Right brain: a descriptive account of two patients' experience with and adaptations to Balint syndrome.

Jason Cuomo, MA Murray Flaster, MD José Biller, MD We provide a narrative account of 2 patients’ experiences with Bálint syndrome, a rare and debilitating neurologic disorder characterized by optic ataxia, ocular apraxia, and simultanagnosia. It was a quiet Thursday afternoon when A.S., a 68-year-old woman from a suburb of Chicago, awakened from a nap to the realization that something was terribly wrong. “I went to lie down, and when I got up, I couldn’t find where the cabinets were, or the doors,” she remembers. Over the next 2 days, A.S.’s confusion heightened as she increasingly lost her ability to name or even distinguish household objects that she’d been surrounded by for years. Unable to read the numbers on her telephone or to see where the bedroom wall ended and the bedroom door began, A.S. naturally thought that there was something wrong with her eyes and made an appointment with the ophthalmologist later in the week. She then did what so many stroke victims do; she put herself to bed early, hoping that everything would be better in the morning. When the meeting finally came, it became clear that whatever A.S. was afflicted with, it was not a simple matter of visual impairment. “We took her to an eye doctor, because we didn’t know what it was at the time,” recalls her husband, Michael. “They ran tests on her eyes, and she passed them with flying colors!” A.S.’s visual acuity test tells the same tale; her vision tested out at 20/30 in each eye, and when she put on her glasses, it rose to 20/20. A.S. and her husband left the doctor’s office with normal examination results and a neurologic referral in hand, wondering what sort of ailment could rob her of her ability to see the bathroom sink while leaving her with what we typically think of as perfect vision. At 66 years old, J.D. was a robust and active man, who was described by those who knew him as a workaholic who could not sit still. After emigrating to the United States from the former Soviet Union, where he had been mayor of a large town, J.D. began his quest for the American Dream as a truck driver. Fast-forward 30 years and he is again a pillar of his community, where he was heading a large extended family while owning and operating his own trucking business. J.D. was often on the road for long hours, and so his family thought little of it when he began swerving erratically on the long drive to his son’s house for Thanksgiving dinner. “He worked double shifts for all 3 days before Thanksgiving because his workers wanted them off,” his daughter recalls. “We just thought he was tired.” Nor did his family know what to make of his bizarre attempts to serve himself at the table. “He was holding the spoon upside down. We all laughed,” she recalls. What happened next was no laughing matter, as J.D. began to experience left-sided weakness, facial drooping, and eventually a loss of consciousness that caused his family to rush him to the emergency room. That scene at the table is his last memory of the 2 months that followed. During that time, J.D. remained unconscious and confined to bed, until suddenly and unexpectedly awakening one afternoon and deciding that it was time to get up and stretch his legs. Since then, his road to partial recovery of powers of speech and the use of his left extremities has been a slow one. The stories of A.S. and J.D. appear dissimilar at first glance, but they are in fact both descriptions of the onset of a rare neurologic disorder known as Bálint syndrome. Bálint syndrome is generally caused by one or more ischemic strokes to the parietal and occipital cortices. Magnetic resonance (MR) studies showed that A.S. had had a series of cardioembolic infarcts involving the parietal and occipital cortices, bilaterally (figure, A). J.D. probably had a series of ischemic infarctions due to severe atherosclerotic vertebrobasilar disease (figure, B). The resulting syndrome is characterized by a triad of symptoms: 1) oculomotor apraxia (difficulty initiating voluntary eye movements toward an object), 2) optic ataxia (inability to reach for objects under visual guidance), and 3) visual simultanagnosia (constriction of the visual attentional field). Every neurology resident will have been acquainted with this syndrome, but to truly understand the Bálint Correspondence & reprint requests to Dr. Cuomo: [email protected]