The Neural Bases of Drawing. A Meta-analysis and a Systematic Literature Review of Neurofunctional Studies in Healthy Individuals (2024)

Drawing is a multi-component process requiring a wide range of cognitive abilities. Several studies on patients with focal brain lesions and functional neuroimaging studies on healthy individuals demonstrated that drawing is associated with a wide brain network. However, the neural structures specifically related to drawing remain to be better comprehended. We conducted a systematic review complemented by a meta-analytic approach to identify the core neural underpinnings related to drawing in healthy individuals. In analysing the selected studies, we took into account the type of the control task employed (i.e. motor or non-motor) and the type of drawn stimulus (i.e. geometric, figurative, or nonsense). The results showed that a fronto-parietal network, particularly on the left side of the brain, was involved in drawing when compared with other motor activities. Drawing figurative images additionally activated the inferior frontal gyrus and the inferior temporal cortex, brain areas involved in selection of semantic features of objects and in visual semantic processing. Moreover, copying more than drawing from memory was associated with the activation of extrastriate cortex (BA 18, 19). The activation likelihood estimation coordinate-based meta-analysis revealed a core neural network specifically associated with drawing which included the premotor area (BA 6) and the inferior parietal lobe (BA 40) bilaterally, and the left precuneus (BA 7).

These results showed that a fronto-parietal network is specifically involved in drawing and suggested that a crucial role is played by the (left) inferior parietal lobe, consistent with classical literature on constructional apraxia.

Literature Search and Selection Criteria

A systematic approach combining different bibliographic medical databases (PubMed, Scopus, and Web of Science) together with a previous meta-analysis (Yuan & Brown, 2015) was adopted to obtain a comprehensive paper selection of the existing neuroimaging literature on drawing in healthy individuals. The following keywords in appropriate combinations were used to identify articles: (“drawing” OR “copying” OR “tracing” OR “constructional”) AND (“neuroimaging” OR “functional magnetic resonance” OR “fMRI” OR “positron emission tomography” OR “PET”). We intentionally used a larger number of keywords compared to the previous meta-analysis (Yuan & Brown, 2015) to increase the likelihood of identifying relevant articles. The process of selecting eligible articles was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement (Moher et al.,2009). Two authors (S.R. and L.T.) screened all titles and abstracts in electronic databases. Inclusion in the present meta-analysis required that articles i) had the full-text published in English peer-reviewed journal, ii) reported original data obtained from groups of healthy adults (not reviews or studies on patients with brain diseases or peripheral motor or sensory impairments), iii) reported results from brain imaging techniques (fMRI or PET), iv) performed whole-brain general linear model analyses since coordinate-based meta-analyses look for spatial convergence across experiments (thereby excluding studies reporting region-of-interest analyses, partial brain coverage, or small volume corrected results; Eickhoff et al., 2012; Müller et al., 2018), v) reported results in relation to a stereotactic coordinates system, and provided coordinates of activation foci either in the Montreal Neurological Institute and Hospital (MNI) or Talairach reference space, vi) focused on drawing tasks, intended as tasks where participants were required to produce a figure with its component parts in their correct spatial relationships in order to form a coherent and organized whole, following the classical definition of constructional abilities (Critchley, 1953; Kleist, 1934; Strauss, 1924). In relation to this last criterion, we included studies using (actual or imagined) ‘drawing’ tasks such as drawing a named object from memory (e.g. a watch, a face, a house, a clock, and so on), and copying simple or complex geometric figures (e.g. a triangle, a square, a cube, the Rey-Osterrieth figure) or objects (e.g. a face, a car, a book illustration, and so on). Studies that only employed tasks such as drawing single curve or straight lines, tracing figures (i.e. following the outline of a visual stimulus), or connecting dots were not included in the study, unless they contrasted any of these graphic ‘non-drawing’ tasks with ‘drawing’ tasks proper. Example of ‘drawing’ and of graphic ‘non-drawing’ tasks are provided in Fig.1.

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Fig. 1

Instances of ‘drawing’ tasks, that were the focus of the study, and of graphic ‘non-drawing’ tasks that were only considered when compared to ‘drawing’ tasks proper; some studies investigated imagined rather than actual drawing to avoid artifacts related to hand and arm movements

For each selected article we assigned a Quality Score according to a modified version of Downs and Black’s checklist for quality assessment (Downs & Black, 1998) as reported by Ayoub et al. (2018). The total scores range from 0 to 20, with higher scores meaning good external and internal validity. Two authors (S.R. and L.T.) evaluated each study independently, and disagreements were discussed and decided by consensus. Based on the recommended best practice guidelines for neuroimaging meta-analyses (Müller et al., 2018), we pre-registered the study on the PROSPERO platform (https://www.crd.york.ac.uk/PROSPERO/; registration number: CRD42020155472).

Data Extraction

Data from each paper were classified according to the type of comparison investigated, namely, ‘drawing vs non-motor conditions’ (e.g. rest, fixation, or passive viewing) or ‘drawing vs other motor conditions’ (e.g. tapping, writing, or ‘non-drawing’ tasks) and the type of stimulus to be drawn, figurative, geometric, or abstract (non-sense). For each primary study the following relevant information was extracted i) the statistically significant brain coordinates (as determined by an α level of 0.05; two-tailed), classified according to the space in which they were reported (Talairach or MNI), ii) number of participants and their characteristics, including age, gender distribution, education, handedness, iii) type of comparison: 'drawing vsnon-motor conditions','drawing vsother motor conditions', iv) type of figure that the participant had to draw, figuratives, geometrics, abstracts, and v) physical device used for drawing, pencil, mouse, tablet.

Activation Likelihood Estimation Meta-analysis and Systematic Review

For a quantitative assessment of inter-study convergence we performed a coordinate-based meta-analysis (CBMA; Müller et al., 2018) using the Activation likelihood estimation (ALE) algorithm (Eickhoff et al., 2009; Turkeltaub et al., 2002) running under GingerALE software (http://brainmap.org/ale/) version 3.0.2. (Eickhoff et al.,2017). This algorithm, using input foci (e.g., brain coordinates) from multiple experiments, allows to identify significant convergence among reported coordinates in experiments that is higher than expected from a random distribution of foci (for further details on the ALE method please refer to the original publications of Eickhoff et al., 2012; Eickhoff et al., 2009; and Turkeltaub et al., 2012; Tahmasian et al., 2019). For each ALE calculation, significance was tested using 1000 permutations with a cluster forming threshold at voxel-level p < 0.001 (Eickhoff et al., 2016), and to provide an appropriate compromise between sensitivity and specificity, significance was corrected with a cluster-level family-wise error threshold of p < 0.05 (cFWE; Eickhoff et al., 2016), as in previous meta-analytic studies (Papitto et al., 2020; Teghil et al., 2019).

The ALE results, as significant clusters of convergence with clear anatomical properties (x, y, and z location in MNI), number of voxels, and p‐value, were automatically exported from GingerALE as NIfTI files (Belyk & Brown, 2014; Garrison et al., 2013; Zaccarella et al., 2017), overlaid onto a standard MNI template of MRIcroGL (http://www.mccauslandcenter.sc.edu/mricrogl/). To control for negative impact on the statistical validity of the meta-analysis, when two experiments were presented in the same paper (Turkeltaub et al., 2002) they were considered as one if the group of participants was the same, or different if the two groups of participants differed (Müller et al., 2018). Before performing CBMA, all coordinates extracted from each primary study and reported in Talairach space were transformed into MNI coordinates using the built-in icbm2tal function implemented in the GingerALE toolbox (Laird et al., 2005; Lancaster et al., 2007) and available at https://www.brainmap.org/ale.

Since the number of studies was not sufficient to achieve sufficient statistical power (i.e. a sample size of at least 17–20 experiments that should be used to guarantee the validity of ALE results; see Eickhoff et al., 2016; Müller et al., 2018), we conducted a systematic review on neuroimaging evidence focusing on the type of comparison investigated (e.g. ‘drawing vs non-motor conditions’ or ‘drawing vs other motor conditions’) and the type of stimulus (figurative, geometric, or abstract).

Literature Search

Figure2 depicted the flow of the selection process based on PRISMA statement. The initial search identified 5090 articles. After removing duplicates, we obtained 2991 articles. Out of these, 2805 articles were excluded on the basis of title and abstract. After the full-text assessment, one study using functional magnetic resonance (fMRI) was excluded as it did not report the stereotaxic coordinates (Farias et al., 2006), whereas 19 articles met inclusion criteria and were considered eligible. As only 2 studies used Positron Emission of Tomography (PET; Seitz et al., 1997; Thut et al., 1997), we decided to perform ameta-analysis considering fMRI studies only. Detailed information concerning participant’s characteristics, experimental paradigm, and neuroimaging techniques of the 17 fMRI studies considered for the current quantitative meta-analysis are reported in Table ​Table1.1. No eligible study compared healthy adults with brain-lesioned patients.

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Fig. 2

Flowchart of the selection process of primary studies

See Also

Is the artist born or made? | Smithsonian Institution

General Meta-analysis

The 17 studies totaled 274 healthy participants with a mean age of 27years (range 18–85years). All participants were right-handed, 97 participants (35.4%) were involved in drawing geometric figures; 140 participants (51%) were involved in drawing figurative images (such as aclock, faces, or common objects), and 37 participants (13.5%) were involved in drawing of abstract images. The general ALE analysis revealed clusters of activation in both hemispheres (Fig.3 and Table ​Table2).2). In particular, we found clusters of activation in the bilateral premotor area (BA 6) and inferior parietal lobe (BA 40), and in the left precuneus and superior parietal lobe (BA 7).

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Fig. 3

Results of the general ALE meta-analysis. Representative slices are displayed on 2D sagittal sections, with x MNI coordinate shown on the top of each, and on a 3D render. The color bar indicates activation likelihood estimation (ALE) values

Drawing Versus Non-motor Conditions

Twelve studies (Ellamil et al., 2012; Gowen & Miall, 2007; Habas & Cabanis, 2008; Harrington et al., 2007, 2009; Makuuchi et al., 2003; Miall et al., 2009; Planton et al., 2017; Schaer et al., 2012; Simos et al., 2017; Talwar et al., 2019; Yuan & Brown, 2014) investigated brain activation comparing drawing tasks with resting-state or non-motor conditions (e.g. mental arithmetics, fixation, passive viewing), and totaled 186 healthy participants, with 96 participants (51%) involved in drawing of figurative images (book cover illustrations, common objects, faces, and a clock). In particular, three of these studies (Makuuchi et al., 2003; Schaer et al., 2012; Yuan & Brown, 2014) investigated the neural bases of drawing by copying tasks, and other three studies (Harrington et al., 2007, 2009; Simos et al., 2017) employed imagined drawing. Since the number of studies was low (see Eickhoff et al., 2016), we did not perform an ALE meta-analysis but systematically reported the main data of the included studies (see Table ​Table33).

All twelve studies reported a significant activation in the superior parietal lobe (BA 7) bilaterally. Almost all of them reported a significant bilateral activation during drawing tasks in the premotor and supplementary motor area (BA 6; n = 11: Ellamil et al., 2012; Gowen & Miall, 2007; Habas & Cabanis, 2008; Harrington et al., 2007, 2009; Makuuchi et al., 2003; Miall et al., 2009; Planton et al., 2017; Schaer et al., 2012; Talwar et al., 2019; Yuan & Brown, 2014), the inferior parietal lobe (BA 40; n = 9: Ellamil et al., 2012; Habas & Cabanis, 2008; Harrington et al., 2007, 2009; Makuuchi et al., 2003; Miall et al., 2009; Planton et al., 2017; Talwar et al., 2019; Yuan & Brown, 2014), and the cerebellum (including the lobuli IV-VI; n = 10: Ellamil et al., 2012; Gowen & Miall, 2007; Habas & Cabanis, 2008; Harrington et al., 2009; Makuuchi et al., 2003; Miall et al., 2009; Schaer et al., 2012; Simos et al., 2017; Talwar et al., 2019; Yuan & Brown, 2014). Moreover, 10 studies found a significant activation in the left precentral gyrus (BA 4; Gowen & Miall, 2007; Habas & Cabanis, 2008; Harrington et al., 2007, 2009; Makuuchi et al., 2003; Miall et al., 2009; Planton et al., 2017; Schaer et al., 2012; Talwar et al., 2019; Yuan & Brown, 2014). The same brain pattern of activation was found in the three studies (Harrington et al., 2007, 2009; Simos et al., 2017) using imagined drawing, in addition to a common activation in the bilateral inferior frontal gyrus (BA 44) and insular cortex (BA13).

Drawing Versus Other Motor Conditions

Seven studies (Ferber et al., 2007; Gowen & Miall, 2007; Harrington et al., 2007; Ino et al., 2003; Ogawa & Inui, 2009; Potgieser et al.,2015; Schaer et al., 2012) compared drawing tasks with other fine motor conditions (e.g. tracing, writing, line drawing), and totaled 115 healthy participants, 61 participants (53%) involved in drawing of figurative images (common objects, faces, and a clock), and 54 participants (46.9%) involved in drawing of geometrics figure. In particular, three of the studies (Ferber et al., 2007; Ogawa & Inui, 2009; Schaer et al., 2012) contrasted copying versus tracing and other two studies (Ferber et al., 2007; Miall et al., 2009) contrasted drawing from memory versus copying. Since the number of studies was low (see Eickhoff et al., 2016), we did not perform an ALE meta-analysis but systematically reported main data of the selected studies (see Table ​Table33).

All studies found a significant activation in the left premotor and the supplementary motor area (BA 6) and the superior parietal lobe (BA 7). Almost all of these studies, but one (Schaer et al., 2012) found an activation of the left inferior parietal lobe (BA 40).

The three studies (Ferber et al., 2007; Ogawa & Inui, 2009; Schaer et al., 2012) in which copying was contrasted with tracing contours reported activation in the cuneus and the lingual gyrus (BA 18, 19) without clear hemisphere lateralization; the same pattern was reported in the three studies comparing copying with drawing from memory (Ferber et al., 2007; Miall et al., 2009; Yuan & Brown, 2014).

Drawing of Figurative, Geometric or Abstract Images

Eleven studies investigated drawing figurative images (Ellamil et al., 2012; Ferber et al., 2007; Harrington et al., 2007, 2009; Ino et al., 2003; Makuuchi et al., 2003; Miall et al., 2009; Miall et al., 2014; Planton et al., 2017; Schaer et al., 2012; Talwar et al., 2019) in a total sample of 177 healthy participants. Among these, 5 studies (Makuuchi et al., 2003; Harrington et al., 2007, 2009; Ferber et al., 2007; Planton et al., 2017) required participants to draw common objects, 3 (Miall et al., 2009, 2014; Schaer et al., 2012) required participants to draw faces, and 2 (Ino et al., 2003; Talwar et al.,2019) required participants to draw a clock; only one study (Ellamil et al., 2012) required to draw book cover illustrations according to book descriptions. Since the number of studies was low (see Eickhoff et al., 2016), we did not perform an ALE meta-analysis but systematically reported main data of the included studies (see Table ​Table33).

All studies reported a significant activation in the bilateral premotor cortex (BA 6), the inferior (BA 40) and superior (BA 7) parietal lobe, and the inferior temporal lobe (BA 37). Almost all studies, but one (Makuuchi et al., 2003) reported a significant activation of the bilateral inferior frontal gyrus (BA 44, 46). Moreover, when participants were required to draw a face, an activation of the bilateral fusiform gyrus was found.

Six studies investigated drawing geometric figures (Gowen & Miall, 2007; Habas & Cabanis, 2008; Ogawa & Inui, 2009; Potgieser et al., 2015; Simos et al., 2017; Yuan & Brown, 2014) in a total sample of 82 healthy participants. Almost all of these required participants to draw single geometric shapes, such as square or triangle or circle, whereas two studies (Gowen & Miall, 2007; Yuan & Brown, 2014) required to draw a pattern of geometric shapes in a specific order. Since the number of studies was low (see Eickhoff et al., 2016), we did not perform an ALE meta-analysis but systematically reported main data of the selected studies. All studies reported a significant activation during drawing geometric figures in the premotor and supplementary motor areas (BA 6), and in the inferior (BA 40) and superior parietal lobe (BA 7), without clear hemisphere lateralization. Almost all these studies, but one (Ogawa & Inui, 2009), showed a significant activation of the right cerebellum (including crus IV-VII).

Two studies (Harrington et al., 2009; Miall et al., 2014) investigated drawing of abstract images in 21 healthy participants and reported that drawing familiar objects compared to drawing non-objects was significantly associated with the activation of the inferior temporal and fusiform gyri as well as the inferior frontal regions (pars opercularis and pars triangularis).

Conflicts of Interest

No potential conflict of interest was reported by the authors. The authors have no competing (financial or personal) interests to declare.

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