Constructional apraxia after left or right unilateral stroke

Lowered Rhythm Tapping Ability in Patients With Constructional Apraxia After Stroke

Rhythm tapping tasks are often used to explore temporal reproduction abilities. Many studies utilizing rhythm tapping tasks are conducted to evaluate temporal processing abilities with neurological impairments and neurodegenerative disorders. Among sensorimotor and cognitive disorders, rhythm processing abilities in constructional apraxia, a deficit in achieving visuospatial constructional activities, has not been evaluated. This study aimed to examine the rhythm tapping ability of patients with constructional apraxia after a stroke. Twenty-four patients were divided into two groups: with and without constructional apraxia. There were 11 participants in the constructional apraxia group and 13 in the without constructional apraxia group. The synchronization-continuation paradigm was employed in which a person performs a synchronized tapping activity to a metronome beat and continues tapping after the beat has stopped. For statistical analysis, a three-way mixed analysis of variance (2 × 2 × 3) was conducted. The factors were groups (with and without constructional apraxia), tapping tasks (synchronization and continuation), and inter-stimulus intervals (600, 750, and 1000 ms). A significant effect of group factor was found (F[1,132] = 16.62; p < 0.001). Patients in the without constructional apraxia group were able to more accurately reproduce intervals than those in the constructional apraxia group. Moreover, a significant effect of tapping tasks was found (F[1,132] = 8.22; p < 0.01). Intervals were reproduced more accurately for synchronization tasks than continuation tasks. There was no significant inter-stimulus interval effect. Overall, these results suggest that there might be a relation between temporal and spatial reproductions in a wide spectrum of processing levels, from sensory perception to cognitive function.

The Simon Effect Based on Allocentric and Egocentric Reference Frame: Common and Specific Neural Correlates

An object’s location can be represented either relative to an observer’s body effectors (egocentric reference frame) or relative to another external object (allocentric reference frame). In non-spatial tasks, an object’s task-irrelevant egocentric position conflicts with the side of a task-relevant manual response, which defines the classical Simon effect. Growing evidence suggests that the Simon effect occurs not only based on conflicting positions within the egocentric but also within the allocentric reference frame. Although neural mechanisms underlying the egocentric Simon effect have been extensively researched, neural mechanisms underlying the allocentric Simon effect and their potential interaction with those underlying its egocentric variant remain to be explored. In this fMRI study, spatial congruency between the task-irrelevant egocentric and allocentric target positions and the task-relevant response hand was orthogonally manipulated. Behaviorally, a significant Simon effect was observed for both reference frames. Neurally, three sub-regions in the frontoparietal network were involved in different aspects of the Simon effect, depending on the source of the task-irrelevant object locations. The right precentral gyrus, extending to the right SMA, was generally activated by Simon conflicts, irrespective of the spatial reference frame involved, and showed no additive activity to Simon conflicts. In contrast, the right postcentral gyrus was specifically involved in Simon conflicts induced by task-irrelevant allocentric, rather than egocentric, representations. Furthermore, a right lateral frontoparietal network showed increased neural activity whenever the egocentric and allocentric target locations were incongruent, indicating its functional role as a mismatch detector that monitors the discrepancy concerning allocentric and egocentric object locations.

A progressive breakdown of the body in space

A 74 year-old woman (MD), free of previous neurological history, presented with difficulty in handling cutlery, clothes, writing with what was initially described as an atypical apraxia in acts related to space. Initial neurological evaluation revealed mixed, asymmetric pyramidal, and extrapyramidal semiology. Νeuropsychological testing revealed dressing and constructional deficits, ideomotor apraxia and signs of executive dysfunction in absence of memory, language, and visual perception pathology. The final diagnosis was that of a corticobasal degeneration, where the rare occurrence of a progressively emerging syndrome of self-management loss within peripersonal space is observed.

Constructional apraxia

Since the classic papers of Kleist, Mayer Gross, and Critchley, constructional apraxia (CA) has been considered to be a typical sign of a parietal lobe lesion, and as a precious tool to appreciate the spatial abilities subserved by this lobe. However, the development of more sophisticated neuropsychologic models and methods of investigation has revealed several problematic aspects. It has become increasingly clear that CA is a heterogeneous construct that can be examined with very different tasks, that are only mildly interconnected, and tap various kinds of visuospatial, perceptual, attentional, planning, and motor mechanisms. On the basis of these considerations, the relationships between parietal lobe functions and constructional activities must be considered, taking into account on the one hand the heterogeneity of the tasks and of the cognitive functions requested by different kinds of constructional activities and, on the other hand, the plurality of functions and of processing streams linking different parts of the parietal lobes to the occipital and frontal lobes.

Time takes space: selective effects of multitasking on concurrent spatial processing

Many everyday activities require coordination and monitoring of complex relations of future goals and deadlines. Cognitive offloading may provide an efficient strategy for reducing control demands by representing future goals and deadlines as a pattern of spatial relations. We tested the hypothesis that multiple-task monitoring involves time-to-space transformational processes, and that these spatial effects are selective with greater demands on coordinate (metric) than categorical (nonmetric) spatial relation processing. Participants completed a multitasking session in which they monitored four series of deadlines, running on different time scales, while making concurrent coordinate or categorical spatial judgments. We expected and found that multitasking taxes concurrent coordinate, but not categorical, spatial processing. Furthermore, males showed a better multitasking performance than females. These findings provide novel experimental evidence for the hypothesis that efficient multitasking involves metric relational processing.

Improved Necker Cube Drawing-Based Assessment Battery for Constructional Apraxia: The Mie Constructional Apraxia Scale (MCAS)

Background/Aims

Constructional apraxia (CA) is usually diagnosed by having patients draw figures; however, the reported assessments only evaluate the drawn figure. We designed a new assessment battery for CA (the Mie Constructional Apraxia Scale, MCAS) which includes both the shape and drawing process, and investigated its utility against other assessment methods.

Methods

We designed the MCAS, and evaluated inter- and intrarater reliability. We also investigated the sensitivity, specificity, and positive and negative predictive values in dementia patients, and compared MCAS assessment with other reported batteries in the same subjects.

Results

Moderate interrater reliability was shown for speech therapists with limited experience. Moderate to substantial intrarater reliability was shown several weeks after initial assessment. When cutoff scores and times were set at 2/3 points and 39/40 s, sensitivity and specificity were 77.1 and 70.4%, respectively, with positive and negative predictive values of 80.0 and 66.7%, respectively. Dementia patients had significantly worse scores and times for Necker cube drawing than an elderly control group on the MCAS, and on other assessments.

Conclusions

We conclude that the MCAS, which includes both the assessment of the drawn Necker cube shape and the drawing process, is useful for detecting even mild CA.

Frames of reference and categorical/coordinate spatial relations in a "what was where" task

The aim of this study was to explore how people use egocentric (i.e., with respect to their body) and allocentric (i.e., with respect to another element in the environment) references in combination with coordinate (metric) or categorical (abstract) spatial information to identify a target element. Participants were asked to memorize triads of 3D objects or 2D figures, and immediately or after a delay of 5 s, they had to verbally indicate what was the object/figure: (1) closest/farthest to them (egocentric coordinate task); (2) on their right/left (egocentric categorical task); (3) closest/farthest to another object/figure (allocentric coordinate task); (4) on the right/left of another object/figure (allocentric categorical task). Results showed that the use of 2D figures favored categorical judgments over the coordinate ones with either an egocentric or an allocentric reference frame, whereas the use of 3D objects specifically favored egocentric coordinate judgments rather than the allocentric ones. Furthermore, egocentric judgments were more accurate than allocentric judgments when the response was Immediate rather than delayed and 3D objects rather than 2D figures were used. This pattern of results is discussed in the light of the functional roles attributed to the frames of reference and spatial relations by relevant theories of visuospatial processing.

Altered Intrinsic Regional Activity and Interregional Functional Connectivity in Post-stroke Aphasia

Several neuroimaging studies have examined cerebral function in patients who suffer from aphasia, but the mechanism underlying this disorder remains poorly understood. In this study, we examined alterations in the local regional and remote interregional network cerebral functions in aphasia combined with amplitude of low-frequency fluctuations and interregional functional connectivity (FC) using resting-state functional magnetic resonance imaging. A total of 17 post-stroke aphasic patients, all having suffered a stroke in the left hemisphere, as well as 20 age- and sex-matched healthy controls, were enrolled in this study. The aphasic patients showed significantly increased intrinsic regional activity mainly in the contralesional mesial temporal (hippocampus/parahippocampus, [HIP/ParaHIP]) and lateral temporal cortices. In addition, intrinsic regional activity in the contralesional HIP/ParaHIP was negatively correlated with construction score. Aphasic patients showed increased remote interregional FC between the contralesional HIP/ParaHIP and fusiform gyrus, but reduced FC in the ipsilesional occipital and parietal cortices. These findings suggested that the intrinsic regional brain dysfunctions in aphasia were related to interregional functional connectivity. Changes in the intrinsic regional brain activity and associated remote functional connectivity pattern would provide valuable information to enhance the understanding of the pathophysiological mechanisms of aphasia.

Asymmetrical white matter networks for attending to global versus local features

The ability to draw objects is a complex process depending on an array of cognitive mechanisms including routines for spatial coding, attention and the processing of both local and global features. Previous studies using both neuropsychological and neuroimaging data have reported hemispheric asymmetries in attending to local versus global features linked to a variety of cortical loci. However, it has not been examined to date whether such asymmetries exist at the level of white matter pathways sub-serving global/local attention. The current study provides a comprehensive analysis of brain-behaviour relationships in the processing of local versus global features based on data from a large cohort of sub-acute stroke patients (n = 248) and behavioural measures from a complex figure copy task. The data analysis used newly developed methods for automated delineation of stroke lesions combined with track-wise lesion deficits procedures. We found (i) that reproduction of local features in figure copying was supported by a neural network confined to the left hemisphere, consisting of cortical loci within parietal, occipital and insular lobes and interconnected by the inferior-fronto-occipital fasciculus (IFOF), and (ii) that global feature processing was associated with a right hemisphere network interconnected by the third branch of the superior longitudinal fasciculus and the long segment of the perisylvian network. The data support the argument that asymmetrical white matter disconnections within long-range association pathways predict poor complex figure drawing resulting from deficits in hierarchical representation. We conclude that hemispheric asymmetries in attending to local versus global features exist on the level of both cortical loci and the supporting white matter pathways.

Hemispheric lateralization in top-down attention during spatial relation processing: a Granger causal model approach

Magnetoencephalography was recorded during a matching-to-sample plus cueing paradigm, in which participants judged the occurrence of changes in either categorical (CAT) or coordinate (COO) spatial relations. Previously, parietal and frontal lobes were identified as key areas in processing spatial relations and it was shown that each hemisphere was differently involved and modulated by the scope of the attention window (e.g. a large and small cue). In this study, Granger analysis highlighted the patterns of causality among involved brain areas--the direction of information transfer ran from the frontal to the visual cortex in the right hemisphere, whereas it ran in the opposite direction in the left side. Thus, the right frontal area seems to exert top-down influence, supporting the idea that, in this task, top-down signals are selectively related to the right side. Additionally, for CAT change preceded by a small cue, the right frontal gyrus was not involved in the information transfer, indicating a selective specialization of the left hemisphere for this condition. The present findings strengthen the conclusion of the presence of a remarkable hemispheric specialization for spatial relation processing and illustrate the complex interactions between the lateralized parts of the neural network. Moreover, they illustrate how focusing attention over large or small regions of the visual field engages these lateralized networks differently, particularly in the frontal regions of each hemisphere, consistent with the theory that spatial relation judgements require a fronto-parietal network in the left hemisphere for categorical relations and on the right hemisphere for coordinate spatial processing.

The anatomy of visuospatial construction revealed by lesion-symptom mapping

Visuospatial construction is a complex cognitive operation that is composed of a purely constructional component (visuoconstruction proper), and visuoperceptive, attentional, and decision-making components. The anatomical correlates of visuospatial construction and its cognitive subcomponents are poorly understood. The purpose of the present study was to determine the anatomical correlates of visuospatial construction by applying lesion-symptom mapping in a cohort of 111 patients with first-ever ischemic stroke. We employed the Rey-Osterrieth Complex Figure (ROCF) copy test and the Judgment of Line Orientation (JLO); both tests measure visuoperception, while only the ROCF has a constructional component. We first performed assumption-free voxel-based lesion-symptom mapping, which revealed large shared right hemispheric correlates for the ROCF and JLO in the frontal lobe, superior temporal lobe, and supramarginal gyrus. These shared anatomical correlates reflect the visuoperceptive component of the ROCF and JLO. Anatomical correlates were discordant in the right superior parietal lobule, and angular and middle occipital gyri: lesions in these regions were associated with poor performance on the ROCF, but not the JLO. Secondly, these findings were reproduced with a region of interest-based analysis that yielded a statistically significant correlation between infarct volume in the right inferior and superior parietal, angular and middle occipital cortices, and poor performance on the ROCF, but not the JLO. This discordance in anatomical correlates of the ROCF and JLO reflects the visuoconstructive component of the ROCF. These findings provide new insights in the anatomical correlates of the visuoperceptive and visuoconstructive components of the ROCF and provide evidence for a crucial role of the right inferior and superior parietal, angular and middle occipital gyri in visuoconstruction proper.

The neural substrates of drawing: a voxel-based morphometry analysis of constructional, hierarchical, and spatial representation deficits

Deficits in the ability to draw objects, despite apparently intact perception and motor abilities, are defined as constructional apraxia. Constructional deficits, often diagnosed based on performance on copying complex figures, have been reported in a range of pathologies, perhaps reflecting the contribution of several underlying factors to poor figure drawing. The current study provides a comprehensive analysis of brain-behavior relationships in drawing disorders based on data from a large cohort of subacute stroke patients (n = 358) using whole-brain voxel-wise statistical analyses linked to behavioral measures from a complex figure copy task. We found that (i) overall poor performance on figure copying was associated with subcortical lesions (BG and thalamus), (ii) lateralized deficits with respect to the midline of the viewer were associated with lesions within the posterior parietal lobule, and (iii) spatial positioning errors across the entire figure were associated with lesions within visual processing areas (lingual gyrus and calcarine) and the insula. Furthermore, deficits in reproducing global aspects of form were associated with damage to the right middle temporal gyrus, whereas deficits in representing local features were linked to the left hemisphere lesions within calcarine cortex (extending into the cuneus and precuneus), the insula, and the TPJ. The current study provides strong evidence that impairments in separate cognitive mechanisms (e.g., spatial coding, attention, motor execution, and planning) linked to different brain lesions contribute to poor performance on complex figure copying tasks. The data support the argument that drawing depends on several cognitive processes operating via discrete neuronal networks and that constructional problems as well as hierarchical and spatial representation deficits contribute to poor figure copying.

Frontal-executive constructional apraxia: when delayed recall is better than copying

In assessments of visuospatial function and memory, patients are often required to copy a figure and later to reproduce that figure from memory. Whereas most people perform better on a copying task than when drawing from memory, in this study we describe an unusual pattern of performance in which patients are better at drawing from memory than copying. Consecutive patients in a neurocognitive disorders clinic were given a battery of clinical cognitive tests that included copying a figure of intersecting pentagons and then drawing the figure from memory. Patterns of drawing performance at the two time points were compared to the profile of other cognitive deficits.

RESULTS

A subgroup of four patients with frontal dysfunction showed marked improvement in drawings at a delay compared to copying. Prior studies have indicated that most patients have declines in drawing performance at a delay. The unusual pattern of better performance at a delay compared to an initial copy occurred in patients with frontal dysfunction. These patients' visuoconstructive deficit and subsequent improvement could be related to either a failure to disengage when a model is present, to memory consolidation with increased reliance on top-down processing in the delay condition, or to relative preservation of global versus local aspects of a stimulus in memory. The addition of a task to assess drawing after a delay to a standard clinical screening battery such as the Mini-Mental Status Examination (MMSE) provides the opportunity to evaluate this phenomenon that may be indicative of frontal-executive dysfunction.

Emergence of realism: Enhanced visual artistry and high accuracy of visual numerosity representation after left prefrontal damage

Over the last two decades, evidence of enhancement of drawing and painting skills due to focal prefrontal damage has accumulated. It is of special interest that most artworks created by such patients were highly realistic ones, but the mechanism underlying this phenomenon remains to be understood. Our hypothesis is that enhanced tendency of realism was associated with accuracy of visual numerosity representation, which has been shown to be mediated predominantly by right parietal functions. Here, we report a case of left prefrontal stroke, where the patient showed enhancement of artistic skills of realistic painting after the onset of brain damage. We investigated cognitive, functional and esthetic characteristics of the patient׳s visual artistry and visual numerosity representation. Neuropsychological tests revealed impaired executive function after the stroke. Despite that, the patient׳s visual artistry related to realism was rather promoted across the onset of brain damage as demonstrated by blind evaluation of the paintings by professional art reviewers. On visual numerical cognition tasks, the patient showed higher performance in comparison with age-matched healthy controls. These results paralleled increased perfusion in the right parietal cortex including the precuneus and intraparietal sulcus. Our data provide new insight into mechanisms underlying change in artistic style due to focal prefrontal lesion.

Focusing narrowly or broadly attention when judging categorical and coordinate spatial relations: a MEG study

We measured activity in the dorsal system of the human cortex with magnetoencephalography (MEG) during a matching-to-sample plus cueing paradigm, where participants judged the occurrence of changes in either categorical or coordinate spatial relations (e.g., exchanges of left versus right positions or changes in the relative distances) between images of pairs of animals. The attention window was primed in each trial to be either small or large by using cues that immediately preceded the matching image. In this manner, we could assess the modulatory effects of the scope of attention on the activity of the dorsal system of the human cortex during spatial relations processing. The MEG measurements revealed that large spatial cues yielded greater activations and longer peak latencies in the right inferior parietal lobe for coordinate trials, whereas small cues yielded greater activations and longer peak latencies in the left inferior parietal lobe for categorical trials. The activity in the superior parietal lobe, middle frontal gyrus, and visual cortex, was also modulated by the size of the spatial cues and by the type of spatial relation change. The present results support the theory that the lateralization of each kind of spatial processing hinges on differences in the sizes of regions of space attended to by the two hemispheres. In addition, the present findings are inconsistent with the idea of a right-hemispheric dominance for all kinds of challenging spatial tasks, since response times and accuracy rates showed that the categorical spatial relation task was more difficult than the coordinate task and the cortical activations were overall greater in the left hemisphere than in the right hemisphere.

Clock drawing in spatial neglect: a comprehensive analysis of clock perimeter, placement, and accuracy

Clock drawings produced by right-brain-damaged (RBD) individuals with spatial neglect often contain an abundance of empty space on the left while numbers and hands are placed on the right. However, the clock perimeter is rarely compromised in neglect patients' drawings. By analysing clock drawings produced by 71 RBD and 40 healthy adults, this study investigated whether the geometric characteristics of the clock perimeter reveal novel insights to understanding spatial neglect. Neglect participants drew smaller clocks than either healthy or non-neglect RBD participants. While healthy participants' clock perimeter was close to circular, RBD participants drew radially extended ellipses. The mechanisms for these phenomena were investigated by examining the relation between clock-drawing characteristics and performance on six subtests of the Behavioral Inattention Test (BIT). The findings indicated that the clock shape was independent of any BIT subtest or the drawing placement on the test sheet and that the clock size was significantly predicted by one BIT subtest: the poorer the figure and shape copying, the smaller the clock perimeter. Further analyses revealed that in all participants, clocks decreased in size as they were placed farther from the centre of the paper. However, even when neglect participants placed their clocks towards the centre of the page, they were smaller than those produced by healthy or non-neglect RBD participants. These results suggest a neglect-specific reduction in the subjectively available workspace for graphic production from memory, consistent with the hypothesis that neglect patients are impaired in the ability to enlarge the attentional aperture.

Lateralization of cognitive functions in aphasia after right brain damage

PURPOSE

The lateralization of cognitive functions in crossed aphasia in dextrals (CAD) has been explored and compared mainly with cases of aphasia with left hemisphere damage. However, comparing the neuropsychological aspects of CAD and aphasia after right brain damage in left-handers (ARL) could potentially provide more insights into the effect of a shift in the laterality of handedness or language on other cognitive organization. Thus, this case study compared two cases of CAD and one case of ARL.

MATERIALS AND METHODS

The following neuropsychological measures were obtained from three aphasic patients with right brain damage (two cases of CAD and one case of ARL); language, oral and limb praxis, and nonverbal cognitive functions (visuospatial neglect and visuospatial construction).

RESULTS

All three patients showed impaired visuoconstructional abilities, whereas each patient showed a different level of performances for oral and limb praxis, and visuospatial neglect.

CONCLUSION

Based on the analysis of these three aphasic patients' performances, we highlighted the lateralization of language, handedness, oral and limb praxis, visuospatial neglect and visuospatial constructive ability in aphasic patients with right brain damage.

The relationship between allocentric and egocentric frames of reference and categorical and coordinate spatial information processing

We report two experiments on the relationship between allocentric/egocentric frames of reference and categorical/coordinate spatial relations. Jager and Postma (2003) suggest two theoretical possibilities about their relationship: categorical judgements are better when combined with an allocentric reference frame and coordinate judgements with an egocentric reference frame (interaction hypothesis); allocentric/egocentric and categorical/coordinate form independent dimensions (independence hypothesis). Participants saw stimuli comprising two vertical bars (targets), one above and the other below a horizontal bar. They had to judge whether the targets appeared on the same side (categorical) or at the same distance (coordinate) with respect either to their body-midline (egocentric) or to the centre of the horizontal bar (allocentric). The results from Experiment 1 showed a facilitation in the allocentric and categorical conditions. In line with the independence hypothesis, no interaction effect emerged. To see whether the results were affected by the visual salience of the stimuli, in Experiment 2 the luminance of the horizontal bar was reduced. As a consequence, a significant interaction effect emerged indicating that categorical judgements were more accurate than coordinate ones, and especially so in the allocentric condition. Furthermore, egocentric judgements were as accurate as allocentric ones with a specific improvement when combined with coordinate spatial relations. The data from Experiment 2 showed that the visual salience of stimuli affected the relationship between allocentric/egocentric and categorical/coordinate dimensions. This suggests that the emergence of a selective interaction between the two dimensions may be modulated by the characteristics of the task.

Exogenous attention differentially modulates the processing of categorical and coordinate spatial relations

Carrasco and her colleagues have suggested that exogenous attention reduces the size of receptive fields at an attended location (Gobell & Carrasco, 2005; Yeshurun & Carrasco, 1998, 2000). Based on the hypothesis that categorical and coordinate spatial relations are more efficiently processed by smaller and larger receptive fields, respectively, we predicted that exogenous attention would be more beneficial to the processing of categorical spatial relations than coordinate spatial relations while it would disrupt the processing of coordinate spatial relations. To test these hypotheses, participants were tested using a variant of Posner's (1980) attentional cueing paradigm. Exogenous attention produced larger facilitative effects on categorical spatial processing than on coordinate spatial processing at a short cue-target stimulus onset asynchrony (100 ms, Experiment 1, N=28), and this result was replicated regardless of cue size in Experiment 2 (N=24). When the coordinate judgment was sufficiently difficult, exogenous attention disrupted the processing of coordinate spatial relations (Experiment 3, N=28). These findings indicate that exogenous attention can differentially modulate the processing of categorical and coordinate spatial relations.

The neural basis for spatial relations

Studies in semantics traditionally focus on knowledge of objects. By contrast, less is known about how objects relate to each other. In an fMRI study, we tested the hypothesis that the neural processing of categorical spatial relations between objects is distinct from the processing of the identity of objects. Attending to the categorical spatial relations compared with attending to the identity of objects resulted in greater activity in superior and inferior parietal cortices (especially on the left) and posterior middle frontal cortices bilaterally. In an accompanying lesion study, we tested the hypothesis that comparable areas would be necessary to represent categorical spatial relations and that the hemispheres differ in their biases to process categorical or coordinate spatial relations. Voxel-based lesion symptom mapping results were consistent with the fMRI observations. Damage to a network comprising left inferior frontal, supramarginal, and angular gyri resulted in behavioral impairment on categorical spatial judgments. Homologous right brain damage also produced such deficits, albeit less severely. The reverse pattern was observed for coordinate spatial processing. Right brain damage to the middle temporal gyrus produced more severe deficits than left hemisphere damage. Additional analyses suggested that some areas process both kinds of spatial relations conjointly and others distinctly. The left angular and inferior frontal gyrus processes coordinate spatial information over and above the categorical processing. The anterior superior temporal gyrus appears to process categorical spatial information uniquely. No areas within the right hemisphere processed categorical spatial information uniquely. Taken together, these findings suggest that the functional neuroanatomy of categorical and coordinate processing is more nuanced than implied by a simple hemispheric dichotomy.

Turning off artistic ability: the influence of left DBS in art production

BACKGROUND

The influence of Parkinson's disease (PD) as well as deep brain stimulation (DBS) on visual-artistic production of people who have been artists is unclear. We systematically assessed the artistic-creative productions of a patient with PD who was referred to us for management of a left subthalamic region (STN) DBS. The patient was an artist before her disease started, permitting us to analyze changes in her artistic-creative production over the course of the illness and during her treatment with DBS.

METHODS

We collected her paintings from four time periods: Time 1 (Early Pre-Presymptomatic), Time 2 (Later Presymptomatic), Time 3 (Symptomatic), and Time 4 (DBS Symptomatic). A total of 59 paintings were submitted to a panel of judges, who rated the paintings on 6 different artistic qualities including: aesthetics, closure, evocative impact, novelty, representation, technique.

RESULTS

Aesthetics and evocative impact significantly declined from Time 2 to Time 4. Representation and technique indicated a curvilinear relationship, with initial improvement from Time 1 to Time 2 followed by a decline from Time 2 to Time 4.

CONCLUSIONS

These results suggest that left STN/SNR-DBS impacted artistic performances in our patient. The reason for these alterations is not known, but it might be that alterations of left hemisphere functions induce a hemispheric bias reducing the influence the right hemisphere which is important for artistic creativity. The left hemisphere itself plays a critical role in artistic creativity and DBS might have altered left hemisphere functions or altered the mesolimbic system which might have also influenced creativity. Future studies will be required to learn how PD and DBS influence creativity.

Cerebral cortical mechanisms of copying geometrical shapes: a multidimensional scaling analysis of fMRI patterns of activation

We used multidimensional scaling (MDS) to characterize the integrative neural mechanisms during viewing and subsequently copying nine geometrical shapes. Human subjects initially looked at a central fixation point ("rest" period), then looked at a geometrical shape ("visual" period) which they copied without visual feedback ("copying" period). BOLD signal was recorded from voxels in 28 cortical areas (14 from each hemisphere) using a 4 Tesla magnet. For each voxel, signal ratios of "Visual versus Rest" (VR), and "Copy versus Visual" (CV) were calculated and used to construct two sets of Euclidean distance dissimilarity matrices for the nine shapes, with separate matrices defined for each region of interest (ROI) across subjects. The relations of perceptual and motor aspects of the shapes to MDS dimensions and specific ROIs were assessed using stepwise multiple regressions. The optimal individually scaled (INDSCAL) solutions were 2-dimensional. For the VR condition, MDS dimensions were significantly associated with the presence of crossing in a shape (Dimension 1), and with perimeter, height, cycles, peak segment speed, and horizontal symmetry (Dimension 2). ROIs most prominently associated with these dimensions essentially comprised the medial frontal lobe bilaterally, the inferior frontal gyrus bilaterally, and the left intraparietal sulcus (Dimension 1), and visual areas, including the calcarine sulcus and cuneus bilaterally (Dimension 2). These results document the expected involvement of visual areas and support the hypothesis advanced on the basis of previous findings (Lewis et al. 2003a) that a motor rehearsal of the upcoming shape copying is occurring during this visual presentation period. For the CV condition, practically one motor feature (number of segments drawn) dominated both dimensions, with a secondary engagement of horizontal symmetry in Dimension 1. The right postcentral gyrus, right intraparietal sulcus, right superior parietal lobule and right inferior parietal lobule contributed mostly to Dimension 1; the superior frontal gyrus bilaterally, right middle frontal gyrus, left postcentral gyrus, left inferior parietal lobule contributed mostly to Dimension 2; and the left superior parietal lobule and left intraparietal sulcus contributed to both dimensions approximately equally. CV BOLD activation of ROIs contributing to Dimension 1 (or to both dimensions) was significantly associated with the number of shape segments drawn. Since the direction of movement differs in successively drawn shape segments, the number of segments (minus one) equals the number of changes in the direction of movement. We conclude that this fundamental spatial motor aspect of drawing geometrical shapes is the critical variable, independent of the particular shape drawn, that dominates cortical activation during copying.

The role of the posterior parietal cortex in drawing by copying

Impaired ability to draw visually presented figures by copying represents one major manifestation of constructional apraxia (CA). Previous clinical studies have indicated that CA is caused by lesions in the posterior parietal cortex (PPC), but the functional roles of the PPC remain unclear. A spared ability to trace with an impaired ability to copy indicates that deficits lie not in low-level visuomotor processing, but rather in a coordinate transformation involving production of an egocentric representation of model trajectory in the drawing space, which is spatially separated from the model space. To test the hypothesis that the PPC plays a role in coordinate transformation, we compared brain activities for drawing by copying and tracing using functional magnetic resonance imaging (fMRI). Healthy participants traced over the visually presented model or copied the model on a separate space. To avoid potential confounders of differences in behavioral performances as well as eye movements, a memory-guided condition was introduced, resulting in four drawing conditions; tracing over or copying a model at different locations (tracing and copying), with or without an on-screen model (visual and memory guidance). As hypothesized, the intraparietal sulcus (IPS) bilaterally in the PPC showed significantly greater activations in copying than in tracing, under both visual and memory guidance, with a distinct activation pattern involving the premotor and mesial motor regions. This study indicates a role of the PPC in coordinate transformation for drawing by copying, which may be important for the copying deficit observed in CA.

Shared and differential neural substrates of copying versus drawing: a functional magnetic resonance imaging study

Copying and drawing-from-memory tasks are popular clinical tests to assess visuo-motor skills in neurological patients. The tasks share some motor and visual processes; however, they differ substantially in their cognitive demands. We used functional magnetic resonance imaging to identify brain regions underlying processes involved in these tasks while avoiding confounds related to basic motor requirements, through use of a specially developed functional magnetic resonance imaging-compatible computer tablet. For the copying task, activation was observed in brain regions subserving visual processing and crossmodal attention (e.g. left lingual gyrus, cuneus). Drawing activated the anterior cingulate, an area associated with motor control and linking intention with action. These findings suggest distinct neural networks subserving copying and drawing.

Apraxia: a review

Praxic functions are frequently altered following brain lesion, giving rise to apraxia - a complex pattern of impairments that is difficult to assess or interpret. In this chapter, we review the current taxonomies of apraxia and related cognitive and neuropsychological models. We also address the questions of the neuroanatomical correlates of apraxia, the relation between apraxia and aphasia and the analysis of apraxic errors. We provide a possible explanation for the difficulties encountered in investigating apraxia and also several approaches to overcome them, such as systematic investigation and modeling studies. Finally, we argue for a multidisciplinary approach. For example, apraxia should be studied in consideration with and could contribute to other fields such as normal motor control, neuroimaging and neurophysiology.