BRIEF COMMUNICATIONS
imitating gestures, and they concluded that ideational
Ideationai Atxaxia:
A Deficit in ?o01
Selection and Use
C. Ochipa, MA,*$ L. J. G. Rothi, PhD,*$
and K. M. Heilman, MD+$
We report a 67-year-old left-handed man who exhibited
an ideational apraxia in both clinical and nonclinical
natural settings following a right hemisphere infarction.
His inability to use tools could not be explained by a
motor production deficit (ideomotor apraxia), because
he made content errors and could not match tools with
objects. His deficit could not be attributed to an agnosia
or language comprehension deficit, because he could
name tools and point to tools on command. Based on our
testing, it appeared that this patient had a loss of knowl-
edge related to tool use.
Ochipa C , Rothi LJG, Heilman KM. Ideational
apraxia: a deficit in tool selection and use.
Ann Neurol 1989;25:190-193
The error patterns in ideational apraxia have been de-
scribed as the perseveration, omission, or misordering
of acts that are components of multistage complex ac-
tions with objects [4, 10, li]. Poeck [lo] maintains
that ideational apraxics are impaired not in their use of
single objects, but only in the correct sequencing of
acts such that an intended goal cannot be achieved.
The term ideational apraxia proposed by Liepmann [b,
71, however, impiies not a sequencing deficit but a
conceptual defect. Morlaas E81 and De Renzi and col-
leagues [i] agreed and operationally defined ideational
apraxia as a defect in tool utilization.
An impairment in the use of tools may, however,
result from either a conceptual defect (ideational
apraxia) or a defect in motor production (ideomotor
apraxia). Zangwill [lb] suggested that ideational
apraxia, as defined by tool use, may be a severe form of
ideomotor apraxia wherein a defect in motor program-
ming results in impaired performance with actual ob-
jects. De Renzi and colleagues [i] found that 11 of
their 140 patients with left hemisphere damage were
more impaired when using actual objects than when
From the *Audiology-SpeechPathology Service and the tNeurol-
ogy Service, Veterans Administration Medicai Center, Gainesville,
FL, and the SDepanment of Neurology, Coiiege of Medicine, Uni-
versity of Florida, Gainesviile, FL.
Received Apr 22, 1988, and in revised form Jun 30. Accepted for
publication Jui 2, 1988.
Address correspondence to Dr Heilman, Box J-236, J. Hillis Miller
Heaith Center, Gainesviile, FL 32610.
apraxia may occur independent of ideomotor apraxia.
These results could be accounted for by several fac-
tors. De Renzi and colleagues used transitive gestures
when testing for ideational apraxia and intransitive ges-
tures when testing for ideomotor apraxia. Ideomotor
apraxics have been shown to be more impaired when
making transitive movements than when making in-
transitive movements 123, suggesting that these move-
ments are mediated differently 13, 151. Second, the
ideomotor task required the imitation of one gesture,
while the ideational task required the selection of an
item to verbal command, which may have been in-
fluenced by language comprehension problems. Third,
the nature of the errors produced by de Renzi and
colleagues’ patients was not described. If ideational
apraxia is a conceptual deficit, content errors (as op-
posed to motor production errors) shouid be ob-
served. Fourth, their patients were not tested for an
agnosia.
We also define ideational apraxia as a loss of concep-
tuai knowledge related to tool use (not necessarily due
to a performance deficit), and we describe a left-
handed patient with a right hemisphere infarction who
exhibited such an ideational apraxia. This patient’s ide-
ational apraxia could not be accounted for on the basis
of an agnosia, impaired language comprehension, or an
ideomotor apraxia.
Case History and Methods
Case History
A 67-year-old left-handed, high school-educated, hyperten-
sive, diabetic man had sudden onset of a left hemiparesis
accompanied by speech difficulty. A computed tomographic
scan conducted 1 week after onset revealed an infarction in
the distribution of the right middle cerebral artery involving
the frontal, inferior parietal, and superior temporal lobes
(Figure). While he was in the hospital, we investigated his
language and praxis, because his performance with actual
tools was impaired.
Metbods
The patient’s language abilities were evaluated 1 week and 1
month after onset with the Western Aphasia Battery [5J.
Praxis testing was conducted at approximately 1 month after
onset. The patient performed al1 tasks with his nonparalyzed,
nondominant right upper extremity. The same stimulus set
of common household tools and objects was used for al1
tasks. The patient was asked to point to these objects on
command, to name objects held before him, to point to
objects described by function (e.g., “Point to the one used
for cutting”), to describe the function of objects upon visual
presentation, and to identify verbally objects described by
their function (e.g., “What do you use for cutting?”). Tests
for ideomotor apraxia included those of pantomime to verbal
command, pantomime imitation, and actual object use. The
Computed tomography scans demonstrating right hemisphere hy-
podense area.

Brief Communication: Ochipa et al: Ideationai Apraxia 191

Tabie 1. Western Aphasaa Battery Scores a t One Month Table 2. Praxz“ Test Pe$oòrmance
Post Onset
Number Correct
Patient SubscoredMaximum (n = 20)
Test Points Possible
~ ~~ ~

Spontaneous speech 11/20
Information content 7/10
Fluency 4/10
Comprehension 7.55110
Yeslno questions 60160
Auditory word recognition 37/60
Sequential commands 54/80
Repetition 5.8110
Naming 7/10
Object naming 48/60
Word fluency 4/20
Sentence completion 8/10
Responsive speech 10110
Aphasia quotient 62.7
patient was also presented with both tools and the objects
that typically receive the tools’ action and was nonverbally
requested to demonstrate the tools’ use. Gesture compre-
hension was assessed by asking the patient to name each of
the 15 gestures on the Florida Apraxia Screening Test (as
produced by the examiner) { 131. The Action Naming Test
197 was also administered as a measure of the patient’s ability
to label actions verbaily.
To determine if our patient had preserved knowledge of
tool-object relationships, and to further ensure that his er-
rors were not production errors from an ideomotor apraxia,
he was given a task wherein he had to select the correct tool
for a target action. For example, he was presented with a
partialiy completed task (e.g., a partially sawed board) and an
array of four tools (e.g., saw, hammer, key, needle) and was
nonverbally requested to select the appropriate tool to com-
plete the task.
Finally, che patient was videotaped on the hospital ward
whiìe participating in activities of daily living (i.e., eating,
personal grooming, etc.). Foils (tools and objects other than
those typically used for a particular activity) were presented
along with those typically used for a specific activity. For
example, a toothbrush and a comb were placed along with
eating utensils at the side of a dinner tray. The patient was
given no instructions during these videotaped activities.
Resdts
One week after onset the patient had a global aphasia.
By 1 month post onset, the patient’s condition had
evolved to a Broca’s aphasia with gains in auditory
comprehension, naming, and repetition. Spontaneous
speech remained reduced in quantity and was charac-
terized by articulatory struggle. Comprehension was
relatively good (Table 1).
Throughout the patient’s hospital stay, he was noted
on multiple occasions spontaneously to use objects in-
appropriately. When the patient was provided with
Tool identification 19
Tool identification by function 7
Tool naming 17
Tool function description 3
Tool use 2
Tool use with object 4
Tool selection 3
Pantomime to command O
Pantomime imitation 4
foils (tools other than those typically used for a particu-
lar activity), he often chose the incorrect tool (e.g., he
was observed to eat with a toothbrush and brush his
teeth with a spoon and a comb).
His defective tool use could not be attributed to an
agnosia because he could name objects upon visual
presentation ( 17 / 2 0 correct). Furthermore, his deficit
could not be attributed to language comprehension
difficulties because he could point to objects on com-
mand (1900 correct). However, the patient’s perfor-
mance when he was required to identify objects by
their function was relatively poor ( 7 / 2 0 correct), and
he was unable to describe verbally the function of visu-
ally presented objects (3/20 correct). He was also un-
able to identify verbally objects described by their
function (3/10 correct). In contrast, gesture compre-
hension (as tested by the Florida Apraxia Screening
Test) was relatively spared (12115 correct), and scores
on the Action Naming Test 197 were within normai
limits.
Pantomime to verbal command was profoundly im-
paired ( 0 / 2 0 correct). Unlike patients with ideomotor
apraxia who make production errors (e.g., spatiai,
orientation, body part as object) 1141, this patient’s
performance on the pantomime task was characterized
by content errors (no response or irrelevant move-
ments). Only a slight improvement was noted upon
imitation of gestures ( 4 / 2 0 correct). The patient was
unable to demonstrate tool function when actuaily
holding tools ( 2 / 2 0 correct). Performance improved
only slightly ( 4 / 2 0 correct) when the patient was given
both the tool (e.g., hammer) and the object that re-
ceives the tool’s action (e.g., a piece of wood contain-
ing a partiaily driven nail). In addition, he was unable
to select the correct tool to complete a task (3/20 cor-
rect), suggesting an impairment in the appreciation of
the associative relationship between tools and the ob-
jects they act upon. See Table 2 for a summary of the
patient’s scores on praxis tasks.

192 Annals of Neurology Vol 25 No 2 February 1989

Discussion
This patient’s inability to use actual objects cannot be
explained by a production deficit (ideomotor apraxia)
because his errors were content errors and because he
couid not match tools with the objects on which they
are used. His deficit could not be attributed to an
agnosia or ianguage comprehension deficit because he
could both name tools and point to tools when they
were named by the examiner. It appeared that this
patient had lost the knowledge of tool function. This
loss of knowledge of tool function was aiso evident in
his language performance. Although he codd point to
a tool named by the examiner, he could not point to
the tools when they were described by function. Simi-
larly, he couid name tools but couid not describe tool
function. Although the patient’s nonfluent speech may
have influenced results, it appeared that when he was
externally provided with a gesture or a picture of an
action, his performance was relatively intact. In con-
trast, when he was presented with the object and re-
quested to describe verbaliy or demonstrate its func-
tion, his performance was severely impaired.
If ideationai apraxia is truly a conceptual deficit, pa-
tients should exhibit impaired object use in natural
settings. Although De Renti and colleagues [i] did
not systematically investigate this aspect of perfor-
mance, they did report that their patients adequately
performed activities of daily living on the hospital
ward. They suggested that in most cases ideational
apraxia was limited to the artificiai test situation. Our
patient differed in that he was observed spontaneously
to use single objects inappropriately in natural settings.
This man’s inability to use objects appropriately in
both naturai and test settings, in the presence of intact
recognition abilities, suggested a deficit of tool knowl-
edge.
There are at least two possibilities as to why idea-
tionai apraxia has not been more commonly reported.
In the natural setting not only do we not provide pa-
tients with foils, but aiso the ward personnel often
provide the brain-impaired patients with the correct
utensil or tool. The second possibility relates to brain
organization. Our patient was left handed and had a
right hemisphere lesion that induced both ideational
apraxia and a Broca’s type aphasia Perhaps at least part
of this man’s ability to name tools and to point to tools
named by the examiner (what we term “what” knowl-
edge) was mediated by his left hemisphere, but his
knowledge of tool use arid movement programs
(“how” knowledge) was mediated by his right hemi-
sphere.
A complementary patient was published by Roelt-
gen and Heilman 1121. This patient was also left
handed but had a left hemisphere lesion. Unlike our
Brief Communication: Ochipa et ai: Ideational Apraxia
patient, Roeltgen and Heilman’s patient could not
name tools or point to tools when named, but he could
point to tools when their action was described and
could also use the tools correctly. In this case the pa-
tient’s “what” left hemisphere was impaired, and his
“how” right hemisphere was intact.
In both our patient and in Roeltgen and Heilman’s
patient, “how” knowledge (which tool to use and
which movement to use with the tool) seemed to be
represented in the hemisphere contralaterai to the pre-
ferred left hand, while the “what” system was, at least
in part, mediated by the hemisphere ipsilaterai to the
preferred hand. In right handers both the “what” and
“how” systems may be mediated by the same left hemi-
sphere, and it therefore may be more difficuit to disas-
sociate ideational apraxia from an agnosia, ideomotor
apraxia, and severe aphasia.
This work was supported by che Medicai Research Service of the
Veterans Administration and the Memory Disorders Clinic, Aging
Adult Services Program, Department of Health and Rehabilitative
Services, State of Florida.
Presented at the 16th Annual Meeting of the International
Neurologicai Society, New Orleans, LA, January 27-30, 1988.
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