Constructional_Apraxia

The patient is a 72 year old right handed woman who presented in November 1995 with the sudden onset of impaired coordination of visual and motor skills following an inner right ear infection. One of her problems was difficulty sitting on a chair as she tended to place her body incorrectly. By late March 1996, she was unable to tie her shoes. In April 1996, during a vacation in Florida to play golf, she frequently missed the ball and had trouble lining herself up with the tee. Her symptoms progressed. Her writing deteriorated and she could not make her bed because the corners that were tucked in were "improperly positioned". On some occasions she mishandled kitchen utensils and one time she tried to cut meat with the handle of a knife. Dressing became a problem. She was unable to put on her bra and frequently she put both legs into the same leg when she tried to put a pair of trousers on. She also stated that she "was unable to line up anything straight" ,for example, when placing tablecloths on a table. She also had a problem walking and described difficulty figuring out which foot to put down next. Going down stairs was particularly difficult and when she came to a curb to cross the road she feared she was going to fall. Frequently she bumped into things particularly on her left side and when she picked things up with her left hand, she tended to drop them. When she attempted to dance with her husband, her left foot dragged. In September 1996 these behavioral changes prompted a referral to Dr. David Caplan for a neurological opinion. Past History: Negative for stroke. Family History: Negative for CNS disease. Social History: She described herself as an average student and left high school after her sophomore year. She worked at GE as a machine operator and retired in 1970. In her retirement, she assisted her husband baking cakes for their restaurant and bookkeeping. Symptomatic Inquiry: Negative for any language difficulty, memory impairment, headache, vertigo, confusion, syncope or visual symptoms. Her general health was good. On examination: •She was fully oriented to time, place and person •Her memory was intact •Her speech was normal. She made only 1 spelling mistake writing Iland for Island •She could not however spell table, leopard and the non- word beff correctly to dictation. She was totally unable to: •Draw a floor plan of her house •Place towns in New Hampshire on a map of New Hampshire correctly. She placed Portsmouth inland and north of the coast and Seabrook slightly to the west of Portsmouth •Multiply 7 x 14 in her head or do simple addition and subtraction sums correctly. The cranial nerve examination was normal. •Visual acuity OU and fields normal Examination of the Motor System showed unilateral left hand apraxia with: A pronator drift of the left arm with impaired dexterous finger movements. Inability to move her left index finger rapidly from her nose to touch the examiner's finger Inability to perform Lurias's metakinetic tests of motor sequencing (touching her knee with her hand in the form of a fist, the edge of her hand, and the palm of her hand in sequence) and failure to make pantomime movements, such as brushing her hair or her teeth, with her left hand The right hand made all the movements correctly. Sensory examination showed: Graphesthesia bilaterally. She was able to name one of three letters written on her right palm but unable to name all the letters or numbers written on her left palm. Limb apraxia: Her gait showed a rigidity in movement of her left arm and on standing, she had external rotation of the left leg. When she came into the office she completely misjudged the position of a chair and sat down with her left leg over the arm of the chair and could not extricate herself from that position. She could not climb onto the examining table using a stool because she tended to put her right foot too far towards the left part of the stool for there to be room for her left foot. When descending from the table she put her right leg on the stool and then did not know how far down either the stool or the ground was for her left leg. A CT Brain scan in April 1996 was normal. Two subsequent MRI scans with Gadolinium were reported to show "mild atrophy". Neuropsychological evaluation by Dr. Janet Sherman showed significant difficulties with visual-motor coordination. Perception: On the line by line bisection task, there was some suggestion of left sided neglect, with lines often bisected very far to the right of center. On a test of tactile perception, stereognosis, she had no difficulty in tactually identifying objects with her right hand, but with her left hand made numerous errors, correctly identifying only 3 of 7 objects. Her errors with the left hand were suggestive for right hemisphere damage. Visual Construction: First, she was asked to copy a number of figures on the Beery Developmental Test of Visual Motor Integration, a test that is normally administered to children. On this test, she successfully copied a vertical line, horizontal line, a circle, diagonal line and a plus sign, but was unable to copy a square, a triangle or any of the more complex figures that required integration of more than one element. Her drawing of a square showed an inability to integrate its parts. Her overall raw score of 6 on this test placed her at a 4 year, 6 month age equivalent level, and demonstrated a profound level of impairment in visual construction. She was unable to copy the two intersecting hexagons on the Mini Mental State Examination, drawing only the right side of each of the figures. She was able to place numbers on a clock face with a fair degree of accuracy but was unable to show the time 11:10 as requested, instead pointing the hands to 10 and 12 on the clock, and then adding a hand pointing to 11. Her free drawing was profoundly impaired as she was unable to draw a daisy, a cube or a house. Her difficulty on this task did not appear to be one of imaging the object, as she was able to tell the examiner, "I know what a house looks like, a square, a roof, a chimney", but was able to draw only two separate horizontal lines. Visual Object Recognition: She was also administered the Boston Naming Test, a test of confrontation naming in which the individual is asked to provide the names for line drawings of objects (e.g. camel, wheelchair, cactus). Of 60 items presented, she provided the correct name for 43 of them, a performance that placed her within normal limits as compared to age-matched controls. This test confirmed that visual-object recognition appeared to be intact. Apraxia Assessment: The Apraxia Test from the Boston Diagnostic Aphasia Examination was administered and she was able to execute all of the commands when asked to perform them with her right hand but was completely uncoordinated in carrying out the same actions with her left hand (for example, patting when asked to wave goodbye with her left hand). Memory: Verbal short-term memory was intact. But, her ability to remember story information was at the 52 percentile for immediate recall. Attention: Performance on the Trial Making Test, a test of visual-motor conceptual tracking was impaired, with difficulties mainly attributed to difficulty in keeping her place on the page and a slow visual search. ( Selected illustrations of the test results are shown in Figure 1-8). Summary: The apraxic deficits exhibited by this patient were Dressing Apraxia Constructional Apraxia Left hand apraxia together with Left-sided neglect and Optic Ataxia The Cognitive Syndrome resulted in impairment of: •The control of the left side of her body •The mental reconstruction of space •The ability to use visual information and proprioceptive information to guide action and •Cognitive deficits that are associated with right hemisphere disease in right handed individuals. Discussion: The first consideration in this case is lesion laterality. Damage to the left hemisphere causes deficits in processing visual stimuli for language content or associations. Deficits in processing visual material for some spatial relations, for some perceptual properties, and for some aspects of emotional content usually are caused by right hemisphere lesions. The second anatomical consideration is dorsal-ventral. Damage to the ventral (inferior) visual association cortex and pathways impairs discrimination and identification of stimuli: the "what" system. Damage to the dorsal (superior) visual association cortex and pathways impairs intentional, spatial, and kinesthetic analyses; the "where" system. (Table 141-1 (1)). The brunt of the disease process in this patient affected the dorsal superior visual association cortex and pathways in the right parietal lobe. It was not at all clear, however, what the etiology was. Her deficits in visual construction and mathematical calculation (spatial dyscalculia) are impairments that are also associated with right parietal functions. Diagnosis: Progressive Lobar Atrophy Affecting the Right Parietal Lobe - a condition which has been better described in the case of left hemisphere disease leading to primary progressive aphasia than in the case of right hemisphere disease leading to progressive apraxia. The patient was lost to follow-up. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/5