Thursday, June 3, 2010

Isolated inability to write cursively after transient ischemic attack (TIA)

Popescu I-M, Vaidya NA.  Cog Behav Neurol 2007; 131-135.  Case report

78 year old right handed truck driver whose TIA was bilateral upper extremity weakness that resolved the same day. Post TIA he could write block letters but not cursively.  On neurologic/behavioral examination, he complained of being unable to remember what he had read.  He was diagnosed with obstructive sleep apnea.  Elemental neurological examination was normal.  Behavioral examination showed a normal MMSE (29/30, minus one for recall) with perseverations noted  on an alternating programs test and Luria loops.  The patient had trouble with cursive copying and writing.  MRI could not be done (pacemaker); Spect showed bilateral hypoperfusion of the parietal and occipital lobes. Literature review of lesions suggests implied lesion of left superior parietal area (Alexander et al, Arch neurol 1992), parieto occipital white matter bilaterally (Baxter and Warrington, JNNP 1986).  Hanley JR, and Peters , S(Cortex, 1996) showed the opposite , in a patient who had a left hemisphere lesion, with impaired spelling of lower case letters  in block and had excellent cursive writing.  Ohno  et al. (Neurology, 2000) had a patient with pure apractic agraphia due to a thalamic lesion which blocked motor programming, and who could not write kana, kanji, Roman alphabet or Arabic numerals.  Otsuki et al. (JNNP, 1999) reported a patient with apractic agraphia due to a hemorrhage in the left superior parietal lobe. Authors believe cursive and block writing are represented differentially.

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