doi:10.1111/ncn3.

10

ORIGINAL ARTICLE

Does a lesion in Broca’s area cause apraxia?

Natsuko Tsuruya,*,†,‡ Mutsutaka Kobayakawa,*,§ Akinori Futamura,* Azusa Sugimoto* and Mitsuru
Kawamura*
*Department of Neurology, Showa University School of Medicine, Tokyo, †Laboratory of Pharmacognosy & Phytochemistry, School of
Pharmaceutical Sciences, Showa University School of Medicine, Tokyo, ‡Practical Engineering Education Program, Academic Foundations
Programs, Kanazawa Institute of Technology, Ishikawa, and §Brain Science Institute, Tamagawa University, Tokyo, Japan

Key words Abstract

action, Broca’s area, ideomotor apraxia,
intransitive gesture, transitive gesture.
Accepted for publication 21 November 2012.
Correspondence
Mitsuru Kawamura, MD, PhD, Department of
Neurology, Showa University School of
Medicine, 1-5-8 Hatanodai, Shinagawa-ku,
Tokyo 142-8666, Japan. Email: kawa@med.
showa-u.ac.jp
Background and Aim: Broca’s area, which comprises the inferior frontal gyrus and
its surrounding regions, is associated with language function. Recent functional
imaging studies showed that it is also related to processing goal-directed
actions.This study aimed to determine the types of action disorders that occur
after damage to Broca’s area.
Methods: Here, we report four patients with left inferior frontal lesions that
included Broca’s area. The patients did not exhibit severe language comprehension
impairment or paralysis that affected the apraxia testing. The patients were asked
to perform intransitive gestures in response to verbal commands, imitate intransi-
tive gestures, perform transitive gestures in response to verbal commands, perform
transitive gestures in response to visual objects, imitate transitive gestures, and use
tools.
Results: All patients exhibited impaired gestures in response to verbal commands,
while the performances regarding imitation and actual tool use were better. An
error pattern analysis showed that the patients predominantly made spatial action
errors. This pattern corresponds to the classical definitions of ideomotor apraxia.
Conclusion: These results indicate that Broca’s area mediates action production
and that a lesion in this area can cause ideomotor apraxia. Although we should be
cautious about the influence of aphasia, we believe that the comprehension deficit
observed in our patients cannot account for their apraxic syndromes. Because the
deficit was seen mainly for verbal commands, damage in Broca’s area may have
disrupted the association between verbal and action domains.

the action was performed by the left or the right hand.11

Introduction
The posterior part of the left inferior frontal gyrus is known
as Broca’s area and is regarded as the centre of speech pro-
duction and other aspects of language.1–3 Recent studies indi-
cate that Broca’s area is engaged not only in language, but
also in action.4 Previous functional imaging studies indicated
that Broca’s area is involved in various aspects of action,
including execution, observation, imitation, mental simula-
tion, planning, and naming.5–7 In addition, this area is
thought to play a role in coding an action goal in an abstract
way, rather than in coding the exact details of the motion.
The type of action disorder that occurs after damage to
Broca’s area is unclear. Action disorders have been studied
in the context of apraxia, which is a deficit of skilled goal-
directed action that cannot be attributed to difficulties in
language or sensory or lower motor functions. Since its
introduction by Liepmann,8 apraxia has been associated
mainly with left-hemisphere lesions,9,10 regardless of whether
Traditionally, lesion studies investigating the neural corre-
lates of limb praxis focused on the left parietal lobe.12
Assuming that Broca’s area is involved in various aspects of
action, its damage may impair various aspects of action.
However, no research has investigated this issue. In the tra-
ditional classification of apraxia, impaired tool use is classi-
fied as ideational apraxia (or conceptual apraxia) and
impaired pantomiming is classified as ideomotor apraxia.13–15
Ideational apraxia often involves the misuse of tools, charac-
terized by a well-performed action that is appropriate to an
object different from the target (semantic error), while ideo-
motor apraxia involves errors in the direction, size and other
aspects of an action.15,16 Because Broca’s area is involved in
many aspects of action, symptoms of both ideational and
ideomotor apraxia might be expected if this region is dam-
aged. If Broca’s area is involved in selecting a set of actions,
then an apraxia test may yield semantic errors. If it is
involved in the articulation of the elemental movements that

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Broca’s area and apraxia
make up an action, then spatial errors might be expected in
apraxia testing. In addition, because Broca’s area is involved
in imitating action, damage to this site may impair such imi-
tation.
In this study, we investigated the effect of lesions in
Broca’s area on apraxia. There are few reports of such
apraxia. This may be because previous studies did not antic-
ipate that a lesion in Broca’s area would cause apraxia or
because apraxia testing was difficult or impossible because
of the presence of a language disorder and hemiparesis in
these patients. Moreover, the effect of the presentation and
response modalities on apraxia is unclear. In the study per-
formed by Goldenberg et al.,17 which indicated a relation-
ship between pantomime ability and the inferior frontal
gyrus, the authors used pantomime of tool use and imitation
of meaningless gestures to test praxis ability. Because the
apraxic syndrome can vary depending on the presenting
modality (verbal or visual), contents of action (intransitive
or transitive), and response style (pantomime, imitation, or
actual use), the effect of these factors on apraxia should be
examined. Here, we report four cases with lesions in the left
inferior frontal regions, including Broca’s area. We exam-
ined apraxic syndrome in these patients using both intransi-
tive and transitive gestures with visual and verbal
presentation and using pantomime, imitation and actual tool
use.
Methods
Patients. We examined four patients with inferior frontal
damage. Three had cerebral infarction, whereas the other
had a brain tumor. None of the patients had severe lan-
guage comprehension impairment and paralysis of both
hands was either nonexistent or mild.
Patient 1. This patients was a 79-year-old right-handed man
who was a regular patient of the Division of Thoracic and
Cardiovascular Surgery of Showa University Hospital,
Tokyo, Japan, for atrial fibrillation.
History of the present illness: While out, the patient was
suddenly unable to speak and came to our facility for emer-
gency treatment. Head computed tomography (CT) scans
obtained a few hours after the onset of the speaking impair-
ment revealed a low-absorption area. Electrocardiography
showed atrial fibrillation and a cerebral embolism was sus-
pected. CT scans obtained on the following day showed
absence of hemorrhaging. Fourteen days after the onset of
the speaking impairment, convulsions occurred on the right
side of his face and in the upper and lower extremities; how-
ever, his progression thereafter was favorable and 55 days
after onset of the symptoms, he was transferred for rehabili-
tation. This patient had developed an acute cardiac infarc-
tion at age 60 and underwent coronary artery bypass graft
surgery at the age of 77 years.
Neuroradiological findings: Head CT scans acquired on
the day of admission showed a comparatively localized
lesion centered on the orbital part of the left inferior frontal
gyrus and extending primarily to the middle frontal gyrus.
The extension also included the triangular part of the infe-
56
N Tsuruya et al.
rior frontal gyrus. A single-photon emission CT (SPECT)
scan taken 10 days after admission showed decreased blood
flow at the same site as that found in the CT scan. No
changes in the lesion were observed.
Neurological findings: On admission, the patient was alert
and cooperative. He did not show sensory deficits or difficul-
ties with motor coordination. He did not have hemiplegia.
Neuropsychological findings: The patient’s score on the
Mini-Mental State Examination (MMSE) was 12/30 (points
lost for orientation regarding time, calculation, delayed
recall of a phrase, repetition, written instruction and mim-
icry). This low score was largely because of aphasia. He
had impaired fluency, repetition and naming on the Wes-
tern Aphasia Battery (WAB).18 In the WAB, his score on
fluency was 2/10. His speech was nonfluent and he often
used stereotypical phrases to respond, indicating poor word
finding and sentence production. His score on auditory
comprehension could not be calculated because the task
was not completed, but he was able to point at named
objects and answer questions using “yes” or “no.” His
score on repetition was 1.4/10, indicating that he was able
to repeat words, but not sentences. His naming score was
3.3/10, which was mainly due to the presence of phonologi-
cal paraphasia. On the standard language test for aphasia
(SLTA, which is a standardized Japanese test for apha-
sia),19 he scored 10/10 and 9/10 points in comprehending
words and short sentences, respectively, but had difficulty
obeying verbal commands (1/10 points on this aspect). He
had severe Broca’s aphasia, alexia with agraphia, buccofa-
cial apraxia and ideomotor apraxia. A similarly strong
impairment in reading was observed; this was more promi-
nent for Japanese kana (syllabic system) than it was for
kanji (Chinese characters). The patient presented with orol-
inguofacial apraxia, having difficulty with actions like whis-
tling and sticking the tongue out. The behavioral symptoms
that are associated with a frontal or callosal lesion were
not observed.
Patient 2. The patient was a 69-year-old right-handed man.
History of the present illness: Upon awakening, the patient
had difficulty forming words and went to work in this state;
however, he visited the Department of Neurology of our
hospital for a consultation when the symptoms persisted.
Head CT scans showed a low-absorption area in the left
frontal lobe and he was admitted with a diagnosis of cere-
bral infarction. Transesophageal echocardiography showed
an ulcerative plaque in the aortic arch; therefore, he was
diagnosed with arteriogenic embolism. His progression was
favorable and he was discharged 13 days after the onset of
symptoms.
Neuroradiological findings: Head CT scans obtained on
the day of onset of symptoms showed an indistinct cortico-
medullary border region in the left frontal lobe. Head mag-
netic resonance imaging (MRI) taken 2 days after the onset
of symptoms showed an acute-phase infarct in the middle
cerebral artery region, centered on the opercular part of the
left frontal lobe and inferior frontal cortex. A head MR
angiogram (MRA) obtained on the same day did not show
any obstruction or stenosis in the major blood vessels.
Neurology and Clinical Neuroscience 1 (2013) 55–62
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N Tsuruya et al.
Neurological findings: The patient was lucid and alert. His
sensory systems and coordinated movement were normal
and no motor paralysis was observed.
Neuropsychological findings: Immediately after the onset
of the speaking impairment, severe motor aphasia was
observed and the patient had difficulty naming objects and
repeating phrases; however, this gradually improved. Part of
the SLTA19 was performed 7 days after the onset of symp-
toms and he scored 8/10 points in comprehending words
and short sentences, but was unable to obey verbal com-
mands (0/10 points). Naming objects (8/20 points) and
explaining actions (5/10 points) were moderately impaired
and his speech was laborious. Repetition was also effortful
and was better regarding words (8/10 points) than sentences
(2/5 points). The patient presented difficulty reading and
writing, particularly Japanese kana. There was no orolinguo-
facial aphasia.
Patient 3. The patient was an 87-year-old right-handed
woman.
History of the present illness: This patient lived alone. Her
family called and noticed that she was stumbling over her
words. They visited her the next day and found that she
could not speak well; therefore, she was admitted to our hos-
pital. During the examination, she was unable to state her
name, the date or location. A head CT scan showed hemor-
rhagic infarction in Broca’s area; thus, she was hospitalized.
Neuroradiological findings: CT scan showed a low-absorp-
tion area that appeared to be a hemorrhagic infarction in
the left frontal lobe. MRI and MRA obtained 2 days later
showed a high-signal region presumed to be an acute-phase
infarct in the left frontal lobe cortex/white matter. The bilat-
eral corona radiata level of the deep white matter showed a
patchy high-signal area that appeared to be due to age-
related changes, while the midbrain/bridge showed a high-
signal area that was suggestive of chronic ischemia.
Neuropsychological findings: The patient presented with
disorientation and motor aphasia characterized by word-
finding difficulty, phonological paraphasia and persevera-
tion. In addition, her speech consisted of only several words.
She retained language understanding regarding both reading
and hearing simple sentences, such as “close your eyes” or
“raise your right hand,” and was able to make simple con-
versation; however, she had difficulty with longer sentences,
such as “pinch your left ear with your right thumb and
index finger.” She was able to answer simple questions cor-
rectly using “yes” or “no.” Repetition was similar, in that
she was able to repeat shorter sentences. She could name 69
daily objects out of 100, with major error perseveration and
circumscribing, and was able to point at objects after hear-
ing their names. The patient also exhibited difficulty writing
kanji. At the time of discharge (17 days after admission),
mild perseveration and impaired word recall remained,
whereas the other symptoms had disappeared.
Patient 4. The patient was an 81-year-old right-handed
woman.
History of the present illness: Two days after having diffi-
culty forming words, the patient moved in with her daughter
Neurology and Clinical Neuroscience 1 (2013) 55–62
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Broca’s area and apraxia
and son-in-law from her home, where she had been living
alone. For the next 10 days, she was unable to form words
or to use the television remote control; therefore, she visited
the Department of Neurology of our hospital and was
admitted. Head CT scans showed a low-absorption area in
the left frontal and temporal lobes and cerebral infarction
was suspected. After 2 weeks, she was transferred to the
Neurosurgery Department and underwent brain tumor
resection surgery, as the presence of a brain tumor was also
possible.
Neurological findings: The patient was lucid and alert. Her
sensory systems and coordinated movement were normal
and no motor paralysis was observed.
Neuropsychological findings: The patient had severe motor
aphasia. Part of the WAB was performed. Her fluency score
was 9/20, with reduced words and impaired word recall, but
normal speed and prosody. She had difficulty naming
objects without a cue effect, showing hesitation and persev-
eration, but no paraphasia. Her score on auditory compre-
hension was 4.6/10. She had difficulty understanding
complex sequential commands, but could answer simple
questions correctly using “yes” or “no.” She was also able
to understand daily objects by name and pointed correctly
at the named objects. However, errors were frequently
observed in pointing at pictures and body parts. Her repeti-
tion and naming scores were 3.2 and 2.7, respectively. She
could only repeat short sentences. The patient also exhibited
difficulty reading and writing both kanji and kana. She was
able to read and write single letters, but had trouble with
words.
Lesion analysis. MRI was performed for all patients,
with the exception of patient 1, who underwent CT scan
because of his heart pacemaker. MRI was performed at
Showa University Hospital using a 1.5 T MR imager (Mag-
netom Essenza; Siemens, M€ unchen, Germany). T2-weighted
axial slices were acquired (23 slices; thickness, 5 mm) using
an interslice gap of 6 mm, a field of view of
196 9 320 mm2, a repetition time of 4000 ms, and an echo
time of 99 ms. MRI was performed 2 days after infarction
in patient 2 and 3 days after infarction in patient 3. CT
axial slices were obtained (Sensation 64; Siemens) at a slice
thickness of 4.8 mm 13 days after infarction in patient 1.
The mapping of lesions was performed by one of the
authors (MKo), without knowledge of the test results or
the patients’ clinical features, and the mapping was verified
independently by MKa, an expert neurologist. Where there
were differences, MKa’s decision prevailed. The lesions
were mapped using the MRIcro software (http://www.sph.
sc.edu/comd/rorden/) on slices of a T1-weighted template
MRI from the Montreal Neurological Institute. This tem-
plate is approximately oriented to match the Talairach
space20 and is distributed with MRIcro. The lesions were
mapped onto the slices that corresponded to z coordinates
–10, –5, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, and 55 mm in
Talairach coordinates using the identical or the closest-
matching transversal slices of each patient. We superim-
posed the lesions using MRIcro to find regions of mutual
involvement.
57
Broca’s area and apraxia
Apraxia testing. Patients were tested in three domains to
assess apraxia: pantomime, imitation and actual tool use.
The tasks consisted of seven transitive gestures of tool use
(combing hair using a comb, brushing teeth with a tooth-
brush, pounding on a nail with a hammer, eating with a
spoon, clipping the fingernails with nail scissors, unlocking a
door with a key and cutting with scissors) and seven intran-
sitive gestures (making a salute, forming a fist, waving good-
bye, shooing away, scratching the head, snapping the fingers
and beckoning). Apraxia testing was performed 1–2 weeks
after the patients were hospitalized.
To pantomime verbal commands, patients were given ver-
bal instructions to perform gestures. For transitive gestures,
participants were instructed to pretend to hold the object in
their hand and perform the gesture (e.g., “Show me how
you would use a hammer”). For intransitive gestures,
patients were told, for example, “Show me how you would
wave goodbye.” To pantomime visually presented tools, the
participants were presented with a tool and asked to show
how they would use it without touching the tool. For imita-
tion, patients imitated gestures presented by the examiner.
The examiner continued the presentation of the gesture until
the patient performed the imitation. For actual tool use, the
patients were given the actual tool to hold and were asked
to pretend to use the tool. The items used to test actual tool
use were the same as those used to test transitive gestures.
All of these tasks were performed by each hand. The
patients were allowed to restart as many times as desired,
until they were satisfied.
Patients were videotaped while executing the test. These
tapes were scored by two trained judges. If the judges
arrived at different decisions, they consulted the video
recording for reaffirmation. Gestures were scored quantita-
tively regarding accuracy. If a patient restarted an action
but was able to express the correct action, it was counted as
being the correct response. Error types were scored for each
apraxic gesture using the scoring system developed by Rothi
et al.21 Errors were categorized as spatial (body-part-as-tool
[BPT]), movement, amplitude (internal and external configu-
ration), temporal (sequencing, timing and occurrence), con-
tent (related and unrelated content), perseveration or other
errors (unrecognizable movement, hesitation or no
response). All false responses that occurred when the patient
restarted the action were included in the analysis; thus, a test
could have more than one type of error.
Statistical analysis. We compared the performances of
intransitive gestures (on verbal command vs. imitation) and
transitive gestures (on verbal command, in response to visu-
ally presented tools, imitation and actual tool use) separately
using a chi-squared test, with Bonferroni correction for mul-
tiple comparisons when necessary. Statistical significance
was set at P < 0.05.
Results
Lesion analysis. Figure 1 illustrates the superimposed
lesion data of our patients. The center of the lesion was in
the pars triangularis or the pars opercularis of the inferior
58
N Tsuruya et al.
frontal gyrus, that is, Brodmann areas 44 (116 voxels) and
45 (16 voxels). Other lesions were located in the precentral
gyrus, middle frontal gyrus, pars triangularis, pars opercu-
laris, partly extending to the inferior orbitofrontal cortex,
insula, postcentral gyrus, caudate nucleus, putamen, superior
temporal gyrus and temporal pole.
Apraxia testing. The performances observed using the
right and left hand were not significantly different; thus, the
analysis was based on the overall mean of all performances.
In general, a decline was observed in the performance of
actions in response to verbal commands (Fig. 2). For intran-
sitive gestures, all patients had a significantly lower number
of correct responses for verbal command compared with
imitation (patient 1, chi-squared = 6.09, d.f. = 1, P < 0.05;
patient 2, chi-squared = 4.67, d.f. = 1, P < 0.05; patient 3,
chi-squared = 9.33, d.f. = 1, P < 0.01; and patient 4, chi-
squared = 4.09, d.f. = 1, P < 0.05). For transitive gestures, a
significant difference was observed between verbal com-
mands and actual tool use for all patients, with the excep-
tion of patient 2 (patient 1, chi-squared = 6.09, d.f. = 1,
P < 0.05; patient 3, chi-squared = 7.63, d.f. = 1, P < 0.01;
and patient 4, chi-squared = 20.5, d.f. = 1, P < 0.01). For
patient 4, a difference in performance was observed between
verbal commands and imitation (chi-squared = 9.96, d.f. =
1, P < 0.01) and between visually presented tools and actual
tool use (chi-squared = 12.1, d.f. = 1, P < 0.01).
Figure 3 shows the results of the error analysis. No signif-
icant differences were observed between intransitive and
transitive gestures and between verbal command and visu-
ally presented tools; therefore, the sums of these values are
presented. Regarding these gestures, spatial errors were more
common than were other errors for patients 1, 2 and 4. Per-
severation was observed frequently for patients 3 and 4. In
addition, regarding imitation and actual tool use, the spatial
errors observed were similar to, or less than, those detected
for pantomiming. Hesitation was the most frequent of the
other types of error.
Discussion
In this study, we investigated four patients with symptoms of
apraxia who had a common lesional site: Broca’s area and
the left inferior frontal gyrus. These patients did not have
severe language comprehension impairment and paralysis
was either nonexistent or mild. Both left-handed and right-
handed apraxia was confirmed. Declined performance related
to verbal commands for both intransitive and transitive ges-
tures was observed for all patients, whereas the performances
of imitation and actual tool use were preserved. Analyses of
error patterns showed the presence of frequent spatial errors
and perseveration. These symptoms fall under the classifica-
tion of ideomotor apraxia.13–16 Previous reports have stated
that the performance of transitive gestures is worse than that
of intransitive gestures in apraxia22–24; on this point, our
findings differ from the results of previous studies. The symp-
toms of apraxia were observed equally for the left and right
hands, which is consistent with the finding that the left hemi-
sphere is dominant with respect to actions.9,10
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N Tsuruya et al. Broca’s area and apraxia

Figure 1 Anatomical location of lesions in our patients. The overlapping lesions of our four patients are shown on the template brain. The
number of overlapping lesions is illustrated by different colors that code increasing frequencies, from violet (n = 1) to red (n = 4). The common
lesioned areas in our four patients were Brodmann areas 44 and 45. The right side of the image corresponds to the left hemisphere.

The left parietal lobe is thought to be the brain region
that is primarily related to apraxia.10,12,25,26 Clinical neuro-
psychological research has revealed that lesion responses in
ideomotor apraxia were from the left frontal to parietal
lobes and the role of the parietal association area, such as
the supramarginal gyrus and angular gyrus, was empha-
sized. However, the patients diagnosed with ideomotor
apraxia include cases with different combinations of impair-
ment. Past research of impaired pantomiming reported its
association with a subcortical lesion of the parietal lobe,27
whereas other researchers noted that patients with lesions
of the parietal lobe have normal pantomiming ability.28,29
These findings show that lesions of the parietal lobe do not
necessarily lead to pantomiming impairment. In fact, the
cases described here presented with pantomiming impair-
ment even though CT and SPECT scan findings failed to
confirm the presence of any lesions in the parietal lobe.
However, the lesions of the four cases spread to the white
matter; thus, the lesion may have severed the bond to
another region related to actions, which may have caused
the apraxia.
Our results suggest that the region centered on the left
inferior frontal gyrus is important for pantomiming.
Recently, Binkofski and Buccino. described a 50-year-old
patient with a focal lesion on the right frontal operculum,
probably including the ventral premotor cortex, who was
unable to associate simple gestures and colors. This suggests
that the ventral premotor cortex plays a substantial role in
pantomiming, at least in the initial phase of visuomotor
associative learning.30 A lesion subtraction analysis per-
formed by Goldenberg and colleagues showed that defective
pantomiming of tool use was associated with damage to the
inferior frontal gyrus and adjacent portions of the insula
and precentral gyrus of the left hemisphere. In contrast,
parietal lesions did not specifically impact pantomime.17
Similarly, Bohlhalter et al investigated the effect of continu-
ous theta burst stimulation (cTBS) on gesture production
and recognition. cTBS of the left inferior frontal gyrus sig-
nificantly impaired action production, whereas stimulation
of the inferior parietal lobule did not.31
The apraxic symptoms in our patients were most promi-
nent on verbal commands: gestures performed in response

Neurology and Clinical Neuroscience 1 (2013) 55–62 59

ª 2013 Japanese Society of Neurology and Wiley Publishing Asia Pty Ltd
Broca’s area and apraxia N Tsuruya et al.

Intransitive and transitive gestures

40

35

30

25

No. of errors
20

15

10

0
Spatial Temporal Content Perseveration Other

Figure 2 Performance in the apraxia tests. For intransitive gestures, Case 1 Case 2 Case 3 Case 4
our patients performed worse regarding verbal commands compared
with imitation. For transitive gestures, patient performances were Imitation
generally worse regarding verbal commands compared with other 25
conditions.
20

to objects presented visually and imitation or actual tool use

No. of errors
15
yielded comparatively better performance, suggesting that
trauma to Broca’s area adversely affected associations
between language and actions. Regarding pantomiming to 10

verbal commands, knowledge about tools and their func-

tions should be transformed into motor sequences that are 5
only triggered from verbal cues. Regarding actual tool use,
the shape of the tool may provide clues about how it is held 0
and used.17 For example, the movement of using a hammer Spatial Temporal Content Perseveration Other
can be cued by the shape and size of the hand-gripped por- Case 1 Case 2 Case 3 Case 4
tion, whereas during pantomiming on verbal commands, this
must be planned without such cues. All of our patients
8
Actual tool use
showed significantly worse performance of intransitive ges-
tures, which are actions that must also be exclusively 7
recalled based on verbal cues, without using external stimuli.
This interpretation is consistent with the fact that perfor- 6

mance was better during imitation. To test imitation, infor- 5

No. of errors

mation related to an action was presented by the tester and

4
the patients did not need to evoke memories or knowledge
about the actions. Because it has been demonstrated that the 3
observation of meaningless gestures does not activate Broca’s
2
area,32 our patients may have succeeded in imitating using an
alternative neural system that does not need action knowl- 1
edge. As previously reported, a lesion of the parietal lobe
0
impaired the spatial relationship processing of the body Spatial Temporal Content Perseveration Other
parts, resulting in impaired imitation.26 The parietal lobe was
Case 1 Case 2 Case 3 Case 4
spared in our patients; therefore, they may have achieved
imitation based on the processing of body-part information
Figure 3 Results of the error analyses. The sums of errors in the
via the parietal lobe. Our results appear to be at odds with performance of intransitive and transitive gestures are presented.
the results of functional imaging studies, which indicated the Spatial errors were more common than were other types of error in
presence of a relationship between the inferior frontal region patients 1, 2 and 4 regarding intransitive and transitive gestures.
and imitation. However, research on imitation uses meaning- Perseveration was observed frequently in patients 3 and 4. Regarding
ful gestures as targets for imitation; thus, it is possible that imitation and actual tool use, the spatial errors were observed similar
Broca’s area functioned in reading the intent of these actions. to, or less than, those observed for intransitive and transitive gestures.
In addition, imitation of goal-directed actions leads to bilat-
eral inferior frontal activation.33 Covert verbalization (“inter- Finally, our study had several limitations. First, there was
nal speech”) during motor actions may be another possible no control group. To ascertain whether trauma to Broca’s
factor involved in the activation of Broca’s area.34 area causes apraxia, a similar set of tests should be per-

60 Neurology and Clinical Neuroscience 1 (2013) 55–62

ª 2013 Japanese Society of Neurology and Wiley Publishing Asia Pty Ltd
N Tsuruya et al.
formed using a group of patients with brain damage without
lesions in Broca’s area. Second, we cannot exclude the influ-
ence of the language disorder on the results of the test. The
apraxic syndrome was observed in our patients during tasks
that used linguistic components (i.e., verbal commands).
Therefore, the pantomime deficits in relation to verbal com-
mands might have been affected by uncontrolled linguistic
processes. However, our patients did not show a comprehen-
sion impairment that would affect the understanding of the
task instructions. Although language comprehension deficits
were reported in patients with lesions in Broca’s area, these
deficits were observed predominantly in response to syntacti-
cally complex sentences.3,35 Further, the spatial errors
recorded during apraxia testing in the present study cannot
be explained by impaired language comprehension. Third,
each patient had a different etiology. The most severe symp-
toms of apraxia were observed in the case with a brain
tumor (patient 4); however, this case had a wider range of
lesions than did the other cases. Accordingly, it is not clear
whether the results obtained were caused by differences in
etiology or by the size of the lesions. To resolve this prob-
lem, future investigations must include larger groups of
patients with a unified etiology and a sufficiently varied
lesion size.
Acknowledgements
This study was supported by a grant from the Tamagawa
University Center of Excellence under the Ministry of Edu-
cation, Culture, Sports, Science, and Technology (MEXT),
Japan; a Grant-in-Aid for Scientific Research (No.
23591283) from MEXT; and a Grant-in-Aid for Scientific
Research on Innovative Areas, “Face perception and recog-
nition,” from MEXT (No. 23119720).
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