Left Unilateral Agraphia and Tactile Anomia
Disturbances Seen After Occlusion of the Anterior Cerebral Artery
Atsushi Yamadori, MD; Yukio Osumi, MD; Hiroto Ikeda, MD; Yasuhisa Kanazawa, MD

\s=b\ A 53-year-old right-handed Japanese

had a callosal disconnection syndrome associated with an occlusion of the
left pericallosal artery. Computerized tomography scan confirmed a left medial
lesion affecting the cingulate gyrus, the
paracentral lobule, the precuneus of the
left hemisphere, and most probably the
corpus callosum. This anterior cerebral
man

artery syndrome was characterized by
right hemiparesis with predominant crural
involvement, unilateral left-sided "disconnection" agraphia, and left unilateral "disconnection" tactile naming deficit.
To our knowledge, this is the first case
in the literature of the anterior cerebral
artery syndrome in which unilateral left\x=req-\
sided apraxia was not associated with
agraphia. The case is also the first in
which Kanji-Kana dissociation of an
aphasic nature has been reported as a
feature of isolated left agraphia.
(Arch Neurol 37:88-91, 1980)

TTThen one anterior cerebral artery
" ' is
occluded, several characteristic
signs may develop, depending on the
exact site of occlusion. According to
Critchley,1 the most frequently en¬
countered signs are contralateral pa¬
ralysis of the lower extremity, forced
grasping or groping of the ipsilateral
upper limb, and ideomotor apraxia of
the left arm, regardless of the side of
the infarction.
Left-sided ideomotor apraxia was
first described by Liepmann and
Accepted for publication Feb 7, 1979.
From the Departments of Neurology and Psychiatry (Drs Yamadori, Osumi, and Ikeda), and
Neurosurgery (Dr Kanazawa), Kobe University
School of Medicine, Kobe, Japan.
Reprint requests to Department of Neurology
and Psychiatry, Kobe University School of Medicine, Kusunokicho 7-chome, Ikutaku, Kobe 650,
Japan (Dr Yamadori).

Maas--' in a patient with left anterior
cerebral artery occlusion. They postu¬
lated that it was due to involvement of
the corpus callosum, the anterior four
fifths of which is nourished by the
anterior cerebral artery.1·4 According
to Liepmann, apraxia of the left hand
is a result of disturbed impulse trans¬
mission from the leading sensorymotor cortex of the left hemisphere to
the right hemisphere.
The role of the callosal lesions as a
cause of the left ideomotor apraxia

accepted by Liepmann's con¬
temporaries. Tumor cases50 as well as
right-sided anterior cerebral artery
occlusion7 have been reported.
was soon

8

In addition to the left-sided aprax¬
ia, left-sided agraphia and left-sided
astereognosis had also been observed
and were attributed to a lesion of the
corpus callosum. The agraphia had
been explained as a partial symptom
of the left-sided ideomotor apraxia.The astereognosis had been explained
as a loss of the dominant left hemi¬
sphere influence of stereognostic ca¬
pacity over the right hemisphere
because of callosal disconnection."
Geschwind and Kaplan,1"" howev¬
er, presented a consistent and persua¬
sive interpretation of these three uni¬
lateral left-sided signs. They ex¬
plained them as a manifestation of
disconnection of the left hemisphere
language zones from the right hemi¬
sphere due to callosal destruction.
Thus the left-sided apraxia to verbal
command is a result of disconnection
of the verbal order from the right
motor cortex. The left-sided agraphia
is not simply a partial phenomenon of
apraxia, but a sign of disturbed flow
of linguistic information from the left
hemisphere to the right. The leftsided astereognosis is not an agnosia,

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but a failure to name resulting from
failure of tactile information to be
transmitted from the right to the left
hemisphere. The hypothesis based on
Geschwind and Kaplan's case of left
anterior cerebral artery infarction
associated with a left frontal tumor
has since been confirmed in patients
with callosal section,12"1"1 with tumor,"1
and after trauma.17
We report a case of the left anterior
cerebral artery syndrome with leftsided agraphia and left-sided tactile
naming deficit but without left-sided

apraxia. Agraphia not accompanied
by apraxia has not so far been
reported in the anterior cerebral
artery syndrome. In addition, the
writing behavior observed in this
Japanese patient handling Kanji
(ideogram) and Kana (phonogram)
was aphasie in nature and thus pre¬

sented further evidence that the leftsided writing disorder has definite
linguistic abnormalities.
REPORT OF A CASE

The patient was a 53-year-old righthanded businessman. He had been hyper¬
tensive for 18 years. There was diminished
hearing and tinnitus in the right ear,
resulting from acoustic trauma in child¬
hood. For the past ten years, he had had
transient episodes of nausea accompanied
by transverse streaming of visual images
lasting about 30 minutes and occurring
once or twice a month. In December 1976,
he experienced sudden loss of power of the
right half of the body, which cleared rap¬
idly. There was no loss of consciousness. In
July 1977, he experienced general weak¬
ness for several minutes. The next day,
weakness of the right side appeared. He
has continued to drag the right leg since. In
the early morning of Dec 14th, 1977, brief
painful clonic convulsion of the right leg
occurred. Standing was impossible because
of weakness of the right leg; in the after-

noon the right arm became weak. The right
hemiparesis soon worsened and he became
dysarthric. Drooling from the right corner
of the mouth and inappropriate laughing

were

noted. He

was

admitted to the

Department of Neurosurgery, Kobe Uni¬
versity School of Medicine, on Jan 11,

1978.
On Jan 24, 1978, detailed neuropsycho¬
logical testing was performed. The patient
was observed closely for two weeks until
his discharge, but it was not possible to
perform subsequent examinations.
The patient was attentive, cooperative,
and oriented to time, place, and person.
Digit span was five forward. Recent mem¬
ory was not impaired. Speech compre¬
hension, naming, and repetition were with¬
in normal range but with slight slurring
and hesitancy. There were no paraphasic or
grammatical errors. Reading and calcula¬
tion were good. Serial sevens were per¬
formed without error. Copying of a cube
and drawing of a human face were done
well with either hand. No apraxia to verbal
command was detected in buccofacial,
limb, and whole body movements, or in
object handling. He could imitate with eyes
closed and with either hand postures
imposed on the fingers of the other hand

by the examiner.
There was right-sided weakness with
predominant involvement of the lower
extremity, which was almost immobile. In
the right upper extremity, there was pre¬
dominantly proximal weakness, with the

hand least affected. The right hand showed
a strong grasp response and he had diffi¬
culty releasing objects placed in that hand.
Often he had to release the grasp byextending each finger with the help of the
left hand. Muscle stretch reflexes were
hyperactive on the right with a Babinski
sign. Sensation to touch and pain was
slightly impaired in the right lower
extremity (30% decreased, by the patient's
description), but there was no loss in the
upper extremity. Position sense of both
toes and fingers was uncertain and often
incorrect on the right side. Two-point dis¬
crimination was normal in both hands.
Point localization was intact on the right
side. In the left arm and hand, there was
wandering of the pointing right index fin¬
ger, although it reached the correct spot
eventually. Double simultaneous stimula¬
tion was correctly perceived on both sides.
Vibration sense was reduced slightly on
the right side. Cranial nerve functions
were intact except for slight right central
facial weakness. Details of specific find¬
ings are described below.
SPECIAL EXAMINATION
RESULTS

Writing

Despite the mild paresis and strong
grasp reflex, the right hand made no
linguistic errors in spontaneous writ¬
ing or writing to dictation. There was
a tendency for letters to become
smaller and for the space between the
letters to get narrower as the patient
continued to write.

In contrast, writing with the left
hand was markedly impaired. There
were
many unintelligible letters.
Some letters could be made out but
were not graphically correct because
of added or missed strokes. Also,
graphically correct letters were ar¬
ranged in wrong order, substituted
for by different letters, or perseverated. There was a definite tendency
for Kanji (ideograms or logograms,
nonphonetic representations of word
meaning) to be correctly produced
more often than Kana (phonograms,
words written phonetically). For in¬
stance, an ideogram kumo (cloud) was
written correctly, but the two phono¬
grams of ku and mo were written
incorrectly. (Note: Substantive words
such as kumo can be written either

f
Fig 1.—Kanji writing. Right, Correct writing
by right hand of Kanji kumo. Left, Writing
by left hand of Kanji "thunder" instead of
"cloud" (kumo). Second attempt by left
hand (center) was correct.

way.) He wrote a complex Kanji graphem of kumo correctly after he had

written a different character, "thun¬
der," which resembles the former
character in shape and meaning. On
the other hand, when he was asked to
write these characters in Kana he
produced two unintelligible Kana-like
patterns and two correct Kana mo and
ku (ie, in reversed order).
Copying of letters and sentences
was correctly performed with either
hand, although left-handed copying
was very clumsy.
Written Calculation

Written calculations were tested
using both hands. Unilateral (left
hand) acalculia was present. For
example, multiplication of 126 x 41
was correctly performed with the
right hand. However, the left hand
produced many perseverative Is and
6s and could not produce a correct
answer. The patient kept saying that
he could not help producing "6." It
seemed that incorrect production of
digits by the left hand made a correct

operation impossible.

Tactile Object Identification

Objects were placed in either hand
for identification. The patient was
blindfolded. The right hand could not

manipulate objects, which usually
remained tightly held in the location
in which they had been placed by the
examiner. Naming of objects placed in

this hand, however, was prompt and
correct without exception. In contrast,
the left hand could manipulate an
object appropriately and adroitly. But
naming of objects held in this hand
was slow, hesitant, and often incor¬
rect; 52 objects were presented over
three sessions, with 38 correct re¬
sponses and 13 incorrect. Incorrect
answers were characterized by per-

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Fig 2.—Kana writing. Right column in
descending order, ku and mo were
correctly written by right hand. Left
column in descending order, unintelligible
character, correct mo, correct ku, and

unintelligible character were produced by

left hand.

severation of the same name or by

gross confabulation.
For example, "toothbrush" was cor¬
rectly used on the first occasion and
was then used for such dissimilar

objects as scissors, pencil, and wire.
The patient described a handkerchief
as "something like a toothbrush," or
"something is attached on top."
When naming was incorrect, the
patient was given the opportunity to
choose the object from five objects
using the same left hand. With vision
shielded, this was easily done, demon¬
strating good preservation of stereognostic capacity.

Graphesthesia
Arabic numerals and Kana letters
were traced on the palms of both
hands for naming. Surprisingly, all
numerals written on the left hand
were identified correctly and prompt¬
ly. However, the patient showed defi-

Fig 7—Left carotid arteriogram demon¬
strates occlusion of left pericallosal artery
(white arrowhead).

Fig 5.—Computerized tomography scan

with contrast enhancement demonstrates
a marked high-density area along medial
aspect of left hemisphere, surrounded by

low-density area.

Fig 3.—Copying with left hand. Characters
clumsily but are correct in their
essential pattern. First and third lines are
are written

model sentences; second and fourth lines
show patient's performance.

Fig 4.—Right, correctly performed multipli¬
cation by right hand. Left, unsuccessful
performance by left hand. Note perseverative tendency.

nite difficulty in naming numerals
written on the right palm; he was slow
and hesitant in response and very
often stated that he did not know the
answer. Of 20 digits tested on the two
occasions, only five were correct. The·
pattern of failure is a reversal of that
seen on the test of tactile naming, but
it should be noted that there was not a

single perseveratory or confabulatory

in contrast to what was
observed in the naming test.
In reading of Kana no such distinct
differences between the two hands
were observed, but those Kana pre¬
sented on the left palm tended to be
identified more frequently than ones
on the right. Of eight Kana written on
each palm, none was named on the
right, while four were correctly named
on the left. Again, there were no
perseverative, confabulatory, or paraphasic errors. Kanji was not tested
error,

Fig 6.—Schematic representation of Fig 5.

Hatched area represents extent of infarc¬
tion.

because of graphic complexity.
Thus, the patient showed poor per¬
formance of the right hand in identi¬
fying Kana and numbers. But the lack
of aphasie features in the errors seems
to distinguish this performance from
the poor naming of objects held in the
left hand. This is very probably due to
impairment of the discriminative
sense of the right hand and may be
attributable to a possible left parietal
lobe lesion.

Computerized Tomography

Computerized tomography (CT)
low-density area in the
parasagittal region of the left hemi¬
sphere. The lesion showed enhance¬
scan showed a

ment with contrast. There

was

no

deviation of the ventricular system.
The lesion most probably involved
part of the cingulate gyrus, the paracentral lobule, and the precuneus of

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the left hemisphere. The state of the
corpus callosum could not be discerned

from the CT scan but it is possible
that the structure was involved.
A left carotid arteriogram showed
diffuse sclerotic change of the intra¬
cranial arteries. The anterior cerebral
artery showed stenosis of a modest
degree at its origin from the internal
carotid artery, and the pericallosal
artery was occluded just after the
callosomarginal artery branched off.
A right brachial arteriogram showed
the same diffuse sclerotic change of
the intracranial arteries as the other
side. The right anterior cerebral
artery was not visualized from its
origin. The peripheral portion of the
right anterior cerebral artery territo¬
ry was partially visualized by collater¬
als from the middle cerebral artery.
It was concluded from these find¬
ings that the lesion responsible for the
symptomatology of the present case
was produced by infarction of the
territory supplied by the left pericallo¬
sal artery. Other areas of the brain

intact, despite sclerotic change
of the intracranial arteries.
were

COMMENT

Foix and Hillemand4 classified the
anterior cerebral artery syndrome
into three subtypes: simple crural
monoplegia, hemiplegia with predom¬
inant crural involvement, and crural
monoplegia (or predominantly crural
hemiplegia) with left-sided unilateral
ideomotor apraxia. The third type,
which has a callosal lesion, is most
relevant to the present discussion,
although apraxia was absent in our
case. Reported cases of this type of
anterior cerebral artery syndrome are
few. Foix and Hillemand collected
three autopsy verified cases of the
third type-71" and added another of
their own. Critchley in 1930 added two
more cases from the literature.1 But
reports of such cases have almost dis¬
appeared from the literature since
then. Only Sweet11' reported a case of
aneurysm of the anterior cerebral

artery with this type of symptoms. In
the 1960s, interest was revived by
Geschwind and Kaplan,1"·" but even
after their work, reports of the syn¬

drome have been very rare. The case
reported by Balaceanu et al in 1970-" is
perhaps the only one.
The left-sided agraphia in the pres¬
ent case had some interesting fea¬
tures that were manifested by clum¬
siness, production of occasional unin¬
telligible scribbles, substitution of
letters, displacement of letter order,
neologistic letter formation, and su¬
perior performance of Kanji writing
over Kana. The patient could also copy
letters well. These symptoms cannot
be explained as a partial symptom of
apraxia, as has been repeatedly
attempted, because the present case
had no accompanying ideomotor
apraxia of the left side. On the other
hand, all of the features enumerated
are essentially the same as those
usually observed in agraphia of apha¬
sie patients. Dissociation of Kanji and
Kana writing of this kind is a charac¬
teristic phenomenon found in some
types of Japanese aphasies.-1"' This
finding is in accordance with Gesch¬
wind and Kaplan's observation10 as
well as Bogen 's.14
This type of agraphia is aphasie in
nature but cannot be identified with
aphasie agraphia. In our patient, the

left hemisphere speech zone was not
affected and aphasia in the strict
sense was not present. The essential
mechanism lay in the failure of trans¬
mission of the programs of writing
from the left speech hemisphere to the
right hemisphere across the corpus
callosum. Thus, as Geschwind sug¬
gested,11 it would be appropriate to
call this type of agraphia "disconnec¬
tion agraphia," to emphasize the dis¬
sociative nature of the disturbance.
Apart from writing, the patient
responded well and without signs of
apraxia to various tasks involving the
left hand. Why should this happen?
According to Geschwind,11'-3 callosal

fibers responsible for praxis probably
arise from the motor association
cortex of one hemisphere and termi¬
nate in the same area of the other
hemisphere. These fibers are concen¬
trated in the anterior portion of the
corpus callosum. The absence of leftsided apraxia in our patient might be
due to sparing of the anteriormost
part of the callosum, since the portion
of the pericallosal artery thought to
serve this region was visualized, as
already mentioned. Sugishita and oth¬
ers24 reported a remarkable case in
relation to the independence of left
agraphia from left ideomotor apraxia.

Their patient underwent an operation
for an arteriovenous malformation of
the corpus callosum. Part of the poste¬
rior half of the trunk of the callosum
was coagulated, and about 2 cm was
subsequently sectioned. The patient
was left with isolated left agraphia
without other neuropsychological ab¬
normalities. The agraphia was charac¬
terized by aphasie errors only. This
case and ours suggest the existence of
independent functional channels of
linguistic information for writing
from channels of linguistic informa¬
tion for other motor performance
within the corpus callosum.
The difficulties in naming objects
placed in the left hand observed in the
present case were aphasie in nature.
The linguistic nature of this left-sided
difficulty was again made clear by
Geschwind and Kaplan1" for the first
time and has since been confirmed by
many workers, especially by the
observation of commissurotomized pa¬
tients1-lil5 and tumor patients.1" Balaceanu's patient also had similar diffi¬
culty.-0 In the present case as well as
in these cases, tactile recognition
itself was not impaired, nor was
speech mechanism affected. The pa¬
tients' abnormal responses are a man¬
ifestation of failure of tactile infor-

mation of the right hemisphere to
reach the intact speech mechanism of
the left hemisphere across the corpus
callosum. Thus the left speech hemi¬
sphere tries to fill this information
blank by confabulation or by repeat¬
ing a previous response (perseveration). This is an associative difficulty,
a failure to name because no stimulus
to naming reaches the left hemi¬
sphere. Here also "disconnection tac¬
tile naming deficit" would be a more
accurate term.
In summary, our patient apparently

had a purely linguistic disconnection
syndrome that was represented by
difficulty of the left hand in coordi¬
nating linguistic information. This
disconnection agraphia and disconnec¬
tion naming deficit can be explained
as a result of a callosal lesion that
disturbs the flow of linguistic infor¬
mation from the left hemisphere
speech area to the right hemisphere.
Transfer of other motor, auditory, and
visual information between the two
hemispheres seemed to be grossly
undisturbed.
Norman Geschwind, MD, Department of Neu¬
rology, Harvard Medical School, aided us consid¬
erably in highlighting the issues involved and in
correcting the text. We are extremely grateful
for his invaluable help.

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