89
Organizational Strategy Influence on Visual Memory
Performance After Stroke: Cortical/Subcortical
and Left/Right Hemisphere Contrasts
Gudrun Lange, PhD, William Waked, PhD, Stephen Kirshblum, MD, John DeLuca, PhD
ABSTRACT. Lange G, Waked W, Kirshblum S, DeLuca J.
Organizational strategy influence on visual memory perfor-
mance after stroke: cortical/subcortical and left/right hemi-
sphere contrasts. Arch Phys Med Rehabil 2000;81:89-94.
Objective: To examine how organizational strategy at encod-
ing influences visual memory performance in stroke patients.
Design: Case control study.
Setting: Postacute rehabilitation hospital.
Participants: Stroke patients with right hemisphere damage
(n ⫽ 20) versus left hemisphere damage (n ⫽ 15), and stroke
patients with cortical damage (n ⫽ 11) versus subcortical
damage (n ⫽ 19).
Main Outcome Measures: Organizational strategy scores,
recall performance on the Rey-Osterrieth Complex Figure (ROCF).
Results: Results demonstrated significantly greater organiza-
tional impairment and less accurate copy performance (ie,
encoding of visuospatial information on the ROCF) in the right
compared to the left hemisphere group, and in the cortical
relative to the subcortical group. Organizational strategy and
copy accuracy scores were significantly related to each other.
The absolute amount of immediate and delayed recall was
significantly associated with poor organizational strategy scores.
However, relative to the amount of visual information originally
encoded, memory performances did not differ between groups.
Conclusions: These findings suggest that visual memory
impairments after stroke may be caused by a lack of organiza-
tional strategy affecting information encoding, rather than an
impairment in memory storage or retrieval.
Key Words: Stroke; Cerebral hemispheres; Visual; Memory
disorders; Rehabilitation.
r 2000 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
From the Department of Psychiatry (Dr. Lange), Department of Radiology (Dr.
Lange), Department of Physical Medicine and Rehabilitation (Drs. Kirshblum,
DeLuca), and Department of Neurosciences (Dr. DeLuca), University of Medicine and
Dentistry of New Jersey–New Jersey Medical School, Newark, and the Research
Department, Kessler Institute of Rehabilitation (Dr. Kirshblum) and the Kessler
Medical Rehabilitation Research and Education Corporation (Dr. DeLuca), West
Orange, NJ; and the Department of Rehabilitation, Mt. Sinai Medical Center, New
York, NY (Dr. Waked).
Submitted for publication March 18, 1999. Accepted in revised form May 8, 1999.
Supported in part by grant 110 from the Henry H. Kessler Foundation.
Presented in part at the 104th meeting of the American Psychological Association,
Toronto, Canada.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to John DeLuca, PhD, Kessler Medical Rehabilitation Research
and Education Corporation, Neuropsychology and Neuroscience Laboratory, 1199
Pleasant Valley Way, West Orange, NJ 07052.
r 2000 by the American Congress of Rehabilitation Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/00/8101-5515$3.00/0
I T IS NOW CLEARLY recognized that effective organiza-
tional strategies influence the encoding of information to be
learned. For instance, the use of a semantic clustering strategy
significantly improves the encoding of verbal material.1 Similarly,
the use of a ‘‘perceptual cluster’’ strategy,2 defined as an organized
(in contrast to a piecemeal or disorganized) approach to encoding
complex visual stimuli, is associated with increased visual memory
performance in patients with different neurologic disorders2 or
amnesics after anterior communicating artery aneurysm.3
It is also recognized that visual spatial/constructional informa-
tion is processed differently in the two cerebral hemispheres in
humans. Left hemisphere damage disrupts the detailed reproduc-
tion of a visual pattern; right hemisphere damage interferes with
the configurational perception (ie, ‘‘gestalt’’) of a design.4
Several authors have employed the Rey-Osterrieth Complex
Figure (ROCF) to study both the influence of side of stroke (left
versus right hemisphere), and the influence of strategy (orga-
nized versus disorganized), on construction and recall of visual
material. Such studies have shown that stroke patients with left
hemisphere lesions tend to reproduce the ROCF by breaking the
design into separate configurational elements, whereas patients
with right hemisphere lesions have difficulty forming an overall
‘‘gestalt’’ of the figure, often missing crucial configurational
units of the ROCF.5-7 As such, both left and right hemisphere
stroke subjects have significant difficulties in organizing com-
plex visual stimuli. Thus, in stroke patients, the decreased ability to
organize complex information may lead to less efficient encoding of
visual information,8 resulting in reduced memory performance on
complex visual tests such as the ROCF.
In addition to perceptual-organizational deficits, stroke pa-
tients also evidence difficulties on measures of visual memory.9,10
Although impaired visual memory performance has tradition-
ally been associated with lesions of the right hemisphere and
verbal memory impairments have been attributed to left hemi-
sphere damage,11 this lateralized distinction has recently come
under considerable scrutiny, particularly with reference to right
hemisphere specificity toward visual memory disturbance.12 An
alternative explanation for some form of right hemisphere
specificity toward impaired visual memory performance may
have less to do with recall and recognition and more to do with
the reduced encoding secondary to inefficient perceptual process-
ing. That is, the observed ‘‘visual memory’’ deficit in right
hemisphere stroke patients may be rooted in the type of
organizational strategy used to encode the visual information
rather than be attributable to a global deficit in storage or
retrieval from long- or short-term memory stores. A major
purpose of this study was to examine the hypothesis that visual
memory impairment after stroke is related more to reduced
encoding because of impaired organizational strategy rather
than to material-specific deficits in recall.
In addition to studying lateralized differences in neuropsycho-
logic performance, clinical neuroscientists are interested in
understanding the functional organization of the brain by
contrasting the damage in cortical and subcortical regions of the
brain. Much of the current literature on the role of subcortical
Arch Phys Med Rehabil Vol 81, January 2000
90 ORGANIZATIONAL STRATEGY IN STROKE, Lange
structures in neurobehavioral processing results from work with
progressive neurodegenerative disorders such as Huntington
disease, Parkinson disease, and Alzheimer disease. Such studies
have described a ‘‘subcortical dementia,’’ characterized by
slowing of cognition, memory disturbance, difficulty with
complex intellectual tasks, visual-spatial abnormalities, and
disturbances in mood and affect.13 Cummings13 and Brandt and
coworkers14 have argued that subcortical dementia differs both
quantitatively and qualitatively from the pattern of neurobehav-
ioral deficits observed in cortical dementias.
It is unclear, however, whether the findings of cognitive
deficits associated with progressive neurologic disorders can be
generalized to patients with focal lesions after cerebrovascular
accident (CVA). One of the few studies that examined neuropsy-
chologic functioning in patients with cortical versus those with
subcortical vascular lesions was done by Wagner and Cush-
man.10 They found that the subcortical group was impaired on
measures of attention, memory, and intellectual performance
and did significantly worse than the cortical group on these
measures. Although it is not clear why the subcortical group
performed so poorly on tasks traditionally ascribed to cortical
processing, factors such as lesion size and location may
contribute significantly to the performance. Whether the ob-
served memory deficits in stroke patients with lesions confined
to subcortical structures result from deficits in retrieval from
long-term storage (as suggested by the subcortical dementia
hypothesis15 ) or to disorganization at the encoding stage has not
been studied.
This study examined the hypothesis that impaired visual-
perceptual recall in stroke patients may be caused by compro-
mised organizational processing of the ROCF during encoding,
and not by visual memory storage or retrieval failure. The
reduced ability to use an efficient perceptual organizational
strategy at the encoding stage of visual-spatial processing
(while the subject copies the ROCF) may be a primary reason
for impaired immediate and delayed memory recall. As such, it
was hypothesized that a disorganized strategy will significantly
reduce copy performance on the ROCF, which in turn will
significantly correlate with recall performance. That is, immedi-
ate and/or delayed visual memory recall scores will be signifi-
cantly affected by the degree of organizational fragmentation on
the copy component of the ROCF. Specifically, we hypoth-
esized that (1) right hemisphere and cortical lesions will have a
significantly greater influence on organizational strategy than
lesions in the left hemisphere or subcortical regions, respec-
tively, (2) a disorganized strategy will result in decreased
immediate and delayed recall performance on the ROCF, and
(3) once information is encoded, recall will not differ between
groups after controlling for differences in original learning (ie,
savings score).
METHOD
Subjects were 28 men and 9 women who were admitted to a
secondary care rehabilitation hospital. All subjects were right-
handed and without a previous history of CVA. Demographic
data are presented in table 1. On the average, the neuropsycho-
logic test battery was administered 39 days postonset
(x ⫽ 39.25; SD ⫽ 38.65; range ⫽ 11 to 208 days). Age of
stroke patients ranged from 29 to 75 years, with a mean of 58
years. Inclusion criteria included a minimum verbal IQ of 85, as
assessed by the North American Reading Test; no aphasia or
only mild aphasia based on clinical assessment; English as a
first language; and no history of prior neurologic illness,
psychiatric disorder, or substance abuse. Subjects exhibiting
symptoms of disorientation, psychiatric complications, or post-
stroke depression as assessed by the Beck Depression Inventory
Arch Phys Med Rehabil Vol 81, January 2000
Table 1: Demographic Characteristics for the Four Stroke Groups
RCVA LCVA CCVA SCVA
(n ⫽ 20) (n ⫽ 15) p (n ⫽ 11) (n ⫽ 19) p
Age 57.85 (3.0) 61.67 (2.5) .3 57.36 (4.1) 58.47 (2.4) .8
Education 14.06 (0.8) 13.50 (0.8) .5 14.30 (1.0) 14.06 (0.6) .8
IQ 107.89 (1.8) 110.73 (1.7) .2 108.20 (2.5) 111.00 (1.4) .3
BDI total 8.94 (1.5) 5.87 (1.9) .2 6.22 (1.6) 7.68 (1.5) .5
score
Days post- 44.6 (11.3) 31.0 (2.8) .3 41.4 (13.2) 43.5 (10.1) .9
stroke
Data reported as mean (SEM). All comparisons are nonsignificant.
Abbreviations: RCVA, right hemisphere stroke; LCVA, left hemi-
sphere stroke; CCVA, cortical stroke lesions; SCVA, subcortical stroke
lesions.
(BDI) score (ie, BDI score of ⬎17, more than mild depression)
were excluded. While some individuals with a BDI score of
⬍17 may have been mildly depressed, we had no reason to
expect that mild depression would adversely influence ROCF
performance. Subjects were classified into the stroke category
groups based on a physician’s review of patients’ medical
records, the clinical diagnosis at admission to the rehabilitation
setting, and computed tomography (CT) scans obtained from
acute care hospital records. Subjects were first dichotomized
into either right hemisphere CVA (ie, cortical as well as
subcortical structures within the right hemisphere) or left
hemisphere CVA (ie, cortical as well as subcortical structures
within the left hemisphere) groups. To examine the influence of
damage to either cortical or subcortical structures on perfor-
mance, these same subjects were again divided into either the
cortical CVA (ie, frontal, temporal, parietal, and occipital
cortex) or subcortical CVA (ie, basal ganglia, cerebellum, pons,
internal capsule, and thalamus) groups. Subjects who could not
be classified into these broad groups were not included in the
study. Five subjects had negative CT scans. Classification of
these subjects was based on a review of medical records, on
clinical presentation, and on neurologic examination during
their acute care stay and at admission to the rehabilitation
institute (2 were classified left CVA, 2 right CVA, 1 subcortical
CVA). No significant differences between the right CVA and
left CVA subjects and cortical CVA and subcortical CVA
patients on age, education, premorbid IQ, and BDI scores were
found (table 1).
Procedure
All neuropsychologic tests were administered and evaluated
by a senior neuropsychologist. Every reasonable attempt was
made to keep the examiner blind to group assignment (ie,
anonymous identification numbers, standardized test administra-
tion, no chart review before neuropsychologic examination).
Subjects were administered a brief battery of standard neuropsy-
chologic tests of approximately 45 to 60 minutes in duration.
The ROCF copy, immediate recall, and 30-minute delayed
recall conditions were administered in accordance with pub-
lished procedures,17 and time to completion was recorded for
each condition. Each subject was presented with a sheet of
paper with a copy of the ROCF placed in the top half of the page
and asked to copy the figure into the space below as quickly as
possible. Upon completion, the subject’s copy of the ROCF was
removed and the subject was asked to reproduce the figure from
memory (immediate recall) on a blank sheet of paper. Thirty
minutes after the immediate recall condition, the subject was
again asked to recall the figure from memory (delayed recall).
During the 30-minute period between immediate and delayed
free memory recall of the ROCF, the following tests were
 ORGANIZATIONAL STRATEGY IN STROKE, Lange 91

Table 2: Rey-Osterrieth Complex Figure Test Indexes

RCVA LCVA CCVA SCVA
Index (n ⫽ 20) (n ⫽ 15) p (n ⫽ 11) (n ⫽ 19) p

Organizational strategy score 86.40 (10.7) 55.26 (10.7) .05 105.00 (13.29) 49.74 (6.95) ⬍.001
Copy accuracy score 46.75 (4.5) 59.07 (3.7) .05 38.73 (6.8) 62.32 (1.5) ⬍.001
Immediate recall score 18.05 (3.40) 23.73 (4.76) .32 15.64 (3.93) 25.95 (4.31) .12
Delayed recall score 16.95 (3.14) 23.73 (4.92) .23 13.82 (3.52) 25.68 (4.26) .07
Savings ratio* .40 (.06) .37 (.07) .79 .41 (.08) .40 (.06) .92
Forgetting ratio† .94 (0.2) .97 (0.1) .90 .89 (0.1) .93 (.09) .77
Copy‡ 209.00 (23.06) 251.86 (44.97) .37 196.20 (35.64) 243.88 (37.80) .41
Immediate recall‡ 127.70 (11.85) 162.07 (19.0) .12 109.0 (16.05) 168.47 (13.91) .01
Delayed recall‡ 96.0 (14.57) 124.23 (12.83) .16 84.38 (13.87) 136.33 (10.81) .01
Scores reported as mean (SEM).
Abbreviations: RCVA, right hemisphere stroke; LCVA, left hemisphere stroke; CCVA, cortical stroke lesions; SCVA, subcortical stroke lesions.
*Immediate recall/copy score.
†Delayed/immediate recall score.
‡Time to completion (seconds).

administered: North American Reading Test, Wechsler Adult
Intelligence Scale–Revised Digit Span, Controlled Oral Word
Association, and Animal Word Fluency. The BDI was adminis-
tered after the ROCF delayed free recall reproduction was
obtained.
Scoring Procedure
A copy accuracy score and an organizational strategy score
were obtained for the copy component of the ROCF. Copy
accuracy was defined as the degree of resemblance of the
subject’s copy to the original model and was scored in
accordance with standardized and published scoring proce-
dures.18 Immediate and delayed free memory recall of the
ROCF was scored in the same manner. Raw scores served as a
dependent variable of the absolute amount of visual information
encoded/learned and recalled.
Organizational strategy was defined as the perceptual ap-
proach used to copy the original figure. Prior research has
shown that subjects often employ 1 of 2 strategies in copying
the ROCF: either a fragmented and detail-oriented approach, or
a configurational/‘‘gestalt’’ approach.19 Although no data are
available regarding the reliability and validity of the organiza-
tional scoring procedure for the ROCF used in this study, the
procedure was similar to that used by Binder.5 For the present
study, an organizational strategy score was obtained by summat-
ing the number of lines it took the subject to draw three key
elements of the ROCF: central rectangle, central cross, central
diagonal. To obtain these scores, the examiner traced the
subject’s path of the ROCF on a separate piece of paper while
the subject was drawing the figure, numbering the lines
consecutively as the subject proceeded. Each of the three main
structural elements could be completed in a noncontiguous
manner and in any order. The lower the organizational strategy
score (ie, the fewer number of lines), the more organized or
configurational was the subject’s approach. Thus, the best
possible organizational strategy score was an 8 (ie, one point for
each line drawn to complete the three main elements of the
ROCF). If 1 of the 3 main elements was not completed, a score
of 50 was assigned for that element. The total organizational
strategy score served as the dependent variable for analyses.
While there was no control for differences in motor ability
across subjects, the scoring system was such that quality of
construction had little impact on the organizational strategy
score.
RESULTS
Planned comparisons were conducted using separate one-
way analysis of variance (ANOVA) comparing right and left
hemisphere CVA groups and cortical and subcortical CVA
groups.
Left Versus Right CVA
The mean organizational strategy score for the right CVA
group in copying the ROCF was significantly more fragmented/
detailed and less configurational/holistic (F(1, 33) ⫽ 4.04,
p ⫽ .05) than the approach used by the left CVA group (table 2).
In addition, the mean copy accuracy scores were significantly
lower in the right CVA group than in the left CVA group (F(1,
33) ⫽ 4.06, p ⫽ .05). This suggests a lower degree of construc-
tional accuracy in the right CVA group than in the left CVA
group. No group differences were observed on immediate and
delayed ROCF recall scores. Organizational strategy scores
were significantly correlated with copy and immediate and
delayed recall scores for both groups (table 3).
To specifically examine the influence of organizational
strategy on ROCF immediate and delayed recall performance,
two groups were formed based on the median split of the
organizational strategy score. The two groups, the lower
organizational strategy (LOS) group (score of ⬍60, n ⫽ 17)
and the higher organizational strategy (HOS) group (score of
⬎60, n ⫽ 18) were compared on immediate and delayed recall
performance. In the HOS (more impaired) group, there were
more subjects with right hemisphere stroke (14 of 20 subjects)

Table 3: Pearson Correlations of Organizational Strategy Score with Copy Accuracy Score and Immediate and Delayed Recall Scores
Organizational Strategy Scores
RCVA (n ⫽ 20) LCVA (n ⫽ 15) CCVA (n ⫽ 11) SCVA (n ⫽ 19)

Copy Accuracy score ⫺.87, p ⬍ .001 ⫺.93, p ⬍ .001 ⫺.91, p ⬍ .001 ⫺.87, p ⬍ .001
Immediate Recall score ⫺.76, p ⬍ .001 ⫺.52, p ⫽ .05 ⫺.95, p ⬍ .001 ⫺.51, p ⫽ .03
Delayed Recall score ⫺.82, p ⬍ .001 ⫺.50, p ⫽ .05 ⫺.85, p ⫽ .001 ⫺.54, p ⫽ .02
Abbreviations: RCVA, right hemisphere stroke; LCVA, left hemisphere stroke; CCVA, cortical stroke lesions; SCVA, subcortical stroke lesions.

Arch Phys Med Rehabil Vol 81, January 2000

92 ORGANIZATIONAL STRATEGY IN STROKE, Lange
than with left hemisphere stroke (4 of 15) (Fisher’s Exact Test,
two-tailed, p ⫽ .02). The HOS group had significantly de-
creased immediate recall scores (x ⫽ 9.94, standard error of the
mean [SEM] ⫽ 1.96) compared with the LOS group (fig 1)
(x ⫽ 31.65, SEM ⫽ 3.91) (F(1, 33) ⫽ 25.47, p ⬍ .001). The
same pattern was observed for the delayed recall scores in the
HOS group (x ⫽ 10.0, SEM ⫽ 2.04) versus the LOS group
(x ⫽ 30.29, SEM ⫽ 4.0) (F(1, 33) ⫽ 21.08, p ⱕ .001).
To examine if the relative amount of visual information
stored and retrieved differed between right and left CVA groups,
a savings ratio (immediate memory/copy score) and a forgetting
ratio (delayed/immediate memory score) were calculated for
each subject (table 2). No significant differences were found
between groups. Right and left hemisphere stroke groups also
did not differ in time to completion of copy or immediate or
delayed recall productions of the ROCF (table 2).
Cortical Versus Subcortical CVA
Both the mean organizational strategy (F(1, 28) ⫽ 16.57,
p ⬍ .001) and mean copy accuracy (F(1, 28) ⫽ 18.18, p ⬍ .001)
were significantly more impaired in the cortical CVA group
than in the subcortical CVA group (table 2). No significant
group differences were observed on either immediate or
delayed recall scores. Organizational strategy was significantly
related to copy and immediate and delayed memory recall
performance for both the cortical and subcortical CVA groups
(table 3). To directly examine the influence of visual informa-
tion encoding on the absolute amount of material recalled, the
median split of the organizational strategy score was calculated
(LOS, score ⬍58, n ⫽ 15; HOS, score ⬎58, n ⫽ 15) (fig 2).
The HOS (more impaired) group (x ⫽ 11.47, SEM ⫽ 2.34)
immediately recalled significantly less visual information than
the LOS group (x ⫽ 32.87, SEM ⫽ 4.48) (F(1, 28) ⫽ 17.92,
p ⬍ .001). The same pattern held true after a 30-minute delay
(HOS group, x ⫽ 11.6, SEM ⫽ 2.49; LOS group, x ⫽ 31.07,
SEM ⫽ 4.57) (F(1, 28) ⫽ 13.97, p ⬍ .001).
When savings and forgetting ratios were calculated and
compared, scores were not significantly different between
cortical and subcortical CVA groups (table 2). Time to comple-
tion of the ROCF copy component was not different between
groups. However, the group with subcortical lesions was
significantly slower recalling the visual information on both the
Fig 1. Mean immediate and delayed recall performance for high
organizational strategy (HOS) versus low organizational strategy
(LOS) groups of the right/left CVA subjects.
Arch Phys Med Rehabil Vol 81, January 2000
Fig 2. Mean immediate and delayed recall performance for high
organizational strategy (HOS) versus low organizational strategy
(LOS) groups of the cortical/subcortical CVA subjects.
immediate (F(1, 24) ⫽ 7.0, p ⫽ .01) and delayed (F(1,
21) ⫽ 8.38, p ⫽ .009) conditions.
DISCUSSION
This study investigated the influence of organizational strat-
egy on visual memory performance in stroke patients. The
results clearly show that decreased organizational skills during
learning (ie, poor encoding) result in significantly reduced
recall from long-term storage. The ability to perceive the ROCF
configurationally (ie, using a holistic or ‘‘gestalt’’ approach, as
measured by the organizational strategy score) was strongly
associated with improved accuracy in copying the ROCF (copy
accuracy score), resulting in better subsequent recall of the
material. These findings support the hypothesis that recall of
visual material is significantly influenced by the quality of
initial encoding of complex visual information.
The results of our study are consistent with other studies in
both stroke patients8 and in those with other neurologic
conditions2 that show that efficient, well-organized categoriza-
tion, configuration, or cluster strategies result in more efficient
visual memory encoding, storage, and retrieval. In contrast, a
piecemeal, perceptually disorganized approach to the acquisi-
tion of visual information results in significantly reduced recall
performance.5 Taken together, these results show that the level
of perceptual-organizational deficiency directly affects the
acquisition (or encoding) of visual information. In addition, the
quality of encoding of visual material on the ROCF in turn
directly influences absolute immediate and delayed recall
performance.
The right CVA group showed the most severe organizational
impairment, a finding consistent with previous research.5 The
finding of decreased organizational skills in the right CVA
group suggests that the previously reported sensitivity of the
ROCF to right hemisphere lesions may not be due to reduced
recall and recognition, but to poor encoding secondary to
reduced use of an organizational approach to copying the
design.12
Importantly, once information was encoded, the groups did
not differ in the subsequent recall or forgetting of the visual
material (ie, savings and forgetting ratios). Specifically, regard-
less of how much visual information was originally learned and
stored, all groups were able to retrieve a similar percentage of
the ROCF information initially encoded (ie, intact storage and
 ORGANIZATIONAL STRATEGY IN STROKE, Lange
retrieval). Note, however, that because a healthy control group
was not included in the present design, it is not clear whether
the rate of forgetting in the stroke groups was accelerated or
within normal limits. The only thing that can be concluded from
this study is that the forgetting rates did not differ between the
stroke groups contrasted.
Memory is composed of multiple processes or stages. Thus,
looking at memory as a single system is clearly too simplis-
tic.20-22 Among other classifications, memory can be divided
into encoding, consolidation, storage, and retrieval processes.23
Consequently, evaluation of the nature of memory performance
or impairment can be viewed within this framework. Using this
approach, studies examining memory impairment in other
populations, eg, multiple sclerosis,16,24,25 chronic fatigue syn-
drome,26,27 anterior communicating artery aneurysm patients,3
and chronic alcoholics and schizophrenic,28 have shown that the
‘‘memory impairment’’ observed in these populations results
largely from deficient encoding of the incoming information
and not from problems in the storage and retrieval stages of
memory. The results of this study are consistent with these
findings, indicating that encoding difficulties are a key compo-
nent of reduced visual memory performance, particularly in
right hemisphere and cortical stroke subjects.
Although right, compared to left, hemisphere stroke patients
and cortical versus subcortical CVA groups are more inefficient
and disorganized in the encoding of visual information, subcor-
tical CVA patients were significantly slower to recall the visual
information than cortical subjects. This latter finding of slower
processing speed is consistent with other patient populations
with primarily subcortical damage (Huntington disease and
Korsakoff).29 It is possible, however, that the subcortical group
had more motoric involvement than the cortical group, which
may explain the slower processing score. The fact that speed
did not differ between the cortical and subcortical groups during
copy, but only during recall, lends some preliminary support
that speed of cognitive processing likely plays some role
beyond simple motoric involvement. Nevertheless, since we
did not control for potential differences in motoric ability, we
are unable to conclude with confidence that group differences
resulted from speed of processing.
Another limitation of the present study was the partitioning
of the subjects, first by left versus right hemisphere lesion, and
then the repartitioning of these same subjects into cortical
versus subcortical lesion groups. An independent-group design
would have been desirable to permit examination of an
interaction effect, but this would have required twice the
number of subjects. Nevertheless, the present design permitted
us to examine the influence of organizational strategy on visual
memory performance and its cerebral representation.
Lastly, findings of this study have important clinical implica-
tions for stroke rehabilitation. If recall and recognition memory
performance is relatively preserved in stroke patients with
visual memory deficits, the focus of rehabilitation should be to
improve the adequacy of encoding or learning. Such efforts to
enhance organizational strategies may provide better functional
memory performance in everyday life, although future research
needs to demonstrate this linkage. For instance, functional
memory performance of patients with subcortical damage may
benefit from an intervention designed to offset slowed informa-
tion processing, such as altering their environment to ensure
that information is adequately encoded. Recent research has
shown that when subjects with either multiple sclerosis30 or
traumatic brain injury (unpublished data) were given additional
time to perform a complex working memory task, their
performance did not differ from healthy controls (ie, perfor-
93
mance was now within normal limits). Future studies could
examine the relative efficacy of treatments designed to improve
encoding strategies versus treatments that focus primarily on
improving recall and recognition (eg, memory books).
CONCLUSIONS
Our results suggest that visual memory impairment after
stroke may result from deficient encoding of information
secondary to decreased organizational skills, rather than to an
impairment in memory storage or retrieval.
Acknowledgment: The authors thank Dr. Leo Korn for his
statistical assistance.
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