We addressed the neuroanatomical correlates of 54 right-brain-damaged neurosurgical patients on visuo-spatial design fluency, which is a measure of the ability to generate/plan a series of new abstract combinations in a flexible way. 22.2% of the patients were impaired. They failed the task because they did not use strategic behavior, in particular they used rotational strategy to a significantly lower extent and produced a significantly higher rate of perseverative errors. Overall performance did not correlate with neuropsychological tests, suggesting that proficient performance was independent of other cognitive domains. Performance significantly correlated with use of rotational strategy. Tasks related to executive functions such as psy-chomotor speed and capacity to shift were positively cor-related to the number of strategies used to solve the task. Lesion analysis showed that the maximum density of the patients’ lesions—obtained by subtracting the overlap of lesions of spared patients from the overlap of lesions of impaired patients—overlaps with the precentral gyrus, rolandic operculum/insula, superior/middle temporal gyrus/hippocampus and, at subcortical level, with part of the superior longitudinal fasciculus, external capsule, ret-rolenticular part of the internal capsule and sagittal stratum (inferior longitudinal fasciculus and inferior fronto–occipi-tal fasciculus). These areas are part of the fronto–pari-etal–temporal network known to be involved in top–down control of visuo-spatial attention, suggesting that the mech-anisms and the strategies needed for proficient performance are essentially visuo-spatial in nature.
