Journal of Neurology, Neurosurgery, and Psychiatry 1986;49:455-457 Short report Dynamic spelling alexia JENNIFER HORNER,* E WAYNE MASSEYt From the Centerfor Speech and Hearing Disorders,* Department of Surgery, and Division of Neurology,t Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA SUMMARY A 59-year-old, right-handed, college-educated male examined after stroke presented spelling alexia with relative sparing of writing. He was not aphasic. A striking feature of the alexia was preserved recognition of letters printed in view by the clinician. He was able to read words through letter-by-letter oral spelling when letters were presented in this dynamic fashion. We describe this as a dynamic form of spelling alexia. Head CT scan showed a large left hemisphere posterior lesion infringing on the corpus callosum, and a right hemisphere opercular lesion. We suggest that sparing of the right parietal-occipital cortex may contribute to the remarkable sparing of dynamic letter reading. Patients with "pure alexia" present relatively preserved writing and are not aphasic as historically defined.' "Visual static agnosia"2 ' refers to impaired recognition of static stimuli with relatively preserved recognition of dynamic (that is, moving) stimuli. We describe a case with bilateral infarcts who had a dynamic form of spelling alexia. Recognition of dynamically-presented words was spared, while recognition of statically-presented words was impaired. Case history A 59-year-old, right-handed, college-educated white male suddenly developed left body weakness and dysarthria which improved over several days. On evaluation several weeks later (27 March 1982), he had a residual nondominant parietal lobe syndrome with considerable constructional apraxia and a left homonymous hemianopsia. Two weeks later he had an abrupt onset of right body weakness and aphasia. Initially he was somnolent but arousable. He had a left gaze preference and a right homonymous hemianopsia and a right central VII paralysis. Muscle stretch reflexes were symmetrical with a right Babinski sign. Pin prick sensation was decreased on the right. Head CT scan showed decreased density in the left posterior temporal hemisphere without Presented at the Thirty-Fifth Annual Meeting, The American Academy of Neurology, San Diego, California, May 1983. Address for reprint requests: Jennifer Horner, PhD, Department of Surgery, Box 3887, Duke University Medical Center, Durham, North Carolina 27710 USA. Received 2 October 1984 and in final revised form 18 July 1985. Accepted 23 July 1985 haemorrhage. He was given anticoagulants because of atrial flutter with 2:1 block. He converted to normal sinus rhythm with digoxin and quinidine. An echocardiogram showed no mural thrombus or mitral valve disease. His hemiparesis improved. A repeat head CT scan (5 April 1982) showed an extensive left posterior cerebral artery distribution infarct. (fig 1). A four vessel cerebral arteriogram demonstrated multiple emboli with normal carotid arteries. He continued to improve but had a persistent right Babinski. Visual fields demonstrated a persistent right superior quadrantanopsia. Our behaviour evaluation was conducted during a 6 to 9 month period after the stroke (September-November, 1982) The Western Aphasia Battery4 was administered. Spontaneous speech was fluent with intact grammatical form. Speech was free of semantic or phonemic paraphasias. Repetition was intact. Auditory comprehension in response to yes/no questions, body part names, and right-left commands was intact, while response to visual stimuli was moderately impaired. Confrontation naming was 2 of 20 (visual alone), improving to 16 of 20 following combined tactile and semantic/phonemic cues. The Aphasia Quotient was 78-8 (out of 100-0). Writing was characterized by occasional misspellings and simplified grammar but was both legible and sensible. Sentence copying.was severely impaired. The writing score was 67 8 (out of 100-0). Reading was his major handicap as reflected in a reading score of 15-0 (out of 100-0). Praxis (oral-nonspeech, ideomotor, and ideational) was intact (60-0 out of 60 0). Drawing was severely impaired (11 0 of 30 0). Mental calculation was spared (24-0 of 24 0). Abstract reasoning as measured by presentation of complex visual problems (Raven's Coloured Progressive Matrices5) was severely impaired (9-0 of 36 0). A cortical quotient (all Western Aphasia Battery subtests combined) was 70-2 out of 100-0 points maximum. Additional nonstandardised tasks involving scanning, 455 Horner, Massey 456 )?