c o r t e x x x x ( 2 0 1 2 ) 1 e1 3

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Special issue: Clinical neuroanatomy

Neurological and neuropsychological characteristics of

occipital, occipito-temporal and occipito-parietal infarction

Antje Kraft a,*, Cathleen Grimsen b, Stefanie Kehrer a, Markus Bahnemann a,

Karoline Spang b, Maren Prass b, Kerstin Irlbacher a, Martin Köhnlein a, Anika Lipfert a,
Freimuth Brunner c, Andreas Kastrup c, Manfred Fahle b,d and Stephan A. Brandt a
a
Department of Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
b
Department of Human Neurobiology, University of Bremen, Bremen, Germany
c
Medical Hospital Gesundheit Nord, Klinikum Bremen Mitte, Bremen, Germany
d
The Henry Wellcome Laboratories of Vision Sciences, City University London, London, UK

article info abstract

Article history: Neuropsychological deficits after occipital infarction are most often described in case
Received 23 November 2011 studies and only a small sample of studies has attempted to exactly correlate the
Reviewed 16 February 2012 anatomical localization of lesions with associated neuropsychological symptoms. The
Revised 1 June 2012 present study investigated a large number of patients (N ¼ 128) in order to provide an
Accepted 15 October 2012 overview of neurological and neuropsychological deficits after occipital, occipito-
Published online xxx temporal and occipito-parietal infarction. A particular approach of the study was to
define exact anatomical correlates of neuropsychological dysfunction by using voxel-
Keywords: based lesion-symptom mapping (VLSM) in 61 patients. In addition to a visual field
Infarct topography defect and phosphenes, patients often reported anomia, difficulties in reading and
Lesion-symptom mapping memory deficits. Visual disorders, such as achromatopsia, akinetopsia or prosopagnosia,
Stroke were rarely reported by the patients. Memory and visual disorders were diagnosed
Vision efficiently using simple clinical screening tests, such as the ReyeOsterrieth Complex
Figure Test for immediate recall, the Demtect and the Lang Stereo Test. Visual field
defects, reading disorders and the perception of phosphenes were associated primarily
with lesions of the calcarine sulcus. Anomia and memory deficits were related to lesions
of the occipital inferior gyrus, the lingual gyrus and hippocampus, as well as to lesions of
principal white matter tracts.
ª 2012 Elsevier Srl. All rights reserved.

1. Introduction et al., 1999; Ntaios et al., 2011). However, several studies

have shown that occipital, occipito-temporal and occipito-
In the clinical context, occipital infarction is often perceived parietal infarction lead to additional clinical and neuro-
as being associated with visual field defects only (see Brandt psychological symptoms, such as deficits in reading, writing,
et al., 2000 for a review; Steinke et al., 1997; Yamamoto memory and executive function (Cals et al., 2002; Kumral

* Corresponding author. Department of Neurology, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.
E-mail address: antje.kraft@charite.de (A. Kraft).
0010-9452/$ e see front matter ª 2012 Elsevier Srl. All rights reserved.
http://dx.doi.org/10.1016/j.cortex.2012.10.004

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
2 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3
et al., 2004; Pessin et al., 1987; Gloning et al., 1966; Maulaz
et al., 2005).
Visual disorders after cerebral lesions in the occipital,
occipito-temporal or occipito-parietal cortex were described
carefully in several studies in large samples of patients (e.g.,
Zihl and von Cramon, 1986; Gloning et al., 1966; Rowe et al.,
2009). These studies did not distinguish between distinct
etiologies such as stroke, tumors, craniocerebral injury or
hemorrhage. Notably, they did not seek to relate the exact
anatomical localization of lesions to associated clinical or
neuropsychological symptoms in a systematic manner. This
attempt was made by more recent reviews (e.g., Girkin and
Miller, 2001; ffytche et al., 2010) that tried to allocate certain
visual syndromes to specific cortical visual areas or to
a disconnection between them. But these reviews still did not
differentiate between distinct brain lesion etiologies.
Focusing on stroke, there is a limited number of reports
which give systematic overviews of neuropsychological defi-
cits after occipital, occipito-temporal and occipito-parietal
infarction (Cals et al., 2002; Kumral et al., 2004; Pessin et al.,
1987; Gloning et al., 1966). Some larger sample studies esti-
mated a frequency of neuropsychological deficits such as
visual agnosia, dyslexia, dysphasia or memory impairment
between 32% and 50% of these patients (Cals et al., 2002;
Milandre et al., 1994; Steinke et al., 1997). However, these
studies did not allocate visual deficits or neuropsychological
symptoms to specific anatomical locations within the infarct
territory. Such an approach was taken by numerous single
case reports or small sample accounts describing neuro-
psychological deficits after posterior strokes (Pessin et al.,
1987; Holt and Anderson, 2000), applying the mini-mental
state examination (Park et al., 2009), or focusing on disorders
of reading and writing (Pillon et al., 1987; Habekost and
Starrfelt, 2006; Pflugshaupt et al., 2009), memory (Benson
et al., 1974; von Cramon et al., 1988; Machner et al., 2009),
executive functions (Park et al., 2011), neglect (Park et al., 2006;
Tomaiuolo et al., 2010) or on specific visual disorders such as
visual hallucinations (Baier et al., 2010a; Tombini et al., 2012)
and visual agnosia (Landis et al., 1986; Carlesimo et al., 1998;
Ohtake et al., 2001; Konen et al., 2011). In summary, these case
reports offer a good overview about the diversity of visual and
neuropsychological deficits after occipital, occipito-temporal
or occipito-parietal infarction, but cannot contribute to
a statistically valid clinico-anatomical correlation between
neuropsychological deficits and anatomical areas within the
occipito-temporo-parietal region.
Conversely, there is only a small sample of studies that
attempt to exactly correlate the anatomical localization of
stroke lesions with associated clinical symptoms using
a relatively new method called “voxel-based lesion-symptom
mapping” (VLSM, e.g., Karnath et al., 2004). The emphasis of
these studies was not to give a systematic overview about
neuropsychological deficits. Instead, they focused on single
clinical aspects, such as phosphenes and complex hallucina-
tions (Baier et al., 2010a), motion processing (Billino et al.,
2011), neglect (Karnath et al., 2004, 2011; Bird et al., 2006;
Molenberghs and Sale, 2011), extinction (Chechlacz et al., in
press), dyslexia (Ptak et al., 2012), alexia (Pflugshaupt et al.,
2009), picture naming (Baldo et al., in press) or action recog-
nition (Kalénine et al., 2010). To date there is no study using
Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
the VLSM approach in a large sample of stroke patients which
tries to exactly correlate a broad array of neuropsychological
deficits with anatomical lesions after occipital, occipito-
temporal or occipito-parietal infarction.
The aim of the present study was to realize both: (a)
a systematic description of subacute clinical and neuro-
psychological deficits after occipital, occipito-temporal and
occipito-parietal infarction in a large sample of patients; and
(b) an exact clinico-anatomical correlation for these deficits
using a VLSM approach (Rorden et al., 2007).
2. Methods
2.1. Patients
An overall number of N ¼ 128 patients participated in this
study. Patients were recruited between 2007 and 2011 at the
Department of Neurology, Charité Universitätsmedizin Berlin
(Berlin, Germany) and at the Stroke Unit of the Medical
Hospital Gesundheit Nord Klinikum Bremen-Mitte (Bremen,
Germany). After receiving the approval of the local ethics
committees, written informed consent was obtained from all
patients and the examination was conducted in conformity
with the Declaration of Helsinki.
Patients with ischemic cerebral infarction, as evidenced by
magnetic resonance imaging (MRI) or computer tomography
(CT), affecting the occipital gyri and sulci were included in this
study. Apart from this primary criterion, lesions additionally
extending into the temporal and/or parietal gyri and sulci were
included as well. Both lesions involving the territories of the
middle cerebral artery (MCA) or posterior cerebral artery (PCA)
qualified for inclusion, if the above stated criteria were fulfilled.
Exclusion criteria were severe aphasia, ophthalmological
disorders such as glaucoma, cataract or macula degeneration in
an advanced stage, or any other severe neurological or
psychiatric disorder (e.g., epilepsy or schizophrenia).
2.2. Neurological testing and neuro-ophthalmological
testing
Patients underwent a clinical neurological examination
including finger perimetry, oculomotor function, reaching,
motor function, extinction, neglect and reading. The basic
neurological examination was carried out at least 24 h after
a patient received a stroke.
Visual acuity (near and far, using Landolt rings) and static
perimetry (30 ) were conducted for the ipsilesional and con-
tralesional eye. The Ishihara Test of color vision (Ishihara,
1917) and the Lang Test of stereo vision (Lang, 1982) were
performed binocularly.
In addition, patients were asked if they experienced the
following subjective general or visual impairments after
stroke. General subjective impairments: 1. memory deficits, 2.
anomia, and 3. reading disorders. Specific visual subjective
impairments: 1. visual field defects, 2. spatial orienting
disorder, 3. disorder of eye-hand-coordination, 4. dysfunction
in visual motion perception, 5. dysfunction of recognizing
faces, 6. dysfunction of color vision, 7. dysfunction of stereo
 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3 3

perception, 8. presence of phosphenes, and 9. presence of
complex hallucinations.
2.3. Neuropsychological testing
Neuropsychological testing included attention/neglect tests
(line bisection, cancellation test, clock drawing, covert shift of
attention [Posner paradigm; a subtest of the Testbatterie zur
Aufmerksamkeitsprüfung (TAP) by Zimmermann and Fimm
(1993)]), the Fragmented Picture Test (FPT) (Kessler et al.,
1993), a visual perception test [copy of the ReyeOsterrieth
Complex Figure Test (ROCF, see Shin et al., 2006 for an over-
view)], a visual/non-verbal working memory test (immediate
recall ROCF, Demtect) and a memory (Demtect delayed recall)
and dementia test (Demtect; Kalbe et al., 2004). The patient’s
performance in all standard neuropsychological tests was
assessed in relation to the performance of a normative
sample.
2.4. Image acquisition, classification of lesions and
further lesion analysis
Patients generally received MRI scans of the brain (only three
patients with a CT scan) with routine clinical parameters while
in the neurology service (Bremen: 1.5 T Espree, Siemens; Berlin:
1.5 T Avanto, Siemens or 1.5 T Signa EXCITE, GE). These scans
included a T2 weighted image (Bremen: 24 slices, flip angle
150 , TR/TE ¼ 8510/136 msec, slice thickness 5 mm, spacing
6 mm; Berlin: 23 slices, flip angle 150 , TR/TE ¼ 4500/97 msec,
slice thickness 5 mm, spacing 6.5 mm or 24 slices, flip angle
90 , TR/TE ¼ 5220/93 msec, slice thickness 5 mm, spacing
6 mm), and usually also a Diffusion-weighted image (Bremen:
24 slices, flip angle 90 , TR/TE ¼ 4400/109 msec, slice thickness
5 mm, spacing 6 mm; Berlin: 24 slices, flip angle 90 , TR/
TE ¼ 3500/94 msec, slice thickness 5 mm, spacing 6.5 mm or 48
slices, flip angle 90 , TR/TE ¼ 8000/72 msec, slice thickness
5 mm, spacing 6 mm). For a minority of patients an additional
T1-weighted 3D image (Berlin: MPRAGE; flip angle 15 , TR/TE
2280/3.93 msec, voxel-size 1  1  1 mm) was acquired.
One neurologist, who was blind to the clinical symptoms
and the outcome of the neurological and neuropsychological
assessments, classified the lesions with respect to the
anatomical characteristics and manually delineated the
lesions to axial MRI images using MRICron software (http://
www.sph.sc.edu/comd/rorden/mricron/install.html) for
lesion-symptom mapping.
Lesion classification was performed as a two-stage process:
First, it was rated, (a) whether the lesion was located in the
right or left hemisphere (unilateral) or whether it was found
bilaterally; (b) whether the MCA or PCA territories were
affected; (c) whether the lesion was located above or below the
calcarine sulcus or both; (d) whether the lesion involved
lateral, medial or both aspects of the occipital cortex; and (e)
whether the lesion involved the occipital, occipito-temporal,
occipito-parietal or occipito-parieto-temporal cortex. For this
purpose, lesions were classified using the automated
anatomical labeling (AAL) atlas of the MRICron software
package, which allows for identification of all major gyri. If
lesions affected one of the occipital gyri, they were termed as
“occipital”. If, in addition to these, temporal gyri were
affected, they were termed as “occipito-temporal”. Likewise, if
beyond the first, parietal gyri were also affected, they were
termed as “occipito-parietal”. Lesions comprising affected gyri
of all three lobes were termed as “occipito-temporo-parietal”.
Second, lesions were classified according to whether or not
the following anatomical regions were affected: optic radia-
tion, white matter, splenium, basal ganglia, mesencephalon,
thalamus, cerebellum, frontal cortex, insula and hippo-
campus. At this step, white matter damage refers to the
subcortical white matter in general. Decisions on the lesion of

Table 1 e Descriptives.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 128 61 27 29
Age in years
Mean  SD 61.5  13.1 56.4  14.2 54.5  16.1 58.0  11.8
Range 20e85 20e82 20e73 29e77
Gender
Male 78 60.9% 38 62.3% 16 59.3% 19 65.5%
Female 50 39.1% 23 37.7% 11 40.7% 10 34.5%
Education 13.3  3.1 13.3  2.9 13.9  3.3 13.3  2.4
9e21 9e21 9e21 9e18
Handiness
Right 118 92.1% 57 93.4% 26 96.3% 26 89.7%
Left 2 01.6% 2 03.3% 0 0% 2 06.9%
Ambidexter 5 03.9% 1 01.6% 0 0% 1 03.4%
Missing 3 02.4% 1 01.6% 1 3.7% 0 0%
Time since lesion
1e10 days 102 79.7% 44 72.1% 18 66.7% 23 79.3%
11e30 days 8 06.3% 7 11.5% 3 11.1% 3 10.3%
31e150 days 5 03.9% 3 04.9% 2 07.4% 1 03.4%
150 days 13 10.2% 7 11.5% 4 14.8% 2 05.9%

Descriptive data from all patients (column 1), from all patients with a delineated lesion (column 2) and for all patients with left-hemispheric or
right-hemispheric delineated lesions (column 3 and column 4, respectively).

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
4 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3

Fig. 1 e Lesion topography. Overlay of left- (upper panel) and right-hemispheric (lower panel) lesions, respectively. Note that
left-hemispheric lesions are flipped to the right side.

the optic radiation were based on a visual comparison with
a histological atlas (Bürgel et al., 2006). A detailed analysis of
the lesion of particular white matter tracts was performed for
VLSM results below.
The patients’ T2 weighted images generally served as the
basis for lesion delineation because they offered the best
contrast for subacute brain lesions. There were only three
patients, for whom an MRI scan could not be performed,
necessitating the use of CT scans. With respect to our 24 slices
T2 weighted images, lesions were manually drawn on 24 slices
(6 mm spacing) of a T1-weighted template MRI scan from the
Montreal Neurological Institute (MNI), thus resulting in
multilayer regions of interest (ROI). Our template was slightly
rotated (pitch 8, Nudge X 1, Y 4, Z 4) to achieve the
anterior commissureeposterior commissure (ACePC)
orientation of clinical data sets. Patients with severe atrophy,
severe white matter lesions (Wahlund score > 4; Wahlund
et al., 2001) or multiple cerebral and subcortical lesions were
excluded from lesion delineation and further lesion analyses.
An overall of N ¼ 61 patients fulfilled the criteria (31 patients
were excluded due to severe white matter lesions, 18 patients
were excluded due to severe atrophy and 19 patients were
excluded due to multiple cerebral and subcortical lesions).
For a detailed analysis of the relationship between lesions
and symptoms in our group of patients, we chose a VLSM
approach using the MRICron Software package (Rorden et al.,
2007) for those neurological and neuropsychological deficits
that were present in a relevant number of patients (10). In
this case, Liebermeister tests as implemented in the MRICron
toolset were performed to assess the statistical significance of

Table 2 e Lesion characteristics and lesion topography.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 128 61 27 29
Imaging
cMRT 116 90.6% 58 95.1% 26 96.3% 27 93.1%
cCT 12 09.4% 3 04.9% 1 03.7% 2 06.9%
Territory
PCA 106 82.8% 48 75.4% 24 88.9% 19 65.5%
MCA 17 13.3% 11 20.3% 3 11.1% 8 27.6%
Junction 4 03.1% 2 02.9% 0 0% 2 06.9%
Missing 1 .8% 0 0% 0 0% 0 0%
Wahlund score
Mean  SD 3.6  3.0 2  1.3 2  1.4 2  1.3
Range 0e13 0e4 0e4 0e4
Lobule
Occipital 47 36.7% 24 39.3% 10 37.0% 12 41.4%
Occipital-temporal 43 33.6% 20 32.8% 14 51.9% 6 20.7%
Occipital-parietal 8 06.3% 3 04.9% 0 0% 2 06.9%
Occi-pari-tempo 30 23.4% 14 23.0% 3 11.1% 9 31.0%
Relation calcarina
Above 14 10.9% 7 11.5% 3 11.1% 3 10.3%
Below 41 32.0% 19 31.1% 13 48.1% 6 20.7%
Both 72 56.3% 35 57.4% 11 40.7% 20 69.0%
Not assessable 1 .8% 0 0% 0 0% 0 0%
Position
More medial 67 52.3% 33 54.1% 18 66.7% 13 44.8%
More lateral 25 19.5% 14 23.0% 3 11.1% 11 37.9%
Both 36 28.2% 14 23.0% 6 22.2% 5 17.2%

Lesion characteristics of all patients (column 1), of all patients with a delineated lesion (column 2) and of all patients with left-hemispheric or
right-hemispheric delineated lesions (column 3 and column 4, respectively).

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3 5

the lesion-symptom-mappings (Rorden et al., 2007). For
precise clinico-anatomical correlations, statistical results
were mapped to atlases of gyral structures and Brodmann
areas (BAs) as implemented in MRICron, as well as to white
matter tracts using a diffusion tensor imaging-based atlas
developed by Thiebaut de Schotten et al. (2011). If a particular
deficit was present in less than 10 patients, we refrained from
a detailed statistical analysis. Instead, the lesion topography
was illustrated using the subtraction analysis tool of MRICron,
which displays the overlap of lesions of patients with
a particular deficit versus those lesions of patients without
this deficit (see Karnath et al., 2002).
3. Results
3.1. Descriptive
The descriptive data are summarized in Table 1. The
majority of patients were investigated in the (sub-)acute
phase (1e10 days) after infarction. There were no significant
group differences in age, gender distribution, or years of
formal education for patients with left-hemispheric delin-
eated lesions versus those with right-hemispheric delineated
lesions.
3.2. Anatomy and infarct topography
The lesion topography is illustrated in Fig. 1 and the lesion
characteristics are further detailed in Table 2. In most cases
the infarction was located in the PCA territory. The center of
mass of lesions for the whole group was located medially in
the occipito-temporal cortex. Left-hemispheric lesions in
patients were most often located medially in the occipito-
temporal cortex, while right-hemispheric lesions extended
more often to the occipito-parietal regions.
Table 3 summarizes which anatomical regions were
damaged. In most patients, the optical radiation and the white
matter were affected. Remarkably, the hippocampus was
affected in half of the patients with a left-hemispheric lesion.

Table 3 e Anatomical classification.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 128 61 27 29
Optic radiation
Damaged 115 89.8% 52 85.2% 24 88.9% 23 79.3%
Not damaged 13 10.2% 9 14.8% 3 11.1% 6 20.7%
White matter
Damaged 125 97.7% 60 98.4% 26 96.3% 28 96.6%
Not damaged 3 02.3% 1 01.6% 1 03.7% 1 03.4%
Splenium
Damaged 12 09.4% 6 09.8% 3 11.1% 3 10.3%
Not damaged 115 89.8% 55 90.2% 24 88.9% 26 89.7%
Not assessable 1 .8% 0 0% 0 0% 0 0%
Basal ganglia
Damaged 12 09.4% 2 03.3% 1 03.7% 1 03.4%
Not damaged 115 89.8% 59 96.7% 26 96.3% 28 96.6%
Not assessable 1 .8% 0 0% 0 0% 0 0%
Mesencephalon
Damaged 10 07.8% 3 04.9% 2 07.4% 1 03.4%
Not damaged 84 65.7% 55 90.2% 24 88.9% 28 96.6%
Missing/n.a. 34 26.5% 3 04.9% 1 03.7% 0 0%
Thalamus
Damaged 41 32.0% 15 24.6% 7 25.9% 7 24.1%
Not damaged 85 66.4% 45 73.8% 19 70.4% 22 75.9%
Not assessable 2 01.6% 1 01.6% 1 03.7% 0 0%
Cerebellum
Damaged 27 21.1% 12 19.7% 6 22.2% 3 10.3%
Not damaged 101 78.9% 49 80.3% 21 77.8% 26 89.7%
Frontal
Damaged 17 13.3% 7 11.5% 1 03.7% 6 20.7%
Not damaged 110 85.9% 54 88.5% 26 96.3% 23 79.3%
Not assessable 1 .8% 0 0% 0 0% 0 0%
Insula
Damaged 10 07.8% 2 03.3% 0 0% 2 06.9%
Not damaged 117 91.4% 59 96.7% 27 100.0% 27 93.1%
Not assessable 1 .8% 0 0% 0 0% 0 0%
Hippocampus
Damaged 48 37.5% 26 42.6% 16 59.3% 8 27.6%
Not damaged 79 61.7% 35 57.4% 11 40.7% 21 72.4%
Not assessable 1 .8% 0 0% 0 0% 0 0%

Anatomical classification all patients (column 1), of all patients with a delineated lesion (column 2) and of all patients with left-hemispheric or
right-hemispheric delineated lesions (column 3 and column 4, respectively).

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
6 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3

3.3. Neurological and neuro-ophthalmological
symptoms
The results of the basic neurological examination are
summarized in Table 4. Initial symptoms are shown in
decreasing order of frequency. While a visual deficit was re-
ported by the majority of patients, all other symptoms were
named considerably less frequently. Apart from the visual
field defect, almost no basic neurological screening test
applied at least 24 h after stroke revealed deficits in patients
with occipital infarction.
Table 5 illustrates the relevant subjective impairments of
patients. Anomia was reported significantly more frequently
in patients with left-hemispheric lesions (p < .05, Chi-Square-
Test). There was no significant difference in the report of
memory deficits and reading disorder between left- and right-
hemispheric groups (p > .05, Chi-Square-Test). A visual field
defect was subjectively declared by half of all patients. Phos-
phenes were reported in one-third of all patients.
Fig. 2 illustrates the results of statistical voxelwise lesion-
behavior mapping analyses for subjective impairments as
reported by the patients. Supplementary Fig. 1 shows the
relation of these results to important white matter tracts.
Memory deficits were associated with lesions of the lingual
and occipital inferior gyrus, as well as the hippocampus (BA
19, 20 and 35) and lesions of the inferior fronto-occipital
fasciculus (IFOF), inferior longitudinal fasciculus (ILF) and
the cingulum (to a minimal extent), respectively. Anomia was
correlated with inferior occipital lesions (BA 19). Reading
disorders were associated with a lesion of the calcarine sulcus
(BA 17) and lesions of the corpus callosum, as well as the IFOF
and ILF to a minimal extent. Visual field defects were corre-
lated with lesions of the calcarine sulcus (BA 17) and lesions of
BA 18, 19, as well as the corpus callosum. Similarly,

Table 4 e Basic neurological examination.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 128 61 27 29
Initial symptoms
Visual 102 79.7% 48 78.7% 25 92.6% 21 72.4%
Sensory 39 30.5% 20 32.8% 10 37.0% 10 34.5%
Headache 38 29.7% 24 39.4% 14 29.6% 10 34.5%
Dizziness 32 25.0% 17 27.9% 10 37.0% 4 13.8%
Paresis 20 15.6% 11 18.0% 2 07.4% 9 31.0%
Aphasia/language 18 14.1% 7 11.5% 3 11.1% 4 13.8%
Nausea/vomiting 15 11.7% 6 09.8% 4 14.8% 1 03.4%
Memory 9 07.0% 3 04.9% 3 11.1% 0 0%
Confusion 8 06.3% 5 08.2% 3 11.1% 2 06.9%
Prior transient ischemic 1 .8% 1 01.6% 0 0% 1 03.4%
attack (TIA)
Visual field
Finger perimetry 66 51.6% 29 47.5% 14 51.9% 11 37.9%
Oculomotoric
No conjugated bulbi 2 01.6% 1 01.6% 1 03.7% 0 0%
Diplopic images 8 06.3% 2 03.3% 1 03.7% 0 0%
Pursuit to left impaired 11 08.6% 3 04.9% 1 03.7% 2 06.9%
Pursuit to right impaired 15 11.7% 3 04.9% 1 03.7% 2 06.9%
Pursuit (up) impaired 6 04.7% 1 01.6% 0 0% 1 03.4%
Pursuit (down) impaired 4 03.1% 1 01.6% 0 0% 1 03.4%
Saccades to left imp. (t) 7 05.5% 2 03.3% 0 0% 2 06.9%
Saccades to left imp. (s) 13 10.2% 5 08.2% 2 07.4% 3 10.3%
Saccades to right imp. (t) 10 07.8% 3 04.9% 2 07.4% 1 03.4%
Saccades to right imp. (s) 17 13.3% 5 08.2% 3 11.1% 2 06.9%
Grasping
Left impaired 4 03.1% 3 04.9% 0 0% 3 10.3%
Right impaired 7 05.5% 3 04.9% 2 07.4% 1 03.4%
Extinction
Visual (left) 8 06.3% 4 06.6% 0 0% 4 13.8%
Visual (right) 6 04.7% 2 03.3% 2 07.4% 0 0%
Acoustic (left) 6 04.7% 2 03.3% 1 03.7% 1 03.4%
Acoustic (right) 2 01.6% 1 01.6% 1 03.7% 0 0%
Tactile (left) 2 01.6% 1 01.6% 0 0% 1 03.4%
Tactile (right) 1 .8% 1 01.6% 1 03.7% 0 0%
Neglect
Fixated view 2 01.6% 0 0% 0 0% 0 0%
Fixated head 2 01.6% 1 01.6% 0 0% 1 03.4%
No spont. movements 5 03.9% 2 03.3% 1 03.7% 1 03.4%
No eye contact 3 02.3% 0 0% 0 0% 0 0%

Results of neurological and neuro-ophthalmological examinations of all patients (column 1), of all patients with a delineated lesion (column 2)
and of all patients with left-hemispheric or right-hemispheric delineated lesions (column 3 and column 4, respectively).

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3 7

Table 5 e Subjective impairments.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 128 61 27 29
Subjective Impairment
Memory 25 19.5% 12 19.7% 7 25.9% 3 10.3%
Anomia 33 25.8% 19 31.1% 13 48.1% 4 13.8%
Reading 58 45.3% 23 37.7% 13 48.1% 9 31.0%
Subjective visual impairment
Visual field defect 67 52.3% 25 41.0% 12 44.4% 11 37.9%
Spatial orientation 21 16.4% 10 16.4% 6 22.2% 3 10.3%
Eye-hand-coordination 17 13.3% 6 09.8% 2 07.4% 3 10.3%
Motion perception 9 07.0% 3 04.9% 2 07.4% 1 03.4%
Prosopagnosia 3 02.3% 2 03.3% 1 03.7% 1 03.4%
Color 6 04.7% 3 04.9% 0 0% 2 06.9%
Stereo 13 10.2% 5 08.2% 2 07.4% 2 06.9%
Phosphenes 43 33.6% 24 39.3% 12 44.4% 10 34.5%
Hallucinations 9 07.0% 3 04.9% 2 07.4% 1 03.4%

Subjective impairments of all patients (column 1), of all patients with a delineated lesion (column 2) and of all patients with left-hemispheric or
right-hemispheric delineated lesions (column 3 and column 4, respectively).

phosphenes were also correlated with a lesion of the primary
visual cortex BA 17 and lesion of the corpus callosum to
a minimal extent.
Extended neurological, neuro-ophthalmological and neu-
ropsychological testing were carried out in 101 patients.
Findings are summarized in Table 6. Overall, nine scotomas
and eight quadrantanopias were detected by automated
perimetry but missed by finger perimetry. The lesion topo-
graphy for patients who had no versus distinct visual field
defects is illustrated in Fig. 3.
Half of all patients obtained normal results in the Lang
Stereo Test, while the remaining patients were either
completely impaired [failure to recognize any of the three
figures (cat ¼ 1200”, star ¼ 600”, car ¼ 600” disparity)], or
partially impaired (failure to recognize at least one of the
figures). Subtraction analysis revealed no specific cortical area
associated with a partial or complete deficit in the Lang Stereo
Test (see Supplementary Fig. 2).
3.4. Neuropsychological symptoms
The majority of patients showed no deficits in the screening
tests, in the ROCF copy and in the FPT. Approximately a third
of our patients showed pathological results in the covert
attention test (TAP) and in the Demtect, and a fifth showed
a deficit in the ROCF recall (see Table 7).
For the TAP, a relationship was found between lesion size
and slowed reaction times in the delineated lesion group.
Lesion size was significantly greater for patients with general
slowing compared to patients with generally intact processing
speed (2864 voxels vs 1758 voxels, p < .05, t-test) and with
slowing after invalid cues (3265 voxels vs 1975 voxels
p < .05, t-test). VLSM revealed no significant correlations.
Supplementary Fig. 3 displays the results of a lesion subtrac-
tion analysis for patients with generally slowed reaction times
versus patients whose reactions became slowed only after
invalid cues in the covert attention test. Both general slowing
and slowing after invalid cues were associated with lesions in
the lingual gyrus.
For the Demtect, VLSM results of patients with a relevant
deficit as compared to unimpaired patients are illustrated in
Fig. 4. Voxels associated with a memory deficit are located in
the hippocampus, parahippocampal gyrus and fusiform gyrus
(BA 18, 19, 20 and 37) and lesions of the cingulum, IFOF, ILF as
well as the corpus callosum (to a minimal extent), respectively
(see Supplementary Fig. 4).
For the ROCF recall, a VLSM could not be performed,
since only eight of the patients with delineated lesions
showed a relevant deficit. A subtraction analysis revealed no
specific area associated with a deficit in ROCF immediate
recall (see Supplementary Fig. 5). Note that half of our
patients with a deficit in ROCF showed no deficit in the
Demtect.
4. Discussion
In the clinical context occipital, occipito-temporal and
occipito-parietal infarction is often perceived as being asso-
ciated with hemianopia alone. In a large patient collective
with such lesions we showed that patients often exhibited
additional clinical signs and symptoms: Apart from a visual
field defect and seeing phosphenes, patients reported
subjective deficits such as anomia, reading disorders and
memory deficits. Overall, the results of our study are
congruent with previous studies which report neuro-
psychological and neurological deficits after occipital,
occipito-temporal and occipito-parietal infarction (Brandt
et al., 2000; Cals et al., 2002; Kumral et al., 2004). Yet, this
study considerably extends our knowledge about occipital,
occipito-temporal and occipito-parietal infarction through
detailed descriptions of infarct topography, neurological,
neuropsychological symptoms, and importantly, the defini-
tion of anatomical correlates of neuropsychological dysfunc-
tion by using a lesion-symptom mapping approach.
Topographically, a visual field defect, a reading disorder,
and the perception of phosphenes (see also Baier et al.,
2010a) were associated with lesions of the calcarine sulcus.

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
8 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3

Fig. 2 e Subjective impairments. Results of the statistical voxelwise lesion-behavior mapping analysis for subjective
memory deficits (first line), subjective anomia (second line), subjective reading disorder (third line), subjective visual field
defects (fourth line) and subjective perception of phosphenes (fifth line). Note that left-hemispheric lesions are flipped to the
right side. The Liebermeister test statistics were used as implemented in the MRICron software. Voxels that were damaged
significantly more often in patients showing the deficit than in patients with no deficit are color-coded in red after
adjustment for multiple comparisons. The range of z-values indicating significance (p < .05), as well as the corresponding
anatomical regions (BA) are given on the right hand side for each subjective impairment.

Anomia and memory deficits were associated with lesions of
the occipital inferior gyrus, or the lingual gyrus and hippo-
campus (see also Szabo et al., 2009). Hodologically, a visual
field defect, a reading disorder and the perception of phos-
phenes were correlated with lesions of the corpus callosum.
Memory deficits were associated with lesions of the IFOF, ILF
and cingulum. These findings are in accordance with
previous studies, suggesting that lesions of the ILF, splenium
and U-shaped tracts can lead to alexia, lesions of the ILF or
IFOF can lead to surface dyslexia (Epelbaum et al., 2008;
Coltheart et al., 1983; ffytche et al., 2010) and visual amnesia
occurs after lesions of the ILF or IFOF (Ross, 1980; ffytche
et al., 2010). As in the current study, memory deficits have
been found to be predominantly associated with left-
hemispheric lesions by Cals et al. (2002). Although reports
of hippocampal lesions after stroke are rare, a recent study of

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3 9

Table 6 e Objective neurological and neuro-ophthalmological impairments.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 101 48 23 22
Neurological impairment
Visual field defect 54 53.5% 22 45.8% 12 52.2% 8 36.4%
(finger perimetry)
Visual acuity
Visus (near) binocular 1.00  .3 1.05  .26 1.09  .22 .99  .30
Visus (far) best out of 2 eyes .88  .3 .92  .25 .97  .28 .90  .24
Automatic static perimetry
Free visual field 31 30.7% 18 37.5% 7 30.4% 10 45.5%
Complete hemianopia 9 08.9% 1 02.1% 1 04.3% 0 0%
Incomplete hemianopia 18 17.8% 5 10.4% 4 17.4% 1 04.5%
Quadrantanopia 29 28.7% 15 31.3% 8 34.8% 5 22.7%
Scotoma 14 13.9% 9 18.8% 3 13.0% 6 27.3%
Color vision
Ishihara impaired 9 08.9% 2 04.2% 1 04.3% 1 04.5%
Stereo vision (Lang)
Intact 50 49.5% 22 45.8% 13 56.5% 8 36.4%
Partially intact 22 21.8% 11 22.9% 6 26.1% 5 22.7%
Impaired 21 20.8% 11 22.9% 3 13.0% 6 27.3%
Out (amblyopia/strabismus) 8 07.9% 4 08.3% 1 04.3% 3 13.6%
Cat impaired 42 41.6% 25 52.1% 10 43.5% 13 59.1%
Star impaired 32 31.7% 15 31.3% 5 21.7% 8 36.4%
Car impaired 36 35.6% 18 37.5% 5 21.7% 11 50.0%

Objective neurological and neuro-ophthalmological impairments of all patients (column 1), of all patients with a delineated lesion (column 2)
and of all patients with left-hemispheric or right-hemispheric delineated lesions (column 3 and column 4, respectively).

Szabo et al. (2009), which reported 57 cases of hippocampal
infarction, demonstrated that careful neuropsychological
testing revealed memory deficits for both left- and right-
hemispheric lesions of the hippocampus. In their study as
well, lesions were not restricted to the hippocampus.
Instead, they also affected the occipital cortex or the
perpendicular thalamus. Importantly, verbal memory was
affected more frequently after left-hemispheric lesions,
which is consistent with our results.
In the study by Szabo et al. (2009), spatial memory as
measured by the ROCF was more frequently impaired in
patients with right-hemispherical-hippocampal-lesions. In
contrast, our results indicate that a deficit in ROCF immedi-
ate recall does not necessitate a right-hemispherical-
hippocampal-lesion. A number of studies also discussed that
the ROCF measures verbal memory, as the figural parts can be
verbalized (e.g., McConley et al., 2008). Half of our patients
with a deficit in ROCF showed no deficit in the Demtect. This
clearly shows that ROCF immediate recall and the Demtect
measure, to a certain extent, distinct deficits.
Standard screening tests such as the line bisection,
cancellation and FPT are less sensitive for deficits in the
subacute period after occipital infarction. These tests might be
more sensitive for identifying deficits in MCA patients, if
larger parts of the parietal cortex are affected (but see also
Baier et al., 2010b).
We found that a general slowing in the TAP correlates with
lesion size, but not with a specific cortical area. This result is
consistent with previous reports of attention research. For
example, Habekost and Rostrup (2007) showed that large
strokes and extended leukoaraiosis can be related to bilateral
deficits in the processing speed of visual attention.
4.1. Conclusion and perspectives
This study underlines the importance of neuropsychological
deficits far beyond a visual field defect that are to be expected
after infarctions in this location. Screening tests for reading,
memory deficits and visual deficits can be easily applied by
any neurologist. We propose a combination of a reading test,
the Demtect, the ROCF Test and the Lang Stereo Test, as well
as an anomia test (anamnesis) as the standard test battery
following occipital infarction. Testing time would not exceed
20 min. If screening tests show positive results, a neuropsy-
chologist should be involved to investigate whether or not the
severity of the patients’ impairment required rehabilitation
measures, by administering a more complex neuro-
psychological test battery. For interpretation of the Demtect
results, it is very important to check whether the hippo-
campus is affected after occipital infarction. Moreover, since
visual field defects, especially scotoma and quadrantanopia
may remain undetected using finger perimetry, we suggest
that automated perimetry should be performed for all patients
with occipital infarction (see also Townend et al., 2007).
In our view, lesion-symptom mapping in larger samples of
patients or in specific subgroups will continue to expand our
understanding of clinico-anatomical relationships in the
occipital lobes and beyond. While the current study reported
the relation of a broad spectrum of neuropsychological deficits
to lesions of cortical areas as well as white matter structures
in a descriptive manner, further insights may be gained by
more detailed analyses of the exact contribution of cortical
versus white matter lesions for a particular deficit. For
example, regression analyses may help in discerning whether
memory deficits after occipital infarction are more likely to

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
10 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3

Fig. 3 e Topography of visual field defects as revealed by automated perimetry. Results of overlap analysis for patients with
no visual field defect (first line), hemianopia (second line), quadrantanopia (third line) and scotoma (fourth line). Note that
left-hemispheric lesions are flipped to the right side.

develop after lesions to the hippocampus itself or to nearby
tracts such as the ILF. Furthermore, 3D volumes of interest
will be needed for each lesion to be able to use this technique
in a statistically meaningful way.
At present, it remains an open question whether or not
specific visual disorders concerning color, motion or stereo
perception, as reported by patients, are indeed rare (see also
Cals et al., 2002; Kumral et al., 2004) or if they simply cannot be
appropriately diagnosed with standard screening tests. Diag-
nosis, differentiation and lesion-symptom mapping of specific
visual deficits such as color, motion or stereo perception, as
well as higher visual cognitive disorders, may need more
specialized testing (e.g., Kraft et al., 2010) by highly skilled
neuropsychologists or neurologists.
4.2. Study limitations
In the current study, the interval between infarction and time
of testing varies between patients. The majority of patients
were tested in the subacute phase at least 24 h after stroke.
Future follow-up studies should address which symptoms can
be consistently observed in distinct time windows after
occipital infarction.
VLSM was performed only for patients without severe
cortical atrophy, multiple cerebral or subcortical lesions or
severe white matter lesions (N ¼ 61). Given these selection
criteria the mean age of the VLSM group was 56.4 years, which
is both below the mean age of the total group and below the
common age for stroke in general.

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3 11

Table 7 e Neuropsychological impairments.

All patients All delineated lesions Left-hemispheric lesions Right-hemispheric lesions

N 101 48 23 22
Screening tests
Cancellation impaired 5 05.0% 0 0% 0 0% 0 0%
Line bisection impaired 12 11.9% 2 04.2% 0 0% 1 04.5%
Clock drawing impaired 21 20.8% 3 06.3% 2 08.7% 1 04.5%
Clock drawing (neglect-like) 1 01.0% 0 0% 0 0% 0 0%
FPT
Intact 69 68.3% 38 79.2% 19 82.6% 17 77.3%
Impaired þ1 SD 17 16.8% 5 10.4% 1 04.3% 4 18.2%
Impaired þ2 SD 7 06.9% 2 04.2% 1 04.3% 0 0%
Missing 8 07.9% 3 06.3% 2 08.7% 1 04.5%
ROCF copy (mean percentile) 75.8  31.2 83.3  26.9 87.5  23.5 79.6  29.2
.1e100 .1e100 7.0e100 .1e100
PR < 2 2 02.0% 1 02.1% 0 0% 1 04.5%
PR < 16 4 04.0% 1 02.1% 1 04.3% 0 0%
PR < 84 34 33.7% 13 27.1% 4 17.4% 8 36.4%
PR < 98 24 23.8% 11 22.9% 8 34.8% 3 13.6%
PR > 98 36 35.6% 21 43.8% 10 43.5% 9 40.9%
Missing 1 01.0% 1 02.1% 0 0% 1 04.5%
Covert attention TAP
Slowed generally 36 35.6% 19 39.6% 11 47.8% 6 27.3%
Slowed invalid cues 27 26.7% 9 18.8% 3 13.0% 5 22.7%
Side difference 21 20.8% 5 10.4% 2 08.7% 2 09.1%
Missing 8 07.9% 5 10.4% 5 21.7% 1 04.5%
Demtect (age-matched norm values)
Intact 66 65.3% 37 77.1% 15 65.2% 20 90.9%
MCI 25 24.8% 8 16.7% 6 26.1% 1 04.5%
Dementia (suspicion) 9 08.9% 3 06.3% 2 08.7% 1 04.5%
Missing 1 01.0% 0 0% 0 0% 0 0%
Word imm. recall (max. 3) 2.53  .7 2.58  .7 2.39  .9 2.82  .4
Numbers (max. 3) 2.47  .7 2.58  .6 2.57  .7 2.64  .6
Supermarket (max. 4) 3.48  1.0 3.52  1.1 3.34  1.2 3.64  1.0
Digits backward (max. 3) 2.62  .6 2.65  .6 2.70  .6 2.59  .7
Word del. recall (max. 5) 2.34  1.9 2.67  1.8 2.17  1.9 3.27  1.6
ROCF immediate recall 35.1  35.8 38.6  35.3 34.8  34.5 39.9  37.3
(mean percentile) 0e99 0e99 .5e99 0e99
PR < 2 21 20.8% 8 16.7% 4 17.4% 4 18.2%
PR < 16 27 26.7% 11 22.9% 6 26.1% 5 22.7%
PR < 84 35 34.7% 19 39.6% 9 39.1% 8 36.4%
PR < 98 11 10.9% 6 12.5% 2 08.7% 3 13.6%
PR > 98 5 05.0% 2 04.2% 1 04.3% 1 04.5%
Missing 2 02.0% 2 04.2% 1 04.3% 1 04.5%

Neuropsychological impairments of all patients (column 1), of all patients with a delineated lesion (column 2) and of all patients with left-
hemispheric or right-hemispheric delineated lesions (column 3 and column 4, respectively).

Fig. 4 e Demtect. Results of the statistical voxelwise lesion-behavior mapping analysis for patients with mild cognitive
impairment (MCI) or dementia suspicion as compared to unimpaired patients. The Liebermeister test statistics were used.
Voxels that were damaged significantly more often in patients showing the deficit than in patients with no deficit are color-
coded red after adjustment for multiple comparisons. The range of z-values indicating significance (p < .05), as well as the
corresponding anatomical regions (BA) are given on the right hand side. Left-hemispheric lesions are flipped to the right
side.

Please cite this article in press as: Kraft A, et al., Neurological and neuropsychological characteristics of occipital, occipito-
temporal and occipito-parietal infarction, Cortex (2012), http://dx.doi.org/10.1016/j.cortex.2012.10.004
12 c o r t e x x x x ( 2 0 1 2 ) 1 e1 3
Since patients were recruited in two different study
centers, imaging was performed at different scanners with
slightly different scanning parameters for the respective
sequences. This difference in scanning parameters may have
lowered the precision for the VLSM analyses. Ideally, future
studies should use the same scanning parameters at different
study sites.
Because high resolution MRI scans were available only for
a minority of our patients, VLSM and analyses of white matter
tract damage were performed on the basis of manually
delineated 2D multilayer ROI. To improve both precision and
statistical power future studies should use unified high reso-
lution MR images for all patients.
Differences in lesion topography between left- and right-
hemispheric lesions may be explained by a selection bias.
First, while left-hemispheric temporomesial lesions
(including both temporomesial projections as well as the
hippocampus itself) have been clearly associated with clini-
cally evident memory deficits (von Cramon et al., 1988), right-
hemispheric lesions of the same location seem to remain
asymptomatic more often, leading to fewer presentation to
hospital and, therefore, less frequent inclusion to our study.
Second, left-hemispheric occipito-parietal lesions usually
caused by infarction in the MCA territory often result in
aphasia, which was an important exclusion criterion of the
present study.
Acknowledgments
This work was supported by the German Research Foundation
(BR 1691/5-1 and FA 119/17-1). We thank M. Sengutta,
I. Käthner, M. Hanke and Y. Schaar for assistance in data
acquisition. We wish to thank M. Catani and M. Thiebaut de
Schotten for useful suggestions and advice on the white
matter tract analysis. We thank two anonymous reviewers for
useful criticisms on the original version of the manuscript. We
thank J. England for corrections to the English text.
Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.cortex.2012.10.004.
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