Knowledge about the consequences of stroke on high level vision comes primarily from single case studies of patients selected based on their behavioural profiles with deficits in the recognition of a specific visual category such as faces or words. There are, however, no systematic, detailed, large-scale evaluations of the more typical clinical behavioural and lesion profiles of impairments in high level vision that may follow posterior cerebral artery (PCA) stroke. These goals were met by the current study through the data collected in the Back of the Brain (BoB) project: to date, the largest (N=64) and most detailed examination of patients with cortical PCA strokes selected based on lesion location rather than behavioural symptoms.

We present here two complementary analyses of the structural neuroimaging data and key indices of behavioural performance with the visual processing words, objects and faces: (1) a multivariate multiple regression analysis to establish the relationships between lesion volume, lesion laterality or the presence of a bilateral lesion with performance on words, objects and faces; and, (2) a voxel-based correlational method (VBCM) analysis to establish whether there are distinct or separate regions within the PCA territory that underpin the visual processing of these categories.

In contrast to the characterization of specific stroke syndromes like pure alexia or prosopagnosia in the literature, most patients in our cohort showed more general deficits in high level vision (n=22) or no deficits at all (n=21). Category-selective deficits were rare (n=6), and were only found for words, which, interestingly could follow left or right hemisphere lesions. The lesion analyses mainly confirmed the pattern reported in more selective cases: word recognition impairments are associated with a left-sided pattern of damage and face recognition deficits with a bilateral albeit right-dominant lesion pattern. Importantly, however, both general and more selective impairment may follow from left or right unilateral as well as bilateral lesions.

While the findings provide partial support for the relative laterality of posterior brain regions supporting reading in the left and, to a lesser extent, face processing in the right hemisphere, the results suggest that both hemispheres are involved in the visual processing of faces, words and objects. This has ramifications for researchers studying the healthy brain and for clinicians working with patients with PCA stroke. Clinicians are recommended to carry out formal assessment of face, word and object recognition as most patients are expected to present with a mixed picture of deficits.