Neurocase
The Neural Basis of Cognition

ISSN: 1355-4794 (Print) 1465-3656 (Online) Journal homepage: http://www.tandfonline.com/loi/nncs20

The painter from Sinaloa: artistic analysis of a case
of spatial agnosia and neglect of visual shapes
Juan Manuel Orjuela-Rojas, Ana Luisa Sosa-Ortiz, Ana Ruth Díaz-Victoria,
Oscar René Marrufo Melendez & Nicolás Leyva Townsend
To cite this article: Juan Manuel Orjuela-Rojas, Ana Luisa Sosa-Ortiz, Ana Ruth Díaz-Victoria,
Oscar René Marrufo Melendez & Nicolás Leyva Townsend (2017): The painter from Sinaloa:
artistic analysis of a case of spatial agnosia and neglect of visual shapes, Neurocase, DOI:
10.1080/13554794.2017.1408842
To link to this article: https://doi.org/10.1080/13554794.2017.1408842

Published online: 29 Nov 2017.

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NEUROCASE, 2017
https://doi.org/10.1080/13554794.2017.1408842

The painter from Sinaloa: artistic analysis of a case of spatial agnosia and neglect of
visual shapes
Juan Manuel Orjuela-Rojasa, Ana Luisa Sosa-Ortizb, Ana Ruth Díaz-Victoriac, Oscar René Marrufo Melendeza
and Nicolás Leyva Townsendd
Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery, Mexico City, Mexico; bLaboratory of Dementias, National Institute of
Neurology and Neurosurgery, Mexico City, Mexico; cCognitive and Behavior Unit, National Institute of Neurology and Neurosurgery, Mexico City,
Mexico; dIndependent researcher, Bogotá, Colombia

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a

ABSTRACT

ARTICLE HISTORY

Paintings produced spontaneously by patients with neurological lesions represent a fascinating opportunity to analyze some aspects of the underlying disease and involved brain mechanisms. Many cases of
artists who have suffered spatial neglect following a neurological disease have been reported in the
literature. However, only a few studies evaluating the different subtypes of graphic neglect and aspects
related to the construction of perspective (three dimensionality) in works of art have been published. In
the present article, we present the case of an artist who, after resection of a central neurocytoma that
affected the right thalamo-parietal connections, suffered an impairment of the ability to create perspective in his paintings and involuntary omission of only shapes in the left side of his paintings,
although colors and contours were preserved.

Received 17 May 2017
Accepted 17 November
2017

Background
Art is a unique human activity that is mainly associated with
the symbolic and abstract aspects of cognition (Zaidel, 2010).
Paintings produced spontaneously by patients with neurological lesions represent a fascinating opportunity to analyze
some aspects of the underlying disease and the brain
mechanisms involved (Schott, 2012). Many cases of artistic
deterioration and/or emergent artistry associated with
dementia, brain tumors, Parkinson’s disease, epilepsy, head
trauma, and cerebrovascular disease have been described
(Bogousslavsky, 2007).
There are many brain areas involved in the visual processing. The primary visual cortex (V1) that receives the sensory
inputs from the thalamus (striate cortex) responds selectively
to oriented edges. The extrastriate areas, for example the
middle temporal area, contain neurons that respond selectively to the direction of a moving edge without regard to
its color. In contrast, neurons in another cortical area called V4
respond selectively to the color of a visual stimulus without
regard to its direction of movement (Purves, 2012). The visual
information travels by two primary pathways called the ventral
stream and the dorsal stream, the latter is directed toward the
parietal regions. Although these cases illustrate in part the
neurobiological complexity underlying artistic expression, the
role of the right parietal lobe (RPL) and its thalamic connections in the construction of perspective and perception of the
left hemispace will be emphasized. Damage to the RPL can
cause disorders of body perception (asomatognosia, Babinski’s
anosognosia, anosodiaphoria, misoplegia, personification,
somatoparaphrenia, and xenomelia) (McGeoch et al., 2011)

CONTACT Juan Manuel Orjuela-Rojas

orjuela.j@javeriana.edu.co

© 2017 Informa UK Limited, trading as Taylor & Francis Group

KEYWORDS

Neglect; spatial agnosia;
artist; painting; central
neurocytoma

and spatial processing (spatial neglect, spatial agnosia), the
latter being of great importance in creating paintings.
In this work, we present a patient with academic education
in plastic arts who, after suffering a brain tumor, experienced
significant changes in artistic expression, including an impairment of perspective ability and an absence of shapes on the
left sides of his paintings. A neuropsychological and artistic
analysis of this patient’s works before and after the illness is
performed, seeking to correlate the cognitive and neurobiological mechanisms underlying these changes and emphasizing
the importance of right hemispheric thalamo-parietal connections in the creation of works of art.

Case report
The patient is a 30-year-old male, right-handed, who is a
native of a small town in Sinaloa, Mexico. He began his artistic
career at the age of 8. During his childhood and adolescence,
he was awarded several prizes for his paintings, and his companions considered him to have a “gift” for drawing. At age
20, he studied plastic arts; he later worked as an arts teacher in
his hometown. In 2010, he won an international small art
exhibition competition in Japan. Figure 1(a,b) show some of
his paintings.
The patient’s condition began in July 2012 with a holocranial headache of moderate intensity and a “heaviness” of the
head that was associated with drowsiness. At that time, he
was evaluated by a neurosurgeon who requested a neuroimaging study, which showed a mass in the right thalamic ventricular zone. In August 2012, the patient underwent partial
resection of the mass, which was histopathologically classified

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J. M. ORJUELA-ROJAS ET AL.

Figure 1. (a) Wolf in watch. Pencil on paper, 2008. (b) Natural freedom. Acrylic on frame, 2011. These two works, which were created prior to the occurrence of the
tumor, allow us to identify the artist’s figurative style and his proper use of basic aspects such as line, drawing, perspective, color, volume, light, and composition.
(c) Sinaloa landscape. Oil on canvas, 2014. In this work, which was created after tumor resection, the drawing has no efficient perspective, the brush stroke is loose
and imprecise, and the representation does not depict a strong light source. There are no figurative details (birds, trees, flowers, clouds) in the left space, but
distribution of color throughout the work remains. [To view this figure in color, please see the online version of this journal.]

as a neurocytoma. In magnetic resonance imaging (MRI) performed after this intervention, a heterogeneous lesion is
observed in right parietal region and a round midline lesion
in the thalamic region (Figure 2(a)).
In September 2012, the patient was transferred to the
National Institute of Neurology and Neurosurgery “Manuel
Velasco Suárez” in Mexico City for complete tumor resection.
The postoperative MRI showed an area of encephalomalacia in
the right cortical–subcortical region of the parietal lobe and
the pulvinar of the thalamus (Figure 2(b)).
Immediately after the last surgery, the patient reported
frequent forgetfulness, losing everyday objects, and difficulty
in remembering new episodic information; these symptoms
were not progressive but were persistent. Since then, his
artistic production has changed considerably. It can be
observed that the left sides of his paintings are lacking in
shape and detail; however, the color distribution in the

paintings is relatively well conserved. The patient has difficulty
creating perspective and to correctly represent the source of
light in his works. In addition, he has lost the ability to correctly align the letters when writing, leading to the cascade
phenomenon (sloping lines); this is evident when designing
notices. His relatives mention that he now often quickly stops
working on a painting and that he appears to be unaware of
the artistic changes previously mentioned. He simply does not
complete his paintings because he considers them “awful,” a
situation that causes him deep frustration. This has resulted in
a significant decline in his working ability, leading him to be
financially dependent on his brothers.
With respect to mood, 6 months after the last tumor resection, the patient reported irritability, sadness, anhedonia, feelings of disability in relation to the loss of productivity, and
poor frustration tolerance and displayed shouting outbursts
when confronted with stressful situations. He was diagnosed

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Figure 2. Brain magnetic resonance. (a) Partial resection of the central neurocytoma. In the FLAIR sequence, the image reveals a heterogeneous lesion in right
parietal region and a round midline lesion in the thalamic region. In (b), total resection of the central neurocytoma. A zone of encephalomalacia in the right cortical–
subcortical region of the parietal lobe and the pulvinar of the thalamus is observed in the T1 sequence. (c) Tractography after total resection of the central
neurocytoma. There is a disruption of fibers in the right corpus callosum at the level of the splenium, forceps major, and posterior corona radiata. In the coronal
section, the lower fiber density in the right thalamo-parietal connections is evident. [To view this figure in color, please see the online version of this journal.]

with major depressive disorder and treated with citalopram
10 mg/day along with psychotherapeutic support; these interventions produced a good response.
During the neuropsychological examination conducted in
May 2014, the revised Barcelona test (Peña-Casanova, 2005)
and the Rey complex figure test (Osterrieth, 1944), as well as
additional clinical tests, were administered. Clinical examination revealed a RPL syndrome characterized by partial spatial
neglect (Figure 3(a–c)), constructive apraxia, spatial agnosia,
and spatial agraphia with line sloping. Digital agnosia, agraphesthesia, and amorphognosia of the left hand were also
documented, as were disturbances of right–left orientation.
With respect to memory, only mild alterations in visual memory and in anterograde episodic memory were identified. The
graphic disabilities displayed by the patient are primarily evident in the memory tasks for the Rey–Osterrieth figure
(Figure 3(e)) while the copy is correct (Figure 3(d)). The documented findings of the neuropsychological examination are
summarized in Table 1.
Structural neuroimaging studies performed after total resection of the tumor were extended by performing tractographies,
with the aim of documenting the neurological pathways altered
by the tumor and the surgical procedure. Diffusion tensor imaging with 25 diffusion gradient directions was obtained using a
1.5-T Signa Excite HDxt (General Electric) with an eight-channel
head coil, and the reconstruction was performed using a separate workstation (AW Volume Share 4, General Electric) and
Functool software. Significant fiber disruption was observed in

the right corpus callosum at the level of the splenium, the
forceps major, and the posterior corona radiata. In the coronal
section, the lower fiber density in the right thalamo-parietal
connections is evident (Figure 2(c)).
To provide evidence for and to observe and analyze the
artistic changes that occurred in this patient after his illness, we
asked the patient to create a free-subject painting in oil on
canvas in our laboratory. We provided the materials and gave
him the time necessary to create the work, which is titled
“Sinaloa Landscape” (Figure 1(c)), which represents a landscape
of his childhood and adolescence.
The artistic analysis was done by an expert in the field. He was
shown the three paintings (Figure 1), he was informed that they
corresponded to the same artist, but we did not mention that he
had gone through a process of illness, so the analysis was blinded.

Artistic analysis of the subject’s paintings before and
after the illness
Art genres are thematic specializations in which traditional
artistic representations are usually divided; they include, for
example, portraiture, landscape, nudes, and still lives
(Gombrich, 1997). In this case, the patient is a genre painter
who specializes in nature.
The analysis of plastic elements in figurative works of
art that attempt to represent reality without abstraction
can be performed according to six criteria: line and drawing, perspective, color, volume, light, and composition.

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J. M. ORJUELA-ROJAS ET AL.

Figure 3. Neuropsychological test results that support the presence of spatial neglect syndrome in the patient. (a) Line cancelation test. Two triangular elements
(indicated by the arrows) located in the left space are omitted. (b) Copy of the house and cube. The poor perspective is evident in the figures and in the omission of
details in the left space (c). Line bisection test. The line of bisection is displaced to the right, an aspect that reveals left neglect. (d) The copy task for the Rey–
Osterrieth figure is essentially normal. (e) Memory for the Rey–Osterrieth figure. Note the absence of shapes and details in the left space where the general contour
of the rectangle is retained.

Hereafter, the paintings discussed in this work will be
referred to as Figure 1(a) (wolf), Figure 1(b) (eagle), and
Figure 1(c) (landscape).

Line and drawing
Drawing is the technique that identifies shapes, which compose the basic structure of the painting to be developed
(Kandinsky, 1991). Figure 1(a) shows a drawing in its entirety;
the drawing shows that the author is a good drawer who is
able to identify textures and proportions. In Figure 1(b), the
drawing shows that the author’s technique is to add color to a
previous delimited area with clear and precise contours. In
Figure 1(c), the drawing in the left portion of the space is
almost nonexistent, mainly focusing on spots of color rather
than shape contouring.

Perspective
Perspective is the fictional representation of the third dimension and can be achieved through various means (Berger,
2001). In Figure 1(a), which shows an animal’s face in the
foreground, perspective is not strongly demonstrated. When
comparing Figure 1(b,c), it can be perceived that there is a
significant difference in the perspective management. In
Figure 1(b), there would be a perspective whose horizon and
vanishing point lies somewhere between the house, the
bridge, and the water tower, and around it lies the planes
parallel to the background. What is closest to the viewer with
respect to that reference increases in pictorial detail and what

is not is only an insinuation or gesture, resulting in the sensation that there is a here and there, a close and a far, that
depends on the handling of the disappearance and chromatic
changes of the figure represented.
Now, when analyzing Figure 1(c), one could say that there
is no management of perspective in academic terms, based on
the idea that there does not seem to be a horizon, a vanishing
point or reference points that allow to imagine in base to what
spatial criterion the image is being organized with respect to
the gaze. It could be argued against this first sentence that
one can know that there are things closer than others, this
achieved by the overlapping of planes (the tree covers the
mountain, one bird is bigger than another, etc.). However, the
false sense of optical depth that is ordered around the viewer
of the image, which is the perspective, has been lost. There is
an intuitive set of hierarchies, but not an academic exercise.
The perception of the landscape as an extension of reality no
longer exists. There is a representation of nature, but with
another order in which it seems that the image is constructed
by means of prior knowledge of how the image should be
seen, rather than by a deliberate intention to develop it based
on criteria such as perspective.

Color
The criterion of color has three elements. The first is color
theory, in which the evaluator determines whether the author
uses primary, secondary, or complementary colors and at the
same time analyzes the level of complexity (Kandinsky, 1991).
The second element is the color gamut, wherein the evaluator

Memory

Praxis

Gnosias

Written language

Impressiv e language

Expressiv
e language

Attention

Cognitive domain
Orientation

X
X

X
X
X

Ideomotor
Ideational
Constructive praxis to the copy
Constructive ability
Dress praxis
Motor sequence
Register

X
X

X

X

Tactile denomination

Spatial

X

Morphognosis

X

X

Auditive
Graphesthesia

X

X

Writing

Visual

X

Reading

X

X
X
X
X

Severe

Digital agnosia

Tactile

X
X

Repetition
Lexico-semantic fluence
Fluence
Content
Comprehension
Complex verbal information

X
X
X
X

X
X

Moderate

Severity of the deficit
Mild

X

Normal
X

Component
Person
Place
Time
Tonic
Phasic
Automatic
Prosody
Denomination

Table 1. Summary of the neuropsychological examination.
Commentary

(Continued )

He shows signs of partial inattention toward the left side
He shows very important spatial disorganization with the design of
models with cubes

In the left hand, he recognizes 6/8 stimuli, which places it in the
percentile <10, lower average. In the right hand, he recognizes 8/8,
maximum average
In the left hand, he recognizes 5/6 stimuli, percentile <10, lower
average. In right hand, he has 6/6, maximum average
Lentification in the recognition of objects, percentile <10, lower
average
In the right hand, he recognizes 11/15 stimuli. In the left hand, he
recognizes 9/11 stimuli. In both cases, scores are set in the lower
range (percentile <5)
In the test of topographical orientation in maps, he is not able to
indicate the location of some geographic elements of his country
(cities, seas)
He is not able to describe a known route. For example, the route
taken from the house to the hospital
In the design of models with cubes, he shows inadequate rotation of
the cubes, disorientation of the figure, and significant difficulty in
integrating the individual parts at the right angles and places

He has difficulties understanding complex logical–grammatical
structures
In comprehensive reading, he shows difficulties when complex logical–
grammatical structures exist
Spontaneous writing is significantly reduced. He doesn´t respect the
left margin of the pages and every line of the paragraph starts some
millimeters to the right in comparison with the above (cascade
phenomenon)
Difficulties are observed in the discrimination of the stimuli found in
the left visual hemifield. He shows a recurrent neglect of the stimuli
that are on the left side of his field of vision

In both naming tasks and spontaneous language, he occasionally
presents anomia

He doesn´t locate the neighborhood
He only fails on the day of the month

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X
X
X

X

X

Semantic
Episodic

Intention
Planning/Programming
Verification

X

X
X
X

Facitation
Maintenance
Short-term visual memory
Long-term visual memory

Moderate

Severity of the deficit
Mild

Normal

Component

The revised Barcelona test, the Rey complex figure test as well as additional clinical tests described in Figure 3 were administered.

Executiv
e function

Cognitive domain

Table 1. (Continued).
Severe

Commentary

He has mild impairment to evoke autobiographical information (places,
moments)

In the memory Rey–Osterrieth figure, there are several mistakes and
omissions. Note the absence of shapes and details in the left space
where the general contour of the rectangle is retained

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determines whether the color range is warm or cold. The third
element is the brush stroke, wherein the evaluator studies the
form in which the painter uses brush strokes. Figure 1(a) has
no color but is richly varied in shade and shows good understanding. In Figure 1(b), primary, secondary, and complementary colors are used in various combinations, with warm colors
in the foreground and cold colors in the background, and the
color is applied using a precise brush stroke. Figure 1(c)
includes only one primary and two secondary colors in limited
combinations; it uses only warm tones and was produced
using loose and inaccurate brush strokes.

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Volume
Volume is the representation of the third dimension of shapes
by means of shading (Gombrich, 1997). Figure 1(a), which is a
play of light and shadow, is based exclusively on the principle
of volume representation; it achieves the representation of a
complex volume using different depths of shading and portrays an intense light coming from the right side of the
picture. Figure 1(b) shows a light that also emerges from the
right side of the picture, and each shape is associated with a
shadow that depends on the position of the light source. This
is the case with the rock in the foreground, the house, and the
mountains, creating not only three dimensionality but also
giving credibility to the painting. Figure 1(c) does not depict
a strong light source; thus, the figures, including the tree that
casts no shadow, lack volume. In addition, although the lightcolored shades in the grass might suggest that light comes
from the right side of the picture, it is difficult to determine
that with certainty.

Light
In short, there are three types of light: natural diurnal, natural
nocturnal, and artificial. In the studied case, Figure 1(a) could
have been made based on a photograph taken under artificial
light; it has the typical high contrast caused by a flash.
Figure 1(b,c), which are without great contrast, appear as
scenes viewed under uniform natural diurnal light. As previously indicated, in the case of Figure 1(c), the light source
cannot be easily determined. For example, in the hill, there is a
strong darkness on the left side but accompanied immediately
by intense moments of brightness, while on the other side of
the hill, the green is notoriously clearer. If you compare the
shadows generated by the lawn, they do not match those of
the tree, in whose leaves the light would come from the left
(see the brightness to the left and the shadow to the right and
down of the leaves). The trunk itself does not seem to have a
concrete source. The origin of light is ambiguous throughout
the image, constantly changing in an arbitrary way.

Composition
Composition is the way in which the figures in a scene are
arranged in the pictorial plane. It represents the sum of all
other criteria, and its end result is an image (a symbolic production based on signs). An example of the use of shapes to
represent an orderly arrangement can be seen in Figure 1(b),

7

in which spatial ordering is imposed on many elements (bird,
flora, etc.), thereby creating a complex composition. Figure 1(c)
does not show a significant degree of complexity in composition and seems improvised, almost resembling a painting created by an inexperienced person.

Discussion
The present case refers to a young man, an artist by profession,
who was attended by a multidisciplinary team at the National
Institute of Neurology and Neurosurgery in Mexico City due to
the cognitive and artistic sequelae that appeared after the
resection of a central neurocytoma requiring two surgeries.
The most relevant clinical aspects of the case are the patient’s
graphic neglect of visual shapes (manifested by an inability to
draw shapes in the left sides of his works of art) and spatial
agnosia; together, these deficiencies prevented him from representing perspective, volume, and the source of light in his
paintings. In addition, neuropsychological analysis revealed
multiple symptoms of RPL dysfunction in this patient
(Table 1). Brain MRI showed a right pulvinar and cortical–subcortical lesion of the parietal lobe (Figure 2(a,b)). Tractography
revealed significant disruption of the right thalamo-parietal
connections and of fibers in the right corpus callosum at the
level of the splenium and the forceps major (Figure 2(c)).
Changes in artistic production caused by cerebral damage are
of great interest in neuroscience because they allow us to establish links between specific cerebral regions and artistic expression. Artistic expression requires the integration of multiple basic
cognitive processes related to the perceptual, motor, and representational systems (Halligan & Marshall, 2001). In the last century, several artists have been affected by spatial neglect
following lesions of the right hemisphere. These artists include
Otto Dix (1891–1969), Bruno Alder (Schnider, Regard, Benson, &
Landis, 1993), Huguette Bouchardy-Rey (Blanke, Ortigue, &
Landis, 2003), Pierre Ambrogiani (Vigouroux, Bonnefoi, & Khalil,
1990), and Anton Raderscheidt (Blanke & Pasqualini, 2011),
among others. In his book Art, Mind and Brain: A Cognitive
Approach to Creativity (1982), Howard Gardner analyzes the
work of Lovis Corinth (1858–1925), a German painter, engraver,
and sculptor, whose work was a synthesis of impressionism and
expressionism and who was affected by spatial neglect after a
stroke in 1911 (Blanke, 2006).
Although RPL is involved in most cases of spatial neglect and
artistic deterioration, it is also interesting to analyze its role in
cases of emergent artistry following neurological damage, that
is, in subjects who previously had no artistic skills but developed them after a brain injury. This phenomenon has been
observed in subjects with frontotemporal lobar degeneration
whose single photon emission tomography (SPECT) (single
photon emission tomography) patterns have revealed right
parietal hyperperfusion (Miller, Ponton, Benson, Cummings, &
Mena, 1996). The case of a 36-year-old woman who became
obsessed with painting beautiful African women after a left
insular infarction has been reported (Thomas-Anterion et al.,
2010). Another well-known case is that of a 49-year-old man
who, after a traumatic brain injury affecting the left frontotemporal structures, developed a great enthusiasm for drawing
biomorphic structures (Midorikawa & Kawamura, 2015).

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Likewise, the cases of savant artists teach us that asymmetric
brain function can lead to the development of extraordinary
cognitive abilities to the detriment of others. In this context,
language difficulties accompanying autism spectrum disorders
(hypofunction of the left hemisphere) enhance visuospatial
skills and photographic memory (hyperfunction of the right
hemisphere), thereby favoring the construction of beautiful
works of art from an early age (Hou et al., 2000). The phenomenon of emergent artistry is interesting because the common
point in all cases is the liberation of the right hemisphere,
particularly of the right temporoparietal structures, after structural or functional damage to the left hemisphere. This phenomenon of liberation was first described by Kapur, who called
it “paradoxical functional facilitation” (Kapur, 1996); it allows us
to understand the importance of the right hemisphere in artistic production.

Spatial neglect
Two major components of the neglect syndrome have been
distinguished: sensory (or attentional) and motor (or inattentional). In the first case, RPL damage can compromise the
perception of the left personal space, resulting in asomatognosia (Orjuela-Rojas et al., 2015), or cause alterations in the
perception of the left extrapersonal space, resulting in spatial
neglect syndromes. In the latter, there is an inability to attend
to or report stimuli presented on the side opposite the lesion,
despite the fact that the patient has no visual sensory deficits
(Corbetta & Shulman, 2011). Neuropsychological assessment
typically reveals alterations in the line bisection, clock drawing,
design copying, and line cancelation tests, findings that were
documented in our patient (Figure 3). In motor neglect, one
limb is underused relative to the other despite the retention of
normal muscle strength, sensitivity, and reflexes (Sampanis &
Riddoch, 2013).
In the case of spatial neglect, artists and nonartists typically
fail to complete the left halves of their paintings (Zaidel, 2010).
This is not a propositional act but a pre-attentive bias toward
the right half of the painting such that artistic exploration is
executed in this zone, ignoring the holistic vision that usually
accompanies works of pictorial art. Perhaps, the most famous
case of spatial neglect in an artist is that of Federico Fellini
who after a right ischemic parietal lesion began to draw
incomplete figures on the left side that displayed a particular
and comic awareness of his deficit (Cantagallo & Della Sala,
1998). In the case of our patient, the degree of anosognosia to
spatial neglect was remarkable.
Many types of neglect are represented in art. In some cases,
only the colors of the left half of a painting may be omitted,
whereas the ability to draw shapes and contours is preserved
(Kondo, Mori, Makino, Okazaki, & Hachisuka, 2012). Neglect of
this type is often described as “color neglect” (Blanke et al.,
2003). However, in the case of our patient, color distribution is
conserved, and the most relevant aspect of the deficiency is
the absence of figurative details such as birds, clouds, flowers,
and trees in the left half of the painting (Figure 1(c)), suggesting a graphic neglect of visual shapes.
RPL lesions are not solely responsible for spatial neglect
syndromes; such syndromes have also been reported as

secondary to focal lesions in thalamic, occipital, (Annoni,
Devuyst, Carota, Bruggimann, & Bogousslavsky, 2005), temporal, and frontal regions (Mort et al., 2003). Spatial neglect
results from any damage to attentional networks at the cortical–subcortical level, with the upper longitudinal fasciculus
representing a key structure for the onset of symptoms (Li &
Malhotra, 2015). The dorsal attentional network, which
extends from the frontal ocular field to the intraparietal sulcus,
is responsible for spatial attentional processing. The ventral
attentional network, which extends from the inferior frontal
gyrus to the posterior temporoparietal junction, is responsible
for sustained attention and attentive reorientation (Li &
Malhotra, 2015). Both networks are lateralized toward the
right hemisphere, and damage to these networks is associated
with spatial neglect (Corbetta & Shulman, 2011). At the functional level, there is an interhemispheric imbalance in which
there is hyperactivity of the left hemisphere, causing an attentional bias and ocular movements toward the right hemispace
(Corbetta, Kincade, Lewis, Snyder, & Sapir, 2005).
In our patient, the right parietal and the thalamic damage
converge, particularly in the case of the pulvinar nuclei, the
function of which is to integrate information coming from
the parieto-temporo-occipital (Behrens et al., 2003) heteromodal association cortex, is a key region for symbolic
expression in a variety of artistic processes. Tractography
(Figure 2(c)) showed damage to the right thalamoparietal
connections and disruption of the forceps major, a structure
responsible for transmitting visual information from the
occipital cortex through the corpus callosum. The cortical–
subcortical lesion of the right hemisphere compromised the
dorsal and ventral attentional networks, can explain the
neuropsychological syndromes observed in our patient,
and allows the plastic elements of figurative art, such as
drawing, perspective, volume, light source, and the composition of the painting, to be studied from a neurobiological
approach.

Graphic neglect of visual shapes
Why does the patient in question only omit figures and not
colors from the left side of the painting? There are very few
published cases of graphic neglect of visual shapes. In 1987,
the case of a painter named IK who had a glioblastoma multiforme of the left parietal lobe and suffered right spatial
neglect was described. His paintings were characterized by
the fact that the canvas was completely covered with color
but only the right portion was lacking in details and shapes
(Marsh & Philwin, 1987).
In our patient, it is evident that the size and location of the
neurological lesion affect both attentional processes and the
spontaneous drawing of figures and shapes in the left space.
The exclusive use of colors may involve mainly visuo-perceptual and premotor component of neglect resulting in the
inability to generate representations of figurative objects in the
left space. Just as one can neglect personal and extrapersonal
space, other subjective levels (i.e., intrapersonal space), such as
thoughts, mental imagery, and creativity, can also be affected.
There have been reports of subjects who omit details from the
left sides of representations of memories of familiar scenes

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NEUROCASE

(Halligan & Marshall, 2001). This “representational neglect” has
been confirmed multiple times (Peru & Zapparoli, 1999), and
that is why drawings that are guided through perception can be
dissociated from those created by mental imagery or “mind’s
eye” (Chatterjee, 2004). In fact, in the copy of the Rey figure
(Figure 3(d)), it is clear that our patient is able to correctly guide
his drawing through perceptual processes practically without
making any mistakes. Instead, when he tries to access to visual
memory of the Rey figure (Figure 3(e)), he omits figurative
aspects and details of the left side. The same phenomenon is
observed in Figure 1(c), which represents a landscape of his
hometown, and thus is a drawing of memory, in which again
omits graphic aspects of the left side. In these two examples, we
find a high level of concordance suggesting a dissociation
between perceptual processes and the access to visual memories through the “mind’s eye”. That’s why, in our patient, we
find signs of spatial-perceptual neglect and spatial-representational neglect that are limited to visual shapes.
As has been described in cases of color neglect, the finding
of neglect of visual shapes emphasizes that the organization
of the affected cerebral cortex not only systematically involves
such elementary functions as vision and manual dexterity but
also more complex forms of human effort such as artistic
graphic expression (Blanke et al., 2003).

Spatial agnosia
What neurocognitive aspects explain the difficulty to create
effective perspective in the patient’s painting, making it
appear two dimensional? This question may be approached
through the concept of spatial agnosia, which refers to the
inability to recognize and use information of a spatial nature
secondary to a brain injury. More specifically, this type of
agnosia refers to the perceptual impossibility of recognizing
and integrating spatial information in the absence of a primary
sensory alteration that justifies it (Roselli, 2015). This definition
would include, among other disorders, alterations in the
recognition of line orientation, defects in depth perception,
and alterations in spatial management as well as spatial memory failures. It is usually found in subjects with parietal or
parieto-occipital lesions such as those presented by our
patient, in whom we observe spatial agnosia due to poor
recognition and integration of visuospatial information, the
inability to locate some geographic elements of his country,
the difficulty to describe known routes, the changes in writing
(spatial agraphia), and changes at the artistic level that are
manifested by his difficulty in creating perspective in his
paintings and the fact that the paintings lack skillful handling
of the planes, depths, light source, and volume of objects,
thereby giving a two-dimensional aspect to his work. In the
copying of the house and cube, there is a poor perspective
and it is also evident the flattening of the figures if we consider that he is an artist (Figure 3(b)). It is important to clarify
that changes in artistic performance and neuropsychological
tests are not generated by executive dysfunction (Table 1).
These elements compel us to think that this patient has
experienced not only a purely attentional/representational

9

alteration similar to the alteration that leads to neglect but
that there are other cognitive/agnosic disorders related to the
construction of the artistic space. The deterioration of perspective is likely caused by damage to the system that processes
binocular information traveling through the dorsal (occipitoparietal) pathway, which regulates the visual and motor
aspects of pictorial creation, as has been demonstrated in
other cases of loss of three dimensionality in artists with
brain damage (Turnbull, Driver, & McCarthy, 2004).

Final remarks
The present case reveals the importance of right hemispheric
thalamo-parietal connections in the creation of works of art. It
allows us to elucidate that sensory neglect can have semiological subtleties, such as the exclusive omission of figurative
aspects of the left side (graphic neglect), being the pictorial art
a good instrument of evaluation complementary to the conventional neuropsychological tests. Likewise, the presence of
conceptual neglect allows us to understand that perceptual
processes can be dissociated from those guided by the
“mind’s eye” and would explain why a particular artist might
perform well copying, for example, a nude model, a portrait or
a landscape, and a poor performance creating drawings
through memories or as a product of his imagination.
Finally, the construction of the perspective in a work of art
can be modified after altering the occipitoparietal pathways
involved in the proper management of the depth. In this case,
the signs of spatial agnosia modified the correct construction
of the perspective and generated difficulties in locating the
source of light in his artistic work. We hope that this case will
contribute to elucidation of the complex labyrinth that links
brain functioning to the subtleties of pictorial art.

Disclosure statement
No potential conflict of interest was reported by the authors.

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