ltaL J. Neurol. Sci. 7: 261-264, 1986

Balint syndrome: a case of
slmultanagnosia
Berti A., Papagno C., Vallar G.
lstituto di Clinica Neurologica, Universitgt di Milano

We describe a patient with a bilateral posterior lesion, who showed optic ataxia,
gaze apraxia and the symptom which most authors call the inability to see more
than one thing at a time. We discuss the last feature and the term simultanagnosia sometimes used to indicate it. Furthermore we stress the unusual localization
o f the lesion in this patient.
Key-Words: Balint syndrome - - gimultanagnosia - - parietal lobe
A 65 year-old retired fight-handed worker, with
five years schooling, had suffered sudden, blurred
vision ten years earlier for two days. He was hospitalized on 17 December 1983 due to a recurrence of sudden blindness which he described as
if somebody had suddenly turned off the light in
the room.
Neurological examination showed neither motor
nor somatosensory deficits. On confrontation, the
visual field seemed narrower than normal, though
the patient could detect some moving stimuli at
the periphery.
Ocular movements to verbal command in the four
cardinal directions were normal. Tracking at different speed in various directions was impossible
at first; however it was possible to obtain irregular
saccadic eye movements with under-and overshooting by moving the target some cms. at a time,
stopping and then instructing the patient to look
for the target again. The performance was better
when the patient's own finger, moved by the examiner, was the target. When the patient was
asked to look at each of the examiner's hands alternately, held in front of him, one in each of his
visual hemi-fields, some irregularly saccadic ocular movements with both under and overshooting
were elicited. Acoustically elicited movements
were normal. Spontaneous eye movements were
present, though when the patient had focused on
an object, he tended to keep his gaze fixed. Even if
the patient was allowed to move his head, he did
not look at lateral stimuli if there was no verbal information about their location.
Manual reaching out to motionless objects was
impossible. In fact, due to the deficit on the visual
field periphery, the patient seemed to have tubular vision. On the other hand, manual reaching out

to a swinging target was possible in both visual
hemi-fields with either hand, with eyes either
open or closed in primary position. Performance
improved when the patient was allowed to look at
the target, but there was almost always overshooting; the patient could not reach the target correctly although he claimed to see it perfectly, and this
caused him much surprise. The deficit was more
evident if the task was performed with the fight
hand.
He had no difficulty in pointing with both hands
and with closed or open eyes to parts of his own
body named by the examiner.
He showed neither apraxia nor disorders of topographic memory.
His visual discrimination of lengths and sizes of
pairs of geometrical figures was good. There were
pronounced difficulties in matching, naming and
indicating colours. Anomic defects were present:
the patient was not able to name common objects
presented in different modalities, but he could describe how to use them perfectly.
The patient was required to mark some circles
drawn on a sheet of paper with a pencil.
In this task he did not show unilateral neglect for
space: in fact he marked all the circles - including
the smallest - because his visual acuity was practically normal. On the other hand it was evident
(see Fig. 1) that he had no strategy in the search
and the sign used to mark the circles was placed
close to but outside the circle. The patient said he
could not perform correctly because as soon as he
got near the sheet with the pencil, the circle disappeared. The same phenomenon was present when
the patient was asked to mark the center of a circle
(see Fig. 2).
In addition, the patient had great difficulty in per261

The Italian Journal of Neurological Sciences

@

0/ h

0
0

"0

16

o

Is

@.

IS

~

.~

,o
o

Fig. 1. Patient's performance in making all the circles drawn on a sheet o f paper.
ceiving the examiner's hand when placed between his face and that of the examiner. He
claimed that he could see either the hand or the
face o f the examiner, but not both together. Although at the beginning o f the task the patient had
declared he could see the whole face, he later admitted that he could see only the eyes and perhaps
the nose but not the face as a whole. The mouth
was seen only when the lips were moving. Furthermore, he asserted that he could not perceive
two parts of the face simultaneously, but only one
at a time.
Reading was very impaired: only occasionally the
patient was able to read single letters, but not a
Fig. 2. Attempts to place a point in the center o f a
circle.

whole word. He could read the acronym USSR,
written in block letters 10 mm. high, but he did not
recognize the acronym USA, written in the same
characters very close to the first word, though he
could see the letter U and with great difficulty the
letter A but not the S.
When shown Poppelreuter's figures he could almost always recognize one of the overlapping
items only (see Fig. 3).
A CT scan showed an ischemic lesion in the left
hemisphere involving the lateral part of the occipital lobe and sparing the gyrus fusiformis and the
calcarine fissure. In the right hemisphere there
was a hemorrhagic lesion involving the parietooccipital junction and the posterior part of the
medial temporal gyms. In the parietal area only
the inferior part appeared involved (see Fig. 4).

Discussion
Our patient presented the three main features of
the Balint syndrome: optic ataxia, gaze apraxia
and the phenomenon described by most authors
as an inability to see more than on thing at a time.
This paper will not discuss optic ataxia and gaze
apraxia but will deal with the symptom described
as an inability to see more than one thing at a
time. Balint [2] believed that this deficit was due to
a narrowing of visual attention. In our patient,
this hypothesis contrasts with the ability to scan,
which was preserved in spite of the severe gaze
apraxia. In addition, even though he appeared to
have tubular vision, it was possible to obtain some
reaction when moving stimuli were used.
262

Berti A.: Balint syndrome and simultanagnosia

Fig. 3. Poppelreuter~figures.
Luria [10, 11] described two patients showing this
symptom and used the term "'simultanagnosia".
The term "simultanagnosia" is found in the literature to indicate different perceptive disorders.
Wolpert [15] was the first to employ this term to
describe a patient unable to give an adequate account of a picture as a whole, though able to point
out most of its individual features. Wolpert considered this syndrome to be due to a disorder at
the "highest level of perception". Kinsbourne and

Warrington [9] described patients - with clinical
evidence of left hemisphere lesion - who appeared to present a symptom corresponding to
Wolpert's description, but they demonstrated that
(at least in their patients) the difficulty in perceiving the meaning of the picture was not due to a
disorder of the "final step in perception", or to an
"apprehension of the whole" (Gesamtauffassung). By means of the brief exposure of visual
forms singly and in pairs Kinsbourne and Warrington were able to show that there was a deficit
in simultaneous visual form recognition, namely:
their patients could see two forms, but they recognized only one. According to Kinsbourne and
Warrington such a deficit could account for the
clinical features of simultanagnosia. Conversely
our patient, when he was indicating one by one
the individual features o f the examiner's face, was
always quite aware of the fact that he was looking
at a face though he could "see" only one single
feature of it at a time. It must be noted that most
cases of Balint syndrome, with bilateral brain lesions, [4, 10, 11, 14, 1, 13, 5] show the phenomenon
present in our patient, i.e. the inability to see (but
not to recognize, as observed by Kinsboume and
Warrington) more than one object at a time.
To avoid confusion, it is necessary to be aware of
the ambiguity of the term "simultanagnosia": in
some cases [15] it seems to refer to a kind of agnosia for the whole meaning of a picture even
though the perception of single fragments is possible. On the other hand, in most cases o f Balint
syndrome, e.g. Luria [10], it refers to the "extinction" of visual stimuli when the patient focuses on
an adjacent one.

Fig. 4. CTscan showed an ischemic lesion in the left occipital lobe and a hemorrhagic lesion in the right par-

ieto-occipitaljunction involving the posterior part of the medial temporal gyrus.

A

B

C

263

The Italian Journal of Neurological Sciences

This distinction is important not only for its conceptual value, but also for its clinical significance.
In fact, while the first type of disorder seems to
follow injuries to the inferior part of the left occipital lobe [9] the second kind is part of the Balint
syndrome resulting from a bilateral posterior lesion.
Post mortem data are available in six cases, [2, 6, 4,
12, 7]. In the case of Hijdra [5] the lesion site was
assessed by C T scan. The element c o m m o n to all
of cases is the bilateral involvement of the parietal
area. The parietal lobe is d a m a g e d either exten-

sively or in its upper part. Only in the Hoff and
Potzl case [6] the lesion involved the occipital lobe
of the left hemisphere a n d the parieto-occipital
convexity of the fight hemisphere. In the patient
of Kase et al [7] a bilateral lesion confined to the
u p p e r parietal lobe was shown. On the basis of
these data De Renzi [3] suggested that a lesion of
the u p p e r part of the parietal lobe is needed to determine the syndrome. The C T scan of our patient
showed a different picture: the left parietal lobe
seemed to be spared, whereas on the fight the lesion involved the inferior part of the parietal lobe.

Sommario
Viene descritto il caso di un paziente, portatore di lesioni vascolari bilaterali posteriori, che presentava : atassia ottica, aprassia dello sguardo e il sintomo the molti autoti definiscono incapacitgl a vedere pi~ di uno stimolo per volta. Quest'ultimo disordine e il termine "simultanagnosia" vengono brevemente discussi, lnfine
viene sottolineata l'inusuale localizzazione delle lesioni cerebrali di questo paziente.

Address reprint requests to: Dr. G i u s e p p e Vallar
Centro di Neuropsicologia Universit~ di Milano,
Via Francesco Sforza, 35 - 20136 M i l a n o

References

[1] ALLISONR.S., HURWITZ L.J., GRAHAM WHITE J.,
WILMOTT.J. : A follow-up of a patient with Balint's
syndrome, Neuropsychologia, 7, 319-333, 1969.
[2] BALINTR.: Seelenlahmung des Schauens, optisehe
Ataxie, raamliche Storung der Aafmerksamkeit, Monatschr Psych Neur, 25, 51-71, 1909.
[3] DE RENZl E.: Disorders of Space Exploration and
Cognition, Chichester Wiley (1982).
[4] HECAEN H., AJURIAGUERRAJ.: Balint's syndrome
(Psychic paralysis of visual fixation) and its minor
forms, Brain, 77, 373-400, 1954.
[5] HUDRAA., MEERWALDTJ.D.: Balint's syndrome in a
man with border-zone infarcts caused by atrial fibrillation, Clin. Neurol..N. eurosurg, 86-1,51-54, 1984.
[6] HOFF H., POTZL D. : Uber ein neues parieto-occipitalessyndrom, Hb. Psychiat. 52: 173-218, 1935.
[7] KASEC.S., TRONCOSOJ.F., COURTJ.E., TAPIAJ.F.,
MOHR J.P.: Global spatial disorientation. J. Neurol.
Sci. 34: 267-278, 1977.
[8] KINSBOURNEM., WARRINGTONE.K.: A disorder of
simultaneous form perception. Brain 85: 461-486,

264

1962.
[9] KINSBOURNEM., WARRINGTONE.K. : The localizing
significance of limited .simultaneous visual form perception. Brain 86: 69?-702, 1963.
[10] LURIAA.R., PRAVDINA-VINARSKAYAE.N., YARBUSS
A.L. : Disorder of ocular movement in a case of simultanagnosia. Brain 86: 219-228, 1963.
[11] LURIAA.R. : Disorder of "simultaneous perception "in
a case of bilateral occipito-parietal brain injury. Brain
82: 437-449, 1959.
[12] MICHEL F., JEANNERODM., DEV1C M.: Trouble de
l'orientation visuelle clans les trois dimensions de I'espace (,4 propos" d'un cas anatomique). Cortex l:
441-466, 1965.
[13] SORGATOP. : Analisi neuropsicologica delle complicanze cerebrali a lungo termine dell'eclampsia. Riv.
Pat. Nerv. Ment. 97: 371-384, 1976.
[l 4] TYLERH.R. : Abnormalities of perception with defective eye movements (Balint's syndrome). Cortex 4:
154-171, 1968.
[15] WOLPERTI.: Die Simultanagnosie Storung der Gesamtauffassung. Z. ges. Neurol. Psychiat. 93:
397-415, 1924.