Mirror writing and reversing single letters in stroke patients and normal elderly

Abstract Mirror writing (MW) refers to the production of individual letters or whole word strings in reversed direction. When held to a mirror, these letters or words can be read normally. We observed MW in a considerable number of stroke patients. Of the 86 patients screened 15 (17.5%) showed at least one instance of mirror writing in any of the tasks. Both right (14% of 36 patients) and left (20% of 50 patients) hemisphere damaged patients produced reversed letters only when writing with their left hand, respectively the contralesional and ipsilesional hand. The dissociated performance between the two hands in brain damaged patients is relevant to the interpretation of MW because, unlike all other peripheral dysgraphias, MW affects the non-dominant hand only. Importantly, healthy elderly also showed MW solely when writing with their left hand (6.9% of 86 participants). MW in controls was less frequent but qualitatively similar to that observed in brain damaged patients. This finding is consistent with the motor interpretation of MW that assumes an inability to transform the stored letter forming programmes for left hand writing. However, several cases have been reported in the literature of a more pervasive form of MW whereby patients mirror reverse entire words or sentences. This pattern has been observed in children learning to write but it has never been observed in healthy adult volunteers. We propose that the diagnosis of MW should be limited to the reversal of whole words, multi-digit numbers and full sentences, which reveal a disorder in coding the correct direction of writing rather than an inability to accomplish the correct spatial orientation of single letters.     

Visual half-field tests of lateralized letter presentations: differences between preliterate and literate children

In the present study, hemispheric differences in global and analytic processing were investigated in preliterate and literate children, using the "dual-letter" matching task paradigm (Navon, 1977). The stimuli consisted of lateralized visual presentations of large uppercase letters made up of small uppercase letters. The task of the subject was to decide on each trial if the large or small letters were the same or not. Vocal reaction time (VRT) and error-frequency were used as dependent measures. In Experiment 1, 28 right-handed 8-years old children participated. The children were split into a preliterate and a literate group depending on teachers evaluations, and on scores on a reading test. The results showed longer VRTs for the preliterate children when the stimuli were initially presented to the right hemisphere and especially when the subjects were required to match the small letters. These results were followed up in Experiment 2, where the preliterate subjects were split into "fast" and "slow" readers. The results showed that the "slow" readers were more impaired in processing the letter stimuli when the stimuli were initially presented to the right hemisphere. It is concluded that hemispheric asymmetry for letter processing interacts with the development of normal reading ability in children.     

Letter position dysgraphia

The article describes AE, a Hebrew-speaking individual with acquired dysgraphia, who makes mainly letter position errors in writing. His dysgraphia resulted from impairment in the graphemic buffer, but unlike previously studied patients, most of his errors related to the position of letters rather than to letter identity: 80% of his errors were letter position errors in writing, and only 7% of his errors were letter omissions, substitutions, and additions. Letter position errors were the main error type across tasks (writing to dictation and written naming), across output modalities (writing and typing), and across stimuli, e.g., migratable words (words in which letter migration forms another word), irregular words, and nonwords. Letter position errors occurred mainly in the middle letters of a word. AE's writing showed a significant length effect, and no lexicality, migratability, or frequency effects. His letter position deficit was manifested selectively in writing; he made no letter position errors in reading, demonstrating the dissociability of letter position encoding in reading and writing. These data support the existence of a letter order function in the graphemic buffer that is separate from the function responsible for activating letter identities.     

The development of writing skills in 4-year-old children with and without specific language impairment

ABSTRACT

Research shows that many preschool children with specific language impairment (SLI) have difficulty acquiring literacy skills including phonological awareness, print concepts, and alphabet knowledge. Limited research suggests that preschool children with SLI also have difficulty with emergent writing tasks such as name writing and word writing. In typically developing children, research indicates that emergent writing skills are acquired in a developmental sequence: (1) linearity, (2) segmentation, (3) simple characters, (4) left-right orientation, (5) complex characters, (6) random letters, and (7) invented spelling. This study compared the emergent writing skills of 4-year-old children with SLI (n = 22) to their age- and gender-matched peers (n = 22). Results indicated that children with SLI demonstrate difficulty with a variety of writing tasks, including letter writing, name writing, word writing, and sentence writing when compared to their typically-developing peers. Children with SLI followed the same developmental sequence in acquiring writing skills as their typically-developing peers.     

A cognitive-neuropsychological analysis of allograph errors from a patient with acquired dysgraphia

Abstract

This paper reports an investigation of the impaired writing of an acquired dysgraphic patient J.E.C. who made several case, substitution, omission, and addition errors when writing lower-case letters cursively, but whose upper-case writing was intact. The main finding was that damage to the lower-case letter production system results in errors that can be predicted from the spatial similarity of the lower-case form of the error to the lower-case form of the target. This was found with both within-case and cross-case letter substitutions. An additional observation was consistent cross-case errors occurred only with targets forming a single cluster of spatially similar lower-case letters (b, d, p, and q). It is concluded access to lower-case letters is constrained by spatial similarity of a target to other letters in allograph store, and this effect may explain letter errors made by dysgraphic patients.     

Progressive peripheral agraphia

We describe RW, a patient who presented with writing difficulty that deteriorated over time. While her graphemes were typically legible, her writing was extremely slow, and her letters were written in an inconsistent and heterogeneous manner (e.g. each "a" in the word "banana" was produced in a different way). Her mental imagery of letters was impoverished, and she also produced allographic errors in her writing. She had some spelling errors as well, but many of these were due to omissions, perseverations, and motor operations. A positron emission tomography scan demonstrated superior parietal occipital and superior frontal defects that were more evident on the left than the right. Our observations are consistent with the hypothesis that RW has a deficit retrieving physical letter forms as manifested by her heterogeneous and slow production of letter forms. This disruption of grapheme retrieval is associated with interruption of a superior frontal-parietal system in the left hemisphere.     

Pure agraphia after infarction in the superior and middle portions of the left precentral gyrus: Dissociation between Kanji and Kana

The present study describes a Japanese patient with pure agraphia displaying differential disturbances in processing Kanji (morphogram) and Kana (syllabogram) letters after an infarction in the middle and superior portions of the left precentral gyrus. Kana errors reflected the patient’s difficulty with retrieving both motor and visual letter images, whereas Kanji errors included partial letter stroke omissions or additions. This present case suggests that differences in writing disturbances between Kana and Kanji letters are caused by a differential dependency on letter motor images.     

Progressive Peripheral Agraphia

We describe RW, a patient who presented with writing difficulty that deteriorated over time. While her graphemes were typically legible, her writing was extremely slow, and her letters were written in an inconsistent and heterogeneous manner (e.g. each ‘a’ in the word ‘banana’ was produced in a different way). Her mental imagery of letters was impoverished, and she also produced allographic errors in her writing. She had some spelling errors as well, but many of these were due to omissions, perseverations, and motor operations. A positron emission tomography scan demonstrated superior parietal occipital and superior frontal defects that were more evident on the left than the right. Our observations are consistent with the hypothesis that RW has a deficit retrieving physical letter forms as manifested by her heterogeneous and slow production of letter forms. This disruption of grapheme retrieval is associated with interruption of a superior frontal-parietal system in the left hemisphere.     

The rise and fall of rapid occipito-temporal sensitivity to letters: Transient specialization through elementary school

Letters, foundational units of alphabetic writing systems, are quintessential to human culture. The ability to read, indispensable to perform in today’s society, necessitates a reorganization of visual cortex for fast letter recognition, but the developmental course of this process has not yet been characterized. Here, we show the emergence of visual sensitivity to letters across five electroencephalography measurements from kindergarten and throughout elementary school and relate this development to emerging reading skills. We examined the visual N1, the electrophysiological correlate of ventral occipito-temporal cortex activation in 65 children at varying familial risk for dyslexia. N1 letter sensitivity emerged in first grade, when letter sound knowledge gains were most pronounced and decayed shortly after when letter knowledge is consolidated, showing an inverted U-shaped development. This trajectory can be interpreted within an interactive framework that underscores the influence of top-down predictions. While the N1 amplitudes to letters correlated with letter sound knowledge at the beginning of learning, no association between the early N1 letter response and later reading skills was found. In summary, the current findings provide an important reference point for our neuroscientific understanding of learning trajectories and the process of visual specialization during skill learning.     

Mirror-image discrimination and reversal in the disconnected hemispheres

Two callosotomized patients and 24 neurologically normal subjects performed simple binary discriminations between upright letters flashed in one or other visual field. Where discrimination of the letters F and R by name either showed a left-hemisphere advantage or no hemispheric effect, discrimination of whether the same letters were normal or backward showed a right-hemisphere advantage. These results suggest that discrimination of mirror-image letters depends on matching to an exemplar, for which the right-hemisphere is dominant, while letter naming depends on abstract category recognition. One commissurotomized patient, DDV, showed systematic left-right reversal of the letters in the left visual field, classifying the normal letters as reversed and reversed ones as normal, and persisted with this reversal when the letters were shown in free vision. This suggests that reversed exemplars of the letters may be laid down the right cerebral hemisphere. There was no such reversal in the other patient (DDC).     

Learning through hand- or typewriting influences visual recognition of new graphic shapes: behavioral and functional imaging evidence

Fast and accurate visual recognition of single characters is crucial for efficient reading. We explored the possible contribution of writing memory to character recognition processes. We evaluated the ability of adults to discriminate new characters from their mirror images after being taught how to produce the characters either by traditional pen-and-paper writing or with a computer keyboard. After training, we found stronger and longer lasting (several weeks) facilitation in recognizing the orientation of characters that had been written by hand compared to those typed. Functional magnetic resonance imaging recordings indicated that the response mode during learning is associated with distinct pathways during recognition of graphic shapes. Greater activity related to handwriting learning and normal letter identification was observed in several brain regions known to be involved in the execution, imagery, and observation of actions, in particular, the left Broca's area and bilateral inferior parietal lobules. Taken together, these results provide strong arguments in favor of the view that the specific movements memorized when learning how to write participate in the visual recognition of graphic shapes and letters.     

Multiple levels of stimulus representation in visual working memory

Object recognition presumably involves activation of multiple levels of representation. Here we use the encoding-related lateralization (ERL) method [Gratton, G. The contralateral organization of visual memory: A theoretical concept and a research tool. Psychophysiology, 35, 638-647, 1998] to describe the sequential activation of several of these levels. The ERL uses divided-field encoding to generate contralaterally biased representations in the brain. The presence and nature of these representations can be demonstrated by examining the event-related potentials (ERPs) elicited by centrally presented test probes for lateralized activity corresponding to the encoding side. We recorded ERPs during a memory-search task. Memory sets were composed of two or four uppercase letters displayed half to the left and half to the right of fixation. Probe stimuli were composed of one letter presented foveally in either upper- or lowercase. Letter case was manipulated to differentiate the time course of physical and symbolic levels of letter representation. Memory set size was manipulated to examine a relational level of letter representation. We found multiple ERLs in response to the probes: (1) An early (peak=170 msec) case-dependent (but set size independent) ERL, most evident at P7/P8, indexing the availability of a physical level of letter representation; (2) a later (200-400 msec) more diffusedly distributed ERL, independent of both letter case and set size, indexing a symbolic level of letter representation; (3) a long-latency (400-600 msec) ERL occurring at posterior sites, larger for the case match, Set Size 2 condition, indexing competition for neural representation across multiple letters. By assuming that these ERL activities track the progression of letter representation over time, we propose a model of letter processing in the context of visual working memory.     

Deficits in visual feature binding under isoluminant conditions

The contribution of the magnocellular stream to visual feature binding was examined psychophysically through the use of isoluminant stimuli. Subjects were presented with three briefly flashed colored letters arranged in an array and asked to identify the shape and color of the center letter. The rate of illusory conjunctions was much higher when the letters were isoluminant with a gray background, compared to when the letters were either brighter or dimmer. Over 90% of conjunction errors involved pairing the wrong shape with the correct color, rather than vice versa. Directing attention to the target location with a nonisoluminant cue did not reduce illusory conjunctions. High rates of binding errors under isoluminance are interpreted here in terms of abnormalities in visual form processing rather than an attentional effect. In another experiment designed to examine the role of synchrony in feature binding, the rate of illusory conjunctions was highest when flanking letters were presented before the central target letter and not synchronously.     

Letter processing automatically recruits a sensory-motor brain network

Behavioral, neuropsychological and neuroimaging research suggest a distributed network that is recruited when we interact with letters. For the first time, we combine several letter processing tasks in a single experiment to study why letters seem to engage such disparate processing areas. Using fMRI, we investigate how the brain responds to letters using tasks that should recruit systems for letter perception, letter writing, letter copying and letter imagery. We describe a network of five cortical regions including the left fusiform gyrus, two left pre-central areas, left cuneus and the left inferior frontal gyrus that are all selectively engaged during a 1-back matching paradigm with letters. Our results suggest involvement of these regions to different extents in different tasks. However, the regions also form an integrated network such that letter perception also engages motor regions while writing recruits letter-specific visual regions as well. We suggest that this distributed network is a direct result of our sensory–motor interactions with letters.     

Developmental attentional dyslexia

Attentional dyslexia is a reading deficit in which letters migrate between neighboring words, but are correctly identified and keep their correct relative position within the word. Thus, for example, fig tree can be read as fig free or even tie free. This study reports on 10 Hebrew-speaking individuals with developmental attentional dyslexia and explores in detail the characteristics of their between-word errors. Each participant read 2290 words, presented in word pairs: 845 horizontally presented word pairs, 240 vertically presented word pairs, and 60 nonword pairs. The main results are that almost all migrations preserve the relative position of the migrating letter within the word, indicating that the between-word position can be impaired while the within-word position encoding remains intact. This result is also supported by the finding that the participants did not make many letter position errors within words. Further analyses indicated that more errors occur in longer words, that most migrations occur in final letters (which are the leftmost letters in Hebrew), and that letters migrate both horizontally and vertically, and more frequently from the first to the second word in horizontal presentation. More migrations occurred when the result of migration was an existing word. Similarity between words in a pair did not increase error rates, and more migrations occurred when the words shared fewer letters. The between-word errors included the classic errors of migration of a letter between words, but also omission of one instance of a letter that appeared in the same position in the two words, an error that constituted a considerable percentage of the between-word errors, and intrusion of a letter from one word to the corresponding position in the neighboring word without erasing the original letter in the same position.     

Writing disorders in primary progressive aphasia]

We investigated longitudinally three patients with primary progressive aphasia (PPA) who exhibited fluent aphasia at the early stage, in terms of writing disorders. The writing disorders were the most striking during the aphasia quotient (AQ) was 50-60 for all these patients. The characteristic features were as follows: (i) several types of perseverative errors, especially on spontaneous writing rather than on dictation (ii) confusion between letters and pictures (iii) preserved copying ability and (iv) total loss of writing ability at the final stage. Additionally, through the progression, linguistic level of the perseverative errors changed from sentence to word and finally to phoneme. The results suggest that the fluent type PPA patients have difficulty to recall proper letters and to arrange them in correct order following the writing plan, in addition to disinhibition and lexical stereotyping which were commonly observed in perseverative patients. The results also suggest that their writing disorders seem to be based on difficulty of letter manipulation as symbols.     

How attentional boost interacts with reward: the effect of dopaminergic medications in Parkinson's disease

There is widespread evidence that dopamine is implicated in the regulation of reward and salience. However, it is less known how these processes interact with attention and recognition memory. To explore this question, we used the attentional boost test in patients with Parkinson's disease (PD) before and after the administration of dopaminergic medications. Participants performed a visual letter detection task (remembering rewarded target letters and ignoring distractor letters) while also viewing a series of photos of natural and urban scenes in the background of the letters. The aim of the game was to retrieve the target letter after each trial and to win as much virtual money as possible. The recognition of background scenes was not rewarded. We enrolled 26 drug‐naïve, newly diagnosed patients with PD and 25 healthy controls who were evaluated at baseline and follow‐up. Patients with PD received dopamine agonists (pramipexole, ropinirole, rotigotine) during the 12‐week follow‐up period. At baseline, we found intact attentional boost in patients with PD: they were able to recognize target‐associated scenes similarly to controls. At follow‐up, patients with PD outperformed controls for both target‐ and distractor‐associated scenes, but not when scenes were presented without letters. The alerting, orienting and executive components of attention were intact in PD. Enhanced attentional boost was replicated in a smaller group of patients with PD (n = 15) receiving l ‐3,4‐dihydroxyphenylalanine (L‐DOPA). These results suggest that dopaminergic medications facilitate attentional boost for background information regardless of whether the central task (letter detection) is rewarded or not.     

A formal analysis of alexia in persistent aura and a comparison to acquired pure alexia

A patient is reported with reversible pure alexia in the context of migraine with aura. Following previous, anecdotal reports, the present study is the first to formally assess word reading, writing, and other linguistic and visual processing and to compare these to a patient with stroke-related pure alexia. The reading impairment, suggestive of letter-by-letter reading, was observed across 7 days but had remitted at a 3-month follow-up. The deficit also affected recognition of letters, suggesting a functional impairment at the level of letter recognition, not just word reading. It went along with reversible abnormalities in diffusion-weighted and fluid-attenuated inversion recovery imaging in areas known to be involved in word reading.