Delayed diagnosis of prosopagnosia following a hemorrhagic stroke in an elderly man: A case report

Table 1 Neuropsychological examinations

Tests	Patient’s performance	Control (n = 10, mean ± SD)	Interpretation
General cognition
MoCA	26/30	25.1 ± 1.97	Normal
Visuospatial/executive	5/5	3.7 ± 0.67
Naming	3/3	3.0 ± 0.00
Memory	N/A	N/A
Attention and calculation	5/6	4.1 ± 0.99
Language	3/3	2.3 ± 0.48
Abstraction	2/2	1.8 ± 0.42
Delayed recall	2/5	3.6 ± 0.70
Orientation	6/6	6.0 ± 0.00
Memory			Impaired
RAVLT immediate	5/15	7.9 ± 1.79
RAVLT delayed	6/15	8.9 ± 1.20
Object recognition
Object-spatial perception
VOSP	118/130	116.5 ± 7.12	Normal
Within-class object recognition
CCMT	54/72	55.6 ± 7.37	Normal
Face recognition
Tests of face familiarity
CFMT	47/72	63.1 ± 6.84	Impaired
Famous faces test	2/12	11.9 ± 0.32	Impaired
Tests of face perception
BFRT	37/54	50.4 ± 3.03	Impaired

SD: Standard deviations; N/A: Not applicable; VOSP: Visual object and space perception battery; RAVLT: Rey auditory verbal learning test; BFRT: Benton facial recognition test; CFMT: Cambridge face memory test; MoCA: Montreal cognitive assessment; CCMT: Cambridge car memory test. Scores less than two SDs was defined as an impairment.

Table 2 Literature summary of acquired prosopagnosia for stroke (42 subjects)

Clinical features		Frequency of pathological findings, patients (%)
Etiologies	Ischemic stroke	34 (81.0)
	Hemorrhagic stroke	7 (16.7%)
	Subarachnoid hemorrhage	1 (2.4)
Cerebral lesions	Unilateral cerebral lesions	Right-sided lesions: 27 (64.3); left-sided lesions: 3 (7.1%)
	Bilateral cerebral lesions	11 (26.2)
Ocular symptoms	Visual field defects	Hemianopia: 28 (66.7); quadrantanopia: 11 (26.2%)
	Blurred vision/deterioration of visual acuity	6 (14.3%)
	Scotomas in the vision	4 (9.5%)
	Dimmer/decreased brightness of vision	3 (7.1%)
	Visual distortion/metamorphopsia	4 (9.5%)
	Visual hallucinations	3 (7.1%)
Agnosia	Spatial agnosia/topographical disorientation	21 (50%)
	Color agnosia/achromatopsia	9 (21.4%)
	Object agnosia	8 (19.0%)
	Alexia/musical alexia	8 (19.0)
	Apraxia	3 (7.1)
	Simultanagnosia	1 (2.4)
Cognitive difficulties	Memory loss	7 (16.7)
	Perceptual impairment	6 (14.3)
	Unilateral neglect	4 (9.5)
	Language difficulties	2 (4.8)
	Dyscalculia	1 (2.4)
	Concentration impairment	1 (2.4)
Other signs/symptoms	Headache/vertigo/dizziness	6 (14.3)
	Tandem walking/gait instability	5 (11.9)
	Hemiparesis/loss of control of limb	4 (9.5)
	Hemisensory loss	4 (9.5)
	Social and emotional difficulties	4 (9.5)
	Hand tremors	1 (2.4)
	Dressing disturbance	1 (2.4)

Table 3 Key characteristics of acquired prosopagnosia with deterioration of visual acuity in reported cases

Ref.	Age at diagnosis(yr), gender	Precipitating factors	Clinical presentation other than prosopagnosia	Neuro-imaging	Face recognition test	Object recognition test
Fadelalla et al[4], 2019	42, female	Acute aneurysmal subarachnoid hemorrhage	Headache, seizure, decreased level of consciousness, blurred vision in right eye, alexia, simultagnosia, impaired within-class object recognition	CT scan showed diffuse SAH, MRI (8 mo) showed presence of hemosiderin deposition around corpus callosum	WRMT: 38/501	VOSP (part): 78/80
Sugimoto et al[9], 2012	82, female	Cerebral infarction in the right PCA	Sudden and transient deterioration of visual acuity, left homonymous hemianopsia, left unilateral spatial agnosia	MRI showed a high signal area in the posterior region of the splenium of the corpus callosum of the right occipital lobe. PET showed decreased oxygen metabolism in the right occipital, temporal lobe	Familiar faces identification test: 0/91; discriminating unfamiliar faces: 31/401 and matching unfamiliar faces: 32/541	N/A
Tohgi et al[10], 1994	62, male	Cerebral infarction in the territory of PCA	Left upper quadrantanopia in the right eye, metamorphopsia, blurred faces on the TV. Visual acuity was 0.5 in the right eye, 0.6 in the left	MRI showed infarctions in right occipital-temporal areas	Discriminating unfamiliar faces: Impaired	Normal
Ettlin et al[11], 1992	54, male	Stepwise succession of infarction	Left homonymous hemianopsia, reversible decreased vision, right superior quadrantanopia, visuo-perceptual and constructional difficulties. Visual acuity with correction was 20/30 in the right and 20/25 in the left eye	Infarction in the right parietal border zone territory, followed by a large occipital/parietal posterior-medial-temporal infarction, and a hemorrhage involving the left parieto-occipital area	Benton matching task: 6/271; famous faces test: 01	Normal
Habib et al[12], 1986	71, female	Right infection in the territory of PCA	Sudden onset of vertigo, posterior cephalalgia, intense palpitations, blurred vision, left hemianopia, impairment of topographical memory, handwriting recognition impairment, emotional changes	CT showed infarction in the territory of the posterior right occipital-temporal area	Famous faces test: Poor	Partially impaired
Renzi et al[13], 1986	73, male	Ischemic stroke	Blurred vision, dense left hemianopia without macula sparing, moderate left visual neglect, topographical disorientation	CT (12 mo) showed an extensive softening involving the entire territory of the right posterior cerebral artery	LEVIN’s face recognition test: 18/271; face memory test: 26/481	N/A

¹Indicates impairment or abnormality. SAH: Subarachnoid hemorrhage; PET: Positron emission computed tomography; WRMT: Warrington recognition memory for faces test; VOSP: Visual object and space perception battery; MRI: Magnetic resonance imaging; PCA: Posterior cerebral artery; N/A: Not applicable.