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Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction.

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Presentation on theme: "Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction."— Presentation transcript:

1 Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction

2 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History The frontal lobes as “silent areas”

3 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History Phineas Gage (Harlow, 1848)

4 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History Wartime Trauma Improvements in military medicine led to markedly improved survivability from head wounds in WWII and subsequent wars. Low velocity shrapnel vs. high velocity projectiles. Example: Luria and localization of function in Russian soldiers.

5 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History Leukotomy and lobotomy

6 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History Advances in neuroimaging

7 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: History Advances in neuroimaging

8 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Comparative studies Evolution Frontal lobes account for increasing proportion of cerebrum across phylogenetic spectrum (Fuster, 1980) Prefrontal areas are 33% of cerebral cortical surface in humans (Goldman-Rakic,1984)

9 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Comparative studies Working memory paradigms Spatial working memory tasks –Delayed response –Delayed alternation Feature working memory tasks –Delayed matching to sample –Delayed object alternation

10 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Comparative studies Working memory paradigms

11 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Development Aging and frontal functions

12 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Functional zones

13 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Primary motor functions Brodmann area 4 Input from ventral lateral thalamic nucleus, primary somatosensory area in parietal lobe Output to internal capsule Pyramidal motor functions

14 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Primary motor dysfunction Initially flacid hemiparesis or hemiplegia on contralateral side Later spastic hemiparesis or hemiplegia

15 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Premotor functions Brodmann area 6 Input from ventral anterior thalamic nucleus and secondary somatosensory area Output to motor area and connections via corpus callosum to contralateral premotor area Integration of sensory and motor information Praxis

16 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Premotor dysfunction Apraxia Preserved postural praxis via basal ganglia Contralateral fine motor deficits Difficulty using sensory feedback

17 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Frontal eye field functions Brodmann area 8 Volitional eye movement in contralateral visual field Active visual search

18 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Frontal eye field dysfunction Failure to move eyes volitionally to contralateral visual field Intact passive eye movement Poor visual search

19 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Dorsolateral functions Brodmann areas 46, 45,47,8, 9 Executive functions –Integration of multimodal sensory information –Generation of multiple reponse alternatives –Selection of appropriate response –Maintenance of set, persistence –Set shifting, flexibility –Spatial working memory

20 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Dorsolateral dysfunction Difficulty integrating sensory information Generation of few, stereotyped response alternatives Poor judgement in response selection Impersistence Perseveration

21 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Dorsolateral tests Figural fluency

22 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Dorsolateral tests Luria’s reciprocal hand movements & graphic designs

23 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Dorsolateral tests Perseverations within and between Lurian tasks

24 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Dysexecutive effects on other tests

25 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes Poor organization of learning and recall CopyFree recall

26 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Orbital functions Brodman areas 10,11,12,13,14 Input from limbic and olfactory systems (amygdala, temporal pole, entorhinal cortex, olfactory nerve); inferotemporal lobe areas, ventral visual pathways Output to autonomic musculature and endocrine system (basal forebrain cholinergic system, caudate, and autonomic system) Modulation of affective and social behavior; “...preservation of behavioral regulation by external stimuli and its dissolution in the absence of external stimulation.” Working memory for feature information Integration of memory and emotional valence Smell discrimination

27 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Orbital dysfunction Disinhibition, socially inappropriate behavior Failure on feature working memory tasks Anosmia Confabulation

28 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Orbital tests Go-NoGo tasks UPSIT Frontal Systems Behavior Scale (FrSBe) SIGO interview for behavior change

29 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Orbital tests Changes in smell with aging

30 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Disinhibition and intrusion in drawing

31 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Cingulate/SMA functions Brodman areas 24, 32 Connections with older cortical and deep limbic structures Drive and motivation Environmental exploration Complex attention

32 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal zones: Cingulate/SMA dysfunction Apathy, akinetic mutism Alien hand syndrome Complex attentional deficits, delayed habituation

33 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Alien hand syndrome

34 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Subcortical connections Parallel but separate connections to caudate and thalamus Topographic mapping of caudate and thalamus Subcortical white matter connections –Long tracts –Cortical U-fibers Small subcortical lesions can mimic large cortical lesions

35 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Subcortical connections Thalamus dorsomedial Dorsolateral prefrontal Dorsolateral caudate Lateral dorsomedial Globus Pallidus VA & MD Thalamus Ventromedial caudate Medial Globus pallidus Anterior Cingulate Nucleus accumbens Rostrolateral Globus Pallidus MD Thalamus Orbital prefrontal VA & MD Thalamus

36 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Subcortical connections Thalamus

37 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Subcortical connections White matter uncinate fasciculus long tracts to posterior association areas cortical u-fibers

38 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Cortical connections

39 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Other signs and syndromes “Frontal release” signs –Disappear with normal development, reappear in aging or frontal systems dysfunction –Snout, suck, glabellar, grasp Gegenhalten vs. cogwheeling Frontal or magnetic gait

40 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Clinical examples

41 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Dementia Korsakoff’s syndrome This 42 year old man was admitted from a rest home, where he had been displaying a number of problematic behaviors, including compulsive eating of all the vegetables in the garden, and perseverative stuffing of toilets with paper. PMH = Severe alcohol abuse. He had impulsively gone to Florida with a barmaid, and spent all his money. He was “rescued” by his wife, but was unable to return to work as a bartender. He was eventually place in a rest home. NP testing = severe anterograde/retrograde amnesia, moderately severe deficits in executive abilities, marked inertia, abulia, and apathy.

42 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Korsakoff’s syndrome: Intrusions and disinhibition

43 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Trauma Localization of TBI from Courville, 1941

44 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Trauma Contusion with hemorrhage Case history: This 57 year old man was found unconscious by his family, and was thought to have struck his head in a fall. LOC x few hours, but remained confused for the next few days. Sent to a nursing facility, but had repeated arguments with staff, made sexually inappropriate and racist remarks, and was hospitalized. NP testing = severe dysexecutive and disinhibitory deficits, which affected his performance on other tasks.

45 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Trauma Contusion with hemorrhage

46 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Dementia of the frontal type vs. Alzheimer’s disease Early changes in behavior/personality Neuropsychological deficits in executive and inhibitory functions, no frank amnesia Relative sparing of posterior functions (must be dissociated from dysexecutive problems) Anterior atrophy Preservation of personality & social behavior Neuropsychological deficits in naming and construction, with frank amnesia after delay Relative sparing of anterior functions Generalized and hippocampal atrophy

47 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes:Dementia Frontal type This 56 year old man presented with a one year history of progressive decline in memory and judgment, and several demotions at work. He had displayed a number of socially inappropriate behaviors, such as visiting a neighbor's swimming pool without invitation, neglect of his personal hygiene, and uncharacteristic episodes of anger dyscontrol. NP testing revealed prominent deficits on tests of executive and self-regulatory functions, failures on memory testing typical of frontal impairment (e.g. perseverative and intrusion errors).

48 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes:Dementia Frontal type

49 Brown UniversityPaul Malloy, Ph.D.Butler Hospital Frontal lobes: Dementia Frontotemporal dementia Normal elderlyFrontal dementia

50 Brown UniversityPaul Malloy, Ph.D.Butler Hospital 5/29/2002

51 Brown UniversityPaul Malloy, Ph.D.Butler Hospital 5/29/2002

52 Brown UniversityPaul Malloy, Ph.D.Butler Hospital 5/29/2002

53 Brown UniversityPaul Malloy, Ph.D.Butler Hospital 5/29/2002

54 Brown UniversityPaul Malloy, Ph.D.Butler Hospital MMSE: 16 6/2002

55 Brown UniversityPaul Malloy, Ph.D.Butler Hospital MMSE: 25 3/2003

56 Brown UniversityPaul Malloy, Ph.D.Butler Hospital 6/2002 MMSE: 16 3/2003 MMSE: 25


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