HIGHER MENTAL FUNCTION EXAMINATION PART 2, ALEXIA, AGRAPHIA, APRAXIA, HEMINEGLECT, GERSTMANN SYNDROME

1. DR. ASHUTOSH RATH
GMCH, GUWAHATI

2. 1.ALEXIA
2.APRAXIA
3.GERSTMANN SYNDROME
4.AGRAPHIA
5.HEMINEGLECT

3. SUPERIOR
TEMPORAL GYRUS
ANTEROLATERAL TEMPORAL
LOBE &
ANGULAR GYRUS(39)
CLASSICAL WERNICKES AREA &
SUPRAMARGINAL GYRUS OF
PARIETAL LOBE(22 & 40)

4. READING AND WRITING : ALEXIA and
AGRAPHIA
• VWFA-visual word form area
• Equivalent to Auditory phoneme perception
area.
• Left occipito-temporal sulcus & left fusiform
gyrus.

5. VWFA

6. Reading with comprehension
• Visual information from the
left occipital lobe reaches
directly the left fusiform
gyrus.
• From the rt occipital lobe
has to cross over to (corpus
callosum)reach the left
fusiform GYRUS.
• ANGULAR GYRUS-
interpretation of visual-
verbal materials.

7. Reading aloud

8. •THE PROBLEM OF
READING WITH
COMPREHENSION
ALEXIA
•THE PROBLEM OF
READING ALOUD
PARALEXIA

9. Reading
CONDITIONS FEATURES
BROCA’S APHASIA OFTEN IMPAIRED(THIRD ALEXIA)
WERNICKE’S APAHSIA IMPAIRED FOR COMPREHENSION,
READING ALOUD
GLOBAL IMPAIRED
CONDUCTION APHASIA INABILITY TO READ ALOUD, SOME
COMPREHENSION
TRANSCORTICAL MOTOR INTACT
TRANSCORTICAL SENSORY IMPAIRED
TRANSCORTICAL MIXED IMPAIRED
ANOMIC APHASIA INTACT

10. ALEXIA WITHOUT AGRAPHIA
• PURE/POSTERIOR ALEXIA
• CAN NOT : read and
understand
• CAN UNDERSTAND: words
spelled aloud, written on the
palm
• Visual function intact(Naming
objects)
• left occipital lobe with
splenium
• Left PCA infarcts
ALEXIA WITH AGRAPHIA
• CENTRAL ALEXIA
• Aquired illiteracy
• Unable to read or write
• Dominant ANGULAR gyrus

11. Al-Ag

12. AL+AG
AL-AG

14. Al+Ag
LIKE WERNICKE’S

15. THIRD ALEXIA
• Inability to comprehend syntax
• “Ravana was killed by rama” vs “ Rama killed
Ravana”
• Seen in Broca’s aphasia

16. OTHER ALEXIAS
SURFACE ALEXIA
• Grapheme to phoneme
conversion problem
• Irregular orthography
• CAN read: mint,dog,cat
• CAN NOT read: pint, dough,
laugh
•
PARALEXIA(DEEP)
• Problem of READIN ALOUD
• SEMANTIC paralexia –m.c
• Eg: infant read as baby

17. WRITING
CONDITIONS FEATURES
BROca’s APAHSIA IMPAIRED(DYSMORPHIC, AGRAMMATICAL)
WERNICKE’S APHASIA WELL FORMED PARAGRAPHIC
GLOBAL APHASIA IMPAIRED
CONDUCTION APHASIA VARIABLE
TRANSCORTICAL MOTOR APHASIA INTACT
TRANSCORTICAL SENSORY APHASIA IMPAIRED
TRANSCORTICAL MIXED APHASIA IMPAIRED
ANOMIC APHASIA INTACT (EXCEPT FOR ANOMIA)

18. LEFT PARIETAL LOBE

19. APRAXIA
CENTRAL ALEXIA
ACALCULIA AND COMPONENTS OF THE GERSTMANN SYNDROME

20. APRAXIA

21. TYPES
CONCEPTUAL APRAXIA
IDEATIONAL APRAXIA
IDEOMOTOR APRAXIA
LIMB KINETIC APRAXIA

22. PRAXIS CONCEPTUAL AND PRODUCTION SYSTEMS
INF.PARIETAL LOBULE
SUP.PARIETAL LOBULE

23. PARIETO-FRONTAL PRAXIS PATHWAYS
• IMAGE 4.2
CRUDE REACHING MOVEM
MEDIAL PATHWAY
LATERAL PATHWAY
FINE GRASPING MOVEMENTS

24. CONCEPTUAL AND IDEATIONAL
APRAXIA(Ochipa’s model)
• PRAXIS conceptual system has 3 types of
knowledge
Knowledge of objects and tools
Knowledge of actions
Knowledge of organization of actions in a
sequence
• 1st two impaired in conceptual A.
• 3rd knowledge in ideational A.

25. Transitive movements
• Movements or pantomimes where an object is
used
1. Act of omission(forgets to spread the Paste)
2. Act of misuse(uses key instead of hammer)
3. Act of mislocation(holds the pen upside down)

26. IDEOMOTOR
• ABNORMALITIES of the action production
system
• Perform poorly on pantomime
• Significant improvement with object.

27. LIMB KINETIC APRAXIA
• PREMOTOR CORTEX
• Deficit confined to finger and hand
movements c/l to the lesion regardless of the
hemispheric side, with preservation of power

28. OTHER APRAXIA’S
• Eg .how to drink using a straw, whistle , cough
• Ventral pemotor cortex
BUCCO-FACIAL
APRAXIA
• Genu and body
• Unilateral apraxia of the non dominant limb
CALLOSAL
APRAXIA
• Inability to generate voluntary saccades to a
visual target
OCULOMOTOR
APRAXIA
• High level gait disorder
• NPHGAIT APRAXIA

29. TESTING
CONCEPTUAL APRAXIA
• TOOL SELECTION TASK : appropriate tool to
complete a task. eg hammer for a partially
driven nail.

31. • ALTERNATIVE TOOL SELECTION TASK : eg.
What will u do if hammer is not available

33. • GESTURE RECOGNITION TASK
Gesture performed by examiner
Name them or match a card corresponding to it

35. IDEATIONAL APRAXIA
• Prepare a letter for mailing
• Use the toothbrush and paste to brush.

37. IDEOMOTOR APRAXIA
• PANTOMIME using a hammer or a
screw driverTRANSITIVE
• Wave good bye, salute
INTRANSITIVE
MOVEMENTS
• Imitation of meaningful and
meaningless posturesIMITATION
ACTUAL TOOL
USE

38. Meaningful movements

39. Meaningless movements

43. LIMBKINETICAPRAXIA Ask the patient to oppose their
thumb to their index , middle , ring
and little fingers in rapid succession
Ask the patient to imitate some
random hand position

45. GERSTMANN’S SYNDROME
1. ACALCULIA(anarithmia)
2. AGRAPHIA
3. FINGER AGNOSIA
4. RIGHT-LEFT
CONFUSION

47. ACALCULIA• PRIMARY acalculia
• A basic defect in computational ability
• Left angular gyrus
ANARITHMIA
• SECONADRY ACALCULIA
• Alexia for numbers
• Also in central alexia & alexia without agraphia
ALEXIC
ACALCULIA
• Difficulty in Written arithmetics
• Carrying over problem
• Mental arithmetics better than written calculation
• Rt . PARIETAL pathology
SPATIAL
ACALCULIA

48. Testing procedure
1. FORWARD and backward counting
2. Symbolic transcoding
1. Numerical to verbal: 109---- one hundred nine
2. Verbal to numerical: vice versa
3. Reading and writing arithmetic signs
4. Mental calculation(add,subsract,multiply,divide)
5. Written calculation
6. Aligning numbers in columns for adding.(eg.
32+333+3456+2)
7. Arithmetic problems requiring planning. (perform the
ebove calculation)

50. FINGER AGNOSIA
• Inability to recognise , distinguish or name
fingers
1. patients own hand
2. examiners hand
3. Drawing of a hand.
• m.C problems index, middle and ring fingers

51. Testing procedure
1. Hands visible: identification of fingers touched by the
examiner
2. Hands visible: identification of examiners fingers
3. Hands hidden: identification of fingers touched by the
examiner
4. Hands hidden: identification of pairs fingers
simultaneously touched by the examiners.

52. RIGHT LEFT DISORIENTATION
• Inability to identify right & left sides of
1. Own body
2. Person seated opposite
3. Photograph/drawing
• Patients also have problems with
1. Up & down
2. Above & below
3. Over & under

53. Testing procedure
ORIENTATION TOWARDS OWN BODY
1. Naming single lateral body parts touched
2. Pointing to single lateral body parts on verbal
command
3. Executing double uncrossed movements on
command(touch left ear with left hand)
4. Executing double crossed movements on verbal
command(touching left ear with right hand)

54. ORIENTATION TOWARDS CONFRONTING
EXAMINER OR PICTURE
1. Naming single lateral body parts shown by the
examiner
2. Pointing to single lateral body parts on verbal
command
3. Imitating double uncrossed movements on
command(touch left ear with left hand)
4. Imitating double crossed movements on verbal
command(touching left ear with right hand)

55. COMBINED ORIENTATION TOWARDS ONE’S
OWN BODY AND CONFRONTING PERSON.
Placing the right hand of the patient on
confronting persons left ear

56. AGRAPHIA
• Aquired abnormalities of writing
• called apraxic agraphia
• Not associated with alexia
• The usual missing element in incomplete
gerstmann

57. AGRAPHIA
• anterior(BROCA’s)-agrammatism with spelling
mistakes
• Posterior(WERNICKE’S)-unintelligible & non-
sensical
Aphasic
agraphia
• Correct letters and words
• Problem with orientation on a paper
• eg,. Moving on to the next line, wider space on
one side
Visuospatial
agraphia
• Language formation is correct along with spatial
arrangement
• Handwriting loses its personal
characters(becomes a scrawl)
Apraxic
agraphia

58. Testing procedure
A. Spontaneous writing:
1. Interpretation of cookie theft picture
2. Why have u come here?
B. Writing to dictation
C. copying

64. RIGHT PARIETAL LOBE

65. 1.HEMINEGLECT
2.CONSTRUCTIONAL APRAXIA
3.DRESSING APRAXIA
4.TOPOGRAPGHICAL DISORIENTATION

66. HEMINEGLECT
• PERSONAL NEGLECT:
ask the pt.
1. Comb your hair
2. Shave
3. Put on a makeup
(cream/powder)

67. REPRESENTATIONAL HEMINEGLECT
• Draw a clock face from
memory

69. NEGLECT TO EXTERNAL SPACE
1. Cancelling targets among distractors.

70. why does everyone in these pictures
seem to have a left hemineglect??
A coincidence!!

72. 2. Horizontal line bisection

73. Hemianopic patients
Direct more eye movements towards
Their contralesional blind side during
Visual sear

74. 3. marking locations of objects with
respect to the patient
• Ask the patients to report ten objects in the
room seating him in the middle of the room.
1. Neglect: report items items from only one side
2. Hemianopia: try to compemste by moving their
head a7 eyes to the contralesional space.

75. CONSTRUCTIONAL APRAXIA
• Inability to copy drawings or three
dimensional constructions accurately.
• No difficulty in making relevant individual
movements.
• commonly used diagrams:
1. Necker’s cube
2. Intersecting pentagons

77. EXPLOSION OF THE CONSTITUENT PARTS
SIMPLIFICATION OF THE
DRAWINGS

78. DRESSING APRAXIA(DA)
• Automatic spontaneous capacity for dressing
oneshelf is lost
• Not a true DA if due to ideational or
ideomotor apraxia
• TEST: put on a jacket given to the patient
upside down with its sleeves deliberately
turned upside down.

80. TOPOGRAPHICAL
DISORIENTATION(TOPOGRAPHOGNOSIA)
1. EGOCENTRIC DISORIENTATION
2. LANDMARK AGNOSIA
3.HEADING DISORIENTATION
4. ANTEROGRADE DISORIENTATION

81. EGOCENTRIC DISORIENTATION
• Dysfunction of localization in space by vision
• Can identify objects
• Have trouble reaching for them & navigating around
them
• Can localize auditory stimuli
• Judge relative location btw objects using proprioceptive
inputs

82. Examples(egocentric d.)
• Bump into things
• Unable to negotiate paths even in familiar
territory
• May walk directly into an obstacle even when
he can see it
• While going towards towards the door the
patient towards the wall & then search for the
door

83. Testing
1. Ask the pt to point in the direction of the
object
2. Touch an object in the visual field
3. Judge the distance of an object
4. Count the no.of objects on a paper placed on
the table

85.  Count the number of dots without
pointing at them(ACE)

86. HEADING
DISORIENTATION
• Allocentric
orientation lost
• Can localize objects
wrt their body
• Unable to describe
route fam. Places
• Can not Draw maps
familiar places
• POSTERIOR
CINGULATE
LANDMARK
AGNOSIA
• Inability to
recognize
landmarks
• LINGUAL GYRUS
ANTEROGRADE
DISORIENTATION
• Inability to aquire
novel topographic
memory
• Getting lost easily
in unfamiliar places
• Eg. Tell me the way
to the bathroom to
a hospitalized
patient
• PARA-
HIPPOCAMPUS
• Common in AD