Original Paper
Eur Neurol 2008;60:43–46
DOI: 10.1159/000127979
Transient Directional Disorientation as a
Manifestation of Cerebral Ischemia
Tadashi Ino Hideo Usami Kazuki Tokumoto Toru Kimura Kyoko Ozawa
Shigenobu Nakamura
Department of Neurology, Rakuwakai-Otowa Hospital, Kyoto, Japan
Key Words
Directional disorientation ⴢ Functional magnetic resonance
imaging ⴢ Cerebral ischemia ⴢ Parieto-occipital sulcus
Abstract
The authors describe 2 patients who presented with tran-
sient directional disorientation (TDD) as a manifestation of
cerebral ischemia. The patients suddenly lost sense of direc-
tion in a familiar environment despite preserved ability to
recognize landmarks, and recovered within a short time.
Brain MRI revealed an ischemic lesion in the right medial oc-
cipital lobe and the corpus callosum in case 1 and in the right
parieto-occipital sulcus (POS) in case 2. After ictus, fMRI
study of a navigation task was performed, which demon-
strated the activation of the POS unilaterally in case 1 and
bilaterally in case 2. We propose that TDD of our patients is
related to temporary dysfunction of bilateral POS.
Copyright © 2008 S. Karger AG, Basel
Introduction
Directional or heading disorientation is defined as im-
paired sense of direction despite preserved recognition of
buildings and landscape, resulting in an inability to nav-
igate in a familiar environment [1, 2]. Most of the cases
with this symptom have been reported following retro-
© 2008 S. Karger AG, Basel
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Received: August 29, 2007
Accepted: November 14, 2007
Published online: April 25, 2008
splenial lesion [2–6]. Functional neuroimaging studies
involving navigation in large-scale spaces have also
shown that the retrosplenial area is activated during the
task [7–9]. We found that the peak of activation in the
retrosplenial area during a mental navigation task is con-
stantly located in the parieto-occipital sulcus (POS) in
the individual subject analysis [8]. We also reported an
fMRI study of a patient who presented with directional
disorientation following retrosplenial hemorrhage and
proposed that the ‘sense of direction’ in a large-scale lo-
comotor environment is subserved by the visual area
along the POS, and that bilateral deterioration of this
function causes directional disorientation [2]. Here we
report 2 cases who suffered from transient directional
disorientation (TDD). Anatomical and functional neuro-
imaging findings of these cases further support our hy-
pothesis.
Case Report
Case 1
A 72-year-old right-handed man with diabetes mellitus sud-
denly became unable to understand the direction to a familiar
store while walking from his home, on the night of August 15th,
2001. He was not aware of visual field defect and could recognize
familiar buildings and landscape normally, but he could not de-
termine which direction to return home. He was finally able to
return home after receiving assistance from a passerby. The next
Tadashi Ino
Department of Neurology, Rakuwakai-Otowa Hospital
Otowachinjicho 2, Yamashina-ku
Kyoto 607-8062 (Japan)
Tel. +81 75 593 4111, Fax +81 75 581 6935, E-Mail rakuwadr042@rakuwadr.com
Fig. 1. Diffusion-weighted images (upper
part, TR/TE = 4,000/100 ms, b value =
1,000) and FLAIR images (lower part, TR/
TE = 8,000/110 ms) showing ischemic le-
sions in the right medial occipital lobe and
splenial portion of the corpus callosum in
case 1 and in the right POS in case 2.
FLAIR MRI in case 2 was taken 7 days af-
ter onset.
Fig. 2. Activation of the APO during mental navigation task
(k 1 30, p ! 0.05, corrected for multiple comparisons using fam-
ilywise error correction), superimposed on the subject’s anatomi-
cal image normalized to the MNI standard space.
morning, his directional disorientation had totally disappeared.
Seven days after ictus, he came to our hospital at the outpatient
clinic for periodic treatment of diabetes mellitus and was intro-
duced to our department by his physician. No abnormality was
found by routine neurological and neuropsychological examina-
tion. His visual field was normal by confrontation test. Diffusion-
weighted and FLAIR MRI revealed ischemic lesions in the right
medial occipital lobe and the splenial portion of the corpus cal-
losum (fig. 1).
Case 2
A 74-year-old right-handed man with atrial fibrillation and
hypertension noticed left visual field defect in his home, at noon
44 Eur Neurol 2008;60:43–46
of April 20th, 2006. He decided to visit our hospital but he could
not find the front door of his own home. He called a taxi, managed
to find the entrance, and came to our hospital. When he arrived
at our hospital, he first went to the lavatory, but when he stepped
out from the lavatory he could not find the way to the emergency
room, even though he had visited many times. He was then
brought by the staff to the emergency room. Neurologically, he
was normal except for a left lower quadrantanopsia. Diffusion-
weighted MRI showed an ischemic lesion involving POS (fig. 1).
About 1 h after onset, he completely recovered his sense of direc-
tion and his left lower quadrantanopsia disappeared.
Functional MRI
fMRI study during mental navigation was carried out 29 days
after onset in case 1 and 7 days after onset in case 2. The experi-
mental procedure was approved by the Medical Ethics Commit-
tee, and all patients gave written informed consent. Echo-planar
images (TR = 5 s, TE = 50 ms, flip angle = 90°, FOV = 200 mm,
matrix = 64 ! 64, slice thickness = 6 mm, gap = 1.2 mm) and a
three-dimensional T1-weighted image for anatomical normaliza-
tion (TR = 11.6 ms, TE = 4.9 ms, flip angle = 8°, FOV = 220 ! 220
mm, matrix = 256 ! 256, slice thickness = 2 mm) were obtained
using a 1.5-tesla Siemens Vision Plus. The design of the task was
identical to our previous reports [2, 8]; consisting of seven 30-sec-
ond mental navigation epochs, in which the patients were given
two names of familiar places in Kyoto City and were required to
mentally navigate between them, and eight 30-second control ep-
ochs, in which the patients were given two successive numbers
and were instructed to count mentally from the last number. Im-
mediately after the fMRI scan, the patients were required to de-
scribe the route on the paper between the same places provided in
the scanner. Both subjects had lived in Kyoto City for more than
30 years, and their correctness of the responses during fMRI was
confirmed by this assessment.
Ino/Usami/Tokumoto/Kimura/Ozawa/
Nakamura
 The data were analyzed with Statistical Parametric Mapping
(SPM2). After realignment, normalization, and smoothing with a
9-mm full-width, half-maximum Gaussian filter, statistical para-
metric maps corresponding to a comparison between the task
condition and control baseline were generated. Activated areas
were regarded as significant if more than 30 voxels exceeded p !
0.05, corrected for multiple comparisons using familywise error
correction. The anterior bank of the POS (APO) was activated
bilaterally in case 2, and only the left side of it was activated in
case 1 (fig. 2). In case 1, activation of the right POS was not found
even when the level of significance was set more liberal to p ! 0.05,
uncorrected for multiple comparisons.
Discussion
Our patients presented with TDD as a symptom of ce-
rebral ischemia. Recently, cases of TDD of unknown eti-
ology have been reported [10, 11], and some of them were
considered to be an epileptic manifestation [10], but vas-
cular origin was not suggested for these cases. Our pa-
tients had vascular risk factors such as diabetes (case 1),
hypertension (case 2), and atrial fibrillation (case 2). Sud-
den onset and disappearance within a short time of their
symptoms suggest artery-to-artery or cardiac embolism
and prompt recanalization. MRI revealed a fresh infarc-
tion in both patients. In particular, the lesion was located
mainly in the right POS in case 2. In fMRI during mental
navigation, activation of APO was found in both cases.
In monkeys, newly defined visual areas (V6 and V6A)
have been identified in the APO by recent anatomical and
physiological studies [12, 13]. V6A includes neurons
whose activities were modulated during reaching toward
a nonvisual memorized target [14]. Neurons which have
a receptive field anchored to head-centered coordinates
irrespective of eye movement were also identified in V6A
[15]. These characteristics of neuronal activities will be
effective for the perception of the directional relation be-
tween the individual’s current position and the perceived
object. Therefore, such neurons appear to be advanta-
geous to egocentric spatial processing during navigation
although they have been considered to be implicated in
somatomotor processing in monkeys. We have observed
that the APO is activated strongly during mental naviga-
tion task consistently across subjects [8]. This anatomical
localization common across individuals appears to sug-
gest that the function of APO during navigation is related
to relatively lower order cognitive function such as some
kind of visual perception, rather than higher order cogni-
tive function such as particular memory for spatial layout
of familiar environments since cortical representation for
the latter process will show great interindividual variabil-
Directional Disorientation
ity. It is generally accepted that activation of the extrastri-
ate visual cortex is observed during visual imagery, al-
though it is unsettled whether the activation of the pri-
mary visual cortex can be observed or not [16, 17]. There
are scant data of the visual-processing-related functions
of the POS in humans, but recent study indicated that the
inferior portion of the POS is involved in the generation
of the first harmonic response of the steady-state visual-
evoked response caused by visual flicker stimuli [18]. It is
also reported that this region is related to the feeling of
vection, particularly rollvection [19].
In case 1, the activation of the right APO was not found
even when the level of significance was set at p ! 0.05,
uncorrected for multiple comparisons. On the other
hand, our previous study showed that the APO was acti-
vated bilaterally in 14 out of 16 subjects when the level of
significance was set at p ! 0.05, corrected for multiple
comparisons [8] and in all subject at p ! 0.001, uncor-
rected for multiple comparisons (unpublished data).
Therefore it is reasonable to assume that the lack of acti-
vation of the right APO in case 1 was caused by the stroke,
albeit this region was structurally normal as shown by
MRI. Although PET or SPECT was not obtained, fMRI
will be more sensitive at detecting disturbance of a spe-
cific function. This impairment may be caused by the dis-
connection from surrounding areas due to the lesion of
the corpus callosum. Because he had already recovered at
the time of fMRI scanning and could perform the navi-
gation task perfectly, it is possible that in the retrosple-
nial area normal function of only the left APO is adequate
for navigation. Normal function of only the right APO
will also be adequate for navigation, since it has been sug-
gested that for navigation the right retrosplenial area is
dominant over [4, 6] or equivalent [2] to the left retrosple-
nial area. Therefore, it is reasonable to assume that bilat-
eral APO were functionally disturbed when directional
disorientation developed, as suggested in our recent re-
port [2]. The function of the APO on the side opposite to
the ischemic lesion would have been disturbed tempo-
rally by mechanisms such as diaschisis.
Although TDD of vascular origin has not been de-
scribed in the literature, it may not be a rare symptom and
has been ignored because its pathophysiological signifi-
cance is unclear.
Eur Neurol 2008;60:43–46 45
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