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Anomia: Case studies with lesion localization

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Anomia: Case studies with lesion localization

Anne L. Foundas , Stephanie K. Daniels & Jennifer J. Vasterling

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 Nrurocase ( 1 998) Vol. 4, pp. 3543 0 Oxjord University Press 1998

Anomia: Case Studies with Lesion Localization

Anne L. Foundas13, Stephanie K. Daniels’*3and Jennifer J. Va~terling‘’~

‘Department of Psychiatry and Neurology, Tulane University School of Medicine, *Neurology Service,
%peech Pathology Service and 4Psychology Service, Veterans Affairs Medical Center, New Orleans, LA, USA

Abstract

In a recent case study of anomic aphasia following a unilateral left hemispheric stroke limited to
Brodmann’s area 37, it was proposed that this area may be important for object naming by allowing the
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semantic system access to stored lexical information. Based on this finding and theories postulating a
modular system for word retrieval, we proposed that a patient with a lesion to area 37 and another patient
with a lesion to a speech production region located serially downstream from area 37 would both be
anomic, and in neither case could the anomia be attributed to a significant semantic impairment. Using a
case study design to investigate the level of naming disturbance in these two patients with unilateral left
hemispheric strokes, we have demonstrated that Patient I,who had a lesion to area 37, and Patient 2,with a
lesion to inferior-lateral portions of Brodmann’s area 6, were anomic with semantic knowledge of words
relatively preserved.

Introduction
The mechanisms that mediate naming are complex, and
many theories exist regarding the process of word retrieval
(for review, Kay and Ellis, 1987; Kremin, 1988; Rothi et al.,
1991). A cognitive neuropsychological approach is one
method that can be used to elucidate the mechanisms of
naming failures in patients who present with anomia.
Although controversy exists regarding some aspects of this
approach, Rothi et al. (1991) have suggested that there are
two assumptions that are central to the accurate processing
and production of words: (i) there is an internal infor-
mation processing system that mediates naming, and (ii)
the system is modular. Therefore, the accurate processing
and production of words comprise discrete subunits or
modules that are organized into four cognitive processes.
These four processes are: lexical input, stimulus recog-
nition, semantic knowledge and lexical retrieval. The integ-
rity of each of these cognitive processes and of their
component subunits is integral for accurate naming to
occur. Furthermore, each of these processes is thought
to be semi-independent and to have different inherent
properties. Whereas lexical input and lexical output are
purported to be modality-specific, the semantic system is
purported to be modality-independent. Consequently,
errors of lexical input and output can occur at the level of
a specific input or output modality, while deficits in the
semantic system are modality-independent. According to
Rothi et al. (1991), at the level of lexical input there are
three input modalities: (i) the object form via visual, tactile
or auditory input, (ii) the word sound, and (iii) the written
word with lexical output occurring via speaking or writing
the target word. Given these assumptions and observa-
tions, the locus of a naming failure can be identified within
a modular information processing system. A model of
naming, based on Rothi et aL’s (1991) approach, was
applied by Raymer et al. (1997) in their case study of a
patient who developed acute anomia following a left
hemispheric ischemic stroke. Raymer et al. (1997) devel-
oped the Florida Semantic Battery to assess their patient’s
naming failures based on Rothi’s cognitive neuropsycho-
logical naming model (Rothi et al., 1991). The battery
assesses the integrity of each component of this modular
language processing system model. Their assessment of
H.H. demonstrated a multimodal naming deficit with rela-
tively intact semantics across input modalities, suggesting
that H.H. had a semantic egress disorder with intact
lexical-semantic processing. That is, their patient was
impaired beyond the level of semantic processing, but prior
to the level of mode-specific verbal and graphemic output
lexicons. H.H.’s difficulty with word retrieval was associ-
ated with a discrete lesion to Brodmann’s area 37 in the left
cerebral hemisphere. Based on these observations, Raymer
et al. (1997) suggested that area 37 may be a portion of
supramodal association cortex that subserves lexical-
semantic associations, and is crucial for accurate naming.

Correspondencefo: Anne L. Foundas, MD. Department of Psychiatry and Neurology. Tulane University School of Medicine, 1430 Tulane Avenue SL-23.
New Orleans. LA 701 12-2632, USA. Fax: (504) 5874270 or (504) 584-2671; e-mail: foundas@mailhost.tcs.tulane.edu
 36 A. L. Foundas, S. K. Daniels and J. 3. Vasterling
We had the opportunity to examine two patients with
acute strokes who presented with relatively pure anomic
aphasia and lesions restricted predominantly to a single
anatomic site. One patient had a lesion to Brodmann’s area
37, and the other patient had a lesion to the inferior-lateral
portion of Brodmann’s area 6. Given Rothi et d ’ s (1991)
model of naming, Raymer et aL’s (1997) localization of
pure anomia, and assuming a distributed neural network
for naming that involves portions of parieto-occipito-
temporal and inferior frontal cortex, we predicted that a
patient with a lesion to area 37 and another patient with a
lesion to neocortical regions in the network located serially
downstream (Le. inferior frontal cortex) would both be
anomic, and in neither case could the anomia be attributed
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to a significant semantic impairment.
Case histories and initial screening
Patient I
This 60-year-old right-handed man with a twelfth-grade
education, had the abrupt onset of word-finding difficulty
on 10 January 1994. On initial examination he was alert
and oriented with fluent spontaneous speech output
except for word-finding pauses. Spontaneous speech was
grammatical with normal phrase length, articulation,
and prosody. Confrontation naming was impaired, while
comprehension and repetition were relatively intact. He
was unable to read except for words with high iconic
recognizability and was unable to write except for some
letters of the alphabet. There was evidence of mild limb
apraxia. Immediate, short-term and remote memory were
intact. There was no evidence of hemispatial neglect,
visuoconstructive deficits, nor extinction to double
simultaneous stimulation. Cranial nerve examination
was intact except for an incongruous right superior
quadrantanopia. Sensory, motor, cerebellar, gait and
station were intact. Deep tendon reflexes were symmetric
with bilateral flexor plantar responses.
Westem Aphasia Battery (WAB) (Kertesz, 1982) con-
firmed an anomic aphasia (Aphasia Quotient = 93.4). His
spontaneous speech fluency score was 19/20. Subscores on
the Naming subtests of the WAB were: Object Naming
54/60; Word Fluency (category animals) 9/20; Sentence
Completion 10/10 and Responsive Speech 10110. The sum
of the Naming subscores divided by 10 gave a naming score
of 8.3 (maximum lo), which fell within a score of 0-9
considered to meet the criteria of anomic aphasia (Kertesz,
1979). The Object Naming subtest constitutes 60% of the
naming score. Cards of pictured objects, forms, letters,
numbers and colors are presented and the patient is asked
to point to each item. Real items are also presented
including objects, furniture, body parts, fingers, and left-
right body parts. This naming task differs from the BNT
(Kaplan et af.,1984) as the patient is required to point to
the named object and is not required to generate the target
word spontaneously. Therefore, in our patients with more
impairment at the level of lexical output, the BNT is a more
accurate measure of the naming deficits. Reading and
Writing subtests of the WAB were not completed due to
failure. On the Boston Naming Test (BNT) (Kaplan et al.,
1983) 24/60 words were produced correctly without cueing,
and 41/60 were produced correctly with phonemic cueing.
He would spontaneously give semantic cues for pictures
that he had difficulty naming on the BNT. For example, for
the target word ‘camel’, he responded ‘animal’. For the
target word ‘bench’, he responded ‘seat’ then ‘yard seat’.
For the target ‘pelican’, he responded: ‘a bird, plenty in
Louisiana’. For ‘trellis’, he responded: ‘keep the flowers
up’. Scores with stimulus cueing are not reported as both
patients spontaneously provided stimulus information
when the name was not spontaneously elicited.
Computerized topographic (CT) scan showed an area of
decreased attenuation in the left posterior inferior medial
occipito-temporal lobe extending onto the lateral ventral
surface. Using Damasio and Damasio’s technique (1989),
the lesion involved area 37 and portions of areas 18 and 19,
but spared areas 39, 40 and 22 (Fig. la,b,c).
Patient 2
This 47-year-old right-handed man, with a college
education, had an abrupt onset of a speech disturbance on
28 December 1993. On initial examination, he was alert and
oriented with fluent spontaneous speech output that was
grammatical, with normal phrase length, articulation and
prosody except when blocked by word-finding pauses
and circumlocutions. Comprehension and repetition were
relatively intact. He was impaired on confrontation
naming, but could demonstrate the use of objects. Reading
and writing were impaired similarly to spontaneous speech
output. There was no evidence of left-right confusion,
finger agnosia, or acalculia. He had mild limb apraxia.
Immediate, short-term and remote memory were intact.
There was no evidence of hemispatial neglect, visuo-
constructive deficits or extinction to double simultaneous
stimulation. Cranial nerves, sensory, motor, cerebellar,
gait and station were intact. Deep tendon reflexes were
symmetrical and plantar responses were flexor.
Formal language testing demonstrated a WAB Aphasia
Quotient (Kertesz, 1982) of 93.2, and was consistent with
an anomic aphasia. His spontaneous speech fluency score
was 18/20, which was mildly more dysfluent than Patient 1.
Subscores on the Naming subtests of the WAB were:
Object Naming 58/60; Word Fluency (category animals)
15/20; Sentence Completion 10110; Responsive Speech
10/10, for a total score (after dividing by 10) of 9.3. This
score falls just outside the range of 0-9 considered to meet
the criteria of anomic aphasia (Kertesz, 1979). The Reading
subtest revealed 92/100, Writing 81/100. On the BNT
(Kaplan rt af., 1984), he correctly named 38/60 pictures of
objects without cues, and 42/60 with phonemic cueing. He
 Anomia: case studies with lesion localization 37
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Fig. 1. CT Scan showing Patient 1’s lesion (a), with axial (b) and lateral (c) views of the full extent of the lesion.

would spontaneously give semantic cues for pictures on the .

responded: ‘stelts . . . sticks . . I forgot’. For ‘knocker’,he
BNT that were often preceded by a phonemic or semantic responded: ‘handle, no lock . . . thing you knock with’. For
paraphrasic error. For example, for the picture ‘stilts’, he ‘tongs’, he said: ’tongue . . . uh, uh . . . ice handle’.
 38 A. L. Foundas, S. K. Daniels and J. J. Vasterling
CT scan demonstrated an area of decreased attenuation
in the left hemisphere involving portions of the frontal
operculum limited to premotor cortex. Using Damasio and
Damasio’s technique (1989) the lesion localized to inferior-
lateral portions of area 6 adjacent to but sparing area 4
(Fig. 2a,b,c).
Experimental testing
In order to demonstrate that the deficits in naming in these
patients were beyond semantic word processing, we admin-
istered portions of the Florida Semantic Battery (Raymer
et a/., 1997). In addition to the standard language tasks
described in the case studies above, we administered a
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tactile and auditory discrimination task to demonstrate
that subjects were anomic across the three input modalities:
visual, tactile and auditory. All tasks were administered to
the two patients and three age-, gender- and education-
matched controls. Each item was scored as correct or
incorrect for a total number of correct responses for each
subtest administered. Scores are summarized in Table 1,
where performance is summarized as percentage correct.
Semantic language tasks
The subtests of the Florida Semantic Battery (Raymer
er al., 1997) that were administered included the: (i)
Semantic Comprehension task (Word-Picture match) with
two subtests including Auditory presentation and/or Word
Form presentation and (ii) Semantic Associate task with
two subtests including a Visual-Visual and a Verbal-
Verbal condition. These Semantic Language tasks assess
lexical-semantic processing, and investigate the subject’s
ability to comprehend the words presented as pictures of
objects or in the word form. For these tasks to be per-
formed accurately, the subject must be able to recognize
the objectlword at the input level, and have semantic
knowledge of the object/word.
In the Semantic Comprehension task, the subject was
requestedto point to the target object from an array of four
semantically related objects. The object was requested in
two conditions: Auditory input and Word form input. In
each condition, 60 stimuli were administered to each sub-
ject. The stimuli consisted of an array of four semantically
related line drawings, similar to the stimuli developed by
Raymer et al. (1997). Equal numbers of high-, middle- and
low-frequency words were used in each semantic task and
in each input condition, and the pictures were selected from
12 different semantic categories. In the Auditory input
condition the target object (n = 60) was requested via
auditory input with the following instructions: ‘Point to the
picture that I name.’ In the Word input condition, the same
objects were then requested via reading the word with the
following instructions: ‘Read the word and point to the
picture for the word’. For the auditory condition, an
example would be: the target picture ‘airplane’ with the
distracter pictures: bus, canoe, boat. For the word form
condition, an example would be: the target word ‘ankle’
with the distracter pictures: wrist, hair, feet.
In the Semantic Associate task, the subject was requested
to select from an array the stimulus that was most closely
related to the target stimulus. This task consisted of 60
stimuli presented in two conditions: Visual-Visual and
Verbal-Verbal. For the Visual-Visual condition the stimuli
consisted of a horizontal array of three pictures of objects
with a single target object below this array. The subject was
instructed to ‘Point to which of the three pictures is closely
related to the target picture.’ The objects were either
semantically related or perceptually related to the target
object. For example, for the target object ‘carrot’, the three
objects included two objects in the same semantic category
(e.g. rabbit and squirrel), and one object that was
perceptually related to the target (e.g. flashlight). For the
Verbal-Verbal condition the stimuli (n = 60) consisted of
an array of written words instead of pictures of objects. As
in the Visual-Visual condition, three words were presented
for each target word. Two words were semantically related
to the target word, and the other was graphemically
related. The examiner would say the target word and
instruct the subject as follows: ‘Which of the three
following words is closely related to the target word?’.
Lexical input tasks
Lexical input was evaluated in three sensory modalities
comprising visual, tactile and auditory. The subjects had to
identify: (i) visually presented pictures of objects (naming
pictures), (ii) tactually presented objects (tactile naming),
and (iii) auditorily presented objects (naming to sound).
These tasks assessed the integrity of these three input
modalities, but performance is also dependent on accurate
processing within the semantic system and was evaluated
by speech output. These tasks were also administered to the
matched controls. The visually presented pictures consisted
of the 60 line drawings of objects from the BNT (Kaplan
et aZ., 1984). The subject was instructed to name the objects
presented. In the tactile naming task, 16 objects were
tactually presented to the subject who was instructed to
identify the object presented. In the naming-to-sound task,
12 environmental sounds (e.g. train whistle) were presented
to the subject, who was instructed to identify the sound.
Results
The performance scores of the patients and the matched
controls are presented in Table 1 as percentage correct
for each subtest. For Patient 1, the performance scores
demonstrate intact semantic language knowledge with
comprehension of wordlpicture match of four semantically
related pictures (59/60) intact. Patient 1 was somewhat
impaired on the semantic associative (visual/visual) task
(46/60 correct). Patient 1 was impaired on the lexical input
 Anomia: case studies with lesion localization 39
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Fig. 2. CT scan showing Patient 2’s lesion (a). with axial (b) and lateral (c) views of the full extent of the lesion.
 40 A. L. Foundas, S . K. Daniels and J. J. Vasterling
Table 1. Results of the performance of Patient 1, Patient 2 and controls on
the experimental tasks (percentages)
Patient 1 Patient 2
Semantics
Comprehension:
Auditory 98 100
Reading - 98
Associate
Visual-Visual 77 92
Verbal-Verbal - 98
Input Lexicon
Naming Pictures 40 63
Tactile Naming 62 69
Naming to Sound 58 42
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tasks as follows: Naming Pictures 24/60 (40% correct),
Tactile Naming 10/16 (62% correct), Auditory Naming 7/12
(58% correct). Clinically, Patient 1 had an anomic aphasia
and alexia with agraphia, and therefore was unable to
complete the reading components of the Semantic tasks.
Furthermore, his performance on the visual-visual com-
ponent of the Semantic Associate task was more impaired
than that of Patient 2, and was more impaired than his
performance on the Semantic Auditory Comprehension
task. Although specific tasks were not administered to
characterize further the nature of his alexia with agraphia
or visuospatial disturbances, it is possible that these
additional deficits may have affected his performance on
the Semantic Associate task. His lesion largely involved
area 37, but extended to portions of visual association
cortex. Thus, his somewhat degraded performance on the
Visual-Visual Semantic Associate task may be due in part
to a mild visuospatial disturbance. Further testing would
be required to confirm this hypothesis.
Patient 2 performed well on the Semantic Word
Comprehension with auditory input (60/60), and visual/
reading input (59160). Semantic Associative tasks including
visual-visual (55/60) and verbal-verbal (59/60) were also
performed well, although performance was more degraded
on the visual-visual condition. Patient 2 was impaired on
the Lexical input tasks as follows: Naming Pictures 38/60
(63% correct), Tactile Naming 11/16 (69% correct), and
Auditory Naming 5/12 (42% correct). Three healthy con-
trol subjects matched for age, gender and educational level
were assessed with the Semantic Battery subtests and the
Lexical output tasks that were administered to the patients.
The mean performance of the controls is summarized
in Table 1. The control subjects’ performances on the
Semantic language tasks did not differ from the perform-
ance of Patient 2, nor from Patient 1 on the Semantic
Comprehension task. The control subjects performed
better than Patients 1 and 2 on the Lexical input tasks.
Patient 1 was poorer at naming pictures than naming from
either of the other two modalities of input, which is a
different pattern from both Patient 2 and the control
subjects. However, both subjects were anomic across the
three input modalities, which tends to preclude a deficit at
Controls the level of sensory (visual, tactile, auditory) input.
(n = 3) Although it is difficult to quantify explicitly fluency in
spontaneous speech output, clinicat assessment in Patients
1 and 2 demonstrated that both patients had fluent and
grammatical speech with normal phrase length, and well
98
98 articulated, prosodic speech output. However, Patient 2’s
spontaneous speech was interrupted by more word-finding
97 pauses and circumlocutions than that of Patient 1, and
98
therefore may differ behaviorally from Patient 2 at the
91 level of speech production-fluency of output. In addition,
100 Patient 1 and Patient 2 differ in performance on a cued
91 word retrieval task. Whereas Patient 1, with a lesion to area
37, produced six animals in a minute, Patient 2, with a
lesion to area 6, produced 15 animals in a minute. Category
fluency data were gathered from the WAB (Kertesz, 1982).
Unfortunately, a letter fluency task was not administered.
Discussion
Two patients with acute ischemic strokes, who presented
with a relatively pure anomic aphasia and lesions restricted
predominantly to a single anatomical site, were evaluated.
Whereas Patient 1 had a lesion restricted to Brodmann’s
area 37, Patient 2 had a lesion restricted to inferior-lateral
portions of Brodmann’s area 6. Clinical evaluation and
language testing in these patients demonstrated that both
patients were anomic, and in neither case could the anomia
be attributed to a significant semantic impairment. In both
cases, the deficit in lexical input was.across three sensory
input modalities, which tends to preclude a problem
specific to any of these input routes. These case studies
suggest that portions of the left inferior temporal lobe
(Brodmann’s area 37) and portions of the left premotor
cortex (Brodmann’s area 6) need to be intact and need
to cooperate to support successful naming. However,
the assumption that these two regions must be intact to
support successful naming does not imply that lesions to
these two locations should have identical consequences.
Although Brodmann’s area 37 and area 6 appear to be
part of a distributed corticaI network involved in naming,
lesions to these two locations may produce different types
of naming deficits, and these regions may mediate different
aspects of word retrieval. Some performance differences did
exist between the two patients. For example, Patient 1, who
had a lesion to Brodmann’s area 37, was more fluent than
Patient 2, but was more impaired on tasks of confrontation
naming. Given that the lesion in Patient 2 was restricted to
frontal motor regions that are located closer to the pure
speech production centers, the observed relative decreased
spontaneous output relative to Patient 2 seems predictable.
In addition, phonemic cueing seemed to improve naming in
Patient I more than in Patient 2. Another difference was
demonstrated by Patient 1’s more degraded performance
on the semantic associate task, and more impaired naming

to confrontation. This finding suggests that area 37 may
be more crucial than area 6 in mediating some aspects
of semantic knowledge of words, notwithstanding that
semantic knowledge was relatively spared in both patients.
Although a double dissociation of semantic category versus
phonemic category fluency could not be determined,
Patient 2 did perform significantly better than Patient 1
on a category fluency task. This finding provides partial
support for the notion that lesions to temporal regions are
more likely to affect performance on the semantic category
task than lesions to frontal cortex, which are more likely
to affect performance on the initial letter fluency task
(Mummery ef al., 1996). Although Patients 1 and 2 differed
on some of the tasks administered, these case studies did
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not explore fully the differential contributions of these
regions to naming. However, the lesions that produced
these deficits differed in location in the two patients, and
therefore subtle differences in the nature of the naming
disturbances may be attributable in part to the different
lesion sites.
Our findings are consistent with Raymer and co-workers’
(1997) study of a patient who developed an anomic aphasia
following a lesion to Brodmann’s area 37. Raymer et 01.
( 1 997) suggested that word retrieval relies on a lexical-
semantic system that contains the meaning of words,
output lexicons which store the word forms, and phono-
logical decoding for the pronunciation of words. They
proposed that Brodmann’s area 37 may be critical for
allowing the semantic system to gain access to stored lexical
information. The anatomical location and cytoarchi-
tectonics of area 37 support this notion. Area 37 is located
on the posterior one-third of the middle and inferior
temporal gyri and extends inferiorly to the medial surface
of the inferior temporal gyrus adjacent to occipital associ-
ation cortex. Therefore, this area is strategically located
between the ventral system important for object recog-
nition, and the auditory and visual association cortex
important for lexical processing (Mishkin et a/., 1983).
Furthermore, area 37 is composed of supramodal associ-
ation cortex, and, therefore, neurons in this area are
responsive to multiple modalities of input (Mesulam, 1985).
Based on these observations, it can be hypothesized that
Brodmann’s area 37 is a portion of heteromodal associ-
ation cortex that subserves lexical-semantic associations,
and thus is crucial for accurate naming. Based on the
premise of a modular system for naming retrieval, and that
lesions downstream from area 37 would also produce a
naming disturbance, we replicated and expanded on
Raymer’s findings by demonstrating that Patient 1, who
had a lesion to Brodmann’s area 37, and Patient 2, with a
lesion in inferior-lateral portions of Brodmann’s area 6,
were anomic with semantic language functions relatively
spared. That is, Brodmann’s area 37 (Patient 1) may be
crucial for allowing the semantic system access to stored
lexical information, while lesions to speech production
regions, such as area 6 (Patient 2), located serially down-
Anomia: case studies with lesion localization 41
stream from area 37, also produce a naming disturb-
ance with relative preservation of semantic function,
but lesions to these two locations do not have identical
consequences.
Portions of the left temporo-parieto-occipital region
have been implicated in many cases of anomic aphasia
(Geschwind, 1965; Benson, 1979; Goodglass, 1993). Some
investigators have suggested that portions of the posterior
temporal cortex may be more important than inferior
parietal regions in naming (Hicaen and de Ajuriaguerra,
1964; Coughlan and Warrington, 1978; McKenna and
Warrington, 1978). In a study of 214 unilateral, left hemi-
spheric stroke patients, Hicaen and de Ajuriaguerra (1964)
found that the temporal lobe was the most common site of
involvement in patients with impaired naming. Benson
(1979) suggested that within the temporal lobe Brodmann’s
area 37 may be the critical cortical substrate for naming
disturbances, and that isolated lesions to this area may
produce an anomic aphasia. In contrast, other investigators
have suggested that word retrieval has no specific localizing
value (Kertesz et ul., 1977, 1979). Evidence from cortical
stimulation (Penfield and Roberts, 1959; Ojemann, 1983)
and functional imaging studies suggests that a distributed
neural network for word retrieval involves portions of the
left inferior parietal lobule, inferolateral temporal lobe, and
frontal regions including left premotor, dorsolateral pre-
frontal and anterior cingulate cortex (Petersen et af., 1988,
1989, 1990; Frith et ul., 1991; Wise et af., 1991; Demonet
e f d.,1992, 1994; Petersen and Fiez, 1993; Zattore et al.,
1996). Damasio et al. (1996) studied lexical retrieval in
subjects with cortical lesions and in a group of normal
right-handed adults, using a positron emission tomography
(PET) activation experiment. They demonstrated that word
retrieval for specific word categories depends on multiple
sites in the left cerebral hemisphere that are located outside
the classic language areas. The areas reported to be crucial
for lexical retrieval by Damasio et al. (1996) included
inferior temporal cortex which includes area 37. Although
we did not analyse deficits in word retrieval for. specific
concrete categories in our subjects, our findings support the
model proposed by Damasio et al. (1996). In addition,
differences in regional cerebral activity during word
retrieval have been documented on semantic category
fluency versus initial letter fluency tasks (Mummery et al.,
1996). Whereas contrasting semantic fluency with letter
fluency produced selective activation of left inferior
temporal regions, the reverse contrast of initial letter
fluency with semantic fluency produced activation of left
inferior frontal regions, including portions of area 44 and
area 6 (Mummery et al., 1996). Although these data suggest
that category fluency is more dependent on temporal
regions and letter fluency is more dependent on frontal
regions, letter fluency tasks were not performed on Patients
1 and 2 in the current case study and, therefore, it is
unclear whether a double dissociation would have been
demonstrable in these cases.
 42 A. L. Foundas, S. K. Daniels and J. J. Vasterling
The neuropathological study of focal lesions in patients
with aphasia, using neuroimaging techniques to localize
involved cortical regions, reveals structures essential for the
behavior assessed. In the current investigation, our clinico-
pathological correlation of a deficit in lexical-retrieval
suggests that Brodmann's area 37 and portions of area 6
are essential for this behavior. These regions are not
essential for the semantic aspects of language assessed, as
semantic knowledge was relatively spared in our subjects.
Limitations of the ablation paradigm include individual
variation in brain topography and function, resolution of
brain images that may obscure measurement of the full and
accurate extent of the lesion, and the notion of distributed
cognitive processing which suggests that additional cortical
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regions beyond those demonstrated by lesion localization
may play a role in lexical-retrieval (Geschwind, 1965;
Steinmetz and Seitz, 1991; Damasio et al., 1996). The case
studies reported support the contention that the regions
identified in our patients mediate some aspects of lexical-
retrieval, although surrounding heteromodal association
cortices and classic language areas also contribute to the
complex interaction of other cognitive and language-
related behaviors important in object naming. These
studies provide converging data to support conventional
notions of the distribution of word retrieval based on
the ablation paradigm, and generally support the notion of
a distributed network of cortical areas with functional
specificity.
Acknowledgements
We are grateful to Carin Fernandez for her help in
preparing the manuscript. This research was supported in
part by the Research Service of the Department of Veterans
Affairs Medical Center, New Orleans and the Department
of Psychiatry and Neurology, Tulane University School
of Medicine, NIH-National Institute of Deafness and
Communication Disorders Grant KO8 DCOO135.
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Received on 14 hlurch. 1997; resubmitted on 18 September, 1997;
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 Anomia: case studies with lesion localization 43

Anomia: case studies with lesion

localization

A. L. Foundas, S. K. Daniels and

J. J. Vasterling
Abstract
In a recent case study of anomic aphasia following a unilateral left
hemispheric stroke limited to Brodmann’s area 37, it was proposed that
this area may be important for object naming by allowing the semantic
system access to stored lexical information. Based on this finding and
theories postulating a modular system for word retrieval, we proposed
that a patient with a lesion to area 37 and another patient with a lesion to
a speech production region located serially downstream from area 37
would both be anomic, and in neither case could the anomia be attributed
Downloaded by [University of Arizona] at 12:57 06 November 2015

to a significant semantic impairment. Using a case study design to

investigate the level of naming disturbance in these two patients with
unilateral left hemispheric strokes, we have demonstrated that Patient I,
who had a lesion to area 37, and Patient 2. with a lesion to inferior-lateral
portions of Brodmann’s area 6. were anomic with semantic knowledge of
words relatively preserved.
Journal
Neurocase 1998, 4: 3 5 4 3
Neurocase Reference Number:
0101

Primary diagnosis of interest

Pure anomiii without semantic or phonological deficits
Author’s designation of case
Patient I. Patient 2
Key theoretical issue
0 Anomic aphasia

Key wards: anomia: aphasia; stroke: semantic memory

Scan, EEG and related measures
CT
Standardized assessment
Western Aphasia Battery (Kertesr, 1982). Boston Naming Test (Kaplan el
crl. , 1984)
Other assessment
Florida Semantic Battery, Tactile Naming, Naming to Sound
Lesion location
Patient I: left posterior inferior medial occipito-temporal lobe
(Brodmann’s areas 37, 18 & 19)
Patient 2: left frontal operculum (Brodmann’s area 6)
Lesion type
Ischaemic
Language
English

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