Right-left Disorientation Research Articles

Anatomical variations of artery of angular gyrus

Context: Angular gyrus is an anatomical structure of the brain located in the parietal lobe, taking part in writing and reading, language-use, memory and attention and spatial recognition. It is supplied by the angular gyrus artery, which is one of the caudal branches of the middle cerebral artery. One of the clinical pathologies of the angular gyrus artery is the ischemic stroke of the angular gyrus in the dominant hemisphere, responsible for the presence of Gerstmann Syndrome: left-right disorientation, agraphia, alexia, acalculia and finger agnosia. This systematic review aims to present the variety of anomalies of the main cerebral artery and the angular gyrus artery.
 Objective: Preparing a systematic review of papers describing the course anomalies of the angular gyrus artery.
 Materials and methods: PubMed and Google Scholar electronic databases was searched for phrases: ‘Angular gyrus artery’, ‘Artery of angular gyrus’, ‘Middle cerebral artery branches’, ‘Branches of middle cerebral artery’, ‘Gerstmann Syndrome’ published between years 2015 and 2023. Also 3 papers published before 2000 were used. From the selected 30 papers, 6 were used to prepare this analysis.
 Results: The middle cerebral artery, from which arises the angular gyrus artery, is marked by a significant variety of its division, mainly the number of the dividing trunks of the artery. Depending on the type of the division, the angular gyrus artery can arise from the upper, middle or lower trunk and vary in sizes. It can also appear as a singular or two separate branches. Instances of the anomaly of both the angular gyrus artery and posterior parietal artery are rare, but reported.
 Conclusions: The angular gyrus artery is characterised by a number of anomalies in its course, separation from the middle cerebral artery, diameter and branching.

A Tetrad Cognitive Presentation of Gerstmann Syndrome: A Rare Manifestation of Stroke

Gerstmann Syndrome is a rare neurological presentation due to a lesion in the left dominant parietal lobe, manifesting as a tetrad of agraphia, acalculia, finger agnosia and right-left disorientation. We present a case of a 52-year-old man, right hand dominant, who presented to the Emergency Department with acute confusion for one day. He was disorientated to time, place and person. Focused neurological examination revealed atypical signs of acute stroke, comprising agraphia, acalculia, finger agnosia and right-left disorientation. Stroke protocol was activated and he underwent computed tomography brain perfusion, which confirmed a large penumbra area at the left middle cerebral artery territory. Computed tomography angiogram of the carotid arteries showed a long segment thrombosis in the left internal carotid artery. Emergency thrombectomy was abandoned due to impenetrable hard thrombus. He was treated with dual antiplatelet therapy and discharged after three days with partial improvement in terms of following commands, simple calculations and reduced finger agnosia. He was scheduled for outpatient follow up. This case highlights Gerstmann syndrome as an atypical manifestation of acute stroke.

Secondary Gerstmann syndrome, a case report

IntroductionGerstmann syndrome is a rare neurological disorder that consist primarily of 4 neuropsychological signs that include acalculia (impairment in performing calcultaions), digital agnosia (dificulty discriminating their own fingers), agraphia (impairment or dificulty to write by hand); and left-right disorientation (impairment of distinguishing left from right.ObjectivesPresentation of a case report of a patient with Gertsmann syndrome secondary to breast cancer metastasis.MethodsWe analyze the case of a 79 years-old female with a history of breast cancer in remission, with a severe depressive episode of 8 months of evolution, dysphoria, apathy, decrease in the ability to carry out basic activities of daily life, acute personality changes and sleep disruption. 15 days previous to the first examination the patient suffers gait disturbances, falling from her own height, memory impairment, suicide ideation and nomination aphasia.ResultsAt the examination we encounter digital agnosia, acalculia, agraphia, right-left disorientation, right hemiparesis. MRI are taken founding 3 tumor lesions in the left and right frontal lobe, 2 solid lesions with a necrotic appearance in the right parietal lobe, one of them in the angular gyrus of the parietal cortex. CT scan found a solid tumor-like lesion in the left pulmonary apex. CA-125 antigen 429.5 U/mL. She was sent to continue her treatment with oncology, receiving radiotherapy.ConclusionsThe psychiatric abnormalities secondary to Gerstmann syndrome make the relatives of this patient seek psychiatric care, requiring multidisciplinary work to reach an accurate diagnosis. Gerstmann syndrome is a rare neurological condition that can mimic lots of other clinical pictures.DisclosureNo significant relationships.

Diagnosing Gerstmann’s syndrome in a case of hypoxic brain injury

Objectives: Gerstmann’s syndrome (GS) is characterised by the cooccurrence of acalculia, finger agnosia, agraphia and left-right disorientation. Although there is a relatively large literature on the syndrome’s theoretical implications, less consideration has been given to the assessment of the syndrome in practice. We aimed to provide an illustrative case study of the differential diagnosis of GS.Methods: We describe a case of a 46-year-old woman who presented with the four classic symptoms of GS following a cardiac arrest. In addition to a standard neuropsychological assessment battery, an additional dedicated brief assessment was conducted to differentiate between GS and alternative possibilities.Results: The assessment revealed specific impairments in performing calculations, finger agnosia, agraphia and left-right disorientation, which could not be accounted for by alternative explanations, including a general cognitive impairment, dysphasia, apraxia, Balint’s syndrome, unilateral spatial neglect or object agnosia.Conclusions: The present article provides an illustrative case study of the differential diagnosis of Gerstmann’s syndrome, highlighting how the syndrome may be assessed in clinical practice.

Синдром Герстмана у дорослої українки

Background. During the screening phase of the study, we observed a middle-aged woman with a rare disorder known as Gerstmann's syndrome. The woman showed four important neuropsychopathological symptoms that describe this disturbance. Methods. To assess the woman's status, we used physical, psychiatric, psychopathological and neurological examinations, laboratory tests interpretation, retrospective analysis of the hospital sheet chart and literature search. Results. A 33-year-old East European woman from Ukraine has been suffering from acalculia since age six, digital agnosia, confusion of left-right orientation, and writing disturbances. She is lifelong right-hand dominant person and somebody in her family suffered from mental illness. She used to be successfully treated for anxiety and obsessions. She does not use any illicit drugs and denies alcohol use or abuse. The woman had never smoked cigarettes. Physical examination, CBC, complex metabolic panel, endocrine tests were within the age range. CT and MRI scans were common. Rheoencephalography revealed signs of moderate changes in venous outflow in the carotid basin on the left. We detected the most important psychopathological and neurological findings in mental health examinations. During assessment the woman was unable to perform simple arithmetic calculations. That is a crucial symptom, well known as a term an acalculia. Digital agnosia as the inability to identify or point to her own or someone else's fingers was present as well. Also, she had left-right disorientation - an inability to distinguish between right and left, and mild writing disturbance - decreasing of the capability to express thoughts in writing. In addition, she had demonstrated constructional apraxia by performing the clock drawing test. Conclusions. We brought to light a rare syndrome in Ukrainian woman. The incidence of that syndrome in the general population has not yet been known. We found all four symptoms from a tetrad as a result of general brain damage with learning disabilities but some of the symptoms were mild. It is believed that some of them diminishing in adults over time.

PATH-05. A CASE OF PILOCYTIC ASTROCYTOMA HARBORING THE FGFR1 GENE MUTATION WITH A PREDOMINANT OLIGODENDROGLIOMA-LIKE COMPONENT

Pilocytic astrocytomas rarely present with oligodendroglioma-like morphological features, which gives rise to a diagnostic challenge. In this report we present a case of pilocytic astrocytoma harboring the FGFR1 mutation, accompanied with a predominant oligodendroglioma-like component, thus initially diagnosed as oligodendroglioma. A 14-year-old female presented with syncope and simple partial seizure involving her right upper limb. Contrast-enhanced MRI revealed an enhancing lesion with substantial cystic portion and perifocal edema in the left parietal lobe. Open surgery was performed and a gross total resection of the tumor was achieved. On initial histopathological diagnosis, tumor cells with monotonous round nuclei and perinuclear halo predominated with branching capillaries, which were strongly suggestive for oligodendroglioma. Immunohistochemically, IDH1 R132H was negative, and Ki-67 index was around 5%. The patient was thus initially diagnosed as oligodendroglioma, WHO grade II, based on the 2007 WHO classification criteria. However, histopathological re-review revealed a minor astrocytic component with Rosenthal fibers and rare eosinophilic granular bodies, thus the diagnosis was changed as pilocytic astrocytoma. FGFR1 K654E mutation was confirmed by Sanger sequencing. Although she postoperatively developed mild sensory disturbance in her right hands, finger agnosia, and left-right disorientation, her symptoms had gradually improved, and she was discharged on day 17 with a Karnofsky performance status (KPS) of 90 and no cognitive decline. Without any adjuvant therapies, she has remained recurrence-free for 85 months. While the diagnosis of pilocytic astrocytoma with predominant oligodendroglioma-like component can be challenging, analysis of IDH1 and FGFR1 mutations can be beneficial in certain cases.

Gerstmann Syndrome.

Gerstmann (left angular gyrus) syndrome includes the tetrad of finger agnosia (inability to distinguish, name, and recognize the fingers), agraphia (acquired disturbance in the ability to write), acalculia (loss of the ability to perform arithmetical operations and use numerical concepts), and right-left disorientation (right-left discrimination defect when using language). There is some disagreement regarding its exact localization, but it most likely involves the left angular gyrus with a probable subcortical extension. This article reviews recent research on the clinical aspects of this syndrome. During the last years, just some few new reports of Gerstmann syndrome are found in neurological and neuropsychological literature. Most of the reports are single-case reports. An association between Gerstmann syndrome and the so-called semantic aphasia has been pointed out. Two different explanations to this unusual syndrome have been recently proposed: (1) the pathological process is located in the left parietal white matter disconnecting separate cortical networks and (2) it represents a disturbance in the ability to verbally mediate some spatial knowledge. Although Gerstmann syndrome continues as a controversial syndrome, and most of the reports are single case reports, recently two different explanations have been advance the understanding of this polemic but fascinating syndrome.

DOES GERSTMANN SYNDROME EXIST?

The aim of the study is to present Gerstmann syndrome, manifested as a neuropsychological deficit resulting from the damage to the parietal lobe of the left hemisphere. Here it is discussed based on the studies conducted mainly since the 1950’s when it attracted considerable interest, as well as and controversy at the same time. The classic symptoms are briefly described, including the clinical tasks useful in any the diagnosis for during the neuropsychological assessment. The paper also presents recent studies and a alternative different proposal for the understanding of this clinical syndrome. Josef Gerstmann described a clinical tetrad in his patients, which was later to be known as Gerstmann syndrome. The symptoms included finger agnosia, agraphia, acalculia and left-right disorientation. He associated the above symptoms with damage to the left angular gyrus, hence the alternative a different name for of the syndrome i.e., the angular gyrus syndrome. The existence of the syndrome was questioned for some time, something which was never approved by Gerstmann. Currently, the occurrence of the syndrome is confirmed by studies. However, the full and pure tetrad of the classic symptoms as observed is not common. The clinical picture of the syndrome often usually remains incomplete and is related to other neuropsychological deficits such as aphasia, which frequently occurs. In modern considerations, the language deficiencies of semantic aphasia are not treated as non- Gerstmann syndrome, disturbing its pure form, but are considered to be a part of Gerstmann syndrome as such.

The making of a syndrome: The English translation of Gerstmann's first report

The label Gerstmann syndrome indicates the co-occurrence of four symptoms in persons with acquired brain lesions: finger agnosia, left–right disorientation, agraphia, and acalculia. The syndrome is often associated with a lesion affecting the posterior parietal lobe of the left cerebral hemisphere. Virtually every paper discussing this tetrad of symptoms refers back to Josef Gerstmann's (1924) first report published in German. To make it accessible to the wider community of scholars and thus enable a more in-depth appreciation of the origins of this enigmatic syndrome, here we publish, for the first time in English, a translation of Gerstmann's initial report. In this paper, the syndromal construct had not yet crystallized into its four cardinal symptoms; Gerstmann's attention was mainly focused on finger agnosia and, to a lesser extent, on left-right disorientation by virtue of their significance for the body scheme theory. Although isolated agraphia and acalculia seemed to be at least as severe as finger agnosia, Gerstmann did not consider them of consequential importance (with the exception of agraphia's localisation value). It is also worth noting that the described patient presented a picture of Gerstmann syndrome associated with other symptoms such as hemianopia, balance impairment, and light memory and reasoning disorders.

Síndrome de Gerstman secundario a malformación arteriovenosa del lóbulo parietal izquierdo. Reporte de caso

El síndrome de Gerstman se caracteriza porque los pacientes presentan 4 síntomas: alteraciones en la capacidad de expresar ideas por la escritura (agrafia), incapacidad para contar y realizar operaciones aritméticas sencillas (acalculia), imposibilidad de reconocer los dedos de la mano (agnosia digital) y desorientación derecha izquierda.
 Se asocia habitualmente con la lesión de una parte específica del cerebro, el giro angular del lóbulo parietal del hemisferio izquierdo. Habitualmente suele ser secundario a un accidentecerebro-vascular cerebral que afecta el territorio de la arteria cerebral media. La importancia del cuadro radica en su pronta detección por las consecuencias como afectación del lóbulo parietal posterior dominante para el lenguaje.
 El objetivo: es hacer una correlación anátomo-clínico-quirúrgica de este síndrome. A continuación se enmarca un caso de malformación arteriovenosa en la región parietal izquierda una paciente que consultó al departamento de Neurocirugía del Hospital Roosevelt por cefalea y alteración conductual.

Gerstmann syndrome in a young man: a case report

Gerstmann syndrome is a classical cerebral syndrome in neurology, named after Joseph Gerstmann, a Jewish Austrian-born American neurologist. Patients present with a tetrad of cognitive symptoms, including agraphia, acalculia, finger agnosia and left-right disorientation. The syndrome is known to result from a lesion of the posterior portion of the dominant parietal lobe and is usually due to stroke or to developmental problems. We describe the case of a 35-year-old man whose illness debuted about 9 months before the initial presentation to the neurology clinic, with memory complaints, anxiety, verbal aggression, sleeping problems, as well as subjective word finding difficulty and depressed mood. The patient had 3 out of the 4 classic symptoms of Gerstmann syndrome, among other, mostly neuropsychiatric symptoms. Initially, structural lesions were sought for, but were not found on magnetic resonance imaging. Psychiatric conditions were discussed but not confirmed by the consulting psychiatrist. We are prone to accepting a non-organic reason for the condition of the patient, but follow-up of the clinical course and repeated assessments, including neuropsychological and psychiatric evaluations, structural and possibly functional neuroimaging will be required to verify and confirm this presumption.

Widespread enlarged perivascular spaces associated with dementia and focal brain dysfunction: case report

BackgroundEnlarged perivascular spaces (PVS) are common magnetic resonance imaging (MRI) findings, whereas widespread enlarged PVS are extremely rare. Although most patients with widespread enlarged PVS remain asymptomatic, some develop neurological dysfunctions; however, it remains unclear whether these are the consequence of widespread enlarged PVS.Case presentationA 64-year-old female patient developed consciousness disturbance, cognitive dysfunctions, fluent aphasia, agraphia, acalculia, and left-right disorientation after suffering from bronchopneumonia. Brain MRI revealed unusually widespread enlarged PVS predominantly in the left cerebral hemisphere. Following bronchopneumonia treatment, her cognitive dysfunction, fluent aphasia, agraphia, acalculia, and left-right disorientation persisted despite improvement of her general condition. Furthermore, the hypoperfusion area on single photon emission computed tomography and slow wave sites on electroencephalography were consistent with the location of enlarged PVS, indicating that severe enlarged PVS impaired focal brain functions.ConclusionsThis case suggested that widespread enlarged PVS could be a potential cause of neurological deficits. We propose that impaired perivascular circulation due to enlarged PVS might lead to focal brain dysfunction.

Brodmann Areas 39 and 40: Human Parietal Association Area and Higher Cortical Function

The anatomy and function of the angular gyrus (Brodmann Area 39) and supramarginal gyrus (Brodmann Area 40) are described here. Both gyri constitute the inferior part of the parietal lobe. Association fibers from the angular gyrus project to the dorsolateral prefrontal cortex via the superior longitudinal fasciculus (SLF) II/arcuate fasciculus (AF), whereas those from the supramarginal gyrus project to the ventrolateral prefrontal cortex via SLF III/AF. Damage to the left angular gyrus causes kanji agraphia (lexical agraphia) and mild anomia, whereas damage to the left supramarginal gyrus causes kana alexia (phonological dyslexia) and kana agraphia (phonological agraphia). Damage to either gyrus causes Gerstmann's syndrome (finger agnosia, left-right disorientation, agraphia and acalculia) and verbal short-term memory impairment. "Angular alexia with agraphia" results from damage to the middle occipital gyrus posterior to the angular gyrus. Alexia and agraphia, with lesions in the angular or supramarginal gyrus, are characterized by kana transposition errors in reading words, which suggests the impairment of sequential phonological processing.

Two Cases with Cerebral Infarction in the Left Middle Frontal Lobe Presented as Gerstmann's Syndrome

Gerstmann's syndrome is a neuropsychological disorder characterized by four symptoms, namely, acalculia, finger agnosia, left-right disorientation, and agraphia suggesting the presence of a lesion in the inferior parietal lobule of the dominant hemisphere, especially at the angular gyrus. Several descriptions of Gerstmann's syndrome have been reported in associated with a lesion to the left frontal lobe, but none of these reports fulfilled the full tetrad of diagnostic criteria. Herein, we report two cases with all four symptoms of Gerstmann's syndrome associated with an uncommon area in the left middle frontal lobe without an angular gyrus lesion. This apparent discrepancy could be explained by disconnection of functional fiber between the frontal and parietal cortex. Moreover, left frontal cortex or the subcortical area may be an important functional area which is closely connected with the parietal lobe in Gerstmann's syndrome.

A proposed reinterpretation of Gerstmann's syndrome.

Gerstmann's syndrome includes the clinical tetrad of finger agnosia, agraphia, acalculia, and right-left confusion. Some disagreement remains with regard to the exact localization of the syndrome, but most probable it involves the left angular gyrus with a subcortical extension. Several authors have suggested that a defect in mental spatial rotations could simultaneously account for acalculia, right-left disorientation, and finger agnosia. It has been also suggested that semantic aphasia is always associated with acalculia; as a matter of fact, left angular gyrus has a significant involvement in semantic processing. In this paper, it is proposed that Gerstmann's syndrome should include: acalculia, finger agnosia, right-left disorientation, and semantic aphasia, but not agraphia. When the pathology extends toward the superior parietal gyrus, agraphia can be found. A fundamental defect (i.e., an impairment in verbally mediated spatial operations) could explain these apparently unrelated clinical signs.

MS-16 * A RARE CASE OF PRIMARY CNS ANGIOSARCOMA PRESENTING AS AN INCOMPLETE GERSTMANN SYNDROME: A CASE REPORT AND REVIEW OF LITERATURE

INTRODUCTION: Primary central nervous system angiosarcoma is a very rare malignancy, with only 22 cases reported in the literature for the past 26 years. A 60-year old Filipino woman, housewife, presented with 1 week history of difficulty performing daily mathematical equations, difficulty reading words, and difficulty writing. On neurologic exam, patient was found to be oriented to person, place, and time. There was note of dyscalculia, agraphia, and right-left disorientation. There were no finger agnosia, agraphesthesia, astereognosia, nor apraxia. Cranial MRI showed a 4 x 4 x 4.1 cm mass at the left parietal lobe. Total excision of the mass done and biopsy revealed angiosarcoma of the brain. Thorough search for another systemic lesion failed to show any other angiosarcomatous lesion. The patient refused any further radiotherapy or chemotherapy. METHOD & RESULTS: Soft tissue sarcomas comprise a small percent 1% of the malignant neoplasms, and of which only 0.5% comprise the primary brain OR spine sarcoma. In the review of literature that we did, of the 22 reported cases, the tumor was commonly located supratentorially (9/22), affecting middle to late ages with 3:1 male to female ratio. It is an aggressive tumor with a <2-year (range of survival is 4 months -3½ years) survival independent of the age, location, or whether chemotherapy or radiotherapy was given. As with the best of our knowledge, there has been no recorded case of angiosarcoma which presented with Gerstmann syndrome in the literature. CONCLUSION: We described the first reported case of primary CNS angiosarcoma in the Philippines and the 23rd worldwide. We also described the first case of angiosarcoma which presented with Gerstmann synd.

P04 * A RARE CASE OF PRIMARY CNS ANGIOSARCOMA PRESENTING AS AN INCOMPLETE GERSTMANN SYNDROME: A CASE REPORT AND REVIEW OF LITERATURE

INTRODUCTION: Primary central nervous system angiosarcoma is a very rare malignancy, with only 22 cases reported in the literature for the past 26 years. A 60-year old Filipino woman, housewife, presented with 1 week history of difficulty performing daily mathematical equations, difficulty reading words, and difficulty writing. On neurologic exam, patient was found to be oriented to person, place, and time. There was note of dyscalculia, agraphia, and right-left disorientation. There were no finger agnosia, agraphesthesia, astereognosia, nor apraxia. Cranial MRI showed a 4 x 4 x 4.1 cm mass at the left parietal lobe. Total excision of the mass done and biopsy revealed angiosarcoma of the brain. Thorough search for another systemic lesion failed to show any other angiosarcomatous lesion. The patient refused any further radiotherapy or chemotherapy. METHOD & RESULTS: Soft tissue sarcomas comprise a small percent 1% of the malignant neoplasms, and of which only 0.5% comprise the primary brain OR spine sarcoma. In the review of literature that we did, of the 22 reported cases, the tumor was commonly located supratentorially (9/22), affecting middle to late ages with 3:1 male to female ratio. It is an aggressive tumor with a <2-year (range of survival is 4 months -3½ years) survival independent of the age, location, or whether chemotherapy or radiotherapy was given. As with the best of our knowledge, there has been no recorded case of angiosarcoma which presented with Gerstmann syndrome in the literature. CONCLUSION: We described the first reported case of primary CNS angiosarcoma in the Philippines and the 23rd worldwide. We also described the first case of angiosarcoma which presented with Gerstmann synd.

TREATING GERSTMANN'S SYNDROME WITH NATALIZUMAB

Gerstmann9s syndrome is a rare disorder resulting from damage to the angular gyrus of the dominant parietal lobe leading to agraphia, acalculia, finger agnosia and left-right disorientation. In adults the syndrome is usually seen after stroke. Particularly in young patients other causes need to be considered. We present video, MRI and pathological evidence of the case of a 30 year old woman who developed Gerstmann9s syndrome as a result of a tumefactive multiple sclerosis (MS) lesion affecting the left cerebral hemisphere. Intravenous corticosteroids failed to stop rapid enlargement of the index lesion and occurrence of additional hemispheric lesions leading to clinical deterioration. Brain biopsy confirmed the diagnosis of MS. Strong contrast enhancement of the lesions prompted us to start treatment with natalizumab 300 mg i.v. every four weeks leading to sustained disease remission over a 14 month follow-up period though complex-focal epileptic seizures require ongoing anti-epileptic treatment. This case highlights the heterogeneous presentation of tumefactive MS, the need in some cases of an early brain biopsy, and the worthwhile consideration of natalizumab treatment where additional evidence supports a diagnosis of relapsing MS.

Primary intravascular large B-Cell lymphoma of the central nervous system - Antemortem diagnosis and review of literature

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of extranodal large B-cell lymphoma occurring in adults, characterised by growth of neoplastic lymphoid cells within the lumina of blood vessels, particularly capillaries. The clinical presentations are non-specific and histological features are often subtle. We report a case of a 60-year-old male who presented with a several week history of headaches, general malaise and fluctuating visual disturbances followed by sudden onset of confusion. Neurological deficits included disorientation, nominal aphasia, left-right disorientation and left sided homonomous hemianopia. MRI of the brain revealed diffuse leptomeningeal enhancement and digital subtraction angiography showed an abnormality of a branch of the left of middle cerebral artery consistent with CNS vasculopathy. The differential diagnosis included vasculitis, stroke and atypical migraine necessitating an open biopsy. The histological sections revealed an intravascular infiltrate of large neoplastic B-cells that express CD20 within leptomeningeal vessels and small intrapar-encymal vessels with no involvement of the brain parenchyma. The case illustrates the protean clinical manifestations of CNS IVLBCL and the subtleties of its histological diagnosis. Correct diagnosis is important as treatment regimes drastically differ between IVLBCL and its clinical mimics.

Clinical Progress of Gerstmann's Syndrome with Left Frontal Lobe Lesion: Two Cases

Gerstmann’s syndrome, assigned to a lesion of the dominant parietal lobe, is a neurological disorder characterized by acalculia, agraphia, right-left disorientation and finger agnosia. Some studies report that these symptoms are also shown in other brain lesions. We report two patients who presented with this tetrad of symptoms in initial assessment. Their Brain MRI images both showed lesion of left frontal lobe. Over time, these symptoms became better but some still remained in last assessment. Accordingly, we suggest that a left frontal lesion cause Gerstmann’s syndrome. Received: December 1, 2013 Revision received: December 12, 2013 Accepted: December 12, 2013