A 56-year-old right-handed woman, with fine penmanship, presented with inability to perform cursive writing due to calvarial metastasis of a tibial osteosarcoma and left frontal lobe involvement (figures 1 and 2). Tumor resection resulted in a regained capacity for cursive handwriting. Allographs are variants of graphemic representations (upper vs lower case or cursive vs print). Writing requires activation of abstract graphemic representations, selection of the allograph, and formulation of a motor plan.1 Allographic agraphia is rare, affecting the second or third of these processes, differing from other forms of nonaphasic agraphia such as apraxia or visuospatial agraphias.2 It has been associated with left frontal lesions in clinical and imaging studies.2,3
Figure 1. Patient's handwriting on 3 different occasions.
Valentine's card handwritten by the patient (A) 1 month prior to presentation, (B) a handwritten copy produced by the patient at the time of presentation (after being asked to use her normal cursive handwriting), and (C) 5 days after resection of the skull-based metastasis.
Figure 2. Brain MRI.
(A) Axial and (B) sagittal brain MRI, postgadolinium spoiled gradient recalled echo sequence, shows a large, enhancing calvarial lesion, exerting mass effect on left frontal lobe.
Footnotes
Author contributions: Marcelo Matiello: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and final approval. Eli E. Zimmerman: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and final approval. David Caplan: analysis or interpretation of data, accepts responsibility for conduct of research and final approval. Adam Cohen: drafting/revising the manuscript, study concept or design, analysis or interpretation of data, accepts responsibility for conduct of research and final approval, acquisition of data, study supervision.
Study funding: No targeted funding reported.
Disclosure: The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
References
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