Supramodal agnosia for oblique mirror orientation in patients with periventricular leukomalacia

Periventricular leukomalacia (PVL) is characterized by focal necrosis at the level of the periventricular white matter, often observed in preterm infants. PVL is frequently associated with motor impairment and with visual deficits affecting primary stages of visual processes as well as higher visual cognitive abilities. Here we describe six PVL subjects, with normal verbal IQ, showing orientation perception deficits in both the haptic and visual domains. Subjects were asked to compare the orientation of two stimuli presented simultaneously or sequentially, using both a two alternative forced choice (2AFC) orientation-discrimination and a matching procedure. Visual stimuli were oriented gratings or bars or collinear short lines embedded within a random pattern. Haptic stimuli comprised two rotatable wooden sticks. PVL patients performed at chance in discriminating the oblique orientation, both for visual and haptic stimuli. Moreover when asked to reproduce the oblique orientation, they often oriented the stimulus along the symmetric mirror orientation. The deficit generalized to stimuli varying in many low level features, was invariant for spatiotopic object orientation, and also occurred for sequential presentations. The deficit was specific to oblique orientations, and not for horizontal or vertical stimuli. These findings show that PVL can affect a specific network involved with the supramodal perception of mirror symmetry orientation.

Verbal auditory agnosia in a patient with traumatic brain injury: A case report

RATIONALE

Verbal auditory agnosia is the selective inability to recognize verbal sounds. Patients with this disorder lose the ability to understand language, write from dictation, and repeat words with reserved ability to identify nonverbal sounds. However, to the best of our knowledge, there was no report about verbal auditory agnosia in adult patient with traumatic brain injury.

PATIENT CONCERNS

He was able to clearly distinguish between language and nonverbal sounds, and he did not have any difficulty in identifying the environmental sounds. However, he did not follow oral commands and could not repeat and dictate words. On the other hand, he had fluent and comprehensible speech, and was able to read and understand written words and sentences.

DIAGNOSIS

Verbal auditory agnosia INTERVENTION:: He received speech therapy and cognitive rehabilitation during his hospitalization, and he practiced understanding of verbal language by providing written sentences together.

OUTCOMES

Two months after hospitalization, he regained his ability to understand some verbal words. Six months after hospitalization, his ability to understand verbal language was improved to an understandable level when speaking slowly in front of his eyes, but his comprehension of verbal sound language was still word level, not sentence level.

LESSONS

This case gives us the lesson that the evaluation of auditory functions as well as cognition and language functions important for accurate diagnosis and appropriate treatment, because the verbal auditory agnosia tends to be easily misdiagnosed as hearing impairment, cognitive dysfunction and sensory aphasia.

[Auditory agnosia associated with bilateral putaminal hemorrhage: A case report of clinical course of recovery]

A 45-year-old right-handed man with a past history (10 years) of putaminal hemorrage presented with auditory agnosia associated with left putaminal hemorrhage. It was suspected that the auditory agnosia was due to bilateral damage in the acoustic radiations. Generalized auditory agnosia, verbal and non-verbal (music and environmental), was diagnosed by neuropsychological examinations. It improved 4 months after the onset. However, the clinical assessment of attention remained poor. The cognition for speech sounds improved slowly, but once it started to improve, the progress of improvement was rapid. Subsequently, the cognition for music sounds also improved, while the recovery of the cognition for environmental sounds remained delayed. There was a dissociation in recovery between these cognitions. He was able to return to work a year after the onset. We also reviewed the literature for cases with auditory agnosia and discuss their course of recovery in this report.

Heterogeneity of Cognitive Anosognosia and its Variation with the Severity of Dementia in Patients with Alzheimer's Disease

Currently, the lack of awareness of deficits, i.e., anosognosia, is a major obstacle in the healthcare circuit that delays the diagnosis of Alzheimer's disease (AD). However, a clear framework is lacking in the literature related to this phenomenon in terms of its definition, mechanisms, and objects. The aim of this study is to assess the different levels of cognitive anosognosia using a prediction-performance procedure and to identify the potential correlates of these levels. A sample of patients with probable AD was divided into three groups according to the severity of dementia (mild (MiD), moderate (MoD), and moderately severe (MSD) dementia), ranked according to the results of the Mini-Mental State Examination. We observed the following three scores: the real score, the prediction score, and the anosognosia score. These scores were calculated based on the prediction-performance task MISAwareness from the Dementia Rating Scale for cognitive processes (i.e., Attention, Initiation, Conceptualization, Construction, and Memory). We obtained a strong plateau effect between the MiD and MoD groups for anosognosia scores for actual performance or prediction for both the level of overall functioning and for specific processes. The sole exception was the result for memory processes. Moreover, the profiles of the patients' responses on the Memory subscale were substantially different and, indeed, opposite from those for the other processes. The main results confirm the multidimensionality of anosognosia and its variability with the stage of dementia and specifically implicate memory processes that indicate a cleavage between memory and other cognitive functions.

The struggle for schizophrenia treatment: A case study

Individual of legal age with schizophrenia presenting anosognosia was abandoned, as a result of a court decision. Close family members were not allowed to provide medical follow-up, treatment, protection regarding his vulnerability, and preserve the dignity of their loved one. The issue was the court's prioritization of the autonomy of the individual over his mental health status. The purpose of this case study was to identify the pitfalls of a court case seeking medical follow-up and treatment for a family member with schizophrenia and anosognosia. The method was qualitative and the design was descriptive and instrumental, linking the law to the life experience resulting from the procedures for its implementation. This study examined the difference between clinical and medical-legal evaluation of the examinee. The application of the Therapeutic Jurisprudence principles to the high number of schizophrenia cases with anosognosia, the abandonment of the mentally ill, and family crisis call healthcare providers and the Judiciary for an improvement action of the process of guardianship.

A Systematic Review of Metacognitive Differences Between Alzheimer's Disease and Frontotemporal Dementia

Clinicians often have difficulty distinguishing between various forms of dementia to achieve a correct diagnosis. Little research has been done to examine whether awareness of one's cognitive deficits, or metacognitive monitoring, might differ between dementia diagnoses, thereby providing an additional means of differentiating between dementia subtypes. We review articles examining metacognitive comparisons between two of the most common dementia subtypes: Alzheimer's disease and frontotemporal dementia. Greater monitoring deficits were apparent in frontotemporal dementia than in Alzheimer's disease, and participants with frontotemporal dementia were less likely to utilize task experience to update and improve the accuracy of subsequent monitoring judgments. Results provide evidence for the utility of metacognitive measures as a means of distinguishing between Alzheimer's disease and frontotemporal dementia.

Efficacy of self-perception after traumatic brain injury

BACKGROUND

Anosognosia is a lack of awareness of personal deficits that is commonly observed in people with a traumatic brain injury (TBI).

OBJECTIVE

The purpose of this paper is to examine whether self-appraisal of executive functioning differs for students with and without TBI.

METHODS

Students who had survived a TBI and those who had never had a TBI filled out the Behavior Rating Inventory of Executive Functioning from three different perspectives. Each participant was paired with an observer who was familiar with the person's behavior. Self-appraisal ratings, observer ratings of the participant, and reflective appraisal of how the participant thought the observer would rate them were compared.

RESULTS

For the students without TBI, reflective appraisal was significantly correlated with self-appraisal but observer appraisal was not. For students with TBI, neither reflected appraisal nor observer appraisal correlated with self-appraisal. Both TBI and non-TBI participants overestimated their problems on measures of Inhibition, Shifting, Emotional Control, Initiation, and Planning/Organizing. TBI participants underestimated their problems on measures of Working Memory, Organization, and Task Monitoring relative to the non-TBI group.

CONCLUSIONS

Students with TBI do not accurately perceive how others perceive their behavior.

Brain lesion-pattern analysis in patients with olfactory dysfunctions following head trauma

The presence of cerebral lesions in patients with neurosensory alterations provides a unique window into brain function. Using a fuzzy logic based combination of morphological information about 27 olfactory-eloquent brain regions acquired with four different brain imaging techniques, patterns of brain damage were analyzed in 127 patients who displayed anosmia, i.e., complete loss of the sense of smell (n = 81), or other and mechanistically still incompletely understood olfactory dysfunctions including parosmia, i.e., distorted perceptions of olfactory stimuli (n = 50), or phantosmia, i.e., olfactory hallucinations (n = 22). A higher prevalence of parosmia, and as a tendency also phantosmia, was observed in subjects with medium overall brain damage. Further analysis showed a lower frequency of lesions in the right temporal lobe in patients with parosmia than in patients without parosmia. This negative direction of the differences was unique for parosmia. In anosmia, and also in phantosmia, lesions were more frequent in patients displaying the respective symptoms than in those without these dysfunctions. In anosmic patients, lesions in the right olfactory bulb region were much more frequent than in patients with preserved sense of smell, whereas a higher frequency of carriers of lesions in the left frontal lobe was observed for phantosmia. We conclude that anosmia, and phantosmia, are the result of lost function in relevant brain areas whereas parosmia is more complex, requiring damaged and intact brain regions at the same time.

[Simultanagnosia and scene agnosia induced by right posterior cerebral artery infarction: a case report]

A 68-year-old man was admitted to our hospital for rehabilitation of topographical disorientation. Brain magnetic resonance imaging revealed infarction in the right medial side of the occipital lobe. On neuropsychological testing, he scored low for the visual information-processing task; however, his overall cognitive function was retained. He could identify parts of the picture while describing the context picture of the Visual Perception Test for Agnosia but could not explain the contents of the entire picture, representing so-called simultanagnosia. Further, he could morphologically perceive both familiar and new scenes, but could not identify them, representing so-called scene agnosia. We report this case because simultanagnosia associated with a right occipital lobe lesion is rare.

The Italian validation of the Anosognosia Questionnaire for Dementia in Alzheimer's disease

Although the Anosognosia Questionnaire-Dementia (AQ-D) is one of the main instruments for assessing awareness in Alzheimer's disease (AD), the normative data were until now limited to people from Argentina and Japan. This study aims to validate this instrument in an European context, in particular in an Italian sample. In a multicenter project (Verona, Padova, and Trapani), 130 patients with AD and their caregivers participated in the study. Psychometric characteristics of AQ-D are confirmed indicating that the scale permits the early identification of anosognosia and the correct care management of patients. Indeed, anosognosia results to be present also in patients with very mild AD (moderate: 44.44%; mild: 47.17%; and very mild: 23.73%). Moreover, the results indicate that deficits in awareness may vary in severity and that different types of anosognosia may be identified.

[Asomatognosia as a manifestation of migraine with aura. case report and review]

INTRODUCTION

For years the study of migraine with aura was surprised by the versatility of its presentation. Auras are manifested with the gradual development of neurological symptoms ranging from visual impairment to perception disorders. The latter are rare forms of presentation being the reason for this article.

CASE REPORT

the case of a female patient of 53 years diagnosed with migraine with aura which makes an autobiographical account of their crises, with special emphasis on a variant of asomatognosia as manifestation is presented. It then discusses the asomatognosia as a phenomenon belonging to the altered body image and the different concepts related to these clinical forms and a brief overview of the possible anatomical locations of these conditions do.

CONCLUSION

Migraine with aura may manifest with varied previous symptoms before the pain. The asomatognosia is an uncommon presentation. A field of interests for research also include an effort to define the specificity and location of the lesion as a method for better understanding of how injuries to very specific areas of the brain affect perception and memory.

[Dementia and mild cognitive impairment in Parkinson's disease: a review]

INTRODUCTION. The cognitive disorders in Parkinson's disease (PD) have traditionally been associated with the presence of dementia in later stages of the disease. Recent studies, however, consider that cognitive impairment can appear as of early stages. Knowing the cognitive profile of PD furthers our understanding of the clinical phenotype, making it easier to reach a timely diagnosis and favouring intervention on the symptoms from the initial stages. AIM. To present a review of the literature on mild cognitive impairment (MCI) and dementia associated with PD. DEVELOPMENT. Several studies report that patients with PD who have a prolonged time to progression develop dementia. Yet, there have also been reports claiming that, as of the early stages, patients can present subtle cognitive alterations known as MCI. The initial neuropsychological profile is mainly of a non-amnesic type, characterised by executive dysfunction, alterations affecting attention, operative memory deficit and faulty retrieval of information. When patients develop dementia, disorders will arise in the storage of information, in semantic fluency, and in visuospatial and visuoperceptual skills. Currently there are criteria available for diagnosing the MCI and dementia associated with PD, as well as valid reliable instruments for detecting those disorders. CONCLUSIONS. Cognitive symptoms are frequent in PD. From the initial stages of the disease onwards patients may present MCI that is mainly characterised by a fronto-subcortical cognitive profile, whereas dementia usually develops at later stages, when a pattern of posterior cortical cognitive disorder is also observed.

[The influence of anosognosia and depression on the perceived quality of life of patients with Alzheimer's disease: a 12 months follow-up]

INTRODUCTION

Anosognosia and depression can influence perceptions of the patient's quality of life (QoL-p) in Alzheimer's disease (AD).

AIM

To explore changes in perceived QoL-p in AD and the influence that depression and anosognosia can have on both patient and caregiver ratings.

PATIENTS AND METHODS

Observational, analytical and longitudinal study over 12 months of a consecutive sample of 221 outpatients. Mean age was 77.8 ± 7.3 years and there were 140 women (63.3%). Instruments: Quality of Life in AD, Anosognosia Questionnaire-Dementia, Geriatric Depression Scale, Disability Assessment for Dementia, Neuropsychiatric Inventory, Mini-Mental State Examination and Global Deterioration Scale. Effect size of the differences between two means was calculated, and a linear regression analysis involving the factors associated with perceived QoL-p was performed.

RESULTS

Patients with anosognosia had less depression and higher scores on the Quality of Life in AD, as compared with patients without anosognosia, and regardless of antidepressant drug treatment. Caregiver ratings of QoL-p were more negative. In the linear regression the largest discrepancies between patient and caregiver ratings of QoL-p were associated with anosognosia, depression, and functional status, factors that explained 35.3, 7.9 and 11.3% of the variance, respectively.

CONCLUSIONS

Anosognosia was associated with less depression and better perceived quality of life in patients.

[Disorders of body schema]

A variety of disorders have been associated with the concept of body schema. However, this concept has been interpreted in many ways, and there is no consensus on the nature and cognitive mechanisms of body schema. Historically, two major issues have been discussed. One was the body-specificity of the body schema, and the other was the relationship between input and output modality. Autotopagnosia, an inability to localize and orient different parts of the body, has been a focus of attention because it is thought to provide insight into the function of body schema. Although there have not been many cases of pure autotopagnosia, a double dissociation indicating the independence of body-specific system. There are a few working hypotheses for cognitive models of body schema, which can explain the different types of autotopagnosia. One model includes multiple representation subsystems for body processing, while another assumes the use of intrinsic and extrinsic egocentric coordinates to maintain on-line processing for body state. The consistency of these accounts should be examined in light of extensive neuroimaging and psychological data, to construct a plausible model for body schema.

[Mirror behaviors in dementia: the many mirror signs]

Mirror behaviors in advanced dementia are: the mirror sign of Abely and Delmas, where the patient stares at his face (environment-driven behavior of Lhermitte); non recognition of the self in the mirror (autoprosopagnosia and/or delirious auto-Capgras); mirror agnosia of Ramachandran and Binkofski where the patient do not understand the concept of mirror and its use; the psychovisual reflex, or reflex pursuit of the eyes when passively moving a minrror in front of a patient (intact vision); mirror writing (procedural learning). We describe four demented patients with mirror behaviors assessing brain mechanisms of self recognition, social brain and mental and visuo-spatial manipulation of images and objects.

Agnosia for accents in primary progressive aphasia

As an example of complex auditory signal processing, the analysis of accented speech is potentially vulnerable in the progressive aphasias. However, the brain basis of accent processing and the effects of neurodegenerative disease on this processing are not well understood. Here we undertook a detailed neuropsychological study of a patient, AA with progressive nonfluent aphasia, in whom agnosia for accents was a prominent clinical feature. We designed a battery to assess AA's ability to process accents in relation to other complex auditory signals. AA's performance was compared with a cohort of 12 healthy age and gender matched control participants and with a second patient, PA, who had semantic dementia with phonagnosia and prosopagnosia but no reported difficulties with accent processing. Relative to healthy controls, the patients showed distinct profiles of accent agnosia. AA showed markedly impaired ability to distinguish change in an individual's accent despite being able to discriminate phonemes and voices (apperceptive accent agnosia); and in addition, a severe deficit of accent identification. In contrast, PA was able to perceive changes in accents, phonemes and voices normally, but showed a relatively mild deficit of accent identification (associative accent agnosia). Both patients showed deficits of voice and environmental sound identification, however PA showed an additional deficit of face identification whereas AA was able to identify (though not name) faces normally. These profiles suggest that AA has conjoint (or interacting) deficits involving both apperceptive and semantic processing of accents, while PA has a primary semantic (associative) deficit affecting accents along with other kinds of auditory objects and extending beyond the auditory modality. Brain MRI revealed left peri-Sylvian atrophy in case AA and relatively focal asymmetric (predominantly right sided) temporal lobe atrophy in case PA. These cases provide further evidence for the fractionation of brain mechanisms for complex sound analysis, and for the stratification of progressive aphasia syndromes according to the signature of nonverbal auditory deficits they produce.

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Deficits of accent processing can be a presenting feature of primary progressive aphasia.

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Accent agnosia can dissociate from a generalised auditory agnosia.

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Progressive aphasia syndromes show different profiles of accent processing deficits.

Self-rated anosognosia score may be a sensitive and predictive indicator for progressive brain atrophy in amyotrophic lateral sclerosis: an X-ray computed tomographic study

We investigated whether a self-rated anosognosia score can be an indicator for progression of brain atrophy in patients with amyotrophic lateral sclerosis (ALS). Scores for 16 patients were compared with the ventricular areas of the bilateral anterior and inferior horns measured on x-ray computed tomography. Longitudinal enlargement was expressed as a monthly increase in size: (ventricular size at the initial scan - ventricular size at the follow-up scan)/scan interval (months). The anosognosia scores ranged from -4 to 3 and 3-18 in patients with and without frontotemporal lobar degeneration (FTLD), respectively (p = 0.0011). Anosognosia scores were significantly correlated with sizes of anterior (r = 0.704, p = 0.0016) and inferior (r = 0.898, p < 0.0001) horns. In non-demented patients for whom follow-up CT scans were available (n = 7), the scores were significantly correlated with the longitudinal increase in inferior horn size (r = 0.754, p = 0.0496), but not with that of anterior horn size (r = -0.166, p = 0.7111). In conclusion, anosognosia in ALS is associated with greater anterior and inferior horn sizes, reflecting frontotemporal lobar atrophy. Moreover, mild anosognosia in ALS patients without FTLD may predict impending inferior horn enlargement, reflecting medial temporal atrophy.

Agnosias: recognition disorders in patients with brain tumors

Two main varieties of recognition disorders are distinguished in neuropsychology: agnosias and semantic disorders. The term agnosias is generally used to denote recognition defects limited to a single perceptual modality (which is itself apparently intact), whereas the term semantic disorders is used to denote recognition defects involving all the sensory modalities in a roughly similar manner. Brain tumors can be one of the aetiologies underlying agnosias and semantic disorders. However, due to the heterogeneity and the rarity of recognition disorders, their investigation can be useful only to suggest or exclude the oncological nature of a brain lesion, but not to systematically monitor the clinical outcome in tumor patients. Furthermore, the relevance of recognition disorders as a hint toward a diagnosis of brain tumor varies according to the type of agnosia and of semantic disorder and the localization of the underlying brain pathology. The hypothesis that a variety of agnosia (or of semantic disorder) may be due to a neoplastic lesion can, therefore, be advanced if it is consistent with our knowledge about the usual localization and the growing patterns of different types of brain tumors.

Right hemisphere syndromes

Stroke is the leading cause of acquired motor disability in the adult. Neuropsychological sequelae are common after vascular brain injury. While left cortical signs and symptoms are clearly evident at neurological examination, right hemispheric dysfunction must be carefully pursued and sometimes can be underrecognized. Indeed, patients with right hemispheric strokes present later to an emergency department and have a lower chance of receiving intravenous recombinant tissue plasminogen activator. For a better comprehension of clinical signs and symptoms in right acute hemispheric stroke, in this chapter we present a review of the principle clinical syndromes.

Visual agnosia and posterior cerebral artery infarcts: an anatomical-clinical study

Background

To evaluate systematically the cognitive deficits following posterior cerebral artery (PCA) strokes, especially agnosic visual disorders, and to study anatomical-clinical correlations.

Methods and Findings

We investigated 31 patients at the chronic stage (mean duration of 29.1 months post infarct) with standardized cognitive tests. New experimental tests were used to assess visual impairments for words, faces, houses, and objects. Forty-one healthy subjects participated as controls. Brain lesions were normalized, combined, and related to occipitotemporal areas responsive to specific visual categories, including words (VWFA), faces (FFA and OFA), houses (PPA) and common objects (LOC). Lesions were located in the left hemisphere in 15 patients, in the right in 13, and bilaterally in 3. Visual field defects were found in 23 patients. Twenty patients had a visual disorder in at least one of the experimental tests (9 with faces, 10 with houses, 7 with phones, 3 with words). Six patients had a deficit just for a single category of stimulus. The regions of maximum overlap of brain lesions associated with a deficit for a given category of stimuli were contiguous to the peaks of the corresponding functional areas as identified in normal subjects. However, the strength of anatomical-clinical correlations was greater for words than for faces or houses, probably due to the stronger lateralization of the VWFA, as compared to the FFA or the PPA.

Conclusions

Agnosic visual disorders following PCA infarcts are more frequent than previously reported. Dedicated batteries of tests, such as those developed here, are required to identify such deficits, which may escape clinical notice. The spatial relationships of lesions and of regions activated in normal subjects predict the nature of the deficits, although individual variability and bilaterally represented systems may blur those correlations.

Auditory agnosia due to long-term severe hydrocephalus caused by spina bifida - specific auditory pathway versus nonspecific auditory pathway

A 27-year-old female showed auditory agnosia after long-term severe hydrocephalus due to congenital spina bifida. After years of hydrocephalus, she gradually suffered from hearing loss in her right ear at 19 years of age, followed by her left ear. During the time when she retained some ability to hear, she experienced severe difficulty in distinguishing verbal, environmental, and musical instrumental sounds. However, her auditory brainstem response and distortion product otoacoustic emissions were largely intact in the left ear. Her bilateral auditory cortices were preserved, as shown by neuroimaging, whereas her auditory radiations were severely damaged owing to progressive hydrocephalus. Although she had a complete bilateral hearing loss, she felt great pleasure when exposed to music. After years of self-training to read lips, she regained fluent ability to communicate. Clinical manifestations of this patient indicate that auditory agnosia can occur after long-term hydrocephalus due to spina bifida; the secondary auditory pathway may play a role in both auditory perception and hearing rehabilitation.