Two action systems in the human brain

The Sound of Grasp Affordances: Influence of Grasp-Related Size of Categorized Objects on Vocalization

Previous research shows that simultaneously executed grasp and vocalization responses are faster when the precision grip is performed with the vowel [i] and the power grip is performed with the vowel [ɑ]. Research also shows that observing an object that is graspable with a precision or power grip can activate the grip congruent with the object. Given the connection between vowel articulation and grasping, this study explores whether grasp-related size of observed objects can influence not only grasp responses but also vowel pronunciation. The participants had to categorize small and large objects into natural and manufactured categories by pronouncing the vowel [i] or [ɑ]. As predicted, [i] was produced faster when the object's grasp-related size was congruent with the precision grip while [ɑ] was produced faster when the size was congruent with the power grip (Experiment 1). The effect was not, however, observed when the participants were presented with large objects that are not typically grasped by the power grip (Experiment 2). This study demonstrates that vowel production is systematically influenced by grasp-related size of a viewed object, supporting the account that sensory-motor processes related to grasp planning and representing grasp-related properties of viewed objects interact with articulation processes. The paper discusses these findings in the context of size-sound symbolism, suggesting that mechanisms that transform size-grasp affordances into corresponding grasp- and articulation-related motor programs might provide a neural basis for size-sound phenomena that links small objects with closed-front vowels and large objects with open-back vowels.

Alterations in the Structural and Functional Connectivity of the Visuomotor Network of Children With Periventricular Leukomalacia

Children born preterm with periventricular leukomalacia (PVL) demonstrate increased difficulties with tasks requiring visuomotor integration. The visuomotor integration network encompasses brain regions within frontal, parietal, and occipital cortices. Because of their proximity to the lateral ventricle the underlying white matter pathways are at a high risk of damage following PVL-related hypoxic-ischemic white matter injury. This study provides an exploratory analysis of the structural and functional connections within the visuomotor integration network, along with an a priori evaluation of the superior longitudinal fasciculus, inferior fronto-occipital fasciculus, and frontal aslant tract. For each pathway, tracts within both hemispheres revealed decreased volume and number of reconstructed fibers and an increase in quantitative anisotropy and generalized fractional anisotropy. The connectivity results also indicate that there may be changes to both the structural integrity and functional integration of neural networks involved with visuomotor integration functions in children with PVL.

Dopaminergic modulation of the praxis network in Parkinson's disease

Apraxia is a deficit in central motor planning impairing praxis functions such as gesture production or tool use that affects a substantial number of patients with advanced Parkinson's disease. We investigated the functional connectivity of the praxis network in patients in early stages of Parkinson's disease having an increased risk for apraxia and evaluated the influence of dopaminergic therapy on praxis abilities and related networks. 13 patients with mild to moderate Parkinson's disease (ON and OFF dopaminergic therapy) and 13 healthy controls completed a praxis sensitive functional MRI task and apraxia assessments. Functional connectivity analyses included a graph theoretical approach analyzing the global efficiency within the praxis network followed by a seed-to-voxel functional connectivity analysis. Patients in the OFF but not in the ON state showed significantly lower praxis scores than controls. Patients in both states displayed higher global efficiency within the praxis network than controls revealing the bilateral supramarginal gyri as hubs. Seed-to-voxel functional connectivity analyses showed aberrations of right-hemispheric praxis areas in the OFF but not in the ON state. Patients in the ON state exhibited a significantly higher functional connectivity between the supramarginal gyrus and the primary motor cortex, basal ganglia, and frontal areas than in the OFF state. Dopaminergic therapy seems to normalize praxis abilities and related praxis networks in early stages of Parkinson's disease potentially by facilitating the propagation of long-term representations of object-related actions to motor execution areas.

Domain-Specific Diaschisis: Lesions to Parietal Action Areas Modulate Neural Responses to Tools in the Ventral Stream

Neural responses to small manipulable objects ("tools") in high-level visual areas in ventral temporal cortex (VTC) provide an opportunity to test how anatomically remote regions modulate ventral stream processing in a domain-specific manner. Prior patient studies indicate that grasp-relevant information can be computed about objects by dorsal stream structures independently of processing in VTC. Prior functional neuroimaging studies indicate privileged functional connectivity between regions of VTC exhibiting tool preferences and regions of parietal cortex supporting object-directed action. Here we test whether lesions to parietal cortex modulate tool preferences within ventral and lateral temporal cortex. We found that lesions to the left anterior intraparietal sulcus, a region that supports hand-shaping during object grasping and manipulation, modulate tool preferences in left VTC and in the left posterior middle temporal gyrus. Control analyses demonstrated that neural responses to "place" stimuli in left VTC were unaffected by lesions to parietal cortex, indicating domain-specific consequences for ventral stream neural responses in the setting of parietal lesions. These findings provide causal evidence that neural specificity for "tools" in ventral and lateral temporal lobe areas may arise, in part, from online inputs to VTC from parietal areas that receive inputs via the dorsal visual pathway.

Neural correlates of differential finger gesture imitation deficits in left hemisphere stroke

Behavioural studies in apraxic patients revealed dissociations between the processing of meaningful (MF) and meaningless (ML) gestures. Consequently, the existence of two differential neural mechanisms for the imitation of either gesture type has been postulated. While the indirect (semantic) route exclusively enables the imitation of MF gestures, the direct route can be used for the imitation of any gesture type, irrespective of meaning, and thus especially for ML gestures. Concerning neural correlates, it is debated which of the visuo-motor streams (i.e., the ventral steam, the ventro-dorsal stream, or the dorso-dorsal stream) supports the postulated indirect and direct imitation routes.

To probe the hypotheses that regions of the dorso-dorsal stream are involved differentially in the imitation of ML gestures and that regions of the ventro-dorsal stream are involved differentially in the imitation of MF gestures, we analysed behavioural (imitation of MF and ML finger gestures) and lesion data of 293 patients with a left hemisphere (LH) stroke.

Confirming previous work, the current sample of LH stroke patients imitated MF finger gestures better than ML finger gestures. The analysis using voxel-based lesion symptom mapping (VLSM) revealed that LH damage to dorso-dorsal stream areas was associated with an impaired imitation of ML finger gestures, whereas damage to ventro-dorsal regions was associated with a deficient imitation of MF finger gestures.

Accordingly, the analyses of the imitation of visually uniform and thus highly comparable MF and ML finger gestures support the dual-route model for gesture imitation at the behavioural and lesion level in a substantial patient sample. Furthermore, the data show that the direct route for ML finger gesture imitation depends on the dorso-dorsal visuo-motor stream while the indirect route for MF finger gesture imitation is related to regions of the ventro-dorsal visuo-motor stream.

•

Identification of differential neural correlates for the imitation of meaningful and meaningless finger gestures.

•

Support for the dual-route model for gesture imitation in a substantial patient sample (n = 293).

•

Left hemispheric damage to dorso-dorsal stream areas is associated with an impaired imitation of meaningless finger gestures

•

Damage to ventro-dorsal regions is associated with a deficient imitation of meaningful finger gestures

What Role Does "Elongation" Play in "Tool-Specific" Activation and Connectivity in the Dorsal and Ventral Visual Streams?

Images of tools induce stronger activation than images of nontools in a left-lateralized network that includes ventral-stream areas implicated in tool identification and dorsal-stream areas implicated in tool manipulation. Importantly, however, graspable tools tend to be elongated rather than stubby, and so the tool-selective responses in some of these areas may, to some extent, reflect sensitivity to elongation rather than "toolness" per se. Using functional magnetic resonance imaging, we investigated the role of elongation in driving tool-specific activation in the 2 streams and their interconnections. We showed that in some "tool-selective" areas, the coding of toolness and elongation coexisted, but in others, elongation and toolness were coded independently. Psychophysiological interaction analysis revealed that toolness, but not elongation, had a strong modulation of the connectivity between the ventral and dorsal streams. Dynamic causal modeling revealed that viewing tools (either elongated or stubby) increased the connectivity from the ventral- to the dorsal-stream tool-selective areas, but only viewing elongated tools increased the reciprocal connectivity between these areas. Overall, these data disentangle how toolness and elongation affect the activation and connectivity of the tool network and help to resolve recent controversies regarding the relative contribution of "toolness" versus elongation in driving dorsal-stream "tool-selective" areas.

Psychological and Cognitive Markers of Behavioral Variant Frontotemporal Dementia-A Clinical Neuropsychologist's View on Diagnostic Criteria and Beyond

Behavioral variant frontotemporal dementia (bvFTD) is the second leading cognitive disorder caused by neurodegeneration in patients under 65 years of age. Characterized by frontal, insular, and/or temporal brain atrophy, patients present with heterogeneous constellations of behavioral and psychological symptoms among which progressive changes in social conduct, lack of empathy, apathy, disinhibited behaviors, and cognitive impairments are frequently observed. Since the histopathology of the disease is heterogeneous and identified genetic mutations only account for ~30% of cases, there are no reliable biomarkers for the diagnosis of bvFTD available in clinical routine as yet. Early detection of bvFTD thus relies on correct application of clinical diagnostic criteria. Their evaluation however, requires expertise and in-depth assessments of cognitive functions, history taking, clinical observations as well as caregiver reports on behavioral and psychological symptoms and their respective changes. With this review, we aim for a critical appraisal of common methods to access the behavioral and psychological symptoms as well as the cognitive alterations presented in the diagnostic criteria for bvFTD. We highlight both, practical difficulties as well as current controversies regarding an overlap of symptoms and particularly cognitive impairments with other neurodegenerative and primary psychiatric diseases. We then review more recent developments and evidence on cognitive, behavioral and psychological symptoms of bvFTD beyond the diagnostic criteria which may prospectively enhance the early detection and differential diagnosis in clinical routine. In particular, evidence on specific impairments in social and emotional processing, praxis abilities as well as interoceptive processing in bvFTD is summarized and potential links with behavior and classic cognitive domains are discussed. We finally outline both, future opportunities and major challenges with regard to the role of clinical neuropsychology in detecting bvFTD and related neurocognitive disorders.

Unveiling the dynamic interplay between the hub- and spoke-components of the brain's semantic system and its impact on human behaviour

The neural architecture of semantic knowledge comprises two key structures: (i) A set of widely dispersed regions, located adjacent to the sensorimotor cortices, serve as spokes that represent various modality-specific and context-dependent contents. (ii) The anterior-temporal lobe (ATL) serves as a hub that computes the nonlinear mappings required to transform modality-specific information into pan-modality, multifaceted concepts. Little is understood regarding whether neural dynamics between the hub and spokes might flexibly alter depending on the nature of a concept and how it impinges upon behaviour. Using fMRI, we demonstrate for the first time that the ATL serves as a 'pivot' which dynamically forms flexible long-range networks with cortical modules specialised for different domains (in the present case, the knowledge about actions and places). In two experiments, we manipulated semantic congruity and asked participants to recognise visually presented items. In Experiment 1 (dual-object displays), the ATL increased its functional coupling with the bilateral frontoparietal action-sensitive system when the objects formed a pair that permitted semantically meaningful action. In Experiment 2 (objects embedded in a scene), the ATL augmented its coupling with the retrosplenial cortex of the place-sensitive system when the objects and scene formed a semantically coherent ensemble. Causative connectivity revealed that, while communication between the hub and spokes was bidirectional, the hub's directional impact on spokes dwarfed the strength of the inverse spoke-to-hub connectivity. Furthermore, the size of behavioural congruity effects co-varied with the strength of neural coupling between the ATL hub and action- / place-related spokes, evident both at the within-individual level (the behavioural fluctuation across scanning runs) and between-individual level (the behavioural variation of between participants). Together, these findings have important implications for understanding the machinery that links neural dynamics with semantic cognition.

A Central Component of the N1 Event-Related Brain Potential Could Index the Early and Automatic Inhibition of the Actions Systematically Activated by Objects

Stimuli of the environment, like objects, systematically activate the actions they are associated to. These activations occur extremely fast. Nevertheless, behavioral data reveal that, in most cases, these activations are then automatically inhibited, around 100 ms after the occurrence of the stimulus. We thus tested whether this early inhibition could be indexed by a central component of the N1 event-related brain potential (ERP). To achieve that goal, we looked at whether this ERP component is larger in tasks that could increase the inhibition and in trials where reaction times (RTs) happen to be long. The illumination of a real space bar of a keyboard out of the dark was used as a stimulus. To maximize the modulation of the inhibition, the task participants had to perform was manipulated across blocks. A look-only task and a count task were used to increase inhibition and an immediate press task was used to decrease it. ERPs of the two block-conditions where presses had to be prevented and where the largest central N1s were predicted were compared to those elicited in the press task, differentiating the ERPs to the third of the trials where presses were the slowest from the ERPs to the third of the trials with the fastest presses. Despite larger negativities due to lateralized readiness potentials (LRPs) and despite greater attention likely in immediate press-trials, central N1s were found to be minimal for the fastest presses, intermediate for the slowest ones and maximal for the two no-press conditions. These results thus provide a strong support for the idea that the central N1 indexes an early and short lasting automatic inhibition of the actions systematically activated by objects. They also confirm that the strength of this automatic inhibition spontaneously fluctuates across trials and tasks. On the other hand, just before N1s, parietal P1s were found larger for fastest presses. They might thus index the initial activation of these actions. Finally, consistent with the idea that N300s index late inhibition processes, that occur preferentially when the task requires them, these ERPs were quasi absent for fast presses trials and much larger in the three other conditions.

Effect of object substitution, spontaneous compensation and repetitive training on reaching movements in a patient with optic ataxia

We report the case of M.B. who demonstrated severe optic ataxia with the right hand following stroke in the left hemisphere. The clinical picture may shed light on both the pathological characteristics of reaching and grasping actions, and potential rehabilitation strategies for optic ataxia. First, M.B. demonstrated a dissociation between severely impaired reaching and relatively spared grasping and tool use skills and knowledge, which confirms that grasping may be more intermingled with non-motoric cognitive mechanisms than reaching. Besides, M.B.'s reaching performance was sensitive to movement repetition. We observed a substitution effect: Reaching time decreased if M.B. repeatedly reached toward the same object but increased when object identity changed. This may imply that not only object localization but also object identity, is integrated into movement programming in reach-to-grasp tasks. Second, studying M.B.'s spontaneous compensation strategies ascertained that the mere repetition of reaching movements had a positive effect, to the point M.B. almost recovered to normal level after an intensive one-day repetitive training session. This case study seems to provide one of the first examples of optic ataxia rehabilitation. Reaching skills can be trained by repetitive training even two years post-stroke and despite the presence of visuo-imitative apraxia.

Increase in Mutual Information During Interaction with the Environment Contributes to Perception

Perception and motor interaction with physical surroundings can be analyzed by the changes in probability laws governing two possible outcomes of neuronal activity, namely the presence or absence of spikes (binary states). Perception and motor interaction with the physical environment are partly accounted for by a reduction in entropy within the probability distributions of binary states of neurons in distributed neural circuits, given the knowledge about the characteristics of stimuli in physical surroundings. This reduction in the total entropy of multiple pairs of circuits in networks, by an amount equal to the increase of mutual information, occurs as sensory information is processed successively from lower to higher cortical areas or between different areas at the same hierarchical level, but belonging to different networks. The increase in mutual information is partly accounted for by temporal coupling as well as synaptic connections as proposed by Bahmer and Gupta (Front. Neurosci. 2018). We propose that robust increases in mutual information, measuring the association between the characteristics of sensory inputs' and neural circuits' connectivity patterns, are partly responsible for perception and successful motor interactions with physical surroundings. The increase in mutual information, given the knowledge about environmental sensory stimuli and the type of motor response produced, is responsible for the coupling between action and perception. In addition, the processing of sensory inputs within neural circuits, with no prior knowledge of the occurrence of a sensory stimulus, increases Shannon information. Consequently, the increase in surprise serves to increase the evidence of the sensory model of physical surroundings.

Action Observation for Neurorehabilitation in Apraxia

Neurorehabilitation and brain stimulation studies of post-stroke patients suggest that action-observation effects can lead to rapid improvements in the recovery of motor functions and long-term motor cortical reorganization. Apraxia is a clinically important disorder characterized by marked impairment in representing and performing skillful movements [gestures], which limits many daily activities and impedes independent functioning. Recent clinical research has revealed errors of visuo-motor integration in patients with apraxia. This paper presents a rehabilitative perspective focusing on the possibility of action observation as a therapeutic treatment for patients with apraxia. This perspective also outlines impacts on neurorehabilitation and brain repair following the reinforcement of the perceptual-motor coupling. To date, interventions based primarily on action observation in apraxia have not been undertaken.

Gesturing tool use and tool transport actions modulates inferior parietal functional connectivity with the dorsal and ventral object processing pathways

Interacting with manipulable objects (tools) requires the integration of diverse computations supported by anatomically remote regions. Previous functional neuroimaging research has demonstrated the left supramarginal (SMG) exhibits functional connectivity to both ventral and dorsal pathways, supporting the integration of ventrally-mediated tool properties and conceptual knowledge with dorsally-computed volumetric and structural representations of tools. This architecture affords us the opportunity to test whether interactions between the left SMG, ventral visual pathway, and dorsal visual pathway are differentially modulated when participants plan and generate tool-directed gestures emphasizing functional manipulation (tool use gesturing) or structure-based grasping (tool transport gesturing). We found that functional connectivity between the left SMG, ventral temporal cortex (bilateral fusiform gyri), and dorsal visual pathway (left superior parietal lobule/posterior intraparietal sulcus) was maximal for tool transport planning and gesturing, whereas functional connectivity between the left SMG, left ventral anterior temporal lobe, and left frontal operculum was maximal for tool use planning and gesturing. These results demonstrate that functional connectivity to the left SMG is differentially modulated by tool use and tool transport gesturing, suggesting that distinct tool features computed by the two object processing pathways are integrated in the parietal lobe in the service of tool-directed action.

Movement Imitation via an Abstract Trajectory Representation in Dorsal Premotor Cortex

Humans are particularly good at copying novel and meaningless gestures. The mechanistic and anatomical basis for this specialized imitation ability remains largely unknown. One idea is that imitation occurs by matching body configurations. Here we propose an alternative route to imitation that depends on a body-independent representation of the trajectory path of the end-effector. We studied a group of patients with strokes in the left frontoparietal cortices. We found that they were equally impaired at imitating movement trajectories using the ipsilesional limb (i.e., the nonparetic side) that were cued either by an actor using their whole arm or just by a cursor, suggesting that body configuration information is not always critical for imitation and that a representation of abstract trajectory shape may suffice. In addition, imitation ability was uncorrelated to the ability to identify the trajectory shape, suggesting that imitation deficits were unlikely to arise from perceptual impairments. Finally, a lesion-symptom mapping analysis found that imitation deficits were associated with lesions in left dorsal premotor but not parietal cortex. Together, these findings suggest a novel body-independent route to imitation that relies on the ability to plan abstract movement trajectories within dorsal premotor cortex.SIGNIFICANCE STATEMENT The ability to imitate is critical for rapidly learning to produce new gestures and actions, but how the brain translates observed movements into motor commands is poorly understood. Examining the ability of patients with strokes affecting the left hemisphere revealed that meaningless gestures can be imitated by succinctly representing only the motion of the hand in space, rather than the posture of the entire arm. Moreover, performance deficits correlated with lesions in dorsal premotor cortex, an area not previously associated with impaired imitation of arm postures. These findings thus describe a novel route to imitation that may also be impaired in some patients with apraxia.

Disruption of motor imagery performance following inhibition of the left inferior parietal lobe

The left inferior parietal lobe (IPL), a brain region localized to the ventro-dorsal stream, is known to be critical to motor imagery (MI) performance. Yet its specific role in processes underlying MI, namely the generation, maintenance, manipulation, and controllability of motor images, is conflicting in the literature. To determine the specific role of the left IPL in MI, the current study sought to examine the effect inhibition of the left IPL has on performance on two disparate measures thought to probe different MI processes within the same participants. Participants (N = 31) completed the hand laterality judgment task (HLJT), employed to probe processes related to manipulation and controllability, and mental chronometry, employed to probe processes related to generation and maintenance, after receiving either inhibitory transcranial magnetic stimulation to the left IPL (Active-TMS group), or with the coil angled away from the scalp (Sham group). Impaired performance on the HLJT was observed following active TMS relative to sham. Similar mental chronometry performance resulted regardless of left IPL inhibition. In showing that inhibition of the left IPL selectively disrupted performance on the HLJT but not mental chronometry, our findings indicate that the left IPL is specifically involved in image manipulation and controllability during MI. Ultimately, the current study extends our understanding of the role of the left IPL in MI.

Getting to grips with endoscopy - Learning endoscopic surgical skills induces bi-hemispheric plasticity of the grasping network

Endoscopic surgery requires skilled bimanual use of complex instruments that extend the peri-personal workspace. To delineate brain structures involved in learning such surgical skills, 48 medical students without surgical experience were randomly assigned to five training sessions on a virtual-reality endoscopy simulator or to a non-training group. Brain activity was probed with functional MRI while participants performed endoscopic tasks. Repeated task performance in the scanner was sufficient to enhance task-related activity in left ventral premotor cortex (PMv) and the anterior Intraparietal Sulcus (aIPS). Simulator training induced additional increases in task-related activation in right PMv and aIPS and reduced effective connectivity from left to right PMv. Skill improvement after training scaled with stronger task-related activation of the lateral left primary motor hand area (M1-HAND). The results suggest that a bilateral fronto-parietal grasping network and left M1-HAND are engaged in bimanual learning of tool-based manipulations in an extended peri-personal space.

The dominant role of functional action representation in object recognition

Action representation of manipulable objects has been found to be involved in object recognition. Recently, studies have indicated the existence of two distinct action systems: functional action specifying how to use an object and structural action concerning how to grasp an object. Despite evidence revealing the systems' anatomical and functional differences, few preceding studies have dissociated their respective roles in object recognition. The present study aimed to tease apart their roles in the recognition of manipulable objects with a priming paradigm. Specifically, we used static stimuli (photos, Experiments 1 and 2) and dynamic stimuli (video clips, Experiments 3 and 4) depicting functional and structural action hand gestures as primes and measured the magnitude of functional and structural action priming effect in object recognition. We found that static and dynamic priming stimuli induced a robust action priming effect only for functional action prime-target pairs. Naming latencies of the target objects were shorter when functional action representations of the prime and target were congruent than when they were incongruent. Moreover, as compared to static priming photos, dynamic priming stimuli induced a larger functional action priming effect. By contrast, neither static nor dynamic priming stimuli elicited a structural action priming effect. Behavioral data from our four experiments provide consistent evidence of the dominant role of functional action representation in the recognition of manipulable objects, suggesting that action knowledge regarding how to use rather than grasp an object is more likely an intrinsic component of objects' conceptual representation.

Decoding Brain States for Planning Functional Grasps of Tools: A Functional Magnetic Resonance Imaging Multivoxel Pattern Analysis Study

OBJECTIVES

We used multivoxel pattern analysis (MVPA) to investigate neural selectivity for grasp planning within the left-lateralized temporo-parieto-frontal network of areas (praxis representation network, PRN) typically associated with tool-related actions, as studied with traditional neuroimaging contrasts.

METHODS

We used data from 20 participants whose task was to plan functional grasps of tools, with either right or left hands. Region of interest and whole-brain searchlight analyses were performed to show task-related neural patterns.

RESULTS

MVPA revealed significant contributions to functional grasp planning from the anterior intraparietal sulcus (aIPS) and its immediate vicinities, supplemented by inputs from posterior subdivisions of IPS, and the ventral lateral occipital complex (vLOC). Moreover, greater local selectivity was demonstrated in areas near the superior parieto-occipital cortex and dorsal premotor cortex, putatively forming the dorso-dorsal stream.

CONCLUSIONS

A contribution from aIPS, consistent with its role in prospective grasp formation and/or encoding of relevant tool properties (e.g., potential graspable parts), is likely to accompany the retrieval of manipulation and/or mechanical knowledge subserved by the supramarginal gyrus for achieving action goals. An involvement of vLOC indicates that MVPA is particularly sensitive to coding of object properties, their identities and even functions, for a support of grip formation. Finally, the engagement of the superior parieto-frontal regions as revealed by MVPA is consistent with their selectivity for transient features of tools (i.e., variable affordances) for anticipatory hand postures. These outcomes support the notion that, compared to traditional approaches, MVPA can reveal more fine-grained patterns of neural activity. (JINS, 2018, 24, 1013-1025).

A network view on brain regions involved in experts' object and pattern recognition: Implications for the neural mechanisms of skilled visual perception

Skilled visual object and pattern recognition form the basis of many everyday behaviours. The game of chess has often been used as a model case for studying how long-term experience aides in perceiving objects and their spatio-functional interrelations. Earlier research revealed two brain regions, posterior middle temporal gyrus (pMTG) and collateral sulcus (CoS), to be linked to chess experts' superior object and pattern recognition, respectively. Here we elucidated the brain networks these two expertise-related regions are embedded in, employing resting-state functional connectivity analysis and meta-analytic connectivity modelling with the BrainMap database. pMTG was preferentially connected with dorsal visual stream areas and a parieto-prefrontal network for action planning, while CoS was preferentially connected with posterior medial cortex and hippocampus, linked to scene perception, perspective-taking and navigation. Functional profiling using BrainMap meta-data revealed that pMTG was linked to semantic processing as well as inhibition and attention, while CoS was linked to face and shape perception as well as passive viewing. Our findings suggest that pMTG subserves skilled object recognition by mediating the link between object identity and object affordances, while CoS subserves skilled pattern recognition by linking the position of individual objects with typical spatio-functional layouts of their environment stored in memory.

Bilateral functional connectivity at rest predicts apraxic symptoms after left hemisphere stroke

Increasing evidence indicates that focal lesions following stroke cause alterations in connectivity among functional brain networks. Functional connectivity between hemispheres has been shown to be particularly critical for predicting stroke-related behavioral deficits and recovery of motor function and attention. Much less is known, however, about the relevance of interhemispheric functional connectivity for cognitive abilities like praxis that rely on strongly lateralized brain networks. In the current study, we examine correlations between symptoms of apraxia-a disorder of skilled action that cannot be attributed to lower-level sensory or motor impairments-and spontaneous, resting brain activity in functional MRI in chronic left hemisphere stroke patients and neurologically-intact control participants. Using a data-driven approach, we identified 32 regions-of-interest in which pairwise functional connectivity correlated with two distinct measures of apraxia, even when controlling for age, head motion, lesion volume, and other artifacts: overall ability to pantomime the typical use of a tool, and disproportionate difficulty pantomiming the use of tools associated with different, competing use and grasp-to-move actions (e.g., setting a kitchen timer versus picking it up). Better performance on both measures correlated with stronger interhemispheric functional connectivity. Relevant regions in the right hemisphere were often homologous to left hemisphere areas associated with tool use and action. Additionally, relative to overall pantomime accuracy, disproportionate difficulty pantomiming the use of tools associated with competing use and grasp actions was associated with weakened functional connectivity among a more strongly left-lateralized and peri-Sylvian set of brain regions. Finally, patient performance on both measures of apraxia was best predicted by a model that incorporated information about lesion location and functional connectivity, and functional connectivity continued to explain unique variance in behavior even after accounting for lesion loci. These results indicate that interhemispheric functional connectivity is relevant even for a strongly lateralized cognitive ability like praxis and emphasize the importance of the right hemisphere in skilled action.

Concurrent Cortical Representations of Function- and Size-Related Object Affordances: An fMRI Study

Previous work has shown that the perception of a graspable object may automatically potentiate actions that are tailored to specific action-related features of the object (e.g., its size) and may be related to its immediate grasping as well as to its long-term, functional use. We investigated the neural correlates of function- and size-related object affordances that may be concurrently potentiated by a graspable object. Participants were lying in a MR scanner holding a large switch in one hand and a small switch in the other hand. They passively attended a large or a small object with clearly separated functional and graspable end that was displayed centrally at an average angle of 45 degrees. Participants responded to the direction of an arrow that was overlaid on the object after a mean period of 1,000 ms after object onset and was pointing to the left or to the right with equal probability. Response times were shorter when the arrow pointed to the functional end of the object and when the responses were made with the switch that was congruent to the size of the perceived object. A clear distinction was found in the representation of function- and size-related affordances; the former was represented in the posterior parietal cortex and the latter in prefrontal, premotor, and primary sensorimotor cortices. We conclude that different aspects of object-directed actions may be automatically potentiated by individual object features and are represented in distinct brain areas.

Intentions: The dynamic hierarchical model revisited

Ten years ago, one of us proposed a dynamic hierarchical model of intentions that brought together philosophical work on intentions and empirical work on motor representations and motor control (Pacherie, 2008). The model distinguished among Distal intentions, Proximal intentions, and Motor intentions operating at different levels of action control (hence the name DPM model). This model specified the representational and functional profiles of each type of intention, as well their local and global dynamics, and the ways in which they interact. A core insight of the model was that action control is the result of integrated, coordinated activity across these levels of intention. Since the proposal of the model, empirical and theoretical works in philosophy and cognitive science have emerged that would seem to support and expand on this central insight. In particular, an updated understanding of the nature of sensorimotor processing and motor representations, as well as of how the different levels of intention and control interface and interact, allows for the further specification and precisification of the original DPM model. This article is categorized under: Philosophy > Psychological Capacities Psychology > Motor Skill and Performance Philosophy > Action.

Task- and domain-specific modulation of functional connectivity in the ventral and dorsal object-processing pathways

A whole-brain network of regions collectively supports the ability to recognize and use objects-the Tool Processing Network. Little is known about how functional interactions within the Tool Processing Network are modulated in a task-dependent manner. We designed an fMRI experiment in which participants were required to either generate object pantomimes or to carry out a picture matching task over the same images of tools, while holding all aspects of stimulus presentation constant across the tasks. The Tool Processing Network was defined with an independent functional localizer, and functional connectivity within the network was measured during the pantomime and picture matching tasks. Relative to tool picture matching, tool pantomiming led to an increase in functional connectivity between ventral stream regions and left parietal and frontal-motor areas; in contrast, the matching task was associated with an increase in functional connectivity among regions in ventral temporo-occipital cortex, and between ventral temporal regions and the left inferior parietal lobule. Graph-theory analyses over the functional connectivity data indicated that the left premotor cortex and left lateral occipital complex were hub-like (exhibited high betweenness centrality) during tool pantomiming, while ventral stream regions (left medial fusiform gyrus and left posterior middle temporal gyrus) were hub-like during the picture matching task. These results demonstrate task-specific modulation of functional interactions among a common set of regions, and indicate dynamic coupling of anatomically remote regions in task-dependent manner.

It takes two to pantomime: Communication meets motor cognition

For over a century, pantomime of tool use has been employed to diagnose limb apraxia, a disorder of motor cognition primarily induced by left brain damage. While research consistently implicates damage to a left fronto-temporo-parietal network in limb apraxia, findings are inconsistent regarding the impact of damage to anterior versus posterior nodes within this network on pantomime. Complicating matters is the fact that tool use pantomime can be affected and evaluated at multiple levels. For instance, the production of tool use gestures requires the consideration of semantic characteristics (e.g. how to communicate the action intention) as well as motor features (e.g. forming grip and movement). Together, these factors may contribute substantially to apparent discrepancies in previously reported findings regarding neural correlates of tool use pantomime. In the current study, 67 stroke patients with unilateral left-brain damage performed a classic pantomime task. In order to analyze different error characteristics, we evaluated the proper use of grip and movement for each pantomime. For certain objects, healthy subjects may use body parts as representative for the object, e.g. use of the fingers to indicate scissors blades. To specify the pathological use of body parts as the object (BPO) we only assessed pantomime items that were not prone to this response in healthy participants. We performed modern voxel-based lesion analyses on MRI or CT data to determine associations between brain injury and the frequency of the specific types of pantomime errors. Our results support a model in which anterior and posterior nodes of the left fronto-temporo-parietal network contribute differentially to pantomime of tool use. More precisely, damage in the inferior frontal cortex reaching to the temporal pole is associated with an increased frequency of BPO errors, whereas damage to the inferior parietal lobe is predominantly linked to an increased frequency of movement and/or grip errors. Our work suggests that the validity of attempts to specify the neural correlates of limb apraxia based on tool use pantomime depends on differentiating the specific types of errors committed. We conclude that successful tool use pantomime involves dissociable functions with communicative aspects represented in more anterior (rather ventral) regions and motor-cognitive aspects in more posterior (rather dorsal) nodes of a left fronto-temporo-parietal network.

Apraxia, Neglect, and Agnosia

PURPOSE OF REVIEW

In part because of their striking clinical presentations, disorders of higher nervous system function figured prominently in the early history of neurology. These disorders are not merely historical curiosities, however. As apraxia, neglect, and agnosia have important clinical implications, it is important to possess a working knowledge of the conditions and how to identify them.

RECENT FINDINGS

Apraxia is a disorder of skilled action that is frequently observed in the setting of dominant hemisphere pathology, whether from stroke or neurodegenerative disorders. In contrast to some previous teaching, apraxia has clear clinical relevance as it is associated with poor recovery from stroke. Neglect is a complex disorder with many different manifestations that may have different underlying mechanisms. Neglect is, in the author's view, a multicomponent disorder in which impairment in attention and arousal is a major contributor. Finally, agnosias come in a wide variety of forms, reflecting impairments ranging from low-level sensory processing to access to stored knowledge of the world (semantics).

SUMMARY

The classic behavioral disorders reviewed here were of immense interest to early neurologists because of their arresting clinical phenomenology; more recent investigations have done much to advance the neuroscientific understanding of the disorders and to reveal their clinical relevance.

The effect of a single dose of escitalopram on sensorimotor networks

INTRODUCTION

Serving as a pilot study of poststroke pharmacotherapy, the present investigation was intended to establish the effect of a single dose of escitalopram on motor task performance in normal volunteers.

METHODS

Ten healthy volunteers of median age 63 years including four females performed a well-studied tactile manipulation task in two fMRI sessions using a double-blind cross-over design. The sessions began approximately three hours after ingestion of 20 mg escitalopram or placebo presented in pseudorandom order. The fMRI image sequences were submitted to principal component analysis (PCA).

RESULTS

Based on volume correlations of task-related principal components with the mean component images derived in our previous study, we established the reproducibility of two networks of sensorimotor activity proposed there. The network reflecting motor control (cerebral pattern I) appeared invariably in placebo and verum conditions. In contrast, the other network, attributed to diminished motor control due to distracting mental processing (cerebral pattern II), emerged less regularly and exhibited more variability. Second-level PCAs of both conditions confirmed the findings of the initial analysis. Specifically, it validated the dominant and invariable expression of cerebral pattern I after application of a single dose of escitalopram. Dynamic causal modeling confirmed enhanced motor output as a result of a significantly increased connectivity between primary motor cortex and dorsal premotor cortex.

CONCLUSION

This pilot study suggests the promise of stimulation by a specific serotonin reuptake inhibitor in regard to recovery and preservation of motor control after stroke.

Abstract Representations of Object-Directed Action in the Left Inferior Parietal Lobule

Prior neuroimaging and neuropsychological research indicates that the left inferior parietal lobule in the human brain is a critical substrate for representing object manipulation knowledge. In the present functional MRI study we used multivoxel pattern analyses to test whether action similarity among objects can be decoded in the inferior parietal lobule independent of the task applied to objects (identification or pantomime) and stimulus format in which stimuli are presented (pictures or printed words). Participants pantomimed the use of objects, cued by printed words, or identified pictures of objects. Classifiers were trained and tested across task (e.g., training data: pantomime; testing data: identification), stimulus format (e.g., training data: word format; testing format: picture) and specific objects (e.g., training data: scissors vs. corkscrew; testing data: pliers vs. screwdriver). The only brain region in which action relations among objects could be decoded across task, stimulus format and objects was the inferior parietal lobule. By contrast, medial aspects of the ventral surface of the left temporal lobe represented object function, albeit not at the same level of abstractness as actions in the inferior parietal lobule. These results suggest compulsory access to abstract action information in the inferior parietal lobe even when simply identifying objects.

Apraxia profiles-A single cognitive marker to discriminate all variants of frontotemporal lobar degeneration and Alzheimer's disease

INTRODUCTION

Apraxia is common in neurodegenerative dementias but underrepresented in clinical workup for differential diagnoses.

METHODS

Praxis-profiles were assessed with the Dementia Apraxia Test in 93 patients with early stages of biologically supported Alzheimer's disease or frontotemporal lobar degeneration: semantic primary-progressive aphasia, nonfluent primary-progressive aphasia, and behavioral variant frontotemporal dementia. Associations with core cognitive deficits of the dementia subtypes (i.e., visuospatial, sociocognitive, and semantic-linguistic) were explored.

RESULTS

Patients showed significant apraxia compared with healthy controls but also disease-specific praxis-profiles. Using only the Dementia Apraxia Test, all four dementia subtypes could be correctly discriminated in 64.4% of cases, and in 78.2% when only distinguishing Alzheimer's disease versus frontotemporal lobar degeneration. Praxis-profiles showed consistent associations with core cognitive impairments of the different dementia subtypes.

DISCUSSION

The Dementia Apraxia Test is a valid, time-efficient and versatile cognitive marker to delineate variants of frontotemporal lobar degeneration and Alzheimer's disease in clinical routine, facilitating differential diagnoses of dementia subtypes in early disease stages.

Action and semantic tool knowledge - Effective connectivity in the underlying neural networks

Evidence from neuropsychological and imaging studies indicate that action and semantic knowledge about tools draw upon distinct neural substrates, but little is known about the underlying interregional effective connectivity. With fMRI and dynamic causal modeling (DCM) we investigated effective connectivity in the left-hemisphere (LH) while subjects performed (i) a function knowledge and (ii) a value knowledge task, both addressing semantic tool knowledge, and (iii) a manipulation (action) knowledge task. Overall, the results indicate crosstalk between action nodes and semantic nodes. Interestingly, effective connectivity was weakened between semantic nodes and action nodes during the manipulation task. Furthermore, pronounced modulations of effective connectivity within the fronto-parietal action system of the LH (comprising lateral occipito-temporal cortex, intraparietal sulcus, supramarginal gyrus, inferior frontal gyrus) were observed in a bidirectional manner during the processing of action knowledge. In contrast, the function and value knowledge tasks resulted in a significant strengthening of the effective connectivity between visual cortex and fusiform gyrus. Importantly, this modulation was present in both semantic tasks, indicating that processing different aspects of semantic knowledge about tools evokes similar effective connectivity patterns. Data revealed that interregional effective connectivity during the processing of tool knowledge occurred in a bidirectional manner with a weakening of connectivity between areas engaged in action and semantic knowledge about tools during the processing of action knowledge. Moreover, different semantic tool knowledge tasks elicited similar effective connectivity patterns.

Boosting the Motor Outcome of the Untrained Hand by Action Observation: Mirror Visual Feedback, Video Therapy, or Both Combined-What Is More Effective?

Action observation (AO) allows access to a network that processes visuomotor and sensorimotor inputs and is believed to be involved in observational learning of motor skills. We conducted three consecutive experiments to examine the boosting effect of AO on the motor outcome of the untrained hand by either mirror visual feedback (MVF), video therapy (VT), or a combination of both. In the first experiment, healthy participants trained either with MVF or without mirror feedback while in the second experiment, participants either trained with VT or observed animal videos. In the third experiment, participants first observed video clips that were followed by either training with MVF or training without mirror feedback. The outcomes for the untrained hand were quantified by scores from five motor tasks. The results demonstrated that MVF and VT significantly increase the motor performance of the untrained hand by the use of AO. We found that MVF was the most effective approach to increase the performance of the target effector. On the contrary, the combination of MVF and VT turns out to be less effective looking from clinical perspective. The gathered results suggest that action-related motor competence with the untrained hand is acquired by both mirror-based and video-based AO.

Decoding intransitive actions in primary motor cortex using fMRI: toward a componential theory of 'action primitives' in motor cortex

Multivoxel pattern analysis (MVPA) over functional MRI data can distinguish neural representational states that do not differ in their overall amplitude of BOLD contrast. Here we used MVPA to test whether simple intransitive actions can be distinguished in primary motor cortex. Participants rotated and flexed each of their extremities (hands and feet) during fMRI scanning. The primary motor cortex for the hand/wrist was functionally defined in each hemisphere in each subject. Within those subject-specific ROIs, we found that the average amplitude of BOLD contrast for two different movements of the contralateral hand (rotation, flexion) were higher than for the ipsilateral hand, as well as movements by both feet; however, there was no difference in amplitude between the two different types of movements for the contralateral hand. Using multivoxel pattern analysis (linear correlation), we were able to distinguish the two movements for the contralateral hand. These findings demonstrate that simple intransitive actions can be distinguished in primary motor areas using multivoxel pattern analysis.

Dorsal and ventral stream contribution to the paired-object affordance effect

Visual extinction, a parietal syndrome in which patients exhibit perceptual impairments when two objects are simultaneously presented in the visual field, is reduced when objects are correctly positioned for action, indicating that action helps patients' visual attention. Similarly, healthy individuals make faster action decisions on object pairs that appear in left/right standard co-location for actions in comparison to object pairs that appear in a mirror location, a phenomenon called the paired-object affordance effect. However, the neural locus of such effect remains debated and may be related to the activity of ventral or dorsal brain regions. The present fMRI study aims at determining the neural substrates of the paired-object affordance effect. Fourteen right-handed participants made decisions about semantically related (i.e. thematically related and co-manipulated) and unrelated object pairs. Pairs were either positioned in a standard location for a right-handed action (with the active object - lid - in the right visual hemifield, and the passive object - pan - in the left visual hemifield), or in the reverse location. Behavioral results showed a suppression of the observed cost of correctly positioning related pairs for action when performing action decisions (deciding if the two objects are usually used together), but not when performing contextual decisions (deciding if the two objects are typically found in the kitchen). Anterior regions of the dorsal stream (e.g. supplementary motor area) responded to inadequate object co-positioning for action, but only when the perceptual task required action decisions. In the ventral cortex, the left lateral occipital complex showed increased activation for objects correctly positioned for action in all conditions except when neither task demands nor object relatedness was relevant for action. Thus, fMRI results demonstrated a joint contribution of ventral and dorsal cortical streams to the paired-affordance effect. They further suggest that this contribution may depend on contextual situations and task demands, in line with flexible views of affordance evocation.

Early dysfunctions of fronto-parietal praxis networks in Parkinson's disease

In Parkinson’s disease (PD) the prevalence of apraxia increases with disease severity implying that patients in early stages may already have subclinical deficits. The aim of this exploratory fMRI study was to investigate if subclinical aberrations of the praxis network are already present in patients with early PD. In previous functional imaging literature only data on basal motor functions in PD exists. Thirteen patients with mild parkinsonian symptoms and without clinically diagnosed apraxia and 14 healthy controls entered this study. During fMRI participants performed a pantomime task in which they imitated the use of visually presented objects. Patients were measured ON and OFF dopaminergic therapy to evaluate a potential medication effect on praxis abilities and related brain functions. Although none of the patients was apraxic according to De Renzi ideomotor scores (range 62–72), patients OFF showed significantly lower praxis scores than controls. Patients exhibited significant hyperactivation in left fronto-parietal core areas of the praxis network. Frontal activations were clearly dominant in patients and were correlated with lower individual praxis scores. We conclude that early PD patients already show characteristic signs of praxis network dysfunctions and rely on specific hyperactivations to avoid clinically evident apraxic symptoms. Subclinical apraxic deficits were shown to correlate with an activation shift from left parietal to left frontal areas implying a prospective individual imaging marker for incipient apraxia.

Limbic Interference During Social Action Planning in Schizophrenia

Schizophrenia is characterized by social interaction deficits contributing to poor functional outcome. Hand gesture use is particularly impaired, linked to frontal lobe dysfunction and frontal grey matter deficits. The functional neural correlates of impaired gesturing are currently unclear. We therefore investigated aberrant brain activity during impaired gesturing in schizophrenia. We included 22 patients with schizophrenia and 25 healthy control participants matched for age, gender, and education level. We obtained functional magnetic resonance imaging data using an event-related paradigm to assess brain activation during gesture planning and execution. Group differences in whole brain effects were calculated using factorial designs. Gesture ratings were performed by a single rater, blind to diagnoses and clinical presentation. During gesture planning and execution both groups activated brain areas of the praxis network. However, patients had reduced dorsolateral prefrontal cortex (DLPFC) and increased inferior parietal lobe (IPL) activity. Performance accuracy was associated with IPL activity in patients. Furthermore, patients activated temporal poles, amygdala and hippocampus during gesture planning, which was associated with delusion severity. Finally, patients demonstrated increased dorsomedial prefrontal cortex activity during planning of novel gestures. We demonstrate less prefrontal, but more IPL and limbic activity during gesturing in schizophrenia. IPL activity was associated with performance accuracy, whereas limbic activity was linked to delusion severity. These findings may reflect impaired social action planning and a limbic interference with gestures in schizophrenia contributing to poor gesture performance and consequently poor social functioning in schizophrenia.

Handling or being the concept: An fMRI study on metonymy representations in coverbal gestures

In "Two heads are better than one," "head" stands for people and focuses the message on the intelligence of people. This is an example of figurative language through metonymy, where substituting a whole entity by one of its parts focuses attention on a specific aspect of the entity. Whereas metaphors, another figurative language device, are substitutions based on similarity, metonymy involves substitutions based on associations. Both are figures of speech but are also expressed in coverbal gestures during multimodal communication. The closest neuropsychological studies of metonymy in gestures have been nonlinguistic tool-use, illustrated by the classic apraxic problem of body-part-as-object (BPO, equivalent to an internal metonymy representation of the tool) vs. pantomimed action (external metonymy representation of the absent object/tool). Combining these research domains with concepts in cognitive linguistic research on gestures, we conducted an fMRI study to investigate metonymy resolution in coverbal gestures. Given the greater difficulty in developmental and apraxia studies, perhaps explained by the more complex semantic inferencing involved for external metonymy than for internal metonymy representations, we hypothesized that external metonymy resolution requires greater processing demands and that the neural resources supporting metonymy resolution would modulate regions involved in semantic processing. We found that there are indeed greater activations for external than for internal metonymy resolution in the temporoparietal junction (TPJ). This area is posterior to the lateral temporal regions recruited by metaphor processing. Effective connectivity analysis confirmed our hypothesis that metonymy resolution modulates areas implicated in semantic processing. We interpret our results in an interdisciplinary view of what metonymy in action can reveal about abstract cognition.

Getting a handle on virtual tools: An examination of the neuronal activity associated with virtual tool use

Tool use is associated with three visual streams-dorso-dorsal, ventro-dorsal, and ventral visual streams. These streams are involved in processing online motor planning, action semantics, and tool semantics features, respectively. Little is known about the way in which the brain represents virtual tools. To directly assess this question, a virtual tool paradigm was created that provided the ability to manipulate tool components in isolation of one another. During functional magnetic resonance imaging (fMRI), adult participants performed a series of virtual tool manipulation tasks in which vision and movement kinematics of the tool were manipulated. Reaction time and hand movement direction were monitored while the tasks were performed. Functional imaging revealed that activity within all three visual streams was present, in a similar pattern to what would be expected with physical tool use. However, a previously unreported network of right-hemisphere activity was found including right inferior parietal lobule, middle and superior temporal gyri and supramarginal gyrus - regions well known to be associated with tool processing within the left hemisphere. These results provide evidence that both virtual and physical tools are processed within the same brain regions, though virtual tools recruit bilateral tool processing regions to a greater extent than physical tools.

Limb apraxia and the left parietal lobe

Limb apraxia is a heterogeneous disorder of skilled action and tool use that has long perplexed clinicians and researchers. It occurs after damage to various loci in a densely interconnected network of regions in the left temporal, parietal, and frontal lobes. Historically, a highly classificatory approach to the study of apraxia documented numerous patterns of performance related to two major apraxia subtypes: ideational and ideomotor apraxia. More recently, there have been advances in our understanding of the functional neuroanatomy and connectivity of the left-hemisphere "tool use network," and the patterns of performance that emerge from lesions to different loci within this network. This chapter focuses on the left inferior parietal lobe, and its role in tool and body representation, action prediction, and action selection, and how these functions relate to the deficits seen in patients with apraxia subsequent to parietal lesions. Finally, suggestions are offered for several future directions that will benefit the study of apraxia, including increased attention to research on rehabilitation of this disabling disorder.

The left supramarginal gyrus contributes to finger positioning for object use: a neuronavigated transcranial magnetic stimulation study

In everyday actions, we grasp dozens of different manipulable objects in ways that accommodate their functional use. Neuroimaging studies showed that grasping objects in a way that is appropriate for their use involves a left-lateralized network including the supramarginal gyrus (SMG), the anterior intraparietal area (AIP) and the ventral premotor cortex (PMv). However, because previous works premised their conclusions on tasks requiring action execution, it has remained difficult to discriminate between the areas involved in specifying the position of fingers onto the object from those implementing the motor programme required to perform the action. To address this issue, we asked healthy participants to make judgements about pictures of manipulable objects, while repetitive transcranial magnetic stimulation (rTMS) was applied over the left SMG, AIP, PMv or, as a control, the vertex. The participants were asked to name the part of the image where the thumb or the index finger was expected to contact the object during its normal utilization or where a given attribute of the same object was located. The two tasks were strictly identical in terms of visual display, working memory demands and response requirements. Results showed that rTMS over SMG slowed down judgements of finger positions but not judgements of object attributes. Both types of judgements remained unaffected when rTMS was applied over AIP or PMv. This finding demonstrates that, within the parieto-frontal network dedicated to object use, at least the left SMG is involved in specifying the appropriate position of the thumb and index onto the object.

Gerstmann's syndrome and unilateral optic ataxia in the emergency department

A 75-year-old right-handed woman presented to the emergency department with simultanagnosia and right unilateral optic ataxia. Moreover, the patient had agraphia, acalculia, digital agnosia and right-left disorientation, consistent with complete Gerstmann's syndrome. This case highlights the concurrence of Gerstmann's syndrome and unilateral optic ataxia in the acute phase of a left middle cerebral artery stroke.