Neurocase

The Neural Basis of Cognition

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Visual texture agnosia caused by bilateral

posterior cerebral artery stroke: a case study

Mamiko Sato, Yasutaka Kobayashi & Masahito Hitosugi

To cite this article: Mamiko Sato, Yasutaka Kobayashi & Masahito Hitosugi (2021): Visual texture
agnosia caused by bilateral posterior cerebral artery stroke: a case study, Neurocase, DOI:
10.1080/13554794.2021.1909068

To link to this article: https://doi.org/10.1080/13554794.2021.1909068

Published online: 14 Apr 2021.

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NEUROCASE
https://doi.org/10.1080/13554794.2021.1909068

Visual texture agnosia caused by bilateral posterior cerebral artery stroke: a case
study
Mamiko Satoa, Yasutaka Kobayashib and Masahito Hitosugic
a
Department of Rehabilitation Medicine, Fukui General Hospital, Fukui, Japan; bGraduate School of Health Science, Fukui Health Science University,
Fukui, Japan; cDivision of Legal Medicine, Shiga University of Medical Science, Shiga, Japan

ABSTRACT ARTICLE HISTORY

A 57-year-old man presented with a bilateral posterior cerebral artery attack and was visually impaired. Received 15 October 2020
He had a hard time identifying familiar faces and shades. He also felt that the familiar building looked Accepted 23 March 2021
different, and complained that it was not possible to tell from visual information alone whether the food KEYWORDS
was cooked or the kimono fabric was soft.We assessed the patient’s visual function using real materials Visual texture agnosia;
and material images and was diagnosed with visual texture agnosia. There are few reports of visual bilateral posterior cerebral
texture agnosia, detailed evaluation is considered important because perceiving texture is important for artery; reversible cerebral
activities of daily living. vasoconstriction syndrome;
texton; real materials;
material images

Introduction analgesics. The patient had no family history of note. His occu­
pation was the manager of a kimono store. Diffusion-weighted
For visual object recognition, not only form and color but also
imaging (DWI) of head magnetic resonance imaging performed
surface characteristics, such as texture, are equally important. It
at the time of onset indicated a high-intensity region corre­
has become clear in recent years that form, color, and texture
sponding to the bilateral posterior cerebral artery region
are often discussed separately because it is now known that
(Figure 1(a)). Moreover, magnetic resonance angiography
each neural pathway is independent of the other. The texture
(MRA) showed narrowing of the bilateral posterior cerebral
of an object is important for identifying an object and knowing
arteries, wall irregularity, and poor visualization of the distal
its state; therefore, texture analysis is important for daily func­
region (P3 segment and beyond; Figure 1(b)). On day 7 of the
tions. For example, determining whether the material of an
patient’s hospital stay, the bilateral posterior cerebral arteries
object is wood or metal, whether the ground is wet or dry,
were well visualized to the periphery using MRA (Figure 1(c)).
whether food is still fresh, and whether meat products are
Based on the above course and the patient’s history of head­
completely cooked requires the individual to distinguish
ache, cerebral infarction was thought to be caused by reversi­
between textures. Textures are understood based on multiple
ble cerebral vasoconstriction syndrome (RCVS). Consciousness
sensory modalities, such as tactile sense, visual sense, and
disturbance was abolished following conservative treatment,
auditory sense. Textures detected by each sensory modality
and the patient had no paralysis of the limbs or trunk. However,
are integrated by learning so that the textures can be inferred
due to the patient’s visual impairment, he required assistance
based on visual information only. A state in which textures can
to move about. He was transferred to our hospital for rehabili­
be recognized by information, such as hearing and touch, but
tation on hospital day 25.
cannot be recognized only by the visual information is called
On admission, the patient had a height of 188 cm,
visual texture agnosia. We report a case of bilateral posterior
a bodyweight of 76 kg, blood pressure of 114/77 mmHg, and
cerebral artery infarction that caused impairment of color and
heart rate of 66/min. There were no general physical findings.
texture perception despite preservation of form perception.
The patient was alert and did not have aphasia or apraxia. He
complained of visual impairment; the visual acuity in the
Materials and methods patient’s right and left eye were 20/500 and 20/333, respec­
tively. The visual field was maintained in the lower right quad­
A 57-year-old male patient was brought to Hospital A on
rant of both eyes. The percentage of correct answers in the
1 September 2018, due to experiencing a disturbance in con­
color vision test was low at 49%. His chief complaint was that all
sciousness at work. The patient was diagnosed with bilateral
his vision looked sepia. He could not understand the cooking
posterior cerebral artery stroke and admitted on the same day.
condition of food, the texture of the kimono, the warmth of
His past medical history included surgery for bladder cancer in
wood, and the skin color and luster of others. Thus, all the faces
1994 and untreated hyperlipidemia, hyperuricemia, and dia­
of others looked like mannequins.
betes since around 2013. Approximately 2 years earlier, the
However, except for visual disorders; cranial neuropathy,
patient began experiencing occasional severe headaches with
limb/trunk movement disorder, limb/trunk sensory disorder,
the subjective symptom of blurred vision, and he began taking

CONTACT Mamiko Sato satomoko@f-gh.jp Department of Rehabilitation, Fukui General Hospital, Egami Town, Fikui, Fukui 58-16-1, Japan
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 M. SATO ET AL.
Figure 1. Head magnetic resonance imaging and magnetic resonance angiogra­
phy (MRA) at onset and on hospital day 7 (a) Diffusion-weighted imaging (DWI)
performed at the time of onset shows a bilateral posterior cerebral artery infarc­
tion. (b) MRA performed at the time of onset showed stenosis and wall irregu­
larity in the bilateral posterior cerebral artery region and poor visualization of
blood vessels from P3. (c) MRA performed on hospital day 7 revealed that the
bilateral posterior cerebral artery stenosis and wall irregularity had disappeared,
and blood vessels were well visualized to the periphery.
ataxia, deep tendon reflex abnormality, and autonomic neuro­
pathy were not observed.
The scores for the neuropsychological tests were as follows.
The cutoff values for each test are shown in parentheses. In the
evaluations done using the Wechsler Adult Intelligence Scale-III
(Fujita et al., 2007), verbal IQ score was 102, behavioral IQ 120,
full-scale IQ 79, verbal comprehension 107, perceptual organi­
zation 91, working memory 135, processing speed 78 (85 each).
Using the Wechsler Memory Scale-Revised (Sugishita, 2007),
verbal memory 86, visual memory 86, general memory 84,
attention/concentration 87, delayed memory 86 (85 each).
Using the the Rivermead Behavioral Memory Test (Watamori
et al., 2002) standardized profile 19 (16), screening 8 (7). Using
the Clinical Assessment for Attention (Japan Society for Higher
Brain Dysfunction, 2008, the time periods required for the visual
cancellation task was 120 s (71), and for the Position Stroop Test
was 94 s (76). The achievement rate of the symbol digit mod­
alities test was 17.3% (50.9%), and the correct response rate of
the Position Stroop Test was below 96% (99.2%). The results for
the visual perception test for agnosia (Japan Society for Higher
Brain Dysfunction, 2006) were as follows: Concerning basic
visual perception, the patient claimed that the scenery looked
like a black and white painting and did not appear realistic.
Also, the patient required time to visually identify the numbers.
In object/image recognition, the patient had trouble under­
standing context picture and could classify pictures; however,
the classification process took time. Regarding face recognition,
the patient made errors in recognizing familiar faces. In per­
forming color recognition, the patient had difficulty
distinguishing between black-navy blue and orange-red hues.
No abnormalities were noted regarding symbol recognition. In
visual space recognition and operation, there was an oversight
regarding the upper side in the line cancellation and number
reading. Concerning topographical orientation, the patient did
not understand the layout of his house or the hospital and
described familiar places in the hospital as if they were seen
for the first time every single time. Visual impairment, visual
field impairment, color blindness, memory impairment, atten­
tion disorder, facial agnosia, and landmark agnosia were noted
based on neurological findings and neuropsychological test
results. Moreover, since abnormalities in texture perception
were suspected based on subjective symptoms related to visual
perception, the following additional tests were performed.
Evaluation of texture recognition
Identification of texton: The evaluation was performed by
using textons proposed by Julesz (Julesz, 1981). As an ele­
mental evaluation of the texture, the task of finding one
texton difference was performed to recognize the qualitative
difference of the texton (Figure 2(a)). Next, the possibility to
discriminate whether the size of the region formed by the
difference in the texton was the same or different was eval­
uated (Figure 2(b)). Furthermore, as a control task, whether
the difference in the size of the region due to the difference in
color could be discriminated was also evaluated (Figure 2(c)).
These evaluations were performed 20 times each in the
patient and five age-matched healthy subjects. The correct
response rate and mean reaction time were calculated. The
correct response rate was 100% by all patients in all the tasks,
but the mean time from task presentation to response was
longer than the five healthy subjects (Table 1). All reaction
times for each evaluation task were plotted and compared
with the data of cases and five healthy subjects in a graph. In
addition, 95% confidence intervals were inserted for each task
(Figure 3).
Identification of real materials
Texture recognition was evaluated based on whether or not the
material could be identified. It is known that the neural path­
ways for discriminating and identifying the real material and
the image material are different from each other. Therefore, the
real material and the image material were identified and eval­
uated. Just as Suzuki conducted an inspection to identify mate­
rials using nine real materials (Suzuki, 2015), this study also
identified real materials in the same way. Nine different types
of materials (i.e. wood, metal, glass, pottery, fur, leather, stone,
bark, and cloth) were partially presented through a 60 mm ×
20 mm hole to block information regarding the shape of the
objects. The tasks were performed five times for each material.
The mean correct response rate was 40%, which was lower than
the correct response rate of 81% among five age-matched
healthy subjects, and the decrease in the correct response
rate was remarkable, especially regarding metal, glass, fur,
leather, bark, and cloth (Table 2).
 NEUROCASE 3

Figure 2. Identification of texton. (a) The task to search for one texton. (b) The task to discriminate the size of the area by texton. (c) The task to discriminate the size of
the area based on the difference in color.

Table 1. Identification of texton.

Patient Healthy controls
a. Search for one texton Correct response rate (%) 100 100
Mean reaction time (seconds) 1.55 0.79 ± 0.16
b. Determination of area by texton Correct response rate (%) 100 100
Mean reaction time (seconds) 2.03 1.34 ± 0.20
c. Determination of areas by color Correct response rate (%) 100 98
Mean reaction time (seconds) 1.65 1.04 ± 0.19

Identification of material images
Using images (90 mm × 60 mm) of the same nine types of material,
the task of asking whether two material images of random combi­
nation are of the same or different materials (as a discrimination
task) and the task of identifying the material of the material image
(as an identification task) were evaluated. Each task was performed
20 times. The correct response rate of the patient was 75% for
discrimination and 25% for identification, which was lower than
the correct response rate of five age-matched healthy subjects
(93% and 99%, respectively). The mean time from task presenta­
tion to response was longer than five age-matched healthy

Figure 3. Reaction times for tasks using texton. (a) The task to search for one texton. (b) The task to determine area by texton. (c) The task to determine area by color.
4 M. SATO ET AL.

Table 2. Identification of real materials.

Wood Metal Glass Pottery Fur Leather Stone Bark Cloth Mean
Examples of incorrect response Paper Mirror Aluminum Paper Cloth Plastic Pottery Paper Paper
Plastic Iron Cotton Kelp Wood
Patients’ correct response rate 60% 20% 40% 80% 20% 40% 60% 0% 40% 40%
Healthy controls’ correct response rate 96% 80% 84% 84% 96% 52% 100% 56% 84% 81%

Table 3. Identification of material images.

Patient Healthy controls
a. Discrimination of materials Correct response rate (%) 75 93
Mean reaction time (seconds) 2.5 1.59 ± 0.57
b. Identification of materials Correct response rate (%) 25 99
Mean reaction time (seconds) 3.15 1.44 ± 0.59

controls (Table 3.). All the reaction times for each evaluation task
were plotted and the data was compared for cases and five healthy
subjects on a graph. In addition, 95% confidence intervals was
inserted for each (Figure 4).
Visual texture agnosia was diagnosed in the patient based
on the results of the aforementioned examinations. Following
hospital transfer, the patient’s vision gradually improved. On
hospital day 40, he could move independently within the ward.
On hospital day 60, oculomotor trainings and visual cognitive
training using a computer and screen were initiated. On
hospital day 90, the patient’s prosopagnosia and memory dis­
order had mostly disappeared, and he was discharged.
However, the patient’s visual field disorder, blue–orange dis­
crimination disorder, visual texture agnosia, and landmark
agnosia persisted. These symptoms, as well as the patient’s
discomfort because familiar buildings near his house looked
similar, prompted the decision to give him a navigation map.
The patient could subsequently go outdoors and returned to
work after 120 days.
Discussion
The present case was characterized by bilateral posterior cere­
bral artery stroke associated with RCVS, which caused visual
cognitive dysfunction, visual field and color blindness, visual
texture agnosia, prosopagnosia, and scene agnosia.
Visual information first reaches the primary visual cortex
on the medial side of the occipital lobe from the retina, and
enters via dorsal and ventral streams (Goodale & Milner,
1992). In particular, the ventral stream is a route for recog­
nizing an object based on shape, color, and texture. When
the ventral stream is impaired, the following conditions may
develop: visual agnosia, in which an object cannot be identi­
fied based on the shape (Lissauer, 1890); color blindness, in
which the color cannot be determined (Tranel, 2001); and
visual texture agnosia, in which the material cannot be iden­
tified from the texture (Suzuki, 2015). Furthermore, it has
been suggested that shape, color, and texture do not inter­
fere with each other and are processed by different neural
pathways (Cant et al., 2008); however, these pathways work
complementarily during the visual recognition of an object.
Recent studies using neuroimaging methods have shown
that the relevant active parts slightly differ depending on
which visual characteristic of the object is focused upon.
For example, it has been demonstrated that the lateral sur­
face of the occipital lobe is activated when focusing on
geometric features and the medial surface of the occipital
lobe is activated when focusing on surface features (Cant &
Goodale, 2007). Visual target recognition is analyzed using
shape, color, and texture. The responsible lesions are related
to the lateral occipital region for shapes, the lingual gyrus to
collateral fissure region for color, and the posterior region of
the collateral fissure for texture (Cavina-Pratesi et al., 2010a).

Figure 4. Reaction time for evaluation tasks. (a) The task to discriminate material images. (b) The task to identify material images.

Poor visual texture recognition has been clinically reported
in patients with lesions of the occipitotemporal cortex caused
by cerebral infarction, traumatic brain injury, encephalitis, or
other pathological conditions (Cavina-Pratesi et al., 2010a;
Suzuki, 2015; Suzuki et al., 2000; Suzuki & Uno, 2012; Vaina,
1990). Texture agnosia has not received much clinical attention
so far. However, reporting cases of texture agnosia will be
important now that the neural basis of texture has begun to
be elucidated. Furthermore, studies in recent years on visual
agnosia of dementia with visual cognitive impairment, such as
Lewy body dementias and Alzheimer’s disease, have been
reported (Oishi et al., 2018, 2020).
The present case had a widespread lesion in the bilateral
occipital and temporal lobes including the bilateral collateral
fissure, fusiform gyrus, lingual gyrus, and the parahippocampal
gyrus. Similar to Cavina-Pratesi’s case and Suzuki’s case A,
shape perception was retained and color and texture percep­
tion were impaired (Cavina-Pratesi et al., 2010b; Suzuki, 2015).
However, Vaina’s case report showed that only the recognition
of shape and texture were impaired (Vaina, 1990). Also, in
Suzuki’s case B, only the recognition of texture was impaired
(Suzuki, 2015). Thus, it is important to separately evaluate
shape, color, and texture to further elucidate neural pathways
based on visual characteristics. Past reports have indicated
a strong correlation with the left medial temporal lobe cen­
tered on the collateral fissure and suggest that symptoms may
be manifested by the additional presence of a lesion in the right
occipital lobe or lateral temporal lobe. Previous reports have
pointed out that the left collateral groove may play a more
important role. However, previous functional MRI studies have
pointed out the involvement of bilateral collateral grooves in
texture recognition (Cant & Goodale, 2011) . Furthermore,
Suzuki reported a case in which the real texture cognition was
not impaired but only the image texture cognitive impairment
was exhibited and inferred that the addition of the lesion in the
right occipital lobe to the lesion in the left medial occipital lobe
would make the symptoms more apparent. When recognizing
an image object, that is, a two-dimensional object, the texture
recognition of the two-dimensional object is more advanced
because other clues of the three-dimensional object, such as
depth cannot be used. Moreover, the function of reconstruct­
ing the two-dimensional object to the third dimension is also
required. Thus, if a problem with visual perception even if no
complaint about the texture of the real object exists, texture
scrutiny is required to pick up potential texture agnosia, tex­
tures, images, and all of the real thing. In cases with problems
with visual cognition, it is important to evaluate the texture
reliably and accumulate cases showing similar findings. Thus,
evaluation and accumulation/collection of data regarding such
cases is important.
Research in the field of texture brain informatics is proceed­
ing. Although detailed neural pathways related to visual cogni­
tion have been clarified by studies using functional
neuroimaging, case reports of visual texture agnosia are rare.
It is likely that when the symptoms are mild, they are difficult to
notice because they do not interfere with the activities of daily
living. Conversely, in severe cases, assessment is difficult due to
the complications of visual and sensory impairment. Standard
NEUROCASE 5
visual perception assessments do not include items related to
texture perception, and visual texture agnosia is likely to be
overlooked. In this case, always being aware of the texture of
the kimono at work is important because the patient was highly
sensitive to the texture even before the onset of the stroke.
A detailed introspection-based appeal of his eyesight during
rehabilitation led to the diagnosis. The texture is an important
source of information in everyday life, and visual texture agno­
sia may interfere with social life, but it is often difficult to notice
the symptoms. Therefore, evaluation for texture agnosia should
be performed in cases with visual perception impairment.
Connecting it with rehabilitation, such as making patients
aware of using other sensory modalities is necessary if abnorm­
alities are found in the evaluation.
Disclosure of interest
No potential competing interest was reported by the authors.
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