Acquired dysgraphia in adults following right or left-hemisphere stroke

Abstract

OBJECTIVE: This study aimed to assess the strengths and difficulties in word and pseudoword writing in adults with left- and right-hemisphere strokes, and discuss the profiles of acquired dysgraphia in these individuals.
METHODS: The profiles of six adults with acquired dysgraphia in left- or right-hemisphere strokes were investigated by comparing their performance on word and pseudoword writing tasks against that of neurologically healthy adults. A case series analysis was performed on the patients whose impairments on the task were indicative of acquired dysgraphia.
RESULTS: Two patients were diagnosed with lexical dysgraphia (one with left hemisphere damage, and the other with right hemisphere damage), one with phonological dysgraphia, another patient with peripheral dysgraphia, one patient with mixed dysgraphia and the last with dysgraphia due to damage to the graphemic buffer. The latter patients all had left-hemisphere damage (LHD). The patterns of impairment observed in each patient were discussed based on the dual-route model of writing.
CONCLUSION: The fact that most patients had LHD rather than right-hemisphere damage (RHD) highlights the importance of the former structure for word processing. However, the fact that lexical dysgraphia was also diagnosed in a patient with RHD suggests that these individuals may develop writing impairments due to damage to the lexical route, leading to heavier reliance on phonological processing. Our results are of significant importance to the planning of writing interventions in neuropsychology.

Full text

Dement Neuropsychol 2014 September;8(3):236-242
236
Original Article
Acquired dysgraphia in adults Rodrigues JC, et al.
Acquired dysgraphia in adults following
right or left-hemisphere stroke
Jaqueline de Carvalho Rodrigues1, Denise Ren da Fontoura2, Jerusa Fumagalli de Salles3
ABSTRACT. Objective: This study aimed to assess the strengths and difficulties in word and pseudoword writing in adults
with left- and right-hemisphere strokes, and discuss the profiles of acquired dysgraphia in these individuals. Methods: The
profiles of six adults with acquired dysgraphia in left- or right-hemisphere strokes were investigated by comparing their
performance on word and pseudoword writing tasks against that of neurologically healthy adults. A case series analysis was
performed on the patients whose impairments on the task were indicative of acquired dysgraphia. Results: Two patients
were diagnosed with lexical dysgraphia (one with left hemisphere damage, and the other with right hemisphere damage),
one with phonological dysgraphia, another patient with peripheral dysgraphia, one patient with mixed dysgraphia and the
last with dysgraphia due to damage to the graphemic buffer. The latter patients all had left-hemisphere damage (LHD). The
patterns of impairment observed in each patient were discussed based on the dual-route model of writing. Conclusion:
The fact that most patients had LHD rather than right-hemisphere damage (RHD) highlights the importance of the former
structure for word processing. However, the fact that lexical dysgraphia was also diagnosed in a patient with RHD suggests
that these individuals may develop writing impairments due to damage to the lexical route, leading to heavier reliance on
phonological processing. Our results are of significant importance to the planning of writing interventions in neuropsychology.
Key words: agraphia, cognitive neuropsychology, written language, cerebral dominance.
DISGRAFIAS ADQUIRIDAS EM ADULTOS APÓS ACIDENTE VASCULAR CEREBRAL UNILATERAL NOS HEMISFÉRIOS DIREITO E ESQUERDO
RESUMO. Objetivo: Investigar aspectos preservados e dificuldades na escrita de palavras e pseudopalavras em adultos
que sofreram acidente vascular cerebral (AVC) à esquerda e à direita e discutir os perfis de disgrafia adquirida nesses
indivíduos. Métodos: Investigaram-se perfis de disgrafia adquirida a partir da avaliação das habilidades e dificuldades
na escrita de palavras e pseudopalavras de seis adultos que sofreram AVC no hemisfério direito (LHD) e no hemisfério
esquerdo (LHE), comparados a adultos neurologicamente saudáveis. Realizou-se análise de séries de casos com os
pacientes que apresentaram desempenho deficitário na escrita de palavras, que indicavam a presença de uma disgrafia
adquirida. Resultados: Foram identificados dois casos com disgrafia lexical (sendo um com LHE e outro com LHD), um
caso com disgrafia fonológica, um com disgrafia periférica, um com disgrafia mista e um com disgrafia por déficit no buffer
grafêmico, todos estes com LHE. Destacou-se nesse estudo a heterogeneidade das habilidades linguísticas dos casos
clínicos, discutidas de acordo com o modelo cognitivo de dupla-rota de escrita. Conclusão: O maior prejuízo encontrado
nos pacientes com LHE ressalta a importância desse hemisfério cerebral para o processamento da escrita de palavras.
A presença de um caso com LHD com perfil de disgrafia lexical destaca a necessidade de melhor estudar o papel do
hemisfério direito no processamento de palavras. Espera-se que esse estudo contribua para o planejamento de estratégias
de intervenção neuropsicológica direcionadas à escrita de palavras.
Palavras-chave: agrafia, neuropsicologia cognitiva, linguagem escrita, dominância cerebral.
INTRODUCTION
Acquired dysgraphia (or agraphia) is the
partial or total inability to produce writ-
ten language following neurological damage.1,2
According to cognitive models of writing, dys-
graphia may be either a result of language im-
1Psychologist, Master Degree and Doctoral Student in Psychology, Graduate Department of Psychology, Federal University of Rio Grande do Sul – UFRGS, RS,
Brazil. 2Speech/Language Pathologist, PhD in Psycholinguistics, Master Degree in Neuroscience, Specialist in Speech Pathology Rehabilitation, Post graduated
in Neuropsychology, RS, Brazil. 3Speech/Language Pathologist, Master Degree and PhD (Psychology), Adjunct Professor of the Department of Developmental and
Personality Psychology, Graduate Department of Psychology, Federal University of Rio Grande do Sul - UFRGS, Head of the Cognitive Neuropsychology Research
Group - NEUROCOG., RS, Brazil
Jaqueline de C. Rodrigues. Instituto de Psicologia – Rua Ramiro Barcelos 2600 / 114 – 90035-003 Porto Alegre RS – Brazil. E-mail: jaquecarvalhorodrigues@
gmail.com / jerusafs@yahoo.com.br
Disclosure: The authors report no conflicts of interest.
Received May 20, 2014. Accepted in Final Form July 20, 2014.

Dement Neuropsychol 2014 September;8(3):236-242
237Rodrigues JC, et al. Acquired dysgraphia in adults
pairment3-5 or of praxis and visuospatial dysfunction.7-9
According to the dual-route or multiple route model,
one of the most widespread and well-accepted models
of writing,10-14 written word production may occur ei-
ther through phonological mediation (the conversion
of phonemes to graphemes) or by direct lexical access.
While the phonological route is involved mainly in the
production of unfamiliar words and pseudowords, the
lexical route is preferred when writing familiar words,
and the only suitable means of writing irregular words.15
e dierent types of dysgraphia caused by distinct
patterns of impairment in one or more components of
the dual route model can be identied by the assess-
ment of psycholinguistic eects in writing (word length,
regularity, frequency, etc.) and of the types of errors
observed in word/pseudoword writing.15 According to
a cognitive model of writing to dictation in the Brazil-
ian Portuguese language developed by Lecours and
Parente,16 dysgraphia can be divided into the following
subtypes: central (lexical, phonological, semantic and
deep dysgraphia) and peripheral (in the case of damage
to the graphemic or allographic buers, or impairments
in the planning and execution of hands articulatory
movements).6
Lexical dysgraphia occurs when there is damage to
the lexical route and heavy reliance on phonological
writing strategies, leading to adequate performance in
tasks involving words and pseudowords, but diculty
writing ambiguous and irregular words. Regularization
errors are common in these patients, as is the tendency
to perform better when writing frequent as opposed
to infrequent words.15 is type of dysgraphia is often
caused by lesions to the left parietal lobe.4
Phonological dysgraphia is associated with extreme
diculty in writing pseudowords as compared to real
words due to impaired phoneme-grapheme conversion,
which may also lead to problems when writing unfamil-
iar words.17 As a result, lexicalization errors, as well as
frequency and lexicality eects, are often observed in
these cases. is type of dysgraphia is often reported in
patients with damage to perisylvian cortical regions.18,19
Mixed (or global) dysgraphia is associated with im-
pairment to both lexical and phonological mechanisms.
Patients with this condition are able to write some regu-
lar words but have diculty writing irregular words
and pseudowords.20,21 Semantic dysgraphia refers to the
inability to attribute meaning to written words, and is
often observed following left hemisphere lesions.5 Deep
dysgraphia is associated with phonological decits,
which lead to semantic paragraphias, lexicality eects,
and diculty writing pseudoword, as well as unfamil-
iar and abstract words.22 Semantic dysgraphia has been
found to occur following extensive lesions to the supra-
marginal gyrus and insula.1
Peripheral dysgraphia caused by damage to the gra-
phemic buer leads to diculties in lexical access and
phoneme-grapheme conversion during the writing pro-
cess.23,24 Patients with this condition retain the ability
to write well-formed graphemes, although the substi-
tution, omission, addition or transposition of letters
within words may be observed.24 Damage to the allo-
graphic buer, on the other hand, tends to impair the
grapheme selection process, which often results in the
use of both upper and lower case letters and cursive and
block letters in the same word.26 ese diculties may
be associated with damage to the left temporo-parieto-
occipital cortex.2 Lastly, apraxic dysgraphia is caused by
alterations in the planning and generation of the mo-
tor sequences required to write letters.6 is condition
is believed to be caused by damage to the left parietal
cortex.28
Language impairments following left hemisphere
damage (LHD) have been extensively investigated in the
literature. However, few studies have investigated the
performance of patients with right hemisphere damage
(RHD) on word writing tasks. Furthermore, the quali-
tative nature of language impairment in dysgraphia
has only been scarcely studied.24 erefore, this study
aimed to assess the strengths and diculties in word
and pseudoword writing in adults with left- and right-
hemisphere strokes, and discuss the proles of acquired
dysgraphia in these individuals.
METHOD
Participants. is was a series of case studies39 involv-
ing six patients, Brazilian-Portuguese native speakers,
with acquired dysgraphia following stroke. Five of the
patients had LHD while one had RHD. ese patients
were drawn from a sample of 40 right-handed adults
who completed writing tasks, ten of whom had LHD
(M=59.2; SD=8.6 years old), ten had RHD (M=53.3;
SD=9.7 years old) and 20 were neurologically healthy
(M=55.7; SD=9.3 years old). Control participants were
matched to patients by gender, age and years of edu-
cation. Dysgraphia was considered when patients ob-
tained a score below two standard-deviations from the
control mean in a word/pseudoword writing task or
when the number of errors on the task was over two
standard-deviations above the control mean (Z score).
e cases selected had distinct sociodemographic char-
acteristics, which are displayed in Table 1.
e type and location of lesions observed in each pa-

Dement Neuropsychol 2014 September;8(3):236-242
238 Acquired dysgraphia in adults Rodrigues JC, et al.
tient are described in Table 2. Two of the patients with
LHD had Broca’s Aphasia (LHD3 and LHD4), while one
patient had transcortical motor aphasia (LHD5).
Instruments and procedures. All participants or caregivers
provided written informed consent prior to enrollment
in the study, which was approved by the local ethics
committee. e patients did not have severe depres-
sion (Yesavage Geriatric Depression Scale – GDS-1532 or
Beck Depression Inventory BDI-II)33 or impairments in
language comprehension (Token Test – short version).35
Furthermore, patients were not aphasic and had pre-
dominantly expressive language impairment (Boston
Aphasia Diagnostic Test - short version)29,30
Patients were administered the spoken and written
language subtests of the Brazilian Brief Neuropsycho-
linguistic Assessment Battery for Expressive Aphasia
(NEUPSILIN-Af).36,37 e spoken language subtests in-
cluded in this battery assess Automatic Language, Nam-
ing, Repetition, Spoken Comprehension and Inferential
Processing. Written language was assessed through
reading aloud, written comprehension, spontaneous
writing, and copying and dictation tasks.
e word/pseudoword writing task (TEPPs)38 was
used to assess written language skills. e participant
was also asked to write down a series of words dictated
by the examiner to exclude individuals with hearing
impairment. Participants were allowed to complete the
task using the hand with which they were most com-
fortable for writing. e percentage of correctly written
Words (Regular, Irregular, Short, Long, Frequent, Infre-
quent) and Pseudowords (Short and Long), as well as a
total score (72 stimuli), were calculated for the task. e
inuence of psycholinguistic variables on performance
was assessed using the dierence between the percent-
age of correctly written short and long words (length
eect), regular and irregular words (regularity eect),
frequent and infrequent words (frequency eect) and
words and pseudowords (lexicality eects). Errors were
also categorized as linguistic (verbal paragraphia, unfa-
miliarity with contextual rules, accentuation, regulariza-
tion, lexicalization, neologisms, nonwords and non-an-
swer) or peripheral (graphemic and graphomotor errors,
rotated or mirrored writing, inclined or wavy writing,
spacing between letters, tremor and perseveration).
RESULTS
Dierent types of dysgraphia were classied based on
comparisons between the performance of cases and
controls (matched by gender, age and education). e
following variables were used to categorize dysgraphia:
number of errors, number of correct answers, psycho-
Table 1. Patient sociodemographic data.
Case Gender Age (years) Years of education RW Habits* Occupation Socioeconomic Status**
LHD1 F58 5Low Housewife C1
LHD2 F73 4High Housewife C2
LHD3 F48 9Low Secretary C1
LHD4 M67 8Low Doorman C2
LHD5 M50 11 Low Taxi Driver C1
RHD6 F61 4Low Housekeeper C1
LHD: left hemisphere damage; RHD: right hemisphere damage; M: male; F: female; R: reading; W=writing. *Scores between 0 and 13 were indicative of a low frequency of reading and writing, while scores
between 14 and 28 corresponded to frequent reading and writing habits. This variable was assessed by a reading and writing inventory, published by Pawlowski et al., 2012.**Assessed according to the
Brazilian Economic Classification Criteria (ABEP, 2012).
Table 2. Patient neurological data.
Case Etiology Region of stroke Location of stroke Months since stroke
LHD1 HSubcortical Basal Ganglia 28
LHD2 ISubcortical Parieto-occipital 24
LHD3 ICortico subcortical Fronto-temporal 70
LHD4 ICortico subcortical Fronto-temporal 18
LHD5 HSubcortical Insula and periventricular region 48
RHD6 HCortical Frontal 22
LHD: left hemisphere damage; RHD: right hemisphere damage; I: ischemic; H: hemorrhagic.

Dement Neuropsychol 2014 September;8(3):236-242
239Rodrigues JC, et al. Acquired dysgraphia in adults
linguistic eects, types of error observed, as well as
qualitative dierences between the errors observed in
patients and controls. Two patients were diagnosed
as having lexical dysgraphia (LHD2 and RHD6), two
as phonological dysgraphia (LHD3 and LHD5), one as
mixed dysgraphia (LHD1) and one with peripheral dys-
graphia (LHD4). ese data are shown in Table 3.
DISCUSSION
Patients LHD2 and RHD6 displayed regularity and fre-
quency eects as well as regularization errors and gra-
phemic paragraphias, suggesting the predominant use
of phonological processing for writing words/pseudo-
words, and the presence of impairments to the lexical
route (lexical dysgraphia).4 Most of the errors made
by patient LHD2 consisted of letter omissions, which
were observed in the spontaneous writing and sentence
copying tasks of the NEUPSILIN-Af. Letter omissions
often result from diculties in the identication and
production of words as a whole (lexical processing) and
in phoneme-grapheme conversion when writing to dic-
tation. Patient LHD2 also displayed letter formation
errors (graphomotor) and excessive spacing between
letters, neither of which were observed in case RHD6.
Similar peripheral errors have been reported in cases of
lexical dysgraphia, suggesting that damage to left cor-
tico-subcortical circuits, which involve structures such
as the putamen, the thalamus, and the premotor and
sensorimotor cortices, can inuence grapheme forma-
tion.40 Parieto-occipital lesions, such as those found in
patient LHD2, have also been identied as an important
cause of lexical dygraphia.41
Patient RHD6 had no symptoms of aphasia, suggest-
ing the presence of right hemisphere language special-
ization, which is found in two percent of right-handed
individuals.42 is patient’s prole was similar to that
reported by Rothi, Roeltgen and Kooistra (1987),43 who
described the case of a right-handed adult with RHD
which displayed both regularity eects and regulariza-
tion errors. ese authors suggested that patients with
RHD may have diculty using visual (or lexical) strate-
gies to write words as a whole, relying instead on phono-
logical strategies.
e patient with RHD assessed in the present study
had a similar performance to that of an adult with
posterior callosal damage described in a previous in-
vestigation, who was found to have diculty writing
Kanji (ideograms with no systematic relationship to
corresponding spoken sounds).44 e study in ques-
tion also found that the right hemisphere relies more
on lexical-semantic processing than on phonological
representations for word writing, possibly because pho-
Table 3. Types of dysgraphia according to percentage of correct answers, number of errors, psycholinguistic effects and types of errors in the TEPPs, and
impairment in the Spontaneous Writing and Sentence Copying tasks of the NEUPSILIN-Af.
Cases
Correct
answers Errors
Main psycholinguistic
effects Types of writing errors
Impairment in
supplementary tasks
Lexical
dysgraphia
LHD2 37 89 Regularity and frequency Letter omission, graphomotor errors,
regularization, graphemic paragraphia,
spacing between letters
Spontaneous writing and
sentence copying
RHD6 49 42 Regularity and frequency Regularization and graphemic
paragraphia
Spontaneous writing
Phonological
dysgraphia
LHD3 44 46 Word length, frequency
and lexicality
Neologism, letter substitution,
lexicalization, non-answer, semantic
paragraphia
–
LHD5 54 44 Word length and lexicality Letter substitution and omission,
neologisms, non-answers,
lexicalization
Spontaneous writing and
sentence copying
Mixed or global
dysgraphia
LHD1 4227 Regularity Graphomotor, tremor, neologism,
omission, perseveration, letter
substitution, graphemic and verbal
paragraphia
Spontaneous writing
Peripheral
dysgraphia
LHD4 39 61 Word length and regularity Mirrored writing, inclined writing,
graphemic paragraphia, letter
omission, addition and substitution
Spontaneous writing
LHD: left-hemisphere damage; RHD: right hemisphere damage.

Dement Neuropsychol 2014 September;8(3):236-242
240 Acquired dysgraphia in adults Rodrigues JC, et al.
nological processes are more closely associated with the
left hemisphere.45 Lexical processing strategies, on the
other hand, tend to be more closely related to activation
in frontal regions of the brain.46 erefore, it is possible
that the writing impairments observed in patient RHD6
as well as his lexical dysgraphia may have been caused by
frontal damage to the right hemisphere. However, fur-
ther studies of patients with frontal RHD are required
to conrm this hypothesis. ere is also a need for re-
search involving larger samples of patients with RHD,
since few studies have investigated the role of the right
hemisphere in lexical processing, especially in Brazilian
samples.
In the present study, two patients with LHD (LHD3
and LHD5) had signicantly greater diculty writing
pseudowords as compared to real words (lexicality ef-
fect), and long words as compared to short ones (length
eect). ese error patterns are indicative of phonologi-
cal dysgraphia. e patterns of brain damage observed
in these patients corroborate the hypothesis that a com-
plex neural network involving left perisylvian regions is
responsible for phoneme-grapheme conversion in word
and pseudoword writing, and that damage to this struc-
ture may be the cause of phonological dysgraphia.2,18,19
In addition to lexicality eects, these patients also
exhibited neologisms, letter substitutions, lexicaliza-
tion errors and non-answers in both the TEPPs and the
Spontaneous Writing tasks of the NEUPSILIN-Af, prob-
ably due to impaired phoneme-grapheme conversion
and to the exclusive reliance on lexical processing when
writing words and pseudowords.20 ese patients also
made similar errors in spoken language tasks, in which
phonological paraphasias, anomias and agrammatisms
were observed. Some of the speech impairments dis-
played by patients with Broca’s and Transcortical Motor
Aphasia were also evident in their performance of word
and pseudoword writing tasks.47
Semantic paragraphias, which are not commonly
seen in phonological dysgraphia but are a common
consequence of deep dysgraphia, were only observed
in patient LHD3. During the writing-to-dictation task,
the patient in question wrote down the word “birds” in
response to the word “wing.” According to Rapcsak et al.
(2009),19 the degree of phonological processing decits
presented by patients can have a direct impact on the
severity of their writing decits. Given the presence of
both semantic and orthographic errors in some of the
most severely impaired participants, the authors pro-
posed the existence of a continuum of written language
impairment, comprising phonological dysgraphia on the
least severe end of the spectrum, followed by deep dys-
graphia and global or mixed dysgraphia, which are asso-
ciated with similar severity levels. erefore, it is possi-
ble that patient LHD3 may have transitioned from deep
dysgraphia to the less severe phonological dysgraphia in
the time since their stroke, either due to spontaneous
language recovery, or to the benecial eects of speech
rehabilitation on phonological impairment. LHD3 is the
youngest patient described in the present study with the
longest time since stroke of 70 months, having already
been through a long recovery period for their decits.
However, a longitudinal evaluation of this patient, in-
volving pre- and post-rehabilitation assessments, would
be required to conrm this hypothesis.
e performance of patient LHD1 was similar to
that observed in patients with mixed or global aphasia,
which lead to substantial impairments in word writing
tasks due to its eects on both lexical and phonological
processing.20,21 However, these patients had less dicul-
ty writing regular words than irregular or pseudowords.
e most frequent errors in our sample were periph-
eral in nature. Tremor and graphomotor (poor letter for-
mation) errors, for instance, were identied in all writ-
ten stimuli. ese errors are often observed in patients
with basal ganglia lesions, which have a signicant im-
pact on motor control.48 Perseveration errors (repeated
writing of previous stimuli) are also common in patients
with damage to the basal ganglia. Patient LHD1 also ex-
hibited both phonological and lexical errors, corroborat-
ing the idea that both types of processing are involved
in word and pseudoword writing, although one may
be more extensively involved than the other in certain
cases.15
Luzzatti et al.20 suggested two main etiologies for
mixed dysgraphia: auditory/phonological impairment
(diculty segmenting spoken words into sounds) or
lexical-phonological output disturbances (grapheme
selection in writing). e latter was more evident in
LHD1, since the patient had adequate spoken language
(including word repetition).
LHD1 developed expressive aphasia following her
stroke, and had spontaneous speech recovery, never
having received speech therapy. erefore, it is possible
that the stroke inicted more damage to subcortical
regions associated with word and pseudoword writing
rather than to areas responsible for spoken language ex-
pression. ese ndings corroborated those of Scarone
et al.,48 who demonstrated that the following cortical
and subcortical regions were involved in word writing
tasks: superior parietal cortex, supramarginal gyrus,
second and third frontal gyri, supplemental motor area
and insula. During the spontaneous recovery period,

Dement Neuropsychol 2014 September;8(3):236-242
241Rodrigues JC, et al. Acquired dysgraphia in adults
some patients may appear to recover from aphasia, but
not from writing impairments, suggesting that these
disturbances are caused by dierent lesions.48
LHD4 made predominantly mirrored and inclined
writing errors, although graphemic errors were also ob-
served (omission, addition and substitution of letters).
e patient also displayed length and regularity eects,
since fewer errors were observed in short and regular
words. ese features are characteristic of peripheral
dysgraphia.2,6
Mirrored writing (writing some letters or the entire
word in mirrored form) is a spatial error caused by im-
pairments in the motor representation of letters, which
is also observed in adults who are asked to write with
their left hand.49 e motor sequences used for letter
writing are associated with the right hands of right-
handed individuals, so that a new motor program must
be learned when individuals attempt to write with their
left hands. Due to stroke-associated motor decits, pa-
tient LHD4 performed the TEPPs with her non-domi-
nant hand, which may explain the presence of mirrored
writing in her responses to the task.
Patient LHD4 also had diculty maintaining letter
sequences while writing, possibly due to graphemic buf-
fer damage.2 It is possible that these errors were caused
by dysfunctions in working memory (namely, in the buf-
fer component) during word writing.23,24 e graphemic
buer is also sensitive to word length eects, since lon-
ger words take up more of its capacity.2,6 Furthermore,
patient LHD4 also displayed regularity eects, suggest-
ing that the graphemic buer may be more sensitive to
certain letter sequences, such as those found in irregu-
lar words. is nding has been previously observed in
a case of non-uent aphasia by Gvion and Friedmann
(2010).50
e errors exhibited by patient LHD4, which con-
sisted mostly of the omission, addition and substitution
of letters, are often observed in cases of graphemic buf-
fer impairment. Graphemic paragraphias, consisting of
phonologically plausible letter substitutions, were also
observed. Although these are usually considered phono-
logical errors, it is possible that in the case of this spe-
cic patient, they may have been caused by damage to
the graphemic buer. Similar errors have been reported
in patients who suered extensive LHD25, akin to that
seen in patient LHD4.
In conclusion, the fact that dysgraphia was diag-
nosed in half the participants with LHD suggests that
this hemisphere plays an important role in word writ-
ing. e presence of lexical dysgraphia in a patient with
RHD also underscores the need for further studies of
the role of the right hemisphere in word processing.
e fact that two patients with LHD displayed poor
performance and made several errors in the TEPPs, in
spite of an absence of aphasia, suggested that the cogni-
tive mechanisms involved in spoken language are distinct
from those responsible for writing. On the other hand,
patients with aphasia made similar errors on both spoken
and written tasks, suggesting that, in more severe cases,
both spoken and written language may be impaired, cor-
roborating the hypothesis of a continuum of severity in
dysgraphia. Results such as those of the present study
help advance knowledge on written word processing,
and may serve as a basis for neuropsychological inter-
ventions which focus specically on the dierent pat-
terns of impairment observed in each type of dysgraphia.
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