increased writing activity is seldom seen in neurological conditions , except in some patients with cerebrovascular disease , frontal - type dementia , temporal lobe epilepsy , and parkinson 's disease .
we report a patient with a left inferior capsular genu infarction who developed abulia and increased writing activity , similar to automatic writing behavior .
the patient was a 79-year - old , right - handed woman who could independently perform daily living activities , including cooking , washing , and cleaning .
one day she suddenly lost spontaneous speech , responded to questions with a nod , and remained in bed all day .
two days later , she was admitted to our hospital for evaluation of decreased spontaneity .
she had a history of angina , but had no history of psychiatric disease or cognitive impairment .
brain magnetic resonance images ( mri ) revealed ischemic lesions involving the inferior genu of the left internal capsule , a part of the internal segment of the globus pallidus , and subcortical white matter with mild cortical atrophy ( fig .
diffusion - weighted mri confirmed that the lesion in the left internal capsule of the genu extended to a part of the internal segment of the globus pallidus , and was responsible for the patient 's symptoms ( fig .
1d ) . magnetic resonance angiography ( mra ) showed no occlusions or stenoses in the main cerebral arteries .
technetium-99 m ethyl cysteinate dimer single - photon emission computed tomography ( spect ) revealed a left - dominant diffuse hypoperfusion in the basal ganglia and frontal lobe ( fig .
electroencephalography findings showed left - dominant theta activity of approximately 7 hz , without epileptic discharges or triphasic waves .
she scored 7 points on the mini - mental state examination scale ( mmse ) .
the wechsler adult intelligence scale - revised and the trail making test were discontinued halfway through the assessment due to decreased spontaneity .
her writing was severely impaired ; she could spell only a few words correctly , although when asked to write her name , she exhibited neologism in kanji and wrote  ishimura - shinbun , combining 
ishimura ( her last name ) and  shinbun ( the newspaper placed before her ) ( fig .
2a ) . when directions to write her favorite food , hometown , and current date or place were given , she continued to write neologistic kanji words related to her last name .
shinkeinaika ( neurology ) was placed in front of her as a written note , she wrote the same word in place of her name and continued writing .
the writing was mainly perseverative with lexicographemic alterations ; many words written along the lines were legible and without spatial distortions . increased writing activity
was observed when ruled paper and a pen were presented to her ; however , this was not observed when blank paper was presented .
she could use other tools such as a toothbrush , scissors , and a comb accurately ; utilization behavior was not elicited by presenting those items .
, when she was asked to write something ( her name , her daughter 's name , current date or her feelings ) , she wrote only a few words related to her last name ; her increased writing characteristic disappeared completely , except for a slight perseveration .
two years later , her response time to questions had become slightly shorter ; however , she replied in a small voice , with a smile , and continued to exhibit decreased spontaneity .
she scored 7 points on the mini - mental state examination scale ( mmse ) .
the wechsler adult intelligence scale - revised and the trail making test were discontinued halfway through the assessment due to decreased spontaneity .
her writing was severely impaired ; she could spell only a few words correctly , although when asked to write her name , she exhibited neologism in kanji and wrote  ishimura - shinbun , combining 
ishimura ( her last name ) and  shinbun ( the newspaper placed before her ) ( fig .
when directions to write her favorite food , hometown , and current date or place were given , she continued to write neologistic kanji words related to her last name .
however , after the word  shinkeinaika ( neurology ) was placed in front of her as a written note , she wrote the same word in place of her name and continued writing .
the writing was mainly perseverative with lexicographemic alterations ; many words written along the lines were legible and without spatial distortions . increased writing activity
was observed when ruled paper and a pen were presented to her ; however , this was not observed when blank paper was presented .
she could use other tools such as a toothbrush , scissors , and a comb accurately ; utilization behavior was not elicited by presenting those items .
when she was asked to write something ( her name , her daughter 's name , current date or her feelings ) , she wrote only a few words related to her last name ; her increased writing characteristic disappeared completely , except for a slight perseveration .
two years later , her response time to questions had become slightly shorter ; however , she replied in a small voice , with a smile , and continued to exhibit decreased spontaneity .
this is the first report of an increased writing activity , together with perseverative writing , that was related to a capsular genu infarction .
however , verbal perseveration in patients with capsular genu infarctions has been reported previously , and all patients had left - sided infarctions and showed abulia ( table 1 ) .
lai et al .   reported a 46-year - old patient with a left capsular genu infarction who exhibited auditory hallucinations and dysgraphia , and whose symptoms predominantly included paraphasia and character error without increased writing activity or perseveration .
van vugt et al .   reported a 70-year - old right - handed man with a history of alcohol abuse who demonstrated progressive memory disturbance ( score of 11 points on the mmse ) , verbal aspontaneity , and increased writing activity , which was described as 
automatic writing behavior. this diagnosis was based on the perseverative , legible writing pieces of language that he produced both visually and verbally at the syntactic or lexical level , and well - ordered spatial arrangement . on the basis of spect findings from right - dominant frontal hypoperfusion ,
the mechanism was considered to be a particular form of utilization behavior caused by suppression of the inhibitory system of the frontal lobes .
the increased writing activity seen in our patient was more similar to automatic writing behavior than hypergraphia .
evyapan and kumral   studied automatic writing behavior in three patients with right cerebral hemispheric strokes .
they suggested that a combination of visuospatial neglect and frontal dysfunction may be responsible for the mechanism , as all of the patients showed left visuospatial neglect , and writing behavior was elicited only by the visual letters on the right side .
in contrast , the neologism in our case of  ishimura - shinbun ( see fig .
2a ) is considered to represent automatic reproduction of the visual stimulus , although our patient did not show visuospatial neglect . in the study by van vugt et al . , the duration of the patient 's automatic writing behavior was permanent , while our patient 's writing characteristic was temporary and similar to that reported by evyapan and kumral . automatic writing behavior in our patient manifested after the oral or written direction to write , or the presence of ruled paper and a pen .
it was probably due to a form of motor perseveration related to the basal ganglia .
the pallidum and substantia nigra are the sites of input from motor corticostriatal pathways that interact as part of normal motor control and the termination of movement .
four patients with infarction in the thalamus and the basal ganglia developed motor perseveration of the upper and lower extremities induced by passive movement .
one of these patients demonstrated perseveration in drawing figures , which suggests impairment of the prefrontal cortico - basal ganglia - thalamocortical loops . in this case
, spect images revealed diffuse hypoperfusion in the left frontal lobe and basal ganglia , which implies that damage in the anterior and inferior thalamic peduncles , adjacent to the capsular genu , led to thalamocortical disconnection   and interruption of the cortico - basal ganglia - thalamocortical loops .
our patient 's repeated writing of her last name may indicate dysfunction of recall and understanding of characters in the dominant hemisphere , which is a requirement for writing .
moreover , a previous study reported that more severe verbal memory loss is caused by lesions on the left side of the capsular genu , compared with lesions on the right .
as described in a previous report , the transient quality of automatic writing behavior implies possible diaschisis .
it remains unclear why other perseverative movements , in addition to writing , did not occur .
however , with regard to speech , we assume that the absence of verbal perseveration can partially be attributed to the effect of severe abulia .
we suggest that this may be due to the involvement of a part of the left internal segment of the globus pallidus .
focal dystonia has been thought to be responsible for globus pallidus and thalamic infarction . in our case ,
the main blood supply route to the capsular genu was undetermined , since cerebral angiography was not performed .
however , based on mra results , our patient did not have occlusions or severe stenoses in the main arteries .
it has been reported that the capsular genu is supplied by perforating arteries , arising from the apex of the internal carotid or anterior cerebral artery , or by the anterior choroidal artery .
the patient was not examined for cognitive or mental function before the onset of the capsular genu infarct ; however , we believe that she did not have dementia or psychiatric diseases on admission , since her family attested that before the stroke she had been able to perform her usual activities properly and had showed no personality changes . moreover , two years after the stroke , the patient showed persistent abulia that did not progress further .
therefore , we suggest that the acute - onset abulia and automatic writing behavior were likely due to the new infarct in the capsular genu ( corresponding to high signal intensity on the diffusion - weighted images ) rather than concomitant psychiatric or neurodegenerative disorders that exhibited dementia
. however , we can not exclude the possibility that an interaction between a concomitant underlying cognitive dysfunction , due to mild cortical atrophy or subcortical multiple infarcts , and the capsular genu infarct may exist .
this may then cause the characteristic writing behavior , since leukoaraiosis has been associated with subtle cognitive impairment . in conclusion
, we suggest that malfunction of the frontal - subcortical circuit , due to an inferior capsular genu infarction , contributed to the development of motor perseveration in writing .
 a 79-year - old , right - handed woman was admitted to the hospital with decreased spontaneity . 
 brain magnetic resonance imaging showed a left inferior capsular genu infarction . 
 99 m tc - ecd single - photon emission computed tomography revealed a left - dominant diffuse hypoperfusionin the basal ganglia and frontal lobe . 
 the patient showed abulia and increased writing activity without motor or sensory deficit . 
 the writing was mainly perseverative , and words written along lines were legible and without spatial distortions . 
 this augmented writing behavior disappeared on day 21 . 
 the writing characteristic was more similar to automatic writing behavior than hypergraphia . 
 dissociation between speech and writing behavior was present in our patient . 
 we suggest that a disconnection within the frontal - subcortical circuit contributed to the development of motor perseveration in writing . 