Apraxia refers to the disorder of movement planning and execution that cannot be accounted for by motor or sensory deficits nor by other cognitive impairments. The term apraxia encompasses several different deficits, including “face apraxia”, which defines the impairment of movements performed within the district of the cranial nerves. Group studies have shown that face apraxia results from lesions of the left hemisphere.1 However, a few cases can be gleaned from the literature of patients whose face apraxia followed lesions in their right hemisphere and was mentioned in fleeting comments.2-4

Face apraxia has generally been equated to oral apraxia and tests aimed at assessing it only comprise items exploring skilled movements of the lips, cheeks, and tongue. However, several early authors reported on patients with face apraxia also showing movement deficits of the eyes and eyebrows.5 Some anecdotal evidence of upper face apraxia is also reported in more recent investigations.6We report on a patient, who, 2 years after a right hemispheric lesion, showed severe face apraxia for movements of both the lower and the upper parts of the face. A 55 year old artist with 17 years of education had an ischaemic stroke in August 1997. A series of CT and MR scans showed a right frontoparietal insular hypodensity also encroaching on the anterior region of the right internal capsule and of the right deep nuclei, sparing the mesial and the anterior part of the parietal lobe. He had always been right handed, scored 100% right handed on both the Edinburgh handedness questionnaire7 and the 12 question handedness inventory.8 He also denied familiarity for left handedness. We examined the patient in October 1999, 5 months after the end of his rehabilitation therapy and more than 2 years after his stroke. He still showed a severe left paresis, hemianopia, and a deficit of the lower facial nerve. No further deficits of the cranial nerves were seen. In particular, spontaneous movements of the oculomotor nerves were normal. The patient did not show general cognitive impairment: his scores on intelligence tests were well within the normal range. At the time of our assessment he did not show clear evidence of visuospatial neglect which was mentioned in the clinical notes at onset. He performed flawlessly tasks assessing the ability to search for particular targets, in reading, or in line bisecting, although he omitted a few left details in copying complex geometrical drawings. During neurological examination the patient proved unable to close his eyes on verbal command. He failed even when the examiner showed him how to do it. He was therefore submitted to a battery of tests assessing apraxia including the upper and lower face apraxia test.9 The nine upper and 29 lower items of the test were performed first on imitation and then, considering the possibility that the patient could have some difficulty in perception, on verbal command. On imitation, the patient scored 2/45 and 320.25/435 (adjusted scores) on the upper and lower face sections of the test respectively, both well below the inner tolerance limit cut off scores (38.43/45; 400.04/435). On command he failed all items of the upper face test and he failed the same items of the lower face test which he failed on imitation.

His errors were perseveration of the previous item or substitutions with another movement—for instance, when asked to make a clip-clop noise with his tongue, he showed his teeth, then made his teeth chatter. Similarly, asked to close his eyes, he said “yes” at first, then he opened his mouth, then he tried to show his tongue. He was unable to close either his right or his left eye, to look leftward or rightward keeping his head motionless, or to wrinkle his forehead or his nose.

The patient's face apraxia could not be due to motor impersistence because he was not required to hold a position for a given time.10 Moreover, the fact that his face apraxia was long lasting excludes the possibility that upper face apraxia has to be drawn back to diaschisis or other similar phenomena. Finally, neglect had recovered at the time of testing and there was no cognitive deterioration to account for the presence of this symptom.

Ideomotor apraxia was also assessed by means of a 24 item test.11 His score with the right arm and hand was normal (64/72, cut off score=53). The patient was not aphasic; his language was emitted with a normal prosody, was well articulated, informative, and without qualitatively aphasic errors.

This case points to a possible role that the right hemisphere might have in normal facial praxis, both for the lower and upper face areas, in some people. Moreover, it confirms the dissociation between face apraxia and aphasia, as well as between limb and face apraxia.