6. FRONTAL
DYSEXECUTIVE
SYNDROME
• POOR ORGANIZATION
• PLANNING
• IMPAIRED COGNITIVE
RESPONSE
• ABSRACTION AND
JUDGEMENTS
ORBITOFRONTAL
DISINHIBITORY
SYNDROME
• SOCIALLY
INAPPROPRIATE
BEHAVIOUR
• LOSS OF MANNERS
AND DECORUM
• IMPULSIVE RASH &
CARELESS ACTIONS
APATHETIC SYNDROME
OF THE MEDIAL
FRONTAL LOBE
• LACK OF INTIATIVE
AND REDUCED
MOTIVATION
• SOCIAL ISOLATION
7. • TOWER OF LONDON TEST
• PROTEUS MAZE TEST
1.TEST OF
PLANNING
• STROOP
• GO-NO-GO
• ANTI-SACCADE TEST
2.TESTS OF
RESPONSE
INHIBITION
• TRAIL B TEST(REITAN’S)
• WISCONCIN CARD SORTING TEST
3.TESTS OF MENTAL
FLEXIBILITY
• WORD F
• SEMANTIC F
• DESIGN F
4.TESTS OF FLUENCY
• GRAPHIC
• MOTOR
• CONCEPTUAL SERIES COMPLETION
5.TESTS OF
SEQUENCING
8. • PROVERB INTERPRETATION
6.ABSTRACT
THINKING
• TAP ‘A’ TEST
• RANDOM LETTER CANCELLATION TEST
7.ATTENTION &
CONCENTRATION
• DIGIT BACKWARD TEST
• LETTER NUMBER SPAN TEST
8.WORKING
MEMEORY
• MOTOR IMPERSISTENCE
• MOTOR PERSEVERATION
• ECHOPRAXIA
9.TESTS OF
INTENTIONAL
MOTOR SYSYTEM
9. TOWER OF LONDON TEST
• Build a tower according to specified
arrangements
• Fewest number of possible steps
• Move one piece at a time
10.
11. PROTEUS MAZE TEST
• Plan strategy for route finding
• Pts with deficits make numerous errors
• Increasingly difficult mazes are used
• Error- new cleaner version is given
• Pts with executive dysfunction will repeat the
identical route they used initially
15. “Go-no-go test “of Luria
• Response inhibition & initiation
• Raise 2 fingers on hearing 1 tap
• Raise 1 finger on hearing 2 taps
Modifications :
• Eg.Tap your feet on hearing “A”
16. WISCONSIN CARD SORTING TEST
• Grant & Berg
• Mental flexibility and set shifting
• 3 stimulus parameters
1. Colour
2. Shape
3. Number
INSTRUCTION:
• respondents are told to match the cards but not how to
match.
• But he will be told if he is right or wrong
24. • PHONEMIC VERBAL FLUENCY(FAS TEST)PVF
As many words beginning with a single letter as
possible in 1 min(F A S)
Norm: 14±5
• SEMANTIC (CATEGORY)VERBAL FLUENCY(SVF)
Eg.animals or fruits or birds in 1 min
Norm: 14 ± 5
35. TESTS OF INTENTIONAL MOTOR
SYSTEM
• MOTOR PERSEVERATION
Luria motor,graphic,tap a etc
• MOTOR IMPERSISTENSE
1. Hold the arm outstretched for 20 seconds
2. Protrude your tongue
3. Grip my finger with your hand
4. Maintaining the conjugate fixed in a particular
direction.
36. TESTS OF INTENTIONAL MOTOR
SYSTEM(CONT…)
• ECHOPRAXIA
Show 2 fingers when I show 1 finger and 1 finger I
show 2 fingers
Pt repeats whatever the examiner does
40. (IMMEDIATE)WORKING MEMORY
FORWARD DIGIT SPAN
1. Repeat non-sequential
numbers (e.g not even
numbers or not in any known
pattern)
2. Start with 1 digit and after
the patient successfully
repeats it, is asked to repeat
increasing number of digits
3. Repetition upto 5 digits is
considered as normal
BACKWARD DIGIT SPAN
1. 1 & 2 same
2. Repetition upto 3 digits is
considered as normal
41.
42.
43. RECENT MEMORY
• 3-5 Mins Word Recall
• Details Of Breakfast,
Admission Date Etc
• Retrieving A
STORY/ADDRESS After
3-5 Mins.
VISUAL MEMORY:
• 5 easily recognizable
objects are hidden in
the vicinity while the pt
is observing
• Distraction
• Ask to locate them after
3-5 mins
46. PAIRED ASSOCIATION MEMORY
• ASSESSMENT OF NEW
LEARNING ABILITY
• Pt is p/w 4 word pairs
• 2 related & 2 unrelated
• After presentation the
examiner repeats the 1 st
word of each pair
• <70 yrs: 2 related and
atleast 1 unrelated pair
EG:
BOOK-PAGE
SCHOOL-TAPE
GLASS-WATER
PENCIL-SPOON
47. REMOTE MEMORY
• Details of schooling
• Years of passing
examinations
• Date of retirement
SEMANTIC MEMORY
• Facts, concepts &
gen.Knowledge.
Color of elephant
No.Of days in a week
Author of ramamyana
1st prime minister of india
49. TERMINOLOGIES
• Complex system of articulation & phonation of
thoughts inside our mind.LANGUAGE
• Disorder of language AQUIRED secondary to brain
damage.APHASIA
• DEVELOPEMENTAL language disordersDYSPHASIA
• Articulation & phonation of language sounds.SPEECH
• DISORDERS OF ARTICULATION of single sounds.DYSARTHRIA
50. • Smallest unit of sound
• Eg. Ba & tPHONEMES
• Smallest meaningful unit of language.
• Eg. BatMORPHEMES
• Rules applied to construction of phrases and
sentencesSYNTAX
• word?/phrase meaningSEMANTICS
• Internal dictionary/vocabulary of a person
LEXICON
• Meaning in the contextPRAGMATICS
• Intonation of speechPROSODY
51.
52. LINGUISTIC ABNORMALITIES
AGRAMMATISM
• Difficulty with grammatical morpheme eg.
Rapidly vs rapid
(usage and understanding)
• Better with lexical morphemes.eg. Rapid
• CONTENT WORDS are fine(noun,verbs- cats
,dog,bat)
• FUNCTIONAL WORDS bad(on,at,shall, may)
• SEMANTIC MAINTAINED,GRAMMAR
IMPAIRED
• Telegraphic speech
• Eg.Broca’s aphasia
PARAGRAMMATISM
• Overuse of grammatical
elements
• More functional words and
less content words
(no meaning)
• Defining limits of sentences
absent.(exceessive verbal
output)
• Eg. Wernicke’s aphasia
53. PHONEMIC PARAPHASIAS
• one /few phonemes
substituteD
• Literal paraphasia
• More than half of
intended word produced
• HEN for PEN
NEOLOGISM
• Multiple phonemic
substitutions
• Less than half of
intended word produced
• Meaningless
• HIPPOPOTAMUS -
TIKKOTOKKAGUS
VERBAL PARAPHASIAS
• SEMANTIC paraphasia
• Meaningful but nearly
wrong word
• CAR for VAN
PARAPHASIAS
• Substitution within a language
57. AUDITARY PHONEME
PERCEPTION SYSTEM
• SUPERIOR TEMPORAL
GYRUS
• 1st stage
• Analyze phoneme
independent of word
meaning
• Bilateral representation
INTERNAL SEMANTIC
SYSTEM
• ANTEROLATERAL
TEMPORAL LOBE &
ANGULAR GYRUS
• 2nd stage
• Word meaning system
PHONOLOGICAL/LEXICAL
RETRIEVAL SYATEM
• CLASSICAL WERNICKES
AREA &
SUPRAMARGINAL
GYRUS OF PARIETAL
LOBE(22 & 40)
• Actiavating knowledge
about the sequence of
phonemes .
• Final Mental stage prior
to the motor speech
61. Anterior language area
• Brocas area is
constituted by 44,45,
(posterior part of the
inferior frontal
gyrus)surrounding
frontal area ,
underlying frontal
white matter and the
caudate nucleus.
63. SPONATANEOUS SPEECH
1. Fluency:
Q. reason for hospitalization/interpretation of cookie theft picture/ten
statements about a pen
1. 50-115/min-normal
2. >200-logorrheic
3. <50-non fluent
2. Prosody(INTONATION OF SPEECH)
3. Grammar & syntax
4. Phrase length(is it telegraphic)
5. Paraphasia
6. Circumlocution & word finding difficulty
7. Initiation difficulty
8. Content of speech
64.
65. COMPREHENSION
• 1,2,3 STEP COMMANDS
1. Point to a fan
2. Point to the fan and
then the switch
3. Take a pencil wrap it in a
paper and throw
AVOID ORDERS THAT
INVOLVES AXIAL
MOVEMENTS
• MARIE’S THREE PAPER
TEST:
• HERE ARE THREE
PAPERS(BIG,MEDIUM &
SMALL)
1. Crumple the big one and
throw it on the ground
2. Give the medium one to
me
3. Keep the small in your
pocket
66. REPETITION
• Single words
• Sentence with min 3 words
• Non-sense words: a word or sentense in
another language
• Nb: no.Of words should not exceed pts
attention span
67. NAMING
• Reasonably unfamiliar objects
• If familiar object is used name the unfamiliar
parts. Eg.Nib of pen, locket of a chain
74. Points to ponder….
BROCA’S APHASIA
• AGRAMMATISM hallmark
• Apraxia of speech
• Comprehension is
preserved???(eg. Ravana
was killed by Ram)
• True Broca’s –anterior
language areas
• Damage restricted to
Broca’s l/t- APHEMIA
WERNICKE’S APHASIA
• FLUENT PARAPHASIC
SPEECH(neologism-
jargon/devil’s speech)
• Involvement of all three
posterior language
systems.
• Unaware of the problem
75. • BROCA’S + WERNICKES
• Spontaneous speech , naming & repetition limited to
a single PERSEVERSTIVE word
• Non-fluent
GLOBAL
PAHASIA
• Wernicke’s with relatively preserved comprehension
• TIP OF THE TONGUE anomia
• Arcuate fasciculus??
• PERISYLVIAN AREA(PHONEMIC/LEXICAL RETRIEVAL
AREA)
CONDUCTION
APHASIA
Aphasia: A clinical perspective
DF Benson, DF Benson, A Ardila - 1996
79. PURE WORD DEAFNESS(PWD)
• Auditory VERBAL
AGNOSIA
• Damage To Bilateral
auditory phoneme
identification
system(hence rare)
• CAN NOT HEAR
WORDS
• CAN HEAR non-
verbal sounds
• Read them & write
them too
PWD
80. APRAXIA OF SPEECH
• Slow ,deliberate, effortful, dysprosodic speech
• Trying to find the correct pronunciation by trial &
error
APRAXIA OF SPEECH
• Monosyllable
repetitions good
• Polysyllable impaired
• Inconsistent
mispronunciation
DYSARTHRIA
• Word distortion
irrespective of length
• Mispronunciation is
consistent
81. SUBCORTICAL APHASIAS
MARIE’S QUADRILATERAL
SPACE APHASIAS
• Acute mutism
• Ext
capsule,claustrum,putamen
& insula
STRIATOCAPSULAR APHASIA
• Head of caudate and
putamen-dysarthria
• AL of IC-Aphemia(broca’s)
• PL of IC-wernicke’s like
THALLAMIC APHASIA
• Transcortical sensory aphasia
82. READING AND WRITING : ALEXIA and
AGRAPHIA
• VWFA-visual word form area
• Equivalent to Auditory phoneme perception
area.
• Left occipito-temporal sulcus & left fusiform
gyrus.
84. Reading with comprehension
• Visual information from the
left occipital lobe reaches
directly the left fusiform
gyrus.
• From the rt occipital lobe
has to cross over to (corpus
callosum)reach the left
fusiform GYRUS.
• ANGULAR GYRUS-
interpreetation of visual-
verbal materials.
86. ALEXIA WITHOUT AGRAPHIA
• PURE/POSTERIOR ALEXIA
• CAN NOT : read and
understand
• CAN UNDERSTAND: words
spelled aloud, written on the
palm
• Visual function intact(Naming
objects)
• left occipital lobe with
splenium
• Left PCA infarcts
ALEXIA WITH AGRAPHIA
• CENTRAL ALEXIA
• Aquired illiteracy
• Unable to read or write
• Dominant ANGULAR gyrus
90. Third alexia
• Inability to comprehend syntax
• “Ravana was killed by rama” vs “ Rama killed
Ravana”
• Seen in Broca’s aphasia
91. Other alexias
SURFACE ALEXIA
• Grapheme to phoneme
conversion problem
• Irregular orthography
• CAN read: mint,dog,cat
• CAN NOT read: pint, dough,
laugh
•
PARALEXIA(DEEP)
• Problem of READIN ALOUD
• SEMANTIC paralexia –m.c
• Eg: infant read as baby
92. Agraphia
• anterior(BROCA’s)-agrammatism with spelling
mistakes
• Posterior(WERNICKE’S)-unintelligible & non-
sensical
Aphasic
agraphia
• Correct letters and words
• Problem with orientation
• eg,. Moving on to the next line, wider space on
one side
Visuospatial
agraphia
• Language fromation is correct along with spatial
arrangement
• Handwriting loses its personal characters.
Apraxic
agraphia
Notas do Editor
Ventral part: social cognition
DLPFC:selective attention working memory
MEDIAL PFC: motivation & initiation
FDS subcortical dementia.
Does not necessarily mean that the lesion has to be in the frontal lobe.
Executive function: goal oriented activity thet requires planning,initiation,response inhibition, mental flexibility(SET SHIFTING), working memory and fluency.
Antisaccades test
Read the words
Read the colours
Image cam scanner
Image camscanner
Comon mistakes performed by pts.
Not shifting from numbers
Levels of increasing difficulty
Image camscanner
Bedside testing , 4 dots can be given
Demonstrate them . Perform it with me..1-2 times…do it on ur own
Mountain valleys plateau
Spirals
M & N
Mountains & plateaus. No.of mountains can be increased sequentially
LEFT MEDIAL FRONTAL LOBE
Mistakes like : they re the same thing,start describing the objects
Instead of saying they are fruits they say both are yellow
IMAGE CAM SCANNER
Cancel or circle all the c’s
DEMONSTRATE
SENSORY MEMORY is the shortest-term element of memory. It is the ability to retain impressions of sensory information after the original stimuli have ended. ... For example, the ability to look at something and remember what it looked like with just a second of observation is an example of sensory memory
Working memory: remembering the phone no before dialling or remembering the OTP before entering them
Filling clerk is the –PFC guides the storage and retrieval of memory
Recent memory file cabinet-medial temporal lobe (storage of recent memory)
Remote memory-cortex. Long term storage.
TESTS REGISTRATION
PROCEDURE FOR STORY RETRIEVAL.
Lexical morphemes: dog, fast
Grammatical morphemes: affix-faster,connectors- neither
AG-39,SMG-40,PMA-41,WA-22,BA-44,45
Conventionally means wernickes area. But functional neuroimaging have found otherwise
Bilateral localization hence difficult to destroy
Location and function of the three areas
Fusiform gyrus serves as the phoneme perception system for visual language while reading
Mapping of the phoneme sesequences to their meaning in the internal semantic system
Repetition : input from the phoneme perception system directly to the phoneme retrieval system bypassing the internal semsntic system justifying the fact we don’t have to understand words inorder to tepeat them
Similarly reading aloud involves phoneme percetion visually through the fusiform gyrus(the visual counterpart for the auditory phoneme system)
Again this does no require understanding and is lot like repeatition in the circuitry
For sponataneous speech retrieval of the word meaning from the semantic system onto the phonological retrieval system
Naming also involves a similar path.
Brocas area is constituted by 44,45, (posterior part of the inferior frontal gyrus)surrounding frontal area , underlying frontal white matter and the caudate nucleus.
Exners writing area: posterior part of the middle frontal gyrus
ABILITY TO UNDERSTAND.
3 animals & 3 musical instruments
Boat,goat, boot,coat,bone,kite
Naming is impaired in all.
Mild transient speech disturbance with impaired prosody nd articulatory agility
Why is repetition impaired in Broca;s then.
Bcoz it’s the final pathwAY for speech output & the articulatory speech agility is impaired here.
Conduction aphasia: logopenic variant of the PPA
Phonemic/lexical retrieval area
Hence comprehensiin is preserved
Where is echolalia seen?
Conventionally means wernickes area. But functional neuroimaging have found otherwise
ALSO important in color integration and facial recognition.
Visual information from the left occipital lobe reaches directly the left fusiform gyrus.
From the rt occipital lobe has to cross over to (corpus callosum)reach the left fusiform GYRUS.
ANGULAR GYRUS- interpreetation of visual-verbal materials.
paralexia
Copies written language as if it was a foreign language.
Color naming impaired
Explaination:
Like wernicke’s where reading is impaired more than auditory perception
Aquired abnormalities of writing: agraphia
They have been asked to describe the cookie jar picture.