1) The document discusses disturbances of body schema and spatial relationships that can occur due to lesions in the parietal lobes. It defines concepts like body schema, autotopagnosia, spatial disorientation, and hemispatial neglect. 2) Tests for evaluating these conditions are described, including those for anosognosia, autotopagnosia, and hemispatial neglect. Common sites of lesions that cause different symptoms are also outlined. 3) Additional syndromes discussed include constructional apraxia, dressing apraxia, loss of topographical memory, allesthesia, and hemi somatognosia. The key features and evaluations of these conditions are summarized.

1. Disturbances of “Body Schema”
and Spatial Relationships.
DR.PRAMOD MEENA
SR NEUROLOGY
GMC,KOTA

2. • Head and Holmes discussed two schemas :
1. One body schema for the registration of posture or movement and
2. Another body schema for the localization of stimulated locations on
the body surface.
• "Body schema" became the term used for the "organized models of
ourselves".
• The term and definition first suggested by Head and Holmes
DEFINITION:

3. • The body schema represents both position and configuration of the
body as a 3-dimensional object in space.
• A combination of sensory information, primarily tactile and visual,
contributes to the representation of the limbs in space.
• This integration allows for stimuli to be localized in external space
with respect to the body.
• Body schema also plays an important role in the integration and use
of tools by humans.
• Both parietal lobe responsible for body schema and spatial
relationship

4. (a) Anosognosia
(b) Autotopagnosia
(c) Spatial disorientation
(d) Hemispatial neglect
(e) Constructional apraxia
1.) Non-dominant hemisphere
f) Dressing apraxia
(g) Loss of topographical memory
(h) Allesthesia
(i) Hemi somatognosia
(j) Asymbolia for pain
2.) Dominant hemisphere
(a) Finger agnosia
(b) Right–left disorientation

5. ANOSOGNOSIA
• The term anosognosia originally referred to a specific unawareness of
paralysis following stroke (Babinski in 1914).
• Anosognosia occurred in 2 phase
1. Hyperacute phase (3 days post stroke) was related to damage in the
anterior insula and anterior subcortical structures.
2. Later phase (still present one week later) was associated with
additional lesions in parietal, frontal, and temporal structures.

6. Questionnaire : for Anosognosia
In Hemiplegic patient
1.Do you have weakness anywhere?
2.Is your arm causing you any problems?
3. Does it feel normal?
4. Can you use it as well as you used to?
5.Are you fearful about losing your ability to use your
arm?

7. Cont..
6.Is the sensation in your arm normal?
7.The doctors tell me that there is some paralysis
of your arm. Do you agree?
8.Left arm is lifted and dropped in left hemispace.
“It seems there is some weakness. Do you agree?”
9.Left arm is lifted and dropped in right hemispace.
“It seems there is some weakness. Do you agree?”
10.Take your right arm, and use it to lift your left
arm. Is there any weakness of your left arm?”
Feinberg, Roane, and Ali (2000).
Each item is scored as
0 -(shows awareness),
0.5- (partial awareness), or
1 -(complete unawareness).

9. AUTOTOPAGNOSIA
• Autotopagnosia is a form of agnosia, characterized by
an inability to localize and orient different parts of the body.
• lesion found in the parietal lobe of the left hemisphere of the brain.
• No medications or pharmaceutical remedies have been approved by
the U.S. FDA to treat or cure autotopagnosia.

10. Test: for self body part localization
TEST 1 Specifications Description
A Verbal command: point to self Examiner names a body part, and the subject instructed
to point to that part on themselves
B Verbal command: point to examiner Examiner names a body part, and the subject instructed
to point to that part on the examiner
C Verbal cue: point to self Examiner point to body part on himself, and su
bject are required to point to the homologus part on
themselves.
D Verbal cue: point to examiner Examiner point to body part on subject,and they are
required to point to the homologus part on the examiner.
E Blindfold post-visual cue:point to self Same as study 1c except subjects are blindfolded after
examiner point to himself, prior to response execution.

11. Parietal
artery

12. SPATIAL DISORIENTATION
• Spatial Disorientation is the
inability to maintain body orientation and
posture in relation to the surrounding environment (physical space) at
rest and during motion.
• Spatial orientation involves visual, auditory, vestibular, &
proprioceptive sensory information & lesion at right parietal or right
prefrontal cortex.

13. CONT…
• Mainly seen in pilots and divers
• Unfamiliar three-dimensional environment of flight to the human
body.
• creating sensory conflicts.
• illusions that make spatial orientation difficult and sometimes
impossible to achieve.

14. Prefrontal
artery

15. HEMISPATIAL NEGLECT
• Hemispatial neglect is
Defined by the inability of a person to process and
perceive stimuli towards the contralesional side of the body or
environment
• Stimulus-visual, auditory, proprioceptive, and olfactory.
• Neglect occurred when damage to the temporo-parietal junction &
posterior parietal cortex.

16. PCA

17. Examination of neglect
1.Letter search test
2.Line cancellation test
3.Clock drawing test
4.Line bisection test

18. 1. 3. 4.
Letter search
2.Line
cancellation
Clock drawing
Line bisection

21. Mayer-Gross closing-in phenomenon
• Pt. place their drawings close to the model or superimpose the copy
on the model.
• Seen in Patients with diffuse cortical damage.
• Alzheimer disease

22. • Inability to draw or construct 2 or 3D figures or shapes
in presence of normal strength, coordination, sensation ,
comprehension.
• More common and severe with
right non dominant parietal lesion than left.
CONSTRUCTIONAL APRAXIA

23. Tests
• Reproduction drawings
1. both 2D and 3D drawings as vertical diamond,
2. 2D cross,
3. 3D block,
4. 3D pipe,
5. triangle within triangle are used.
Scoring done from poor (0) to excellent (3)

24. Cont..
scoring interpretation
Poor(0) Non recognizable, gross
distortion
Fair(1) Moderately distorted or rotated
2D
Good(2) Minimal distortion
Excellent(3) Perfect or near perfect
Rating 0 = 100% probability of brain damage
Rating 1=80% probability of brain damage
Vertical diamond

25. Cont…

26. • Unable to properly cloth themselves.
• Most often leaves left side partly undressed.
• MC with Right non-dominant parietal lesions.
• Associated with impaired tactile and visuo
spatial coordination Considered as part of
neglect syndrome.
DRESSING APRAXIA

28. Definition:
Inability to find way to familiar environments
Difficulty in localize places on maps
And find his way to new environment
LOSS OF TOPOGRAPHICAL MEMORY

29. Evaluation
History obtained from family
1.Does patient lost at neighborhood, or home?
2.Has pt. lost travelling less frequent location?
3.Does pt. have difficulty orienting new
environment?

30. CONT…
Localizing places on maps
Ask pt. to draw map of India, if pt. can’t draw then
doctor should draw map.
Ask pt. to locate cities on map eg. Delhi, Mumbai, Calcutta.
1.Are cities located in appropriate states?
2.Are cities located on one half of map(either east or west)?
Ability to orient self in hospital environment
Ask nurses staff regarding pt. capacity to find their bed, ward & bathroom.

31. ALLESTHESIA
• In which sensation is felt at a different point on the body from that
stimulated.
• Most commonly patients with allesthesia incorrectly identify left-
sided stimuli as coming from the right side.
• When stimulated on the side contralateral to a hemispheral lesion(rt
parietal), in which they misplace the location of the stimulus to the
normal side.
• Patients with allokinesia respond with the wrong limb or move in the
wrong direction.

32. HEMISOMATOGNOSIA
• It is a unilateral misperception of one’s own body.
• Lesion in right parietal hemisphere.
• Types -
1. conscious -the patient feels like a hemiampute.
2. unconscious -the patient behaves as a hemiampute.

33. Cont..
1. The conscious form is
transient, subcortical origin, unimodal, non-lateralizing & seen in
paroxysmal disease, e.g. migraine or seizure disorder.
2.The unconscious form is
permanent, non-dominant parietal origin,
multimodal (i.e., associated with neglect, anosognosia,
astereognosis, and constructional apraxia), (e.g., stroke).

34. ASYMBOLIA FOR PAIN
• Pt. recognize pain but lack appropriate motor and emotional
responses to painful stimuli applied anywhere on the body surface
& appear insensitive to visual threats and to verbal menaces.
• Lesion present at left supramarginal gyrus infarction and additional
damage involving the angular gyrus, the second frontal and first
temporal convolutions, the external capsule, and the insular cortex

36. Cont..
• Superficial pain
assessed through pinprick and thermal stimuli applied in a single,
repetitive, or prolonged way over the face, neck, trunk, limbs, and perineal
region.
• Deep pain
tested by heavy pressure to pretibial, sternal, and supraorbital
regions; passive hyperextension of fingers and toes; squeezing of calf
muscles and Achilles tendons; and pinching of soft tissues on all four limbs.
• Motor responses -withdrawal and grimacing.
• emotional behavior and autonomic reactions to noxious stimuli.
• AP commonly associated with transient hemiparesis, sensory loss, visual
field defects, neglect, body-schema disorders, aphasia, and apraxia.

37. FINGER AGNOSIA
• Inability to recognize, name, and point to individual fingers on
self and others
• Pt. have lesion in dominant hemisphere
• Lt handed pts. may have finger agnosia with lesions of either
hemisphere.

38. TESTS
1.Non verbal finger recognition:
Pt. eyes closed touch pt finger, then ask pt to point same finger on
examiner hand Identification of named fingers on examiner’s hand &
examiner’s hand placed in various positions.
2.Verbal identification
naming of finger on self and examiner: hand placed in various
positions, ask pt “what is the name of this finger”

39. RIGHT-LEFT DISORIENTATION
 Inability to distinguish right from left on self or environment.
 More common with left hemisphere lesion Normal population
 9%males, 17% females.
Tests
• Identification on self(show me your right foot),
• Crossed commands on self(With your right hand touch your left shoulder)
• Identification on examiner(point to my left elbow)
• Crossed command on examiner(with your right hand point to my left eye)

40. GERSTMANN SYNDROME
It is tetrad
i. FINGER AGNOSIA,
ii. RIGHT-LEFT DISORIENTATION,
iii. AGRAPHIA
iv. ACALCULIA
lesions in the
angular & supramarginal gyri of the dominant hemisphere

41. Angular artery

43. ALEXIA
Definition Inability to read written language
Types:
1.ALEXIA WITH AGRAPHIA or CENTRAL ALEXIA
 lesion in angular gyrus.
 Inability of reading and writing & these patients usually also have
acalculia, finger agnosia, right-left disorientation and difficulty with
spelling words and understanding spelled-out words

44. Dejerine described it in 1892
damage of the corpus callosum fibers connecting the parieto-occipital regions of
the two hemispheres.
It represents the first described inter-hemispheric disconnection syndrome.
Patients cannot read but are able to write on dictation.
Alexia without agraphia results from damage to the pathways conveying visual
input from both hemispheres to the dominant angular gyrus. It may also rarely
occur with infarction of the left lateral geniculate body and the splenium of the
corpus callosum.
2.ALEXIA WITHOUT AGRAPHIA (PURE ALEXIA OR PURE WORD BLINDNESS)

46. APRAXIA
• Inability to carry out a commanded task despite the retention of
motor and sensory function.
• Sensory areas 5 & 7 in dominant parietal lobe, supplementary and
premotor cortex of both cerebral hemispheres and their integral
connection.
• Types
1.Ideomotor apraxia(how to do)
2.Ideational apraxia (what to do)

47. IDEOMOTOR APRAXIA
• Failure to perform previously learned motor acts accurately.
• Results from left hemisphere lesion
TESTS
carrying out motor acts to command:
1.Buccofacial-blow out a match, protrude tongue, drink through a
straw
2.limb-use a toothbrush, flip a coin, hammer a nail, comb hair,

48. IDEATIONAL APRAXIA
• Able to carry out individual components of a complex motor act but
can not perform the entire sequence properly leading to a goal.
• Results from left hemisphere lesion( temporo-parietal)
TESTS
• Opening tooth paste and placing toothpaste on brush.
• How to drive a car
• How to mail a letter.

49. CONCLUSION
• Parietal lobes are important to the processing of sensory information,
understanding spatial orientation and body awareness.
• The parietal lobes process the information and help us to identify
objects by touch & work in concert with other areas of the brain,such
as the motor cortex and visual cortex to perform certain tasks.
• Even after assessment of clinical symptom and signs it is difficult to
ascertain all signs to particular area of the parietal lobe.

50. REFRENCES
• Paul M. Jenkinson , Catherine Preston & Simon J. Ellis (2011)
Unawareness after stroke: A review and practical guide to understanding,
assessing, and managing anosognosia for hemiplegia, Journal of Clinical
and Experimental Neuropsychology, 33:10, 1079-1093,
• " Mosby's Medical Dictionary, 2009. Volume 8. Last updated 2009.
Accessed February 22, 2011
• Bradely′s Neurology in clinical practice, 8th edition
• Brazis 7th edition neurology
• Up to date