We read with great interest the review by J. Pearson on visual mental imagery (Pearson, J. The human imagination: the cognitive neuroscience of visual mental imagery. Nat. Rev. Neurosci . 20, 624–634 (2019)) 1 . The author outlines a model of visual mental imagery based on neuroimaging findings that involves large-scale brain networks spanning prefrontal areas to sensory areas, and that highlights the activation of occipital areas during visual mental imagery. Specifically, the model indicates that it is the “sensory and spatial representations of the imagery content” that would be formed in early visual areas. However, individuals with acquired brain damage restricted to the occipital cortex typically have perfectly vivid visual mental imagery. For example, a patient with bilateral strokes in the white matter between the occipital and the temporal cortices 2 had severe visual deficits for object form and colour, faces, words and letters but demonstrated perfectly preserved visual mental imagery abilities for these same items 3 . In addition, people with cortical blindness due to bilateral occipital lesions can experience vivid visual mental images 4,5 . By contrast, patients with damage extending anteriorly in the temporal lobe, especially in the left hemisphere, often find themselves unable to build visual mental images 6,7 . Where does the discrepancy between the neuroimaging and neuropsychological findings come from? The neuroimaging results supporting the hypothesis of an implication of early visual areas are correlative in nature, whereas deficits in people with brain injury demonstrate a causal contribution of the lesioned circuits to the relevant cognitive ability (it is true that transcranial magnetic interference on the primary visual cortex was shown to impact visual mental imagery 8 , but this effect might depend on modulation of downstream visual areas). A recent case report 9 provided more specific evidence on the neural bases of visual mental imagery. After a bilateral stroke in the territory of the posterior cerebral artery, an architect, who before the stroke could easily imagine objects and buildings, spontaneously reported to have become unable to visualize items. By comparing his lesion location with those of other individuals with strokes in the Paolo Bartolomeo 1 ✉ , Dounia Hajhajate 1 , Jianghao Liu 1,2 and Alfredo Spagna 1,3 1 Sorbonne Université, Inserm U 1127, CNRS UMR 7225, Paris Brain Institute, ICM, Hôpital de la Pitié-Salpêtrière, 75013, Paris, France. 2 Dassault Systèmes, Vélizy-Villacoublay, France. 3 Department of Psychology, Columbia University in the City of New York, New York, NY, USA 10027. ✉ e-mail: paolo.bartolomeo@icm-institute.org https://doi.org/10.1038/s41583-020-0348-5 1. Pearson, J. The human imagination: the cognitive neuroscience of visual mental imagery. Nat. Rev. Neurosci. 20, 624–634 (2019). 2. Bartolomeo, P., Bachoud-Levi, A. C. & Thiebaut de Schotten, M. The anatomy of cerebral achromatopsia: a reappraisal and comparison of two case reports. Cortex 56, 138–144 (2014). 3. Bartolomeo, P. et al. Multiple-domain dissociation between impaired visual perception and preserved mental imagery in a patient with bilateral extrastriate lesions. Neuropsychologia 36, 239–249 (1998). 4. Chatterjee, A. & Southwood, M. H. Cortical blindness and visual imagery. Neurology 45, 2189–2195 (1995). 5. de Gelder, B., Tamietto, M., Pegna, A. J. & Van den Stock, J. Visual imagery influences brain responses to visual stimulation in bilateral cortical blindness. Cortex 72, 15–26 (2015). 6. Moro, V., Berlucchi, G., Lerch, J., Tomaiuolo, F. & Aglioti, S. M. Selective deficit of mental visual imagery with intact primary visual cortex and visual perception. Cortex 44, 109–118 (2008). 7. Bartolomeo, P. The neural correlates of visual mental imagery: an ongoing debate. Cortex 44, 107–108 (2008). 8. Kosslyn, S. M. et al. The role of area 17 in visual imagery: convergent evidence from PET and rTMS. Science 284, 167–170 (1999). 9. Thorudottir, S. et al. The architect who lost the ability to imagine: the cerebral basis of visual imagery. Brain Sciences 10, 59 (2020). 10. Ralph, M., Jefferies, E., Patterson, K. & Rogers, T. T. The neural and computational bases of semantic cognition. Nat. Rev. Neurosci. 18, 42 (2017). Competing interests The authors declare no competing interests same arterial territory, the authors found that the architect had selective damage in the left fusiform gyrus, a region in the ventral temporal cortex. The left temporal location is consistent with previous reports of individuals with impaired mental imagery after stroke 6,7 . During perception, this fusiform region might act as a neural interface between sensory information coming from the occipital cortex and semantic processing in the anterior temporal lobe 10 . In visual mental imagery, it could endow semantic memories with visual information. Taken together, the results from brain-damaged persons invite a revision of the neural model of visual mental imagery proposed by Pearson 1 , whereby fronto-parietal networks initiate, modulate and maintain activity in a core left temporal network centred on high-level visual regions in the ventral temporal cortex, with no causal role of early visual cortex. There is a reply to this letter by Pearson J. Nat. Rev. Neurosci. https://doi.org/10.1038/ s41583-020-0349-4 (2020). Assessing the causal role of early visual areas in visual mental imagery Paolo Bartolomeo , Dounia Hajhajate, Jianghao Liu and Alfredo Spagna VOLUME 21 | SEPTEMBER 2020 | 517 CORRESPONDENCE NATURE REVIEWS | NEUROSCIENCE In a recent review paper 1 , I outlined a model of visual mental imagery proposing a reverse visual hierarchy starting from prefrontal areas back to sensory areas. I would like to thank Paolo Bartolomeo, Dounia Hajhajate, Jianghao Liu and Alfredo Spagna for their correspondence on our Review (The human imagination: the cognitive neuro science of visual mental imagery. Nat. Rev. Neurosci. 20, 624–634 (2019)) 1 , which raises some important issues (Assessing the causal role of early visual areas in visual mental imagery. Nat. Rev. Neurosci. https:// doi.org/10.1038/10.1038/s41583-020-0348-5 (2020)) 2 . Neuropsychological work reports that individuals with visual cortex damage can show some imagery-like processes without perception 3,4 , while damage to the temporal lobe can correspond to a lack of imagery/ memory abilities 5,6 . Further, individuals with aphantasia (no imagery vividness or sensory imagery) 7,8 show normal sensory perception (although this is yet to be tested in detail), sug- gesting a general dissociation, and has been linked to areas outside of early visual cortex 9 . Based on these reports Bartolomeo et al., suggest a revision to the reverse visual hierar- chy model I described, without a causal role of early visual cortex. Here I outline three reasons why this is not required. Much of the neuropsychological work on imagery is actually correlational, often documented brain injury is correlated with Reply to: Assessing the causal role of early visual areas in visual mental imagery Joel Pearson