioni, and Sargato (1982). These deficits represent a modalityspecific apraxia (in this case a disconnection apraxia).
To satisfy the criteria for optic aphasia, the patient fulfilled among
other things, the following requisites: absence of spatial neglect and

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APHASIA

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69

correct copy, and discrimination
of drawings (Bender’s tests, Rey’s test,
and copy of classic items of constructional praxis: house, daisy in flower
pot, etc.) The perceptual and graphoperceptual
capacity was also better
than in the case reported in 1973 by Lhermitte and Beauvois (4 errors
in 27 min in our case as compared with 13 errors in 30 min in the case
of these authors in Thurstone’s test of identical forms; Type I recall of
the Rey figure as compared with Type IV in the case of these authors).
The patient’s global intellectual capacity was preserved and his IQ
was not far from that of patients with optic aphasia or visual agnosia in
which a minimal intellectual level is required (Albert, Reches, & Silverberg,
1975: Hecaen, Goldblum,
Masure, & Ramier, 1974; Rubens & Benson,
1971). The WAIS showed lower performances in the subtests in which
elements of previously known visual images play an important role (picture
completion and object assembly).
Furthermore,
the patient shows a pure alexia as well as a color-naming
deficit. This combination of symptoms may be related to a lesion in the
mesial temporo-occipital
junction of the left hemisphere, as Damasio and
Damasio (1983) have recently discussed.
The deficit in word recall in confrontation naming characterized by
delay and circumlocutions,
as well as absence of pharaphasias, makes
it similar to amnesic aphasia as described by Lecours and Lhermitte
(1979, p. 141). In our case, however, this deficit contrasts with the quick
and correct naming upon tactile presentation and quick and correct naming
in sentence completion tasks or in responsive naming (verboverbal) tasks,
The deficit in naming faces constitutes what we call “prosopanomia”
and is similar to the case reported by Assal and Regli (1980). This clinical
manifestation
is evidently different from that observed in true prosopagnosia. The phenomenon of prosopagnosia “appears in relation to any
visually ‘ambiguous’ stimulus whose recognition depends on contextual
memory evocation”
(Damasio, Damasio, & Van Hoesen, 1982).
The memory deficit exhibited by the patient remained centered around
the more demanding verbal tasks of the WMS (logical memory and
associative learning). The dissociation between visuospatial and visuographic memory (visual reproduction of the WMS and the Rey figure)
could be related to the focal left-hemisphere
lesion.
The deficit in performance with concrete words as orposed to abstract
words may be related to the visualizable-verbalizable
dichotomy and
relates to the problem expressed by Warrington (1979) when she speaks
of the “fine grain semantic details” of the semantic memory (the patient
loses the concrete-the
visualizable-and
retains the abstract-the
verbalizable). This case report gives support to the multidimensionality
of
semantic memory and points to the loss or delayed accessibility to the
visual components of this semantic memory store.

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The patient exhibited a difficulty in accessing language from visual
information
(optic aphasia or optic anomia) and exhibited, as well, a
difficulty in evoking the image (revisualization
or reminiscence) from
verbal stimuli. The case report of Cambier, Masson, Elghozi, Henin,
and Viader (1980) stresses the importance of the posterior inferotemporal
cortex in the construction of the visual object and shows that, between
a normal elemental visual perception and normal language, a pathological
process is interposed (agnosia or, in our case, a disconnection).
The patient also reported a lack of dreams, which, if substantiated,
would represent the Charcot-Wilbrand
syndrome, defined by Critchley
(1953) as “the symptom whereby a patient loses the power to conjure
up visual images or memories and, furthermore,
ceases to dream his
sleeping hours.” This deficit brings further support to the idea of a deficit
in the function of the so-called “mental images.” Lyman, Kwan, and
Chao (1938) similarly reported the case of a patient who complained of
difficulties in visualizing things (he was unable to draw a chair without
seeing one) and claimed he had no more dreams since his illness. More
recently, Deleval, De Mol, and Noterman (1983) reported a case of loss
of mental imagery and reviewed 35 cases previously reported in the
literature. The authors do not think that their case presents a disconnection
between the visual and language areas. Yet, like ours, their patient shows
confrontation naming difficulties. Cases of facilitation on presentation of
first phoneme clearly indicate a word-finding difficulty, not a difficulty
in recognizing the objects.
Gainotti, Silveri, Villa, and Caltagirone (1983) discuss drawing objects
from memory in aphasia. Among other things they found that there was
a significant correlation between impaired drawing from memory and
disruption at the semantic-lexical
level of language integration.
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