Apperceptive agnosia due to carbon monoxide poisoning. An interpretation based on critical band masking from disseminated lesions

A review of the impairments, preserved visual functions, and neuropathology in 21 patients with visual form agnosia - A unique defect with line drawings

We present a comprehensive review of the rare syndrome visual form agnosia (VFA). We begin by documenting its history, including the origins of the term, and the first case study labelled as VFA. The defining characteristics of the syndrome, as others have previously defined it, are then described. The impairments, preserved aspects of visual perception, and areas of brain damage in 21 patients who meet these defining characteristics are described in detail, including which tests were used to verify the presence or absence of key symptoms. From this, we note important similarities along with notable areas of divergence between patients. Damage to the occipital lobe (20/21), an inability to recognise line drawings (19/21), preserved colour vision (14/21), and visual field defects (16/21) were areas of consistency across most cases. We found it useful to distinguish between shape and form as distinct constructs when examining perceptual abilities in VFA patients. Our observations suggest that these patients often exhibit difficulties in processing simplified versions of form. Deficits in processing orientation and size were uncommon. Motion perception and visual imagery were not widely tested for despite being typically cited as defining features of the syndrome - although in the sample described, motion perception was never found to be a deficit. Moreover, problems with vision (e.g., poor visual acuity and the presence of hemianopias/scotomas in the visual fields) are more common than we would have thought and may also contribute to perceptual impairments in patients with VFA. We conclude that VFA is a perceptual disorder where the visual system has a reduced ability to synthesise lines together for the purposes of making sense of what images represent holistically.

The impact of simulated hemianopia on visual search for faces, words, and cars

Tests of visual search can index the effects of perceptual load and compare the processing efficiency for different object types, particularly when one examines the set-size effect, the increase in search time for each additional stimulus in an array. Previous studies have shown that the set-size effect is increased by manoeuvres that impede object processing, and in patients with object processing impairments. In this study, we examine how the low-level visual impairment of hemianopia affects visual search for complex objects, using a virtual paradigm. Forty-two healthy subjects performed visual search for faces, words, or cars with full-viewing as well as gaze-contingent simulations of complete left or right hemianopia. Simulated hemianopia lowered accuracy and discriminative power and increased response times and set-size effects, similarly for faces, words and cars. A comparison of set-size effects between target absent and target present trials did not show a difference between full-view and simulated hemianopic conditions, and a model of decision-making suggested that simulated hemianopia reduced the rate of accumulation of perceptual data, but did not change decision thresholds. We conclude that simulated hemianopia reduces the efficiency of visual search for complex objects, and that such impairment should be considered when interpreting results from high-level object processing deficits.

From Action to Cognition: Neural Reuse, Network Theory and the Emergence of Higher Cognitive Functions

The aim of this article is to discuss the logic and assumptions behind the concept of neural reuse, to explore its biological advantages and to discuss the implications for the cognition of a brain that reuses existing circuits and resources. We first address the requirements that must be fulfilled for neural reuse to be a biologically plausible mechanism. Neural reuse theories generally take a developmental approach and model the brain as a dynamic system composed of highly flexible neural networks. They often argue against domain-specificity and for a distributed, embodied representation of knowledge, which sets them apart from modular theories of mental processes. We provide an example of reuse by proposing how a phylogenetically more modern mental capacity (mental rotation) may appear through the reuse and recombination of existing resources from an older capacity (motor planning). We conclude by putting arguments into context regarding functional modularity, embodied representation, and the current ontology of mental processes.

Visual object agnosia is associated with a breakdown of object-selective responses in the lateral occipital cortex

Patients with visual object agnosia fail to recognize the identity of visually presented objects despite preserved semantic knowledge. Object agnosia may result from damage to visual cortex lying close to or overlapping with the lateral occipital complex (LOC), a brain region that exhibits selectivity to the shape of visually presented objects. Despite this anatomical overlap the relationship between shape processing in the LOC and shape representations in object agnosia is unknown. We studied a patient with object agnosia following isolated damage to the left occipito-temporal cortex overlapping with the LOC. The patient showed intact processing of object structure, yet often made identification errors that were mainly based on the global visual similarity between objects. Using functional Magnetic Resonance Imaging (fMRI) we found that the damaged as well as the contralateral, structurally intact right LOC failed to show any object-selective fMRI activity, though the latter retained selectivity for faces. Thus, unilateral damage to the left LOC led to a bilateral breakdown of neural responses to a specific stimulus class (objects and artefacts) while preserving the response to a different stimulus class (faces). These findings indicate that representations of structure necessary for the identification of objects crucially rely on bilateral, distributed coding of shape features.

When apperceptive agnosia is explained by a deficit of primary visual processing

Visual agnosia is a deficit in shape perception, affecting figure, object, face and letter recognition. Agnosia is usually attributed to lesions to high-order modules of the visual system, which combine visual cues to represent the shape of objects. However, most of previously reported agnosia cases presented visual field (VF) defects and poor primary visual processing. The present case-study aims to verify whether form agnosia could be explained by a deficit in basic visual functions, rather that by a deficit in high-order shape recognition. Patient SDV suffered a bilateral lesion of the occipital cortex due to anoxia. When tested, he could navigate, interact with others, and was autonomous in daily life activities. However, he could not recognize objects from drawings and figures, read or recognize familiar faces. He was able to recognize objects by touch and people from their voice. Assessments of visual functions showed blindness at the centre of the VF, up to almost 5°, bilaterally, with better stimulus detection in the periphery. Colour and motion perception was preserved. Psychophysical experiments showed that SDV's visual recognition deficits were not explained by poor spatial acuity or by the crowding effect. Rather a severe deficit in line orientation processing might be a key mechanism explaining SDV's agnosia. Line orientation processing is a basic function of primary visual cortex neurons, necessary for detecting "edges" of visual stimuli to build up a "primal sketch" for object recognition. We propose, therefore, that some forms of visual agnosia may be explained by deficits in basic visual functions due to widespread lesions of the primary visual areas, affecting primary levels of visual processing.

A detection theoretic explanation of blindsight suggests a link between conscious perception and metacognition

Blindsight refers to the rare ability of V1-damaged patients to perform visual tasks such as forced-choice discrimination, even though these patients claim not to consciously see the relevant stimuli. This striking phenomenon can be described in the formal terms of signal detection theory. (i) Blindsight patients use an unusually conservative criterion to detect targets. (ii) In discrimination tasks, their confidence ratings are low and (iii) such confidence ratings poorly predict task accuracy on a trial-by-trial basis. (iv) Their detection capacity (d') is lower than expected based on their performance in forced-choice tasks. We propose a unifying explanation that accounts for these features: that blindsight is due to a failure to represent and update the statistical information regarding the internal visual neural response, i.e. a failure in metacognition. We provide computational simulation data to demonstrate that this model can qualitatively account for the detection theoretic features of blindsight. Because such metacognitive mechanisms are likely to depend on the prefrontal cortex, this suggests that although blindsight is typically due to damage to the primary visual cortex, distal influence to the prefrontal cortex by such damage may be critical. Recent brain imaging evidence supports this view.

Disorders of color and object recognition: syndromes of the ventral occipitotemporal pathway

Although lesions of the striate cortex are associated with hemifield defects, lesions of the inferior and medial occipitotemporal cortex often are associated with disorders of more high-level and complex visual processing. These disorders of the ventral processing stream can be considered as impairing the perception of color and recognition of objects, in contrast to the problems with motion and spatial localization seen with lesions of the dorsal occipitoparietal stream. Dysfunction in the ventral stream leads to the prototypic syndromes of achromatopsia, general visual agnosia, prosopagnosia, alexia without agraphia, and some forms of topographagnosia. Most of these are not single entities but families of disorders in which dysfunction in different cognitive and perceptual processes can lead to the same symptom. Continuum Lifelong Learning Neurol 2010;16(4):111-127.

Top-down activation of fusiform cortex without seeing faces in prosopagnosia

Face processing can be modified by bottom-up and top-down influences, but it is unknown how these processes interact in patients with face-recognition impairments (prosopagnosia). We investigated a prosopagnosic with lesions in right occipital and left fusiform cortex but whose right fusiform gyrus is intact and still activated during face-processing tasks. P.S., a patient with a well-established and selective agnosia for faces, was instructed to detect the presence of either faces or houses in pictures with different amounts of noise. The right fusiform face area (FFA) showed reduced responses to face information when visual images were degraded with noise. However, her right FFA still activated to noise-only images when she was instructed to detect faces. These results reveal that fusiform activation is still selectively modulated by task demands related to the anticipation of a face, despite severe face-recognition deficits and the fact that no reliable stimulus-driven response is evoked by actual facial information. Healthy controls showed stimulus-driven responses to faces in fusiform, and in right but not left occipital cortex, suggesting that the latter area alone might provide insufficient facial information in P.S. These results provide a novel account for residual activation of the FFA and underscore the importance of controlling task demands during functional magnetic resonance imaging.

The anatomy of object recognition--visual form agnosia caused by medial occipitotemporal stroke

The influential model on visual information processing by Milner and Goodale (1995) has suggested a dissociation between action- and perception-related processing in a dorsal versus ventral stream projection. It was inspired substantially by the observation of a double dissociation of disturbed visual action versus perception in patients with optic ataxia on the one hand and patients with visual form agnosia (VFA) on the other. Unfortunately, almost all cases with VFA reported so far suffered from inhalational intoxication, the majority with carbon monoxide (CO). Since CO induces a diffuse and widespread pattern of neuronal and white matter damage throughout the whole brain, precise conclusions from these patients with VFA on the selective role of ventral stream structures for shape and orientation perception were difficult. Here, we report patient J.S., who demonstrated VFA after a well circumscribed brain lesion due to stroke etiology. Like the famous patient D.F. with VFA after CO intoxication studied by Milner, Goodale, and coworkers (Goodale et al., 1991, 1994; Milner et al., 1991; Servos et al., 1995; Mon-Williams et al., 2001a,b; Wann et al., 2001; Westwood et al., 2002; McIntosh et al., 2004; Schenk and Milner, 2006), J.S. showed an obvious dissociation between disturbed visual perception of shape and orientation information on the one side and preserved visuomotor abilities based on the same information on the other. In both hemispheres, damage primarily affected the fusiform and the lingual gyri as well as the adjacent posterior cingulate gyrus. We conclude that these medial structures of the ventral occipitotemporal cortex are integral for the normal flow of shape and of contour information into the ventral stream system allowing to recognize objects.

Exaggerated color perception in a patient with visual form agnosia

Previous studies on visual form agnosic patients have shown that their color perception is relatively preserved when monochromatic figures are used. However, it is unclear whether their color perception remains normal when figures are composed of two parts in different colors. The results showed that patient X.F. had difficulty in naming both colors when the two colors were placed next to each other, and in discriminating the two-color figure from the figure presented in its larger color. In contrast, X.F. could name the two colors when they were physically separated. These data suggest that X.F. manifests exaggerated color perception, producing a color filling-in effect that may be mediated by her spared early visual area.

The physiological basis of visual hallucinations after damage to the primary visual cortex

We used functional magnetic resonance imaging to examine the neuroanatomical correlates of visual hallucinations in a patient with a left visual field defect who had suffered bilateral occipital infarction. By cross-correlating the functional magnetic resonance imaging data with the hallucination events, we were able to identify the cerebral activity underlying the hallucinations. Bilateral activation was observed during visual stimulation in the calcarine fissure and the same activation was found medially in the left and right occipital cortex adjacent to the infarcted areas. This pattern of perilesional visual cortex activation is consistent with the suggestion that primary sensory areas may be involved in visual hallucinations after stroke.

A higher order Bayesian decision theory of consciousness

It is usually taken as given that consciousness involves superior or more elaborate forms of information processing. Contemporary models equate consciousness with global processing, system complexity, or depth or stability of computation. This is in stark contrast with the powerful philosophical intuition that being conscious is more than just having the ability to compute. I argue that it is also incompatible with current empirical findings. I present a model that is free from the strong assumption that consciousness predicts superior performance. The model is based on Bayesian decision theory, of which signal detection theory is a special case. It reflects the fact that the capacity for perceptual decisions is fundamentally limited by the presence and amount of noise in the system. To optimize performance, one therefore needs to set decision criteria that are based on the behaviour, i.e. the probability distributions, of the internal signals. One important realization is that the knowledge of how our internal signals behave statistically has to be learned over time. Essentially, we are doing statistics on our own brain. This 'higher-order' learning, however, may err, and this impairs our ability to set and maintain optimal criteria for perceptual decisions, which I argue is central to perception consciousness. I outline three possibilities of how conscious perception might be affected by failures of 'higher-order' representation. These all imply that one can have a dissociation between consciousness and performance. This model readily explains blindsight and hallucinations in formal terms, and is beginning to receive direct empirical support. I end by discussing some philosophical implications of the model.

Preserved implicit form perception and orientation adaptation in visual form agnosia

Visual form agnosia is mainly characterized by profound deficits in visual form and shape discrimination. Previous studies have shown that patients retain the capacity for coordinated motor behaviors, color naming and implicit letter perception. However, it is unknown to what extent other visual functions, such as implicit form and orientation perception, are preserved. To address these questions, we investigated a single visual form agnosic patient, X.F., in two distinct experiments. X.F.'s visual lesions were mainly localized in the bilateral occipitotemporal cortex, with the dorsal visual stream and early visual cortex largely spared. In Experiment 1, X.F. named the color of different forms across 12 blocks of trials. After the first six blocks, the combinations of a form with its color were changed and the new combination was presented for the remaining six blocks. X.F.'s reaction time increased during the switch block and was significantly greater than the overall RT changes between adjacent, non-switch blocks. This indicates that X.F. retained the ability to perceive changes in form despite her inability to discriminate the forms. In Experiment 2, X.F. showed selective orientation adaptation effects to different spatial frequencies; that is, her contrast threshold was significantly higher when the adapting and test orientations were the same than when they were orthogonal, although her orientation discrimination performance was severely impaired. These data provide evidence of a functional dissociation between explicit and implicit visual abilities, and suggest that the residual early visual cortex mediates form and orientation processing in the absence of awareness.

Visual agnosia

As was originally proposed by Lissauer, visual recognition may break down either at an apperceptive or at an associative level. At an apperceptive level, finer grain distinctions may be made; the authors distinguished here between disorders of shape recognition and perceptual integration. It is not the case, however, that all patients with visual recognition deficits have impaired perception: poor recognition and naming may also result from damage to stored perceptual knowledge (e.g., structural descriptions), from problems in accessing semantic knowledge, from perceptual knowledge, or from impairments to semantic knowledge itself. These represent different types of associative deficit. In some cases, mild damage to stored perceptual knowledge also generates problems that are more severe on naming than on recognition and more severe for some categories of objects than others.

Dissociating 'what' and 'how' in visual form agnosia: a computational investigation

Patients with visual form agnosia exhibit a profound impairment in shape perception (what an object is) coupled with intact visuomotor functions (how to act on an object), demonstrating a dissociation between visual perception and action. How can these patients act on objects that they cannot perceive? Although two explanations of this 'what-how' dissociation have been offered, each explanation has shortcomings. A 'pathway information' account of the 'what-how' dissociation is presented in this paper. This account hypothesizes that 'where' and 'how' tasks require less information than 'what' tasks, thereby allowing 'where/how' to remain relatively spared in the face of neurological damage. Simulations with a neural network model test the predictions of the pathway information account. Following damage to an input layer common to the 'what' and 'where/how' pathways, the model performs object identification more poorly than spatial localization. Thus, the model offers a parsimonious explanation of differential 'what-how' performance in visual form agnosia. The simulation results are discussed in terms of their implications for visual form agnosia and other neuropsychological syndromes.

Central disorders of vision in humans

Over the past 20 years, researchers have discovered over 30 separate visual areas in the cortex of the macaque monkey that exhibit specific responses to visual and environmental stimuli. Many of these areas are homologous to regions of the human visual cortex, and numerous syndromes involving these areas are described in the neurologic and ophthalmic literature. The focus of this review is the anatomy and physiology of these higher cortical visual areas, with special emphasis on their relevance to syndromes in humans. The early visual system processes information primarily by way of two separate systems: parvocellular and magnocellular. Thus, even at this early stage, visual information is functionally segregated. We will trace this segregation to downstream areas involved in increasingly complex visual processing and discuss the results of lesions in these areas in humans. An understanding of these areas is important, as many of these patients will first seek the attention of the ophthalmologist, often with vague, poorly defined complaints that may be difficult to specifically define.

Associative visual agnosia resulting from a disconnection between intact visual memory and semantic systems

We report the case of a patient (RC) who developed a severe visual agnosia, associated to alexia without agraphia, color anomia and amnesia, following an ischemic stroke in the territory supplied by the left posterior cerebral artery. Based on his proficient performance on tests evaluating analysis of elementary visual features, formation of viewer-centered and object-centered representations of visual stimuli and discrimination between drawings representing real and unreal objects, we concluded that the critical locus of deficit was a disconnection between the normally functioning visual memory store and the semantic system. RC's disturbance in visual processing of human faces paralleled his recognition disorder of other classes of objects. The possible contribution of neurobiological factors in determining RC's agnosic deficit is discussed.

What processing is impaired in apperceptive agnosia? Evidence from normal subjects

Visual agnosia is a neuropsychological syndrome characterized by a failure of object identification. Apperceptive agnosia, an object identification deficit caused by damage to early perceptual processes, has been explained by appealing to both damaged early sensory processes and to damaged preattentive grouping processes. Which of these two explanations best accounts for the behavior of these patients? We present results from two experiments designed to distinguish rival theoretical accounts of apperceptive agnosia. In our studies, we attempted to simulate apperceptive agnosia in neurologically intact subjects. Sensory-deficit accounts of the syndrome predict that degrading visual processing would make normal subjects perform like patients; grouping-deficit accounts predict that removing perceptual organization cues from visual displays would make normal subjects perform like patients. We were able to simulate the behavior of an apperceptive agnosic patient by removing perceptual organization cues, consistent with a grouping-deficit account of this syndrome. The implications for understanding both apperceptive agnosia and normal visual functioning are discussed.

The asynchrony of consciousness

We present below a simple hypothesis on what we believe is a characteristic of visual consciousness. It is derived from facts about the visual brain revealed in the past quarter of a century, but it relies most especially on psychophysical evidence which shows that different attributes of the visual scene are consciously perceived at different times. This temporal asynchrony in visual perception reveals, we believe, a plurality of visual consciousnesses that are asynchronous with respect to each other, reflecting the modular organization of the visual brain. We further hypothesize that when two attributes (e.g. colour and motion) are presented simultaneously, the activity of cells in a given processing system is sufficient to create a conscious experience of the corresponding attribute (e.g. colour), without the necessity for interaction with the activities of cells in other processing systems (e.g. motion). Thus, any binding of the activity of cells in different systems should be more properly thought of as a binding of the conscious experiences generated in each system.

What is it like to be a patient with apperceptive agnosia?

Neuropsychological deficits have been widely used to elucidate normal cognitive functioning. Can patients with such deficits also be used to understand conscious visual experience? In this paper, we ask what it would be like to be a patient with apperceptive agnosia (a deficit in object recognition). Philosophical analyses of such questions have suggested that subjectively experiencing what another person experiences would be impossible. Although such roadblocks into the conscious experience of others exist, the experimental study of both patients and neurologically normal subjects can be used to understand visual processing mechanisms. In order to understand the visual processes damaged in apperceptive agnosia, we first review this syndrome and present a case study of one such patient, patient J.W. We then review several theoretical accounts of apperceptive agnosia, and we conclude that studies of the patients themselves may not allow us to discriminate between the various explanations of the syndrome. To test these accounts, we have simulated apperceptive agnosia in neurologically normal subjects. The implications of our results for understanding both apperceptive agnosia and normal visual processing are discussed.

Object recognition difficulty in visual apperceptive agnosia

Two patients with visual apperceptive agnosia were examined on tasks assessing the appreciation of visual material. Elementary visual functioning was relatively preserved, but they had profound difficulty recognizing and naming line drawings. More detailed evaluation revealed accurate recognition of regular geometric shapes and colors, but performance deteriorated when the shapes were made more complex visually, when multiple-choice arrays contained larger numbers of simple targets and foils, and when a mental manipulation such as a rotation was required. The recognition of letters and words was similarly compromised. Naming, recognition, and anomaly judgments of colored pictures and real objects were more accurate than similar decisions involving black-and-white line drawings. Visual imagery for shapes, letters, and objects appeared to be more accurate than visual perception of the same materials. We hypothesize that object recognition difficulty in visual apperceptive agnosia is due to two related factors: the impaired appreciation of the visual perceptual features that constitute objects, and a limitation in the cognitive resources that are available for processing demanding material within the visual modality.

Carbon monoxide poisoning and frontal lobe pathology: two case reports and a discussion of the literature

Two patients, a brother and a sister, experienced carbon monoxide (CO) poisoning simultaneously. Both showed deficits in frontal lobe/executive functioning along with mild disturbances in memory and visual-spatial information processing. A review of the literature indicates that frontal lobe deficits are commonly found following CO poisoning along with the 'better-known' deficits in memory and visual-spatial information processing. This type of deficit can affect the personality of the CO-exposed individual and lead to enduring changes in his or her ability to plan, organize and manage activities of daily living.

Childhood prosopagnosia

K.D. has been unable to recognize people's faces since sustaining cerebral injury in infancy. Investigation of this disorder carried out when K.D. was aged 8 to 11 years showed that although her basic visual abilities were impaired, they were no poorer than those of other children who recognized faces without difficulty. K.D. had learned to read, but had not regained ability to recognize people's faces; instead she relied primarily on voices as a cue to person recognition. There was no evidence of any degree of overt or covert recognition of familiar faces, and K.D. also experienced problems in visual object recognition. She could, however, classify a visual input as a face, was able to perceive and imitate facial expressions, and was able to perform face matching tasks to an extent limited by her use of a feature by feature matching strategy. It is suggested that K.D.'s impairment affected higher order perceptual abilities, and is in a number of respects comparable to the impairments found in adult prosopagnosic patients.