proceed directly The abnormal response results from damage to the

fiber pathway responsible for ipsilateral pursuit in the parietal lobe. When these fibers are damaged,
patients have poor pursuit toward the side of the lesion. This

deficit can be brought out by rotation of an OKN Most drum or horizontal movement of an OKN
stripe in one direction and then in the other, necessitating repetitive rapid pursuit movements in the
direction of drum/stripe movement followed by refixation sac posterior cades in the opposite
direction (Video 12.2)

A disturbance of fixation reflexes sufficient to

interfere with reading ability may develop before the

appearance of other symptoms. This disturbance is

etimes manifest during visual field testing, during

which the patient cannot maintain central fixation

structions to do so, an apparent

som

despite repeated in

understanding of the instructions, and an apparentterior willingness to comply. Other types of visual
distur

ns in the parietal lobe include

visual neglect, visual agnosia, and difficulties with word recognition

Patients with parietal lobe lesions and homony tend mous visual field defects often are unaware of
their visual deficits. This phenomenon is more likely to occur when the underlying

nondominant cerebral hemisphere (usually the right parietal lobe), but it also can occur in patients
with

dominant parietal lobe lesions. In other patients, the primary visual pathways may be unaffected or
mini- mally affected, but the patient neglects the contralat Because eral visual field.

abnormality is in the

The parietal lobe is the principal sensory area of the cerebral cortex, and its postcentral convolution

is of particular importance. The patient may com-

plain of numbness but more commonly has complex

problems of sensory integration that can be demon-

strated using tests of tactile discrimination, position

sense, stereognosis, and visual-spatial coordination.

Irritative lesions of the postcentral convolution cause

sensory Jacksonian seizures that begin contralateral to

the lesion at the part of the body that corresponds to

the focus of excitation. Tingling or numbness spreads

to other adjacent parts of the body according to the

order of their representation in the cortex. Lesions

in the dominant parietal lobe can cause aphasia (usu-

ally fluent), apraxia, agnosia, acalculia, and agraphia.

A lesion in the dominant parietal lobe involving the

angular gyrus may produce the Gerstmann syndrome

(finger agnosia, right-left disorientation, agraphia.

and acalculia) associated with a right homonymous

hemianopia. Lesions in the nondominant parietal lobe

may cause impaired constructional ability, dyscalculia

and, most commonly, inattention or neglect. Indeed.

eleft spatial neglect after a right hemisphere lesion ma

accentuate the left hemianopia, hemianesthesia, an

hemiplegia, and thus contribute to poor recovery

Topical Diagnosis of Lesions of the

Occipital Lobe and Visual Cortex

Most lesions affecting the occipital lobe are vascula

or traumatic in origin, with tumors, abscesses, dem

elinating, and toxic disorders of white matter occu

ring much less frequently. Lesions of the central and

posterior occipital lobe cause field defects that are

homonymous and congruous, whereas lesions of the

anterior occipital lobe may cause contralateral monoc

ular defects (see below)

Unilateral Lesions of the Central and

Posterior Occipital Lobe

Field defects seen with lesions of the central and pos-

terior occipital lobe are always homonymous and

almost always extremely congruous (Fig. 12.26). The

phenomenon of sparing of the macula is often seen

in such cases (see below). Lesions of the tip of theportion

occipital lobe (the occipital pole) produce defects thatthese

tend to be scotomatous; however, unlike the homony

mous scotomas that occur in some patients wi

tract lesions (see above), the homonymous scotomas

produced by occipital tip lesions are exquisitely con

gruous (Figs. 12.26 and 12.27)

Unilateral Lesions of the Anterior

Occipital Lobe

Because the temporal field of each eye is larger th

the nasal field, the fibers subserving that portion of

the peripheral temporal field that has no nasal cor-

relate must be unpaired throughout the postchiasmal