I t a L Z NeuroL Sci. 2: 233-23~ 1983

Pure "aphasic" agraphia due to
damage of the left superior parietal
lobule.
Paolino E., De Bastiani P., Monetti V.C., Boidrini P., Rosati G.*
Clinica Neurologica Universit& di Ferrara e Clinica Neurologica Universit?t di Sassari*.

A case ofpure agraphia, due to an &chaemic lesion of the left superiorparietal
lobule, is reported. The neuropsychological analysis of writing performances
suggests an aphasic nature of this patient's pure agraphia. The authors discuss
the role played by diffuse and~or localized brain lesions in writing function,
emphasizing that the left superiorparietal lobule in man may be crucial for t h e
sensorimotor linguistic integration needed for writing.
Key-Words: agraphia

Introduction
Pure agraphia, that is a selective disorder of
writing which arises without disturbances in oral
language, reading, praxis or in graphomotor
functions, has rarely been described in the literature. The question of the localization of the
brain lesion responsible for it is still under discussion. In the hypothesis advanced by Chedru
and Geschwind [5], after an analysis of the published cases, this disorder may be attributed to
diffuse brain lesions which may cause confusional states with reduction and/or shifting of
attention. On the other hand, some observations
suggest that pure agraphia may be the result of
isolated focal brain damage which involves different areas of the left hemisphere: the second
and third frontal gyri [1, 7, 10, 12], the superior
parietal lobe [3, 4], the temporal lobe [1 I], the
region of the caudate nucleus and the anterior
crus of the internal capsule [8]. In recent years,
the assumption of a specific centre for writing in
the second and third frontal convolution ("Exner's writing centre") has been rejected [5, 9]. On
the contrary, a considerable role is attributed to
the left superior parietal lobule which is supposed to be essential for the sensorimotor

linguistic integration needed for writing [4].
We describe a case of pure agraphia due to an
ischaemic lesion involving this area.

Case report
A 66-year-old, fight-handed tradesman, with a
grade school certificate, was in good general
health until one week prior to admission when
he began to complain of diffuse headache. Six
days afterwards, attempting to invoice the goods
ordered by a customer, he realized he was writing scrawls. Further attempts to write correctly
failed and the next day he was admitted to the
Neurological Clinic of Ferrara University.
On admission, general medical examination
showed no abnormality. On mental status assessment, he was alert and fully oriented in time,
space and person. Judgement and memory, both
for new and old events, were found to be unimpaired. Pupils, visual acuity, and visual fields,
as well as fundi and ocular movements were all
normal. The other cranial nerves were intact.
The remainder of the neurological examination
disclosed no abnormality, except for slight
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The Italian Journal of Neurological Sciences

SPONTANEOUS

WRITING

Caro

sono

amico

andato

ospedale

armi

WRITING

TO

in

che

mi

del I e

devono

anal i si

DICTATION

i

oggi

1u c e r t o l a

~

una

bella

ombrel 1o

giornata

o r o l ogio

occhi al i

ci l i e g i a

I ampada

ventagl io

tamburel l o

maial e

Fig. 1. Examples of spontaneous writing and writing to dictation showing paragraphias and neologisms.

increase of deep reflexes in the right limbs.
A neuropsychological examination was carried
out the day after admission. Intelligence and
reasoning capabilities tested by WAIS were norreal according to age educational level (IQv: 89,
234

IQp: 80 with the low score on Digit Symbol
subtest, IQfs: 84), as well memory tested by
WMS (MQ: 80). Word fluency was normal and
finger naming, right-left orientation, calculation
and stereognosis were unaffected. No impair-

Paolino." Pure aphasic agraphia

ment was found in the tests for the apraxias such
as oral (imitation of buccofacial gestures), ideomotor (imitation of intransitive upper limb gestures); constructional (copying geometrical
drawings), and use praxis (showing the use of
actual objects). On the Token Test the patient
scored 29 out of 36. The Language Test (Copyright Association for Development of N e u r o p sychological Research, Milan 1974) disclosed no
abnormalities in spontaneous speech, repetition, comprehension, denomination and reading, while impairment of writing was striking.
Examples of spontaneous writing and writing to
dictation are shown in Fig. I. Omissions and
substitutions of letters in a word, transposition
and repetition of words in a sentence were present. The first or last syllables of a word were
often omitted. Occasionally he would omit an
entire word. Paragraphias and neologisms occurred in one sentence. In both spontaneous
writing and writing to dictation he m a d e mistakes, whereas when he was asked to spell orally
the same words he could usually do so correctly.
N o difference was found in writing concrete and
abstract words or in writing short and long letter
strings, although an increase in the rate of errors
was detected in writing non-words. Ability to
write numbers to dictation was preserved as
long as they did not exceed three figures; above
this level, some minor mistakes were made.
Reproduction of a printed text was relatively
conserved and not "imitative". Transcription of
capital letters into lower case was correct about
70% of the time. F o r m i n g words and short sentences with alphabet blocks on c o m m a n d was
better than spontaneous writing, although not
without errors.
The patient was always aware of his mistakes,
which caused reactions of despair.
An electroencephalogram showed a discontinuous focal disturbance in the region of the left
parietal lobe and a C T scan a small hypodense
lesion in the left superior parietal lobule (Fig. 2
A, B, C). The CT-anatomical correlation was
made by using the criteria suggested by Takayoshi et al. [ 13].
He was discharged after two weeks. In the
course of the following months the patient's
visits to the Neurological Clinic were frequent
and regular. On these occasions, it was consistently observed that no appreciable change occurred in his neuropsychological test scores,
although his writing problems did show a slight
tendency to improve.
Discussion

In the case reported here, there is clinical evidence of a condition of agraphia without asso-

Figg. 2 A, B, C. Three successive computed tomographic scans with contrast enhancement showing
a small hypodense lesion in the left superior parietal lobule.
ciated aphasic, apraxic, spatial or g r a p h o m o t o r
disorders.
On the basis of the particular writing components which are disturbed, various clinical forms
of agraphJa have been described [9~. In our
patient, initially, the disruption of writing was
so serious that he was able to write only scrawls
or loops; therefore, the writing disorder might
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The Italian Journal ofNeurological Sciences

be classified as "apraxic" agraphia. Nevertheless, the neuropsychological analyses of writing
performed over the following days showed linguistic errors such as paragraphias, neologisms,
graphemic elisions, and reiterated attempts at
correction (conduites d'approche), without associated disorders in the visuospatial arrangement of letters, words and lines. These findings,
in our opinion, might suggest a selective disorder of the language output and, thus, the aphasic
nature of this patient's pure agraphia similar to
those reported by Rosati and De Bastiani [11]
and Laine and Marttila [8], who have suggested
that a focal brain damage, even in various localizations, can produce an isolated writing disorder of aphasic nature as distinct from apraxic and
spatial agraphias. In Chedru and Geschwind's
opinion [5], however, pure agraphia may be produced by diffuse brain lesions. It would seem to
be confirmed by the findings of Assal et at. [2],
who have proposed that an isolated writing disorder might be the result of a conjunction
between a state of general intellectual impairment and a selective deficiency corresponding to
a more localized damage, and furthermore by

Dubois et al. [6], who have emphasized the
importance of the decrease in intellectual capabilities present in four out of their six patients.
In our patient, the CT scan demonstrated an
ischaemic lesion in the left superior parietal
lobule, without any other signs of diffuse brain
damage and, furthermore, no impairment of
intellectual functioning was disclosed by WAIS
and WMS. Basso and co-workers [4] have advanced the hypothesis that the left superior parietal lobule in man may be "crucial for the sensorimotor linguistic integration needed for writhag". The present case would seem to confirm
that this area plays a role in writing, but, in our
view, additional information is needed before
drawing conclusions on the nature of this role.
In fact, some authors [8, 11] have described cases
of pure agraphia, clinically indistinguishable
from ours, in which the left superior parietal
lobule is spared. Accordingly, although pure
agraphia is more often the result of a localized
brain lesion, we are led to conclude that it has no
localizing value.

Sommario

Viene descritto un ca.so di agrafia pura dovuta ad una lesione ischemica del lobulo parietale superiore
sinistro. L'analisi neuropsicologica della scrittura indica la natura afasica di tale disordine. Gli autori
discutono il ruolo rivestito da lesioni cerebrali diffuse e/o localizzate nei processi della scrittura,
sottolineando quello del lobulo parietale superiore sinistro, ritenuto un importante punto di integrazione
sensorio-motoria del linguaggio necessaria per tale funzione.

Address reprint requests to: Dr. Ezio Paolino
Clinica Neurologica dell'Universit/l,
Corso della Giovecca 203, 44100 - - Ferrara

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