Clinical/ScientificNotes

J. Van den Stock, PhDM. Vandenbulcke, MD,

PhDQ. Zhu, PhDN. Hadjikhani, MD,

PhDB. de Gelder, PhD

DEVELOPMENTAL PROSOPAGNOSIA IN APATIENT WITH HYPOPLASIA OF THEVERMIS CEREBELLIIndividuals who have not acquired normal face rec-ognition abilities but are otherwise cognitively intacthave developmental prosopagnosia (DP). AlthoughDP prevalence is estimated at around 2.5%, the neu-ral underpinnings remain elusive and are presumablymore heterogeneous than prosopagnosia acquired inadulthood. Here we report a patient exhibiting severeDP and hypoplasia of the vermis cerebelli.

Case report. A 30-year-old right-handed femalefitness instructor, with no neurologic or psychiat-ric history and holding a university degree in liter-ary studies, consulted our department afterobserving remarkable similarities between her owndaily experience of poor face-recognition abilitiesand descriptions provided in an article on prosop-agnosia in the local newspaper. During intake, shereported lifelong difficulties in recognizing familiarfaces. For instance, after individually coaching aregular fitness client during half an hour, she doesnot recognize him an hour later. The similar gymoutfits and the absence of recognition cues besidethe face exacerbate her problem. She does notwatch movies, because she has problems tellingapart the characters and does not recognize famousfaces. She does not report difficulties recognizingfamiliar objects.

Behavioral testing. The patient performed withinthe normal range on a number of subtests of the Bir-mingham Object Recognition Battery (MatchLength � 26/30; Size Match � 26/30; OrientationMatch � 27/30; Position of Gap Match � 38/40;Minimal Feature View � 25/25; ForeshortenedView � 25/25; Object Decision � 23/32), indicat-ing that her low and midlevel visual perception andobject recognition abilities are intact.

Her performance on a computerized Warrington Rec-ognition Memory Test revealed impaired recognitionmemory for faces (accuracy � 36/50, Z score � �2.55,p � 0.005; reaction time (RT) � 4,861 msec, Z score �

�3.15, p � 0.001) and her performance on the BentonFacial Recognition Test was at borderline level (40/54).

Imaging. MRI revealed hypoplasia of the vermis(figure) as the only abnormality. We localized herface-selective areas by means of fMRI.1 Compar-ing faces with objects revealed activity in the well-known face regions: bilateral fusiform face area (FFA),right occipital face area (OFA), bilateral superior tem-poral sulcus (STS), and right amygdala. Her right FFAfalls within the area activated in a group of 20 controlsubjects. Controls were scanned with the same proto-col, but using a one-back task to activate short-termface and object memory processes. Two anatomicallydefined subdivisions of the vermis that are hypoplas-tic in the patient were more active during face mem-ory processing than object memory processing in thecontrol group (the vermis VI; Z score � 3.384; p �

0.001 and Crus II; Z score � 4.029; p � 0.001),indicating that the hypoplastic region is face-sensitive. She also took part in an fMRI study that wepreviously conducted with a DP group and normalcontrols.2 The results of that study revealed decreasedactivation in the right FFA for perceiving neutralfaces in the DP group (mean [SD] activation level �

4.8 [1.9]) compared to the control group (mean[SD] activation level � 8.5 [3.0]) (p � 0.05). Inter-estingly, her activation level (14.3) was among thehighest of all subjects and significantly higher thanthe DPs (Z � 4.76; p � 0.001). We compared face-specific activity in the control and DP group in thecerebellar region missing in the patient and found nodifference between the control and DP group (p �

0.65), suggesting that her face-recognition difficul-ties result from a different underlying mechanismthan the DP group with intact vermis cerebelli.

The behavioral and neuroimaging findings pointto a link between the face-recognition difficulties andhypoplasia of the vermis. Lesions3 and malforma-tions4 of the cerebellum can lead to socioemotionaland neuropsychiatric deficits like autistiform symp-toms, but also cognitive symptoms, including mem-ory impairments. The deficit in prosopagnosiaphenomenologically lies in face recognition memory,rather than in face perception: the clinical observa-tion as well as the complaint of prosopagnosia pa-tients is not that they have a deficit in perceivingfaces, but they are impaired at recognizing familiarfaces. It has been reported that face recognition

1700 Neurology 78 May 22, 2012

memory (measured with a 3-back task) is associatedwith activation of cerebellar midline structures.5 Thecerebellar peak of activation in ref 5 borders on themissing area in the patient. Furthermore, a well-documented patient with acquired prosopagnosiahas a lesioned vermis, although the prosopagnosiahas hitherto been presumed to originate fromoccipito-temporal lesions.6 A study inducing a virtuallesion in the midline cerebellum by means of repeti-tive transcranial magnetic stimulation showed im-paired processing of facial expressions.7

Our patient’s imaging and clinical data supportthe hypothesis that hypoplasia of the cerebellar ver-mis and prosopagnosia are related and converge todescribe a case of “cerebellar prosopagnosia.” How-ever, we grant that, when subclinical syndromic al-terations and congenital abnormalities exist at theoutset, functional brain reorganization may accountfor increased heterogeneity in clinical phenotypes.

From the Brain and Emotion Laboratory Leuven (BELL), Division ofPsychiatry (J.V.d.S., M.V., B.d.G.), and Laboratory for Neuro- and

Psychophysiology (Q.Z.), Department of Neurosciences, KU Leuven,Leuven, Belgium; Cognitive and Affective Neuroscience Laboratory(J.V.d.S., B.d.G.), Tilburg University, Tilburg, the Netherlands; BrainMind Institute (N.H.), Swiss Federal Institute of Technology, Laus-anne, Switzerland; and Athinoula A. Martinos Centre for BiomedicalImaging (N.H., B.d.G.), Massachusetts General Hospital, HarvardMedical School, Charlestown.

Author contributions: Jan Van den Stock designed the study, analyzedand interpreted the data, and wrote the paper. Mathieu Vandenbulckedesigned the study, interpreted the data, and wrote the paper. Qi Zhuanalyzed and interpreted the data. Nouchine Hadjikhani designed thestudy and analyzed and interpreted the data. Beatrice de Gelder de-signed the study, interpreted the data, and wrote the paper.

J.V.d.S. and Q.Z. are postdoctoral researchers supported by FWO-Vlaanderen.

The authors report no disclosures relevant to the manuscript. Go toNeurology.org for full disclosures.

Received November 15, 2011. Accepted in final form January 17, 2012.

Correspondence & reprint requests to Dr. Van den Stock:jan.vandenstock@med.kuleuven.be

Copyright © 2012 by AAN Enterprises, Inc.

1. Hadjikhani N, de Gelder B. Neural basis of prosopagnosia:

an fMRI study. Hum Brain Mapp 2002;16:176–182.

Figure Structural and functional imaging data in the patient and controls

(A) Sagittal MRI slices of the patient’s brain, showing hypoplasia of the vermis cerebelli. The yellow dot on slice X � 4 demarks the position of the localcerebellar maximum of reference 5 (indicating more activation for recognition memory of faces compared to spatial location). The vertical lines on the axialslice on the top left correspond to the position of the outer sagittal slices. (B) Stimulus examples from the functional face localizer experiment and the colorcoding corresponding to the statistical parametric maps (left). Face-selective activity from the patient projected on her brain showing right superiortemporal sulcus (STS) (right) and right fusiform face area (FFA) (center). The bottom middle shows the FFA and occipital face area (OFA) of the patientprojected on the averaged inflated right hemisphere of 20 control subjects. The yellow line demarks the contour of the face-selective activity in the controlgroup. Coordinates refer to Montreal Neurological Institute space.

Neurology 78 May 22, 2012 1701

2. Van den Stock J, van de Riet WA, Righart R, de Gelder B.Neural correlates of perceiving emotional faces and bodiesin developmental prosopagnosia: an event-related fMRI-study. PLoS ONE 2008;3:e3195.

3. Schmahmann JD, Sherman JC. The cerebellar cognitiveaffective syndrome. Brain 1998;121:561–579.

4. Tavano A, Grasso R, Gagliardi C, et al. Disorders of cog-nitive and affective development in cerebellar malforma-tions. Brain 2007;130:2646–2660.

5. Courtney SM, Ungerleider LG, Keil K, Haxby JV. Ob-ject and spatial visual working memory activate separate

neural systems in human cortex. Cereb Cortex 1996;6:39 – 49.

6. Simon SR, Khateb A, Darque A, Lazeyras F, Mayer E,Pegna AJ. When the brain remembers, but the patientdoesn’t: converging fMRI and EEG evidence for covertrecognition in a case of prosopagnosia. Cortex 2011;47:825– 838.

7. Schutter DJ, Enter D, Hoppenbrouwers SS. High-frequencyrepetitive transcranial magnetic stimulation to the cerebellumand implicit processing of happy facial expressions. J Psychia-try Neurosci 2009;34: 60–65.

AAN Publishes New Guidelines on MigrainePrevention

Research shows that many treatments can help prevent migraine in certain people, yet few peoplewith migraine who are candidates for these preventive treatments actually use them, according totwo new guidelines issued by the American Academy of Neurology. The guidelines were publishedin the April 24, 2012, issue of Neurology�.

To read the guidelines and access PDF summaries for clinicians and patients, a slide presentation,and a clinical example, visit www.aan.com/go/practice/guidelines. For more information, contact JulieCox at jcox@aan.com or (612) 928-6069.

AAN Webinars: Help for Your Practice, CME forYour Career

The American Academy of Neurology offers cost-effective Practice Management Webinars that can beattended live or through convenient recordings after the event. AAN members can benefit from two freesessions and save 25% on all regular webinars! Plus, registrants can earn 1.5 valuable CME credits for eachwebinar. For more information and to register, visit www.aan.com/view/pmweb today!

Online Now Decoding the 2012 Physician Fee Schedule: Changes that Impact Neurology(FREE to AAN members!)

Online Now EHR Implementation: What You Need to Know from A-Z

Online Now CPT Coding for Neurodiagnostic Procedures Made Easy

Online Now Incentive Programs and Penalties: What Do They Mean for My Practice?(FREE to AAN members!)

Online Now Ready, Set, Payment: Using Certified EHRs for Meaningful Use Payments

June 12 The ABCs of Coding

July 17 E/M: Minimize Mistakes, Maximize Reimbursement

September 18 Thriving in the Face of an Audit

October 16 ICD-10: Are You Prepared?

November 6 Coding Accurately for Stroke and Critical Care

1702 Neurology 78 May 22, 2012