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Applied Neuropsychology
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Rehabilitation of Balint's Syndrome: A Single Case

Report
Mónica Rosselli , Alfredo Ardila & Christopher Beltran
Published online: 07 Jun 2010.

To cite this article: Mónica Rosselli , Alfredo Ardila & Christopher Beltran (2001) Rehabilitation of Balint's Syndrome: A Single
Case Report, Applied Neuropsychology, 8:4, 242-247

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 Applied Neuropsychology Copyright 2001 by
2001, Vol. 8, No. 4, 242–247 Lawrence Erlbaum Associates, Inc.

Rehabilitation of Balint’s Syndrome:

A Single Case Report
Mónica Rosselli
Department of Psychology, Florida Atlantic University, Davie, Florida, USA
Alfredo Ardila
Department of Neuropsychology, Memorial Regional Hospital, Hollywood, Florida, USA
Christopher Beltran
Department of Psychology, Miami Institute of Psychology, Miami, Florida, USA

Very little research has been done in the area of rehabilitation of the visual perceptual deficits
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observed after Balint’s syndrome. This syndrome is characterized by difficulties with visual
scanning, dysmetria secondary to visual perceptual deficits, and an inability to perceive more
than 1 object at a time. This article describes the effects of a neuropsychological treatment
protocol on a 23-year-old patient who suffered a fat embolism involving the territory of the
posterior cerebral arteries. A neuropsychological evaluation carried out 12 months after the
brain embolism disclosed Balint’s syndrome, alexia without agraphia, visual agnosia,
prosopagnosia, and memory impairments. The rehabilitation protocol included both visuo-
perceptual retraining and a functional program designed to provide rehabilitation in contexts
that were meaningful to the patient. After 1 year of treatment, a second neuropsychological
evaluation was carried out. Significant improvement was demonstrated in terms of both
objective testing and the return of an integrated and productive lifestyle.

Key words: Balint’s syndrome, case report, neurorehabilitation

Balint’s first description of this visuoperceptual dis-
order dates back to the early 20th century (Balint,
1909). He described it as a psychic paralysis of visual
fixation. Three main clinical signs characterize this
condition. The first sign is fixed gaze, or ocular apraxia.
This is the inability to scan the visual field despite nor-
mality of eye movement, intact visual fields, and intact
reflex motility. The second sign is optic ataxia. This is
the inability to do precise hand movements, such as
grasping or touching an object, while under visual
guidance. Patients with optic ataxia lack the integration
of visual and hand coordination (Ayuso-Peralta et al.,
1994). The third sign, which may be considered the
essence of Balint’s syndrome, is simultanagnosia. This
is the inability to attend to more than a very limited sec-
Requests for reprints should be sent to Mónica Rosselli, Florida
Atlantic University, Department of Psychology, 2912 College
Avenue, Davie, FL 33314-7714, USA. E-mail: mrosell@fau.edu
tor of the visual field at any given time. Simultanag-
nosia has been described as “impaired simultaneous
perception” (Thaiss & DeBleser, 1992). Luria (1959)
noted that although it has been described as a visual
disorientation, it has alternately been characterized as a
constriction of visual attention by Holmes (1918).
Hécaen and Angelergues (1963) proposed a similar
explanation. Patients presenting with simultanagnosia
often report that objects in the visual field “disappear”
from direct view. These patients describe a fragmented
perception of the visual environment (Rizzo & Hurtig,
1987). It has been explained using the analogy of a
camera lens (Humphreys & Bruce, 1989). A reduction
in the attention-processing capacity of the wide-angle
aspect of the lens leaves only a small diameter of reso-
lution, resulting in a patient being unable to use global
form information to derive a gestalt (Thaiss &
DeBleser, 1992).
Balint’s syndrome is associated with bilateral dam-
age to the parieto-occipital areas of the cerebral cortex,
with disrupted connections between the visual cortical

242
 BALINT’S SYNDROME
regions and the prerolandic motor areas (Ayuso-
Peralta et al., 1994). The fixed gaze, or ocular apraxia,
may be due to the inability to attend to peripheral tar-
gets or to the loss of parietal neurons involved in visu-
ally guided eye movements (Watson & Rapscak,
1989). Hof, Bouras, Constantinidis, and Morrison
(1990) added that ocular apraxia may exist because of
damage in Brodmann’s area 7b in the posterior parietal
lobe. This cortical area appears to be involved in tar-
geting the gaze on a stimulus and controlling smooth-
pursuit ocular movements.
Disruption of fronto-parieto-occipital pathways
subsequent to parieto-occipital lesions has been impli-
cated in the manifestation of Balint’s syndrome
(Girotti et al., 1982; Hof et al., 1990). Patients with
this syndrome present with optic ataxia that implies a
dysfunctional transferring of information from sen-
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sory to motor areas. Damage directly to the fronto-
parieto-occipital pathways, however, is not necessary
to produce the symptoms of Balint’s syndrome
(Girotti et al., 1982).
Lesions in the superior occipital cortex have been
implicated in difficulty with constriction of the visual
field (Hof et al., 1990), as in simultanagnosia. Watson
and Rapscak (1989) added that the restricted visual
attention of simultanagnosia may be explained as result-
ing from bilateral damage to the ambient visual system.
It functions to signal peripheral visual stimuli as well as
to shift attention from a stimulus being viewed by the
peripheral system, with a sparing of the foveal system.
In terms of the specific rehabilitation of visuo-
perceptual disorders, such as Balint’s syndrome, the lit-
erature is virtually silent. Based on the main character-
istics of the syndrome, the rehabilitation training
should focus on the improvement of visual scanning,
the development of visually guided manual move-
ments, and the improvement of the integration of visual
elements. Lopera (1996) and Solhberg and Mateer
(1989) recommended exercises that allow practice of
spatial analysis and visuomotor skills. Perez, Tunkel,
Lachmann, and Nagler (1996) described the individual-
ized rehabilitation of three cases of Balint’s syndrome.
The mean age of the three patients was 61. The etiology
of two of them was degenerative (posterior cortical
atrophy), and one was vascular (bilateral occipito-
parietal infarct). Treatment was focused on compensa-
tory strategies to visual impairment and memory
deficits and strategies to improve reading and calcula-
tions. A significant improvement in visual recognition
was reported 6 months after treatment initiation.
Humphreys and Riddoch (1994) described the cogni-
tive rehabilitation of two cases with visual memory
impairment. Their patients were able to learn new
visual–verbal associations, but the generalization of
this learning was scarce.
The aim of this article is to analyze the neuro-
psychological profile and the cognitive rehabilitation
protocol in a 23-year-old man diagnosed with Balint’s
syndrome.
Case Report
Clinical History
The patient was a 23-year-old male officer in the
Colombian army whose medical history was unremark-
able prior to a serious car accident. In this accident, the
patient received multiple limb fractures, including that
of the left femur; at no time did he experience loss of
consciousness. The patient did not show any neuropsy-
chological deficits at admission to the hospital. How-
ever, 3 days after the accident, the patient experienced
a fat embolism, probably due to the multiple fractures,
which produced an occlusion in the posterior cerebral
arteries (vertebro-basilar system; Adams, Victor, &
Ropper, 1997). This condition initially resulted in the
patient experiencing cortical blindness. One week later,
the patient was given the diagnosis of Balint’s syn-
drome, as evidenced by ocular apraxia, optic ataxia,
and simultanagnosia. A CT scan was performed and
indicated significant bilateral parieto-occipital damage.
The patient remained hospitalized for several months.
A neuropsychological assessment was given
12 months after the vascular accident and before any
cognitive retraining. Table 1 shows the tests used and
the scores obtained by the patient in this first neuro-
psychological evaluation.
Neuropsychological Test Results
The patient was right-handed and was alert and
cooperative. He was oriented to person, place, and
time. No gross motor deficits were observed. Speech
was abundant and contained no articulation, grammat-
ical, or prosodic errors. During conversation, the
patient did not establish visual contact. There were no
defects in language comprehension, and the patient
had preserved judgment and insight. He was aware and
concerned about his neurological deficits. Depression
was evident in his subjective report of feelings of
worthlessness due to his visual problems; however, he
did not meet the Diagnostic and Statistical Manual of
243
 ROSSELLI, ARDILA, & BELTRAN

Table 1. Results Obtained in Different Neuropsychological No visual field defects were presented, but horizon-
Tests Before and After the Treatment Protocol tal diplopia was evident. The patient was able to draw
a clock and a map of Colombia adequately but
Test Before After
painstakingly. The spontaneous drawing of geometri-
WAIS: Verbal IQ 115 118 cal figures was found to be relatively well preserved,
Wechsler Memory Scale: MQ 90 92 but his copying of the same figures was deficient and,
Rey–Osterrieth Complex Figure: 2/36 15/36
on occasions, impossible. The copying of the
Copy
Letter Reading 16/20 20/20 Rey–Osterreith Complex Figure (ROCF) Test (Oster-
Word Reading 0/20 18/20 reith, 1944) was defective. He was unable to locate a
Verbal Fluency point in the center of a circle.
Phonologic 15 — In summary, results from the neuropsychological
Semantic 18 — testing led to the conclusion that the patient had
Recognition of Real Objects 7/7 —
Recognition of Schematized Figures 0/15 12/15
Balint’s syndrome characterized by ocular apraxia,
Recognition of Overlapped Figures 0/15 9/15 optic ataxia, and simultanagnosia. He also had alexia
Recognition of Colors 6/6 — without agraphia, prosopagnosia, visual agnosia for
Boston Naming Test 42/60 50/60 schematized objects, and a diminished memory
Trail-Making Test A 15 min 1 min, capacity.
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30 secs
Famous People Photographs 2/10 9/10
Ideomotor Praxis 10/10 — logical tests (see Table 1), a cognitive rehabilitation
Note: WAIS = Wechsler Adult Intelligence Scale.
Mental Disorders (4th ed., [DSM–IV]; American Psy-
chiatric Association, 1994) diagnosis criteria for a
major depressive episode. His Verbal IQ (Wechsler,
1968) was within normal limits. Mild memory prob-
lems were observed. His MQ (Wechsler, 1945) was
lower than Verbal IQ, suggesting a mild deficit.
A complete Balint’s syndrome was corroborated. The
patient displayed ocular apraxia, optic ataxia, and simul-
tanagnosia. He was unable to scan moving target objects;
eye movements under verbal command were very diffi-
cult. His inability to reach target objects (misreaching)
and his dysmetria secondary to visuoperceptual deficits
were interpreted as an optic ataxia. He had very severe
difficulty in visual searching and made compensatory
head movements. In attempting to describe a compli-
cated figure, he could only describe individual details,
with failure to recognize the integrated figure (simul-
tanagnosia). He presented significant difficulties in the
identification of photographs of famous people (Ardila
& Rosselli, 1990) and in the recognition of schematized
objects.
The patient recognized handwritten letters and was
able to perform tactile identification of letters cor-
rectly. He also recognized words spelled by the exam-
iner but was unable to read them. He was capable of
writing spontaneously and to dictation but was unable
to copy words or phrases. Given his visuoperceptual
difficulties, the distribution of his writing was erratic.
No components of apraxic agraphia were observed in
his handwriting.
Based on the deficits revealed in the neuropsycho-
protocol was developed, with focus on the improve-
ment of the visuoperceptual symptoms. The rehabilita-
tion protocol was based on the process-specific
approach (Solhberg & Mateer, 1989) and attempted to
retrain specifically the impaired visual spatial func-
tions (Prigatano, 1986, 1999).
According to the report of the patient’s mother, no
noticeable improvement of the symptoms had
occurred during the 6 months prior to the initial test-
ing. The effectiveness of the treatment was assessed
through a retest neuropsychological evaluation and
generalization of treatment to daily life activities.
Rehabilitation Procedure
The rehabilitation program used visuoperceptual
retraining and a functional adaptation program, as
described in the following.
Visuoperceptual Retraining
During 12 months, the patient attended an outpa-
tient rehabilitation program 2 hr a week. These ses-
sions were devoted to teaching the patient visual exer-
cises to be practiced at home. Some exercises were
specially developed to target the patient’s impair-
ments. The participation of the family (mother and sis-
ter) was essential within the retraining process. They
were periodically interviewed and informed us about
the patient’s progress. They also reported on the gen-
eralization of the training at home.

244
 BALINT’S SYNDROME
The following exercises were used within the train-
ing protocol.
Eye movements. The patient first had to visually
follow objects moved by the examiner. The aim of this
exercise was to improve visual scanning.
The patient then had to place the index fingers at
a distance of 15 to 20 cm in front of his face and look
alternately toward the right index finger, then the left
index finger, during a 5-min period. Three centime-
ters was the initial distance between the index fin-
gers. This distance was progressively increased
based on the improvement in visual targeting with-
out head movements. The distance between the fin-
gers was increased up to 50 cm. The aim of this exer-
cise was to increase the self-control of visual
scanning.
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Convergence exercises. From a central point
30 cm away from the face, the patient should bring the
right or left index finger gradually closer to the nose,
maintaining permanent eye contact on the index finger.
This exercise should be done for approximately 30 min
each day. The aim of this exercise was to acquire more
control of eye movements.
Word reading. Single two-syllable words were
presented on white index cards. The patient was
requested to use the index finger as an aid to find the
letters of the words and to spell out loud all the words
he was reading. This task was alternated with the read-
ing of two-syllable words that were written in large
size (2 cm in height) and in two colors. The vowels
were written in red, and the consonants were written in
green. The patient was asked to read only the vowels,
using the finger as a guide. The letters used in this
exercise were progressively smaller in size, whereas
words had more syllables. The aim of this exercise was
to teach the patient to scan and read words by spelling
them out.
Visuokinetic functioning. Letters and words
were placed in front of the patient. He had to read them
aloud and simultaneously reproduce the letter in the air
using the index finger. The aim of this exercise was to
develop a kinesthetic learning of words.
Exercises of visual search. The patient had to
look for letters and words in a crossword puzzle. The
level of difficulty was progressively increased. The
aim of this exercise was to improve visual scanning
and recognition of words.
Trail-making exercises. Exercises similar to the
Trail-Making Test A were developed, using an increas-
ing level of difficulty: The distance between numbers
and the amount of numbers increased; the size of the
numbers became smaller. Initially, colors were used to
increase salience, but later these were eliminated.
Writing exercises. The patient had to write letters
and words, spontaneously and to dictation, on paper
with lines. Large letters were required to facilitate sub-
sequent self-reading.
Functional Adaptation Program
The applicability to everyday life of skills learned or
relearned during rehabilitation in a laboratory or clini-
cal setting has come into question (Sbordone & Long,
1996). Thus, it was advisable to devise a rehabilitation
program that would, at least in a partial fashion, facili-
tate improvement in ways that are useful in the patient’s
world. Bearing this in mind, a functional program,
complementary to the visuoperceptual retraining, was
developed. The focus of this complementary program
was to assign tasks that, although part of everyday life
(e.g., reading a newspaper), would address the retrain-
ing of the deficits found in Balint’s syndrome. In
addition, it would increase independence and self-
confidence. With this in mind, the intended goal was
for the patient to return to work at his highest capacity.
The following activities were recommended:
1. The patient was encouraged to go out with his
mother or his sister as frequently as possible and to
participate in daily life activities, such as shopping,
going to parks, and so on. In addition, social activities
were reinforced in an attempt to reduce isolation and to
increase self-confidence. This was an initial step, con-
sidering that the patient had become socially isolated
after the vascular accident.
2. The use of public transportation to come to the
rehabilitation sessions was suggested. This required
that the patient use visuoperceptual skills and fostered
a sense of independence. Initially, the patient was
escorted to the sessions, but later he independently
used public transportation.
3. It was suggested to the patient to remain active
at home: do homework, help with housekeeping,
watch television, and try to read the newspaper. Dur-
ing each session, he had to report at least three topics
from the previous day’s newspaper that were interest-
ing to him.
245
 ROSSELLI, ARDILA, & BELTRAN
4. When the rehabilitation program was advanced
enough, it was suggested that the patient look in the
newspaper for educational or vocational courses he
may be capable of attending. It was further suggested
that he go to the corresponding office, initially with a
companion and in the following months by himself, to
gather information, brochures, and so on. This would
maximize the use of visuoperceptual skills and also
helped the patient regain confidence.
5. It was recommended to the patient that he attempt
to rejoin the military. This was the patient’s desire, and
although he may rejoin at a less demanding position, this
would represent the optimal recovery scenario.
Table 2 summarizes the changes in community
independence before and after the treatment.
After 1 year on this treatment protocol, a follow-up
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neuropsychological evaluation was performed (see
Table 1). A significant improvement was observed,
particularly in those tests that are sensitive to scanning
deficits, such as word reading and the Trail-Making
Test, as well as measures sensitive to simultanagnosia,
such as the ROCF: copy, recognition of schematized
figures, recognition of overlapping figures, and
famous people photographs. No significant improve-
ment was seen in the Wechsler Memory Scale or in
Verbal IQ. At this point, the patient reported feeling
more confident. He returned to the army and was
appointed to an activity not requiring special visuo-
perceptual abilities (a communication section).
Discussion
This article describes a case report of a 23-year-old
man presenting with Balint’s syndrome and analyzes
the rehabilitation program that was effective for him.
The patient developed the visuoperceptual disorder of
Balint’s syndrome, characterized by ocular apraxia,
optic ataxia, and simultanagnosia, secondary to a cere-
brovascular accident resulting from a fat embolism.
The patient also presented with pure alexia (alexia
without agraphia), visual agnosia to superimposed and
schematized figures, prosopagnosia, and a diminished
memory capacity.
The patient began a rehabilitation program 1 year
after the embolism. Based on a family report, no spon-
taneous recovering had occurred in the previous 6
months. Most spontaneous recovery in cases of brain
damage occurs during the first 3 months after the
injury, with some recovery occurring in the following
6 months (Kertesz, 1979). Thereafter, very little or no
246
Table 2. Changes in Community Independence Before and After
the Treatment
Before After
Socially Isolated Frequent Group Activities: Family,
Friends, etc.
Inability to Use Public Independent Use of Public
Transportation Transportation
Escorted to Appointments Attending Appointments by Himself
Inactive at Home Reading, Writing, Watching Television
at Home
No Attempt to Work Actively Searching for a Job
Inability to Work Returned to Work
recovery is expected. Despite the difficulty of measur-
ing the exact amount of recovery in the months fol-
lowing a brain injury, it is usually accepted that a good
amount of spontaneous recovery occurs during the first
year. Converging evidence, however, supports that
increased functioning can be observed with treatment
begun later than 1 year (Prigatano, 1999). Recovery in
stroke patients is less pronounced than recovery in
posttraumatic brain injury (Kolb & Whishaw, 1996). It
is suitable to propose that, in the case described here,
most of the spontaneous recovery had occurred at the
beginning of the rehabilitation treatment. Most new
visual spatial improvements may be attributed to the
introduction of the rehabilitation protocol.
Age may affect the recovery from brain damage.
Better recovery is expected from younger patients. Our
patient was a young adult, which may have contributed
to his good recovery. The recovery after brain damage
of soldiers in the 21-to-25 age group is greater than in
the 26-and-over age group (Kolb & Whishaw, 1996).
The patient described here had a neuropsychologi-
cal evaluation before the beginning of the treatment
protocol. These scores were used as baseline for treat-
ment effectiveness. One year after the introduction of
treatment, the same neuropsychological assessment
was done. Improvement was observed in all visual
tests but was absent in memory and intelligence tests.
The rehabilitation program consisted of a visuopercep-
tual training, however, and no memory retraining was
included. Thus, it is reasonable to propose that the
rehabilitation protocol used was effective. This case
study suggests that a successful rehabilitation program
for visuoperceptual disorders should also include a
functional component.
There are some limitations to this single case report.
There was no control over confounding variables, such
as the test–retest effects, that may have affected the
neuropsychological test scores. The patient attended
the rehabilitation program a limited amount of time
 BALINT’S SYNDROME
(2 hr weekly), so there was no control over activities
performed by the patient in his own time. There was a
significant similarity between some of the testing tasks
and some of the rehabilitation exercises. For example,
the patient was practicing plenty of times (even hun-
dreds of times) in exercises similar to the Trail-Making
Test. At the beginning of the program, the patient was
socially isolated and overtly depressed, whereas at the
end, depression had cleared, and he was significantly
positive and active in his extratreatment environments.
All these variables may have affected the final testing
results. Nonetheless, using a functional criterion, dur-
ing the 12 months of the rehabilitation program, a sig-
nificant improvement was observed. The patient was
able to return to the army, securing a limited position
that did not require special visuoperceptual abilities.
In summary, significant improvement in objective
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testing and the return to a productive life can be
attained via cognitive rehabilitation, even after the
period in which the majority of spontaneous recovery
is likely to occur.
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247