Allographic agraphia: a case study

Frontal allographic agraphia in a patient with behavioral variant frontotemporal dementia

We report a patient with behavioral variant frontotemporal dementia who developed agraphia, irritability, perseverative and stereotyped behavior, and dietary changes. MRI revealed bilateral frontal convexity atrophy. Neuropsychological examination showed fluent aphasia with perseverative allographic agraphia, mild semantic impairment, and dysexecutive syndrome. Allographic agraphia featured unidirectional conversion from hiragana (cursive form of Japanese phonograms) and kanji (Japanese morphograms) to katakana (square form of Japanese phonograms), as opposed to mutual (bidirectional) conversion between hiragana and katakana in parieto-occipital gyri lesions. Furthermore, all letters of the word were converted and this whole-word conversion may be characteristic of perseverative behavior in frontotemporal dementia.

The Modularity of Dysgraphia

Research regarding dysgraphia, an impairment in writing, is attaining more attention in recent times. The existing studies on dysgraphia draw insights from cognitive, behavioural, neurological, and genetic fields of knowledge. However, these multiple studies on dysgraphia fail to illustrate how these cognitive, behavioural, neurological, and genetic systems interact and intersect in dysgraphia. Therefore, the studies could not offer a comprehensive understanding of dysgraphia. In order to fill this gap, the review attempts to study dysgraphia using the notion of modularity by accommodating insights from cognitive, behavioural, neurological, and genetic aspects of dysgraphia. Such a profound understanding could facilitate an early diagnosis and holistic intervention towards dysgraphia.

Properties of graphic motor plans in the writing system

The present study explores the extent to which properties of abstract graphemic representations are maintained at the post-graphemic level of graphic motor plans, where the sequences of writing strokes for producing the letters in a word are represented. On the basis of results from a stroke patient (NGN) who has a deficit affecting the activation of graphic motor plans, we explore the post-graphemic representation of 1) consonant/vowel status of letters; 2) geminate (double) letters, such as the BB in RABBIT; and 3) digraphs, such as the SH in SHIP. Through analyses of NGN's letter substitution errors, we conclude that 1) consonant-vowel status is not represented at the level of graphic motor plans; 2) geminates have special representations at the motor-plan level, as at the graphemic level; and 3) digraphs are represented by two separate single-letter graphic motor plans, and not by unitary digraph motor plans.

Writing errors in primary progressive aphasia

Peripheral errors in writing, that is errors produced download the spelling, have been occasionally described in primary progressive aphasia (PPA), but the possibility that these errors might be a marker of parkinsonism associated to some subtypes of PPA has not been explored. We investigated whether errors of peripheral nature characterize the writing disorder in PPA when associated with parkinsonian signs (PSs). Subgroups of PPA without PSs and with PSs were studied. The proportion of the central and peripheral errors in writing words and pseudowords was calculated in each group. In writing words, central errors significantly exceeded peripheral errors in subgroups without PSs. The higher the number of peripheral errors, the higher the probability of presenting PSs. No relation emerged between any error and the Unified Parkinson's Disease Rating Scale, but both types of errors correlated with measures of cognitive ability. Peripheral errors emerge when PSs are associated with PPA and may be linked to a decay of the cognitive control on movement, possibly involving the right hemisphere. Peripheral errors have clinical relevance in PPA, to the extent that they may assume the significance of a marker of specific subtypes and can help to outline the specific clinical picture of individual patients.

Progressive macrographia for block letter writing: A case study

"Macrographia", a relatively rare symptom generally following cerebellar diseases, consists of an abnormally large handwriting. The case reported in the present investigation shows several outstanding features. First, it is of the progressive variety, letters increase in size as one goes through the word towards the lower-right portion of space. Moreover, it is limited to one allographic variety, that is, block letters. This phenomenon is previously unreported, all allographic varieties being usually equally affected. Finally, no prominent cerebellar or basal ganglia abnormality could be demonstrated with structural MRI or PET. From a cognitive point of view, a peculiar combination of spatial attention, executive function and working memory deficits is proposed to account for the progressive misalignment and elongation of individual letters when specifically writing in block prints. From an anatomical perspective, the pattern of multifocal lesions, encompassing multiple cortical areas in both hemispheres and the corpus callosum, may support this multi-componential interpretation of the reported phenomenon.

Phenotypic variability and neuropsychological findings associated with C9orf72 repeat expansions in a Bulgarian dementia cohort

BACKGROUND

The GGGGCC repeat expansion in the C9orf72 gene was recently identified as a major cause of amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) in several European populations. The objective of this study was to determine the frequency of C9orf72 repeat expansions in a Bulgarian dementia cohort and to delineate the associated clinical features.

METHODS AND FINDINGS

PCR-based assessments of the C9orf72 hexanucleotide repeat expansion in all study samples (including 82 FTD, 37 Alzheimer's disease (AD), and 16 other neurodegenerative/dementia disorder cases) were performed. We report the clinical, neuropsychological, and neuroimaging findings obtained for the C9orf72 repeat expansion carriers. Of the 135 cases screened, 3/82 (3.7%) of all FTD cases and 1/37 (2.7%) of all clinical AD cases had a C9orf72 repeat expansion. In this cohort, the C9orf72 pathological expansion was found in clinical diagnoses bridging the FTD, parkinsonism, ALS and AD spectrum. Interestingly, we showed early writing errors without aphasia in two subjects with C9orf72 expansions.

CONCLUSIONS

This study represents the first genetic screening for C9orf72 repeat expansions in a Bulgarian dementia cohort. The C9orf72 repeat expansion does not appear to be a common cause of FTD and related disorders. This report confirms the notion that C9orf72 repeat expansions underlie a broad spectrum of neurodegenerative phenotypes. Relatively isolated agraphia in two cases with C9orf72 repeat expansions is a strong motivation to provide detailed and sophisticated oral and written language assessments that can be used to more precisely characterize early cognitive deficits in these heterogeneous conditions.

A deficit in post-graphemic writing processes: Evidence for a graphomotor buffer

Post-graphemic writing processes transform abstract letter representations into representations of writing movements. We describe an individual with an acquired post-graphemic writing deficit. NGN is normal in spelling words aloud, but impaired in writing words to dictation, with most errors involving letter substitutions (e.g., RUMOR written as BUMOR). NGN's deficit affects graphic motor plans, which specify the writing strokes for producing letters. Analyses of writing speed, fluency, and stroke patterns suggest that NGN's errors result from incomplete motor-plan activation. NGN's error rate is high for the first letter in a word, and declines across subsequent positions. On the basis of this serial position effect and other results, we propose that post-graphemic writing mechanisms include a graphomotor buffer, a writing-specific working memory that holds activated graphic motor plans bound to specific serial positions. We suggest that NGN's graphomotor buffer is damaged such that early serial positions are affected most severely. Finally, we present results speaking to the roles and capabilities of the graphomotor buffer, and the structure of graphic motor plans.

Revival of Historical Kana Orthography in a Patient with Allographic Agraphia

Japanese people born before World War II learned Japanese kana (Japanese syllabograms) writing in a style that is not currently used. These individuals had to learn the current style of kana orthography after the war. An 85-year-old man was taken to our hospital by his family who were surprised by his diary. It was written with kanji (Japanese ideograms) and katakana using the prewar style. A neuropsychological examination revealed impaired recall of hiragana. Neuroimaging studies revealed atrophy of the left fronto-parietal lobe and hypoperfusion of the left frontal lobe. His allographic agraphia might have resulted from the disturbance of the current style of kana orthography.

Developmental dysgraphia: An overview and framework for research

Developmental deficits in the acquisition of writing skills (developmental dysgraphias) are common and have significant consequences, yet these deficits have received relatively little attention from researchers. We offer a framework for studying developmental dysgraphias (including both spelling and handwriting deficits), arguing that research should be grounded in theories describing normal cognitive writing mechanisms and the acquisition of these mechanisms. We survey the current state of knowledge concerning developmental dysgraphia, discussing potential proximal and distal causes. One conclusion emerging from this discussion is that developmental writing deficits are diverse in their manifestations and causes. We suggest an agenda for research on developmental dysgraphia, and suggest that pursuing this agenda may contribute not only to a better understanding of developmental writing impairment, but also to a better understanding of normal writing mechanisms and their acquisition. Finally, we provide a brief introduction to the subsequent articles in this special issue on developmental dysgraphia.

Agraphia in patients with frontotemporal dementia and parkinsonism linked to chromosome 17 with P301L MAPT mutation: dysexecutive, aphasic, apraxic or spatial phenomenon?

OBJECTIVES

Patients with frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17) may be agraphic. The study aimed at characterizing agraphia in individuals with a P301L MAPT mutation.

METHODS

Two pairs of siblings with FTDP-17 were longitudinally examined for agraphia in relation to language and cognitive deficits.

RESULTS

All patients presented with dysexecutive agraphia. In addition, in the first pair of siblings one sibling demonstrated spatial agraphia with less pronounced allographic agraphia and the other sibling had aphasic agraphia. Aphasic agraphia was also present in one sibling from the second pair.

CONCLUSION

Agraphia associated with FTDP-17 is very heterogeneous.

Letter representations in writing: an fMRI adaptation approach

Behavioral and neuropsychological research in reading and spelling has provided evidence for the role of the following types of orthographic representations in letter writing: letter shapes, letter case, and abstract letter identities. We report on the results of an fMRI investigation designed to identify the neural substrates of these different representational types. Using an fMRI adaptation paradigm we examined the neural distribution of inhibition and release from inhibition in a letter-writing task in which, on every trial, participants produced three repetitions of the same letter and a fourth letter that was either identical to (no-change trial) or different from the previous three (change trial). Change trials involved a change in the shape, case, and/or identity of the letter. After delineating the general letter writing network by identifying areas that exhibited significant neural adaptation effects on no-change trials, we used deconvolution analysis to examine this network for effects of release from inhibition on change trials. In this way we identified regions specifically associated with the representation of letter shape (in the left SFS and SFG/pre-CG) and letter identity [in the left fusiform gyrus (FG)] or both [right cerebellum, left post-central gyrus (post-CG), and left middle frontal gyrus (MFG)]. No regions were associated with the representation of letter case. This study showcases an investigational approach that allows for the differentiation of the neurotopography of the representational types that are key to our ability to produce written language.

A combined fMRI study of typed spelling and reading

In this study we employed a novel technique to examine the neural basis of written spelling by having subjects touch-type single words on an fMRI compatible QWERTY keyboard. Additionally, in the same group of participants we determined if task-related signal changes associated with typed spelling were also co-localized with or separate from those for reading. Of particular interest were the left inferior frontal gyrus, left inferior parietal lobe as well as an area in the left occipitotemporal cortex termed the Visual Word Form Area (VWFA), each of which have been associated with both spelling and reading. Our results revealed that typed spelling was associated with a left hemisphere network of regions which included the inferior frontal gyrus, intraparietal sulcus, inferior temporal/fusiform gyrus, as well as a region in the superior/middle frontal gyrus, near Exner's area. A conjunction analysis of activation associated with spelling and reading revealed a significant overlap in the left inferior frontal gyrus and occipitotemporal cortex. Interestingly, within the occipitotemporal cortex just lateral and superior to the VWFA we identified an area that was selectively associated with spelling, as revealed by a direct comparison of the two tasks. These results demonstrate that typed spelling activates a predominantly left hemisphere network, a subset of which is functionally relevant to both spelling and reading. Further analysis revealed that the left occipitotemporal cortex contains regions with both conjoint and dissociable patterns of activation for spelling and reading.

Dyscravia: voicing substitution dysgraphia

We report a new type of dysgraphia, which we term dyscravia. The main error type in dyscravia is substitution of the target letter with a letter that differs only with respect to the voicing feature, such as writing "coat" for "goat", and "vagd" for "fact". Two Hebrew-speaking individuals with acquired dyscravia are reported, TG, a man aged 31, and BG, a woman aged 66. Both had surface dysgraphia in addition to their dyscravia. To describe dyscravia in detail, and to explore the rate and types of errors made in spelling, we administered tests of writing to dictation, written naming, and oral spelling. In writing to dictation, TG made voicing errors on 38% of the words, and BG made 17% voicing errors. Voicing errors also occurred in nonword writing (43% for TG, 56% for BG). The writing performance and the variables that influenced the participants' spelling, as well as the results of the auditory discrimination and repetition tasks indicated that their dyscravia did not result from a deficit in auditory processing, the graphemic buffer, the phonological output lexicon, the phonological output buffer, or the allographic stage. The locus of the deficit is the phoneme-to-grapheme conversion, in a function specialized in the conversion of phonemes' voicing feature into graphemes. Because these participants had surface dysgraphia and were forced to write via the sublexical route, the deficit in voicing was evident in their writing of both words and nonwords. We further examined whether the participants also evinced parallel errors in reading. TG had a selective voicing deficit in writing, and did not show any voicing errors in reading, whereas BG had voicing errors also in the reading of nonwords (i.e., she had dyslegzia in addition to dyscravia). The dissociation TG demonstrated indicated that the voicing feature conversion is separate for reading and writing, and can be impaired selectively in writing. BG's dyslegzia indicates that the grapheme-to-phoneme conversion also includes a function that is sensitive to phonological features such as voicing. Thus the main conclusion of this study is that a separate function of voicing feature conversion exists in the phoneme-to-grapheme conversion route, which may be selectively impaired without deficits in other functions of the conversion route, and without a parallel deficit in reading.

Oral spelling and writing in a logographic language: insights from a Chinese dysgraphic individual

The oral spelling process for logographic languages such as Chinese is intrinsically different from alphabetic languages. In Chinese only a subset of orthographic components are pronounceable and their phonological identities (i.e., component names) do not always correspond to the sound of the whole characters. We show that such phonological identities can nevertheless be selectively preserved when visual-motoric compositions are lost. We report a Chinese right-handed dysgraphic individual with left temporal and occipital damage, MZG, who was severely impaired in writing Chinese characters but was able to orally spell the same characters using the names of pronounceable components. MZG's writing deficit arose at the level of processing that is dedicated to the retrieval of the shapes (allographics) of the writing components. Such patterns show that phonological identities of components are part of the orthographic representation of Chinese characters, and that dissociation between oral and written spelling modalities is universal across different script systems. The temporal and occipital lobes in the language-dominant hemisphere are possibly important regions for allographic conversion in writing.