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Article history: Brain damage can produce acquired deficits of color perception, or cerebral achromatopsia. In
Received 3 October 2012 these patients, lesions tend to overlap on a restricted region in the ventral occipitotemporal
Reviewed 4 December 2012 cortex, close to the reported locations of the putative V4 complex and to foci of increased blood-
Revised 21 December 2012 oxygen-level-dependent (BOLD) activity related to color perception in normal participants.
Accepted 26 January 2013 Unilateral lesions give rise to achromatopsia in the contralateral visual field (hemi-
Published online 10 February 2013 achromatopsia). Here we present a partial English translation of the first case report of a
hemiachromatopsic patient with detailed anatomical evidence (Madame R., Verrey, 1888), and
Keywords: discuss these results in relation to a more recent case report (Madame D., Bartolomeo et al.,
Color processing 1997) of a patient with two consecutive hemorrhagic lesions in the occipitotemporal regions
Occipital lobe of the two hemispheres. Strikingly, Madame D. developed full-field achromatopsia after the
Temporal lobe second lesion in the right hemisphere, without having shown any signs of hemiachromatopsia
Brain damage after the first lesion in the left hemisphere. Thanks to the comparison of the reconstructed
Achromatopsia lesion patterns between the two patients and with the putative location of color-related areas
in the human brain, we offer a possible, if speculative, account of this puzzling pattern of
anatomo-clinical correlations, based on intra- and inter-hemispheric connectivity.
© 2013 Elsevier Ltd. All rights reserved.
* Corresponding author. Inserm U975; UPMC-Paris6, UMR_S 975; CNRS UMR 7225, Centre de Recherche de l'Institut du Cerveau et de la
Moelle epinie
re, Groupe Hospitalier Pitie
-Salpe
^trie
re, 75013 Paris, France.
E-mail address: marsicanus@gmail.com (P. Bartolomeo).
http://dx.doi.org/10.1016/j.cortex.2013.01.013
0010-9452/© 2013 Elsevier Ltd. All rights reserved.
c o r t e x 5 6 ( 2 0 1 4 ) 1 3 8 e1 4 4 139
Fig. 1 e (A) Color-related areas in the human brain. Cytoarchitectonic areas hOC4v (Rottschy et al., 2007), FG1, FG2 (Caspers
et al., 2012), the functionally activated area V8 (Hadjikhani et al., 1998) and the midfusiform color center explored in the right
hemisphere of an epileptic patient by Murphey et al. (2008). (B) Reconstruction of Madame R.'s lesion. (C) Reconstruction of
Madame D.'s lesions.
involvement; no aphasia symptoms, no word blindness in its Madame R. and confirm the stability of her condition, except
proper sense, no paresis or paralysis of the extremities. Finally, for a possible slight worsening of her visual sensitivity in the
the necroscopic examination of the brain confirmed the right hemifield.
generally accepted hypothesis, that of the existence of a “The 20th of March at 5 in the evening, Madame R. sud-
cortical center of the chromatic sense, a hypothesis that was denly fell and lost consciousness in a store in town where she
however disputed by several authors, and in particular was doing some errands. She was carried home and her doc-
Schneller, who sought to explain these symptoms by a lesion tor, called in urgency, noted a total left hemiplegia, whole-
of the chiasma or of the optic tracts. This brain examination body anesthesia, violent vomiting, clonic and tonic convul-
led us to discover a pre-existing lesion of the inferior part of the sions of the face and on the right side. After the 21st of March,
left occipital lobe that was very precisely localized” (page 289). the convulsions ceased and in the following days the coma
Verrey then describes the clinical presentation of his pa- became deeper, her respiration stertorous; death in the
tient. “Madame R., 60 years old, from Neufchatel, came to my morning of the 28th” (page 293f).
office for a consultation on the 4th of October in 1887. She Autopsy discovered a large, recent hematoma in the right
complained of no longer being able to read easily, a difficulty hemisphere, and a smaller, more ancient lesion between the
she first noticed several weeks ago. After reading several lines, basal portion of the left occipital lobe and the floor of the oc-
she felt tired and needed to put her book aside; she believed cipital horn of the left lateral ventricle. The lesion occupied
that it would come to be that she would receive a stronger the white matter of the third occipital gyrus and destroyed
glasses prescription. She associated this weakness of sight more or less completely the white matter of the occipital end
with a gastric discomfort that she had experienced near the of the lingual and fusiform gyri (see Fig. 1B), as well as that of
end of July that same year” (page 290). the caudal-ventral tip of the cuneus. Ventrally, the lesion
In July 1887, Madame R. had indeed suffered an episode of approached the medial surface of the occipital lobe, destroy-
acute vertigo with headache and vomiting. On examination, ing its deep cortical layers but not reaching the superficial
Verrey noted that reading was possible but slowed, especially ones. The lesion was an intracerebral hematoma, with a
for the right part of long words. Visual fields were normal, sagittal length of 3.5 cm, 1-cm wide and 1.75-cm high. Verrey
except for a concentric restriction to 15e20 in all directions concluded that “the center of the chromatic sense would lie in
and a slightly decreased acuity in the right visual field. Form the most inferior part of the occipital lobe, probably in the
perception was apparently normal. However, colored paper caudal part of the lingual and fusiform gyri” (p. 298).
patches of .5 cm in diameter, presented along a Foerster
perimeter, were systematically perceived as being gray in
color in the whole right visual field, whereas they were nor- 3. The case of Madame D. (Bartolomeo et al.,
mally perceived in the left hemifield. The patient's status 1997)
remained stable from July 1887 until March 1888, when
Madame R. died as a consequence of a second stroke. Two In 1997, Bartolomeo, Bachoud-Le vi and Denes published
weeks before the fatal stroke, Verrey was able to re-examine on Cortex the case study of a patient that did not seem to
c o r t e x 5 6 ( 2 0 1 4 ) 1 3 8 e1 4 4 141
conform to the picture suggested by these cases of hemi- appeared normal on clinical examinations. Goldman peri-
achromatopsia, i.e., the existence of bilateral color centers, metry, however, showed the persistence of a mild paracentral
each competent for color processing in the contralateral scotoma. This deficit, situated between 38 and 158 for the left
hemifield (Bartolomeo et al., 1997). Madame D. had two eye and 28 and 258 for the right eye (see Fig. 2 in Bartolomeo
consecutive hemorrhagic lesions in the occipitotemporal et al., 1998a), was apparent only with the II test, and thus
cortex and underlying white matter, in roughly mirror-image allowed some residual visual processing. In particular, on
locations. The patient was a 74-year-old, right-handed retired clinical testing color naming was entirely normal in the right
secretary. She was hospitalized in May 1995 after the sudden hemifield. Thus, after the first lesion in the left hemisphere,
occurrence of headaches and visual disturbances. On admis- Madame D. had no signs of right hemiachromatopsia on
sion, Madame D. presented a right homonymous hemianopia. clinical examination; she had a moderate alexia (see Bachoud-
Her reading was slow and letter-by-letter, with occasional vi and Bartolomeo, 2003), but kept enjoying painting and
Le
confusion among letters. Writing was preserved. She showed remained able to accurately name color patches in either
a mild anomia, without any comprehension or repetition hemifield. Seven months later, while Madame D. was recov-
deficits, which subsided a few weeks later. CT scan revealed a ering from pure alexia, she unfortunately suffered from a
left occipitotemporal hematoma. An MRI performed in second stroke, in an approximately symmetrical location in
September 1995 showed a reduction in the size of the hema- the right hemisphere (see Fig. 1C). Upon occurrence of the
toma, which involved Brodmann's areas 18, 19 and 37 (see second stroke, Madame D. suddenly found herself unable to
Fig. 1C). Two months after lesion occurrence, visual fields identify faces, objects and letters, despite reasonably well
preserved elementary visual abilities (Bartolomeo et al., 1998a,
1998b, 2003); importantly, she had also become full-field
achromatopsic, and complained to see the world in shades
of gray or, later on, in reddish-brown nuances.
Thus, Madame D. developed full-field, clinically evident
achromatopsia after the second lesion in the right hemi-
sphere, without any clinical signs of right hemiachromatopsia
after the first lesion in the left hemisphere. The 1997 Cortex
study did not offer a complete account of this “puzzling
sequence of events”. The authors noted that their results
supported the hypothesis of a critical role of the right hemi-
sphere in color processing, but this putative pattern of hemi-
spheric laterality has not been confirmed by subsequent
neuroimaging studies. It is, moreover, inconsistent with the
case of Madame R. (Verrey, 1888), who had right hemi-
achromatopsia after a left occipitotemporal lesion.
brain damage can give rise to hemiachromatopsia for the anterior color-related regions, such as the midfusiform color
opposite hemifield, without appreciable differences between center putatively implicated in conscious color experience
right and left hemisphere lesions (Short and Graff-Radford, (Murphey et al., 2008). Nevertheless, the callosal connections of
2001). Moreover, the available data do not suggest the possibil- V4 might have prevented Madame D.'s first lesion from pro-
ity of an atypical pattern of hemispheric laterality for either ducing hemiachromatopsia. It is well known that the callosal
Madame R. or Madame D. (who was right-handed). connections of V4 (Fig. 2) are much more widespread than those
A second possibility is that the left hemisphere lesions of V1 and V2, which are limited to the representation of the
damaged different anatomical systems in the two patients. A vertical meridian (Clarke and Miklossy, 1990; Zeki, 1990).
precise test of this hypothesis would require state-of-art im- Color-related information might thus have traveled from
ages of the lesions of Madame R. and Madame D., which are V1 to V4 in the left hemisphere and then crossed to the right
unfortunately not available. However, based on the autopsy hemisphere thanks to V4 callosal connections, with conse-
report and figure provided by Verrey (1888) for Madame R., and quent full-field conscious color experience. Madame D.'s sec-
on CT and clinical MRI scans obtained for Madame D., we ond lesion appears, instead, to have damaged at least partially
reconstructed their lesions on standardized brain slices, the right hemisphere V4 (Fig. 1C), thus impairing this
shown in Fig. 1 together with the location of areas crucial for pathway, with consequent full-field achromatopsia.
color processing.
7. Discussion
5. Methods
Color processing in the brain proceeds along multiple stages,
Mapping of the lesions was performed by using MRIcron (http:// starting from the activity of L, M, and S cones in the retina to
www.mccauslandcenter.sc.edu/mricro/mricron). For each pa- color-opponent neurons in the lateral geniculate nucleus and
tient, we rotated the Colin27 template (Holmes et al., 1998) V1 (Conway et al., 2010), to hue maps with color constancy in
provided in MRIcron from the MNI space to the orientation of V2 and V4 (Roe et al., 2012) and finally more “cognitive” as-
sectional drawings for Madame R. (Verrey, 1888), and of indi- pects in more anterior areas in the temporal cortex. These
vidual clinical MRI scans for Madame D. (Bartolomeo et al., high-level, cognitive aspects include elements of color
1998a, 1997). The lesion was then drawn on the reoriented knowledge (i.e., knowledge about prototypical object colors,
template and subsequently taken back to the MNI space using Miceli et al., 2001) and perhaps the possibility of full conscious
the inverse rotation (see Doricchi and Tomaiuolo, 2003). experience of color (Murphey et al., 2008).
The ventral part of V4 (hOC4v, Rottschy et al., 2007) and the The present reappraisal of two published cases of acquired
subdivisions of the fusiform gyrus (FG1 and FG2, Caspers et al., color deficits contributes to our understanding of the role of
2012) were obtained from recent post-mortem cytoarchitec- the human homolog of V4 to color perception, by showing that
tonic atlases (SPM Anatomy Toolbox V2, http://www.fz- direct damage to the putative human localization of the V4
juelich.de) and overlapped on the Colin27 template. These complex is correlated to a perceptual color processing deficit
maps were thresholded in order to only show voxels with a in the contralateral hemifield (Verrey, 1888), and resolves the
probability superior to 50% (above the chance level of being in apparently contradictory findings, obtained in another patient
the given area for a given voxel). (Bartolomeo et al., 1997), that occipitotemporal damage in
MNI coordinates for area V8 and the midfusiform color the left hemisphere did not produce hemiachromatopsia,
area were respectively extracted from previous functional MRI whereas subsequent damage to the right hemisphere was able
study (Hadjikhani et al., 1998) and direct electrical recording to determine full-field achromatopsia.
and stimulation in an epileptic patient (Murphey et al., 2008), Note, however, that experimental evidence from intra-
and plotted in the Colin27 template. Note that when areas operative stimulation (Lee et al., 2000) and studies of visual
were reported in Talairach coordinates we used the Yale non- hallucinations (ffytche et al., 1998) suggest that V4 might have
linear MNI 2 Talairach conversion (http://www.bioimagesuite. in itself a role in conscious processing of color (Zeki, 2005).
org/Mni2Tal/index.html) in order to obtain MNI coordinates. If so, then the reason why Madame D. did not develop
hemiachromatopsia after her left hemisphere lesion is
because V4 was not affected. It remains, however, difficult to
6. Results explain why Madame D. developed full-field achromatopsia
after her second lesion to right V4, given that left V4 was un-
The results of the anatomical analysis are displayed in Fig. 1. affected throughout. In addition to the above-mentioned
Inspection of the figure suggests that Madame R.'s lesion possibility of an individual right-hemisphere dominance for
encroached directly upon areas crucial for color processing (V4/ color processing, one might posit changes in input to left V4 at
V8). This provides a straightforward explanation for her hemi- initial presentation, as implied by the transient hemianopia.
achromatopsia, precisely along the lines suggested by Verrey in Perhaps during the seven months prior to the second lesion
the original case report (Verrey, 1888). On the other hand, Fig. 1 Madame D. was relying on callosal connections from right V4
also indicates that Madame D.'s first, left hemisphere lesion to left V4 for full-field color vision. If, however, conscious color
did not damage directly the color processing regions. However, experience does not require solely the activity of V4, but also
as suggested by the predominant involvement of the white its integration with more rostral regions such as the mid-
matter nearby these regions, Madame D.'s first lesion could have fusiform color area, then our present hypothesis seems to
disconnected these posterior color processing areas from more account for most of the available evidence.
c o r t e x 5 6 ( 2 0 1 4 ) 1 3 8 e1 4 4 143
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