CHAPTER 1

INTRODUCTION
The frontal lobe is the largest lobe of the brain associated with behavioral
aspects. Frontal lobe syndrome is a change in behavior, emotion and personality
that results from damage of the forebrain. The incidence that can lead to this
syndrome includes head traum, vascular syndrome, tumor, frontotemporal
dementia, and surgery due to aneurysm. Clinical manifestation arouse is highly
diverse but it is nucleated on the inability to regulate the behavior. The treatment
that we are doing today is to treat the underlying disease from the occurrence of
the frontal lobe syndrome, family counseling, and surgery when necessary.

CHAPTER 2
LITERATURE REVIEW

2.1 Frontal Lobe Syndrome

2.1.1 Definition
Frontal lobe syndrome is associated with behavioral aspects and is
influential in bringing the personality and social adaptation. A head trauma often
leads to a frontal lobe syndrome and provides a wide range of clinical
manifestations that is difficult to make a clinical diagnosis. (1,3)

The symptoms occurred are often confused by psychiatric symptoms. The

patients with frontal lobe lesions arising slowly often cause vague symptoms; it
requires understanding of the function of the frontal lobe syndrome occurred to
evaluate a state of frontal lobe syndrome, due to impairments in mental status
such as memory impairment, attention impairment, behavioral change, impaired
function of control and execution, is the essential in the frontal lobe, in addition to
impairment due to the increase in intracranial pressure. (1,2,3,4,5)

2.1.2 Etiology dan pathophysiology

Frontal lobe syndrome is a change in behavior, emotion and personality
that results from from damage of the forebrain. The incidence that can lead to this
syndrome includes head injuries, vascular syndrome, tumor, frontotemporal
dementia, and surgery due to aneurysm.1) The main factor of frontal lobe
syndrome is still a head injury. Although the definitive incidence rate is hard to
obtain, but the authors quite agree of it.(1,3,4)
The frontal lobe is one-third of the human cerebral cortex. Each part of
frontal lobe is divided into three areas, among others: the primary motor cortex,
the premotor cortex and the prefrontal cortex. (1,2,6)
The primary motor cortex is primarily for voluntary movements. Damages
in these areas will lead to paralysis of the opposite side of the body. Premotor
cortex is associated with the primary motor cortex and is essential for the

integration and consecutive movement programs. Pre-frontal cortex is divided into

three regions, namely, the orbito-frontal region (anterior frontal lobes),
dorsolateral region, as well as the anterior cingulum.
There are five known circuits, namely: motor circuits in the motor areas,
oculomotor circuits in frontal visual field, and three circuits in the pre-frontal
cortex areas; namely the dorsolateral pre-frontal circuit, pre-frontal orbitofrontal
circuit, and anterior cingulatum. Each circuits has projection fibers to striata
(caudate nucleus, putamen, and anterior striatum), and from the striata is
associated to the globus pallidus and substantia nigra, projections to the nucleus
thalamus and back to the frontal lobe.
Dorsolateral circuit commences from pre-frontal dorsolateral cortex,
dorsolateral caudate nucleus, lateral dorsomedial globus pallidus, dorsomedial and
anteroventral nucleus thalamus, pre-frontal dorsolateral regions. Damages on this
circuit cause impaired executive function, including difficulty in learning new
information, impaired motor movement programs, impaired verbal and non verbal
fluency, impairment in reconstructing the complex forms. These circuits receive
inpuls of afferent fibers in pre-frontal areas 4, 6 and parietal area 7a involved in
the process of sight. Afferent fibers from limbic system is received through the
projection of dopamine from the substantia nigra.
Orbitofrontal cortex circuits commence from orbitolateral, ventromedial
caudate nucleus, medial dorsomedial globus pallidus, ventroanterior nucleus
thalamus and orbitolateral mediodorsal cortex. Damages on this circuit cause

impaired disinhibition, such as behavioral disorders in the form of simple,

emotional lability and obsessive compulsive disorder. This circuit receives
afferents fibers from temporal area 22 and orbito frontal 12 consisting of the
heteromodal sensory and the limbic.
Anteriot cingulatum circuit commences from the anterior cingulatum
anterior cortex, nucleus accumbens, rostrolateral globus pallidus, mid-dorsal
thalamus to the anterior cingulatum cortex. Damages on this circuit are
characterized by apathy, decreased willingness and the absence of emotion. This
circuit receives afferent fibers from the hippocampus, an enttorhinal area 28 and
perirhinal area 35. (1)
In addition to the above circuit circuit, there is also direct and indirect
pathways that play a role in the function of the frontal lobe .(1)

2.1.3 Clinical Manifestation

Frontal lobe syndrome is in the form of symptoms of an inability to
regulate the behavior such as impulsive, no motivation, apathy, disorganization,
deficit of memory and attention, executive dysfunction, inability to regulate
his/her mood, easy to forget, words that often offend or dirty, lazy/no willingness
to do any kind of activity, unruly, always feel the most correct .(1,2,3)

2.1.4 Clinical Examination

The clinical diagnosis of a frontal lobe syndrome is quite difficult; because
the pre-frontal lobe dysfunction is often not detected on standard neurological
examination,

and

mental

status

examinations

and

conventional

neuropsychological tests. There are several clinical examinations, a mental status

test and neurobehavior scale that should be used in these circumstances.(1)
1. Motor movement control and programs :
a. emphasis on motor impulses and reflexes:

reflex to hold

test go/no go
b. Rapid motor movement: rhytm tapping
c. Complex serial movement

Lurias hand sequences

Alternating pattern

2. Mental control :
a. trial making test
b. Ability to repeat the words, day, and month in reverse
1. influency and creativity with five point test
2. memory with range of digit dan word list learning
3. behavior and emotion; 12 items of neurobehavioral rating include:
emotional distress, depression, slow motion, blunted affect, mood
lability, disinhibition, inability to to cooperate, excessive
excitement, lack of attention, poor planning, inappropriate selfassessment.

2.1.5 Treatment
The treatment in a frontal lobe syndrome is to overcome the symptoms
arouse in accordance with the underlying unknown diseases, and then performed
conventional therapy or surgery. In addition to say that the treatment of this
condition is not specific, the authors say that we must consider counseling against
the patient's family, because their families who are now experiencing this
syndrome is not the their formerly families, in terms of nature, behavior, even
their daily lives have changed.(1,2,3,4,5)

CHAPTER III
CONCLUSION

Frontal lobe syndrome is a syndrome caused by an impairment of frontal

lobe function. There are many incidences causing frontal lobe syndroma, but the
most common factor is head trauma. It requires clinical history and examination,
especially the examination of noble function very carefully so that these cases can
be detected. The treatment done still requires patience and good cooperation
between patients, physicians, and the patient's family in order to obtain optimal
treatment results.