Visuospatial and Perceptual Disorders Problems with visuo spatial orientation and function are commonly encountered after

traumatic and non traumatic brain injuries. Consequences of impaired visiospatial orientation and apraia are drastic in terms of regaining independence. To properly assess for these functions the subject must be conscious to perceive the environmment and must have selective attention to focus on particular sensorium. Perceptual processing is then activated via various sensory modalities and accessing semantic knowledge. On a basic level percept remain uimodal but as the higher centres are recruited to translate it into meanigful picture, it becomes multimodal. Perception is highly active function and requires good attentional resources like selective, divided and sustained attention. prima Although primary visual cotex is oganised accoding to visual field, the stimuli once forming an image there undego further processing in though two streams. Vental occipito temporal is involved in object recogition and the dorsal occipito parietal stream is more concerned with spatial processing. Deficits in visual attention results in neglect which could be towards self or towards environment. As right hemisphere monitors both right and left hemifields and left monitoring only the right hemifield, lesions involving right pariental lobes cause left hemi neglect while lesions involving left hemisphere will not result in neglect due to adequate representation of right side in right hemisphere. Sensory inattention to visual stimuli are examined by enquiring patient to report which finger is moving in visual field on providing one sided and bilateral stimulation. when presented simultaneously ipsilateral stimullus will "extinguish" the contralateral one from awareness. The stimulus should be provided in the field of vision. Paper based tests like line cancellation and bisection tests and clock face drawing will test for neglect as well. Similarly nursing observation and occupational therapy assessments helpd to uncover subtle cases. Anasognosia in patient's inability to recognise conciously the presence of somatic dysfunction indicating a disease process. It is a common problem in non dominant parietal lesions. It is regarded as a disorder of attention rather than perception. Disorders of ventral occipitotemporal stream Agnosias: Agnosia is a modality specific deficit in accessing semantic knowledge of stimulus in patients with intact basic perceptula processing. The stimulus is devoid of meaning. Visual agnosia result in failure to identify information regarding the objects seen like name and purpose. Broadly classified as "apperceptive" implicating loss of high level perception in widespread bilateral occipitotemporal lesions and "Associative" with preserved higher level perception but failure to accessing semantic information to identify object indicative of anterior temporal lobe pathology. Patients retain the ability to access required semantic memory via alternate sensory modalities. Simple bedside tests about visually presented objects and also enquiring about the semantic information related to object may expose any undiscovered agnosia. Alexia Language is a specified symbolic representation of the world around us which is mainly perceived through vision or hearing. Reading is a complex task involving eye movemetn and coordination, fixation and attention as well as central language function to decipher meaning of symbols. Alexia or difficulty in reading may be peripheral from imparment of transmission of visual percept to language centres or central due to impairment of language centres.Examples of peripheral alexia is neclect alexia. The patients often are unable to read left side of the words or left. Alexia without agraphia implies high level visual deficit. Patients are unable to comprehend written words but they can copy what they see and again are unable to read it back. This indicate disconnection syndrome. Patients can recognise words if they are spelled aloud indicating that it is a transmission of visu=ion to language that may be the problem. This syndrome is accompanied by righ homonynmous hemianopia, color anomia or achromatopsia from right occipital lobe lesions.

Face recognistion disorders Prosopagnosia refers to inability to recognise person by looking and studying the face. Knowledge about same person may be preserved using modalities like hearing or looking at person's gait and behaviour. Several disorders previously thought to be psychiatric in origin are now recognised as disorder of percept. Capgras syndrome is a delusional misidentification in whihc affected person believes that familiar people have been replaced by imposters. In contrast in Fregoli syndrome patients will accuse strangers of being a familiar person in disguise. Disorder of color perception Achromatopsia is the loss of ability to perceive colors. Lesions involving medial occipito temporal regions cause what patients decribe their life as watching black and white television. Clour agnosia reflects probles with accessing semantic information about colours. Meanwhile colour anomia is the inability to name color in the presence of semantic knowledge about it.

Disorders of dorsal occipito parietal stream Disorders of motion perception Damage to lateral occipito temporal areas bilaterally results in impairment of perceiving motion of the objects. Things may appear to jump if moving faster. Problems encountered are difficulty in judging speed and direction particularly of cars in the street. Disorders of spatial perception Simultanagnosia is the inability to comprehend a complex scene in its entirety resulting in only one component perceived at a time. it is a feature of Balint's syndome. Other problems encountered in this esyndrome are optic ataxia resulting in inability to reach a visual target and ocular mnotor apraxia where the impairment is in directing gaze to a visual target. Patients often become functionally blind. A characterstic feature is the use of head thrust to scan environement item by item. Pathology is mainly bilateral in superior parieto occipital parts. Dressing apraxia and constructional apraxia Although termed apraxias, they represent visuospatial disturbance. Bedside tests like requesting patient to don jacket with sleeves deliberately turened inside out. Overlapping pentagons and copying Neckar Cube may unearth constructional disorders. Left sided pathologies result in simplified drawings while right side pathologies cause explosion of constituent parts of complex figures copied. Other higher level deficits of vision Anton's Syndrome A form of anosognosia, it relates to denial of visual perceptual disorder by patients who are functionally blind. Pathoology usually involves primary visual cortices. Charles Bonnet Syndrome Pathological gain of visual function results in complex hallucinations involving areas lost in visual fields. Insight is retained into blindness. Topographagnosia Deficits in ventral or dorsal visual association areas result in getting lost in familiar surroundings.

Apraxias
Apraxias are the inability or difficulty in performing motor acts which is not due to a weakness, proprioceptive loss or lack of understanding of task. The patints are unaware of the problems on most occasions. Enquiry from patients and caregiver regarding use of everyday tools may help highlighting the problem. Therapy staff and nursing reports often identify problems before the physicians. Dyspraxias are commonly encountered in left frontal premotor cortex and parietal lesions. Orobuccal

dyspraxia arise from insular and left inferior frontal lesions. Traditionally ideational and ideomotor are used as terms to describe and subclassify apraxia. Clinically it is described by parts of the body affected but folowing a neuropsychological model needs to be followed to assess apraxia n detal. Praxis require an active conceptual system of knowledge rearding tool fnction and actions and a production sstem which includes motor rogrammes concerned with generation of controlled movement. Ideational Apraxia Damage to the conceptual system lead to impaire gesture comprehension and discrimination along with production deficit. Patient performs poorly to command or on copying gestures. They fail to descriminate poor performance from good performance. Errors are common in tool selection and has deficits in tool actio knowledge. On he other hand preserved tool naming shows that object agnosia is not the cause. Gaham et al assessed concptual system by testing names of actions, naming tools,. specification of tool use. Ideomotor Apraxia In this the production system is disturbed but genture comprehension and discriminaion remain intact. Both spatial and tempral errors are common. Spatial errors are charcterized by postural errors like using body part as a tool. tools may be used in incorrect orientation orspatial movements are affected. temporal problems may resut in losing fluidiy of movement. conduction apraxias become eident as difficulty in imitating movements but better performance in pantomiming. Verbal dissociaton apraxia results in impaired performance of gesture on command but intact ability on imitating or on using the tool. Action production system was assesed by hand and figer position imitation and execution of familiar action sequencs like "fold paper,place in envelope and seal it". Executiuon of familiar single actions onverbal command and imitation of examiner's mime and ability to pantomime usage when presented atool against actual tooluse. Simpler tests like imitation of gentures, performig gestures ncommand and finally copying them may be performed at the bedside. Sequencing tasks like Luria three step tet may be done.