Subject: Neurology I Second Semester A.Y.

2013-2014
Topic: Neuro 1.3 Approach to Cerebral Function
Lecturer: Dr. Martinez
Date: June 30, 2014

OUTLINE
 Lateralization in the Brain II. LOBES OF THE BRAIN
 Lobes of the Cerebrum
o Frontal Lobe
o Parietal Lobe
o Temporal Lobe
o Occipital Lobe
 Functional Areas of the Brain
 Assessment of Higher Cortical Function
 Mental Status Examination
o Folstein’s Mini Mental State Exam

I. LATERALIZATION IN THE BRAIN

Table 1. Comparison of Lateralization in the Brain

LEFT HEMISPHERE RIGHT HEMISPHERE

Right handed, 96% left 4% of R handed: right hemisphere
hemisphere dominance dominance
Left-handed: 70% left, 15% right,
15% both hemisphere verbal Figure 2. Lobes of the Cerebrum. Frontal, Parietal, Temporal,
Verbal centers, verbalization
Occipital and Insula.
Naming No language output
Categorization of everyday Spatial perceptual problems  Postcentral gyrus
objects Facial expressions o Sensory area
Rationale Intuitive thinking o Temperature, pressure and pain.
Analytic Emotional o Discriminatory sensation
Intellectual
A. Frontal Lobe
SEX DIFFERENCE
Male – spatial orientation, Women – verbalization, facial
mathematics expression
NUMERICAL COMPUTATION
Exact calculation, numerical Approximate calculation,
comparison, estimation numerical comparison, estimation
LANGUAGE
Grammar / vocabulary, literal Intonation / accentuation,
prosody, pragmatic, contextual

Figure 3. Frontal lobe. Yellow circle = Broca’s Area, Blue circle = Pre-
central gyrus,

 Pre-frontal

o Concerned with higher mental functions e.g. intelligence,

planning and elaboration of thoughts.
o Preservation of recent memory (through its connection with
hippocampus)--working memory-episodic
o Regulation of some autonomic functions (through its
connection with hypothalamus).
o Regulation of behavior and personality character.
Figure 1. Lateralization in the brain o One of the primary area of the brain that is affected by trauma

Trans Group: Talento, Tan, Tan, Tasani Page 1 of 7

Edited By:
 Limbic B. Parietal Lobe
o Orbitofrontal: emotions, aggression, general arousal reaction  It receives the following sensations:
o Fine touch (tactile localization, tactile discrimination, etc.).
 Broca’s Area o Fine grades of temperature.
o Speech control and expression of language vocally o Discrimination of weight (by deep pressure & muscle tension).
o Inferior frontal gyrus o Vibration sense.
o Pars orbicularis o Sense of position and sense of movements.
o Pars triangularis o Taste sensation in the face area
o Pars opicularis  Concerned with understanding the meaning of the various
 Pars triangularis and opicularis of the dominant sensation.
hemisphere contains the motor (Broca’s) speech center o So the person can recognize the objects without using his
vision; i.e. by size, shape, texture, weight and temperature of
 Precentral gyrus the objects.
o Responsible for control of voluntary muscles o Its lesion leads to astreognosis i.e. he can't recognize the
o Responsible for UMN which decussates at the level of the objects.
lower third of the medulla therefore, all clinical manifestation  Body space relationship
of the affectation of primary motor cortex would be paralysis  Object oriented motions(reaching)
of ½ of the body contralateral to the lesion (hemiparesis of the  Spatial orientation
½ of the body including the face).
o Motor homonculus depicts the organization of the motor strip Table 3. Lesion in the parietal lobe.
according the body part innervated
DOMINANT NON-DOMINANT
o More used = higher representation BILATERAL LESION
HEMISPHERE LESION LESION
Gertsmann’s syndrome: Neglect syndrome: Balint syndrome:
right-left disorientation, complete ignorance inability for optic
agraphia, acalculia, of the contralateral eye movements,
finger agnosia, aphasia part of the body optic ataxia

Sensory neglect:
posterior right
parietal area can
feel stimulation on
right but not on left
(right side of the
brain is the
dominant
hemisphere)

Figure 4. Motor Homonculus.

Table 2. Functions and observed problems of frontal lobe
FUNCTIONS of FRONTAL LOBE
 Initiation
 Problem solving
 Judgment
 Inhibition of behaviour
 Planning/anticipation
 Self-monitoring
 Motor planning
 Personality/emotions
 Awareness of
abilities/limitations
 Organization
 Attention
 Mental flexibility
 Speaking (expressive
language)
OBSERVED PROBLEMS
 Depression
 Anxiety
 Personality changes
 Aggression, acting out
 Social inappropriateness
 Broca’s aphasia (executive
dysfunction)
C. Temporal Lobe
FUNCTIONS
 Perceives and recognizes verbal materials (understanding/
receptive language)
 Memory
 Hearing
 Organizing and sequencing
 Music awareness
 Acquisition and retention of visual tasks (inferotemporal region)
 Auditory task (superotemporal region)
 Reception and understanding of spoken language
(superotemporal region)
OBSERVED PROBLEMS
 Difficulty screening out distractions
 Thinking (memory and reasoning)

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Temporal Lobe Lesions
LEFT UNILATERAL LESION RIGHT UNILATERAL LESION Functional Areas of the Brain

 Production of speech, naming,  Impaired memory of sensory

and verbal memory damage. input, face discrimination,  Precentral Gyrus: Movement (BA 4,6)
 Language comprehension and altered emotions.  Post Central Gyrus: Sensation (BA 312)
understanding.  Loss of musical abilities and  Temporal Lobe: Hearing, Language, Memory
foreign languages, visual  Inferofrontal area: Smell (BA29)(the primary sensation
memory and comprehension affected when there is an inferotemporal lobe lesion
of environment. especially in a patient with dementia)
 Unexplained tearing, and  Parietal: sensations, language, perception, body awareness,
crying and unexplained panic attension
 Occipital lobe: Visual Recognition
I. Inferotemporal  Inferior frontal: Broca’s Area (speech control)
 Acquisition and retention of visual tasks  Superior temporal: Wernicke’s Area (language
Lesions: patients cannot interpret what they have seen comprehension
 Brainstem: consciousness, breathing, heart rate
II. Superotemporal
 Auditory task
 Reception and understanding of spoken language .
IV. Assessment of Higher Cortical Function
Lesions: Wernicke’s Aphasia (Receptive/Fluent Dysphasia)  Be sure to observe gaze preference or hemiparesis.
 Why? (From lecturer including sample cases)
D. Occipital Lobe
o The middle frontal gyrus is concerned with aversive eye
movement, meaning if you stimulate on the RIGHT side, the
FUNCTIONS
 Vision (Main visual center) eyes with conjugally deviate to the other side – LEFT.
 Reading (perception and recognition of printed words) o If there is excessive stimulation in the RIGHT, especially in
patients with a seizure disorder, one of the initial clinical
OBSERVED PROBLEMS manifestation of the patient would be a deviation or a
 Depth perception (problems picking up things out of space or may preferential gaze to the LEFT.
misperceive pictures and objects  Caution: patient might go into a generalized motor seizure
 Colour perception because of excessive stimulation.
 Difficulty tracking moving objects  So when the head turns to the left, and the eyes goes to
 Partial or total blindness (may experience “holes” or “blind spots” the left, be sure there might be an excessive; but it is NOT
in what they see) ALWAYS an excessive.
 Example: The patient has a destructive lesion. The patient
suffered a stroke or had a tumor; THE EYES WOULD LOOK
Remember: (From Ana: Neuro Optic Pathway)
ON THE SIDE OF THE LESION.
Optic Nerve Lesion: unilateral Blindness
o Why?
Optic Tract and Optic Radiation Lesion: Homonymous
Hemianopsia  Because the right and the left sides are giving stimulation,
Both Occipital Lobes: Total Cortical Blindness that’s why our eyes are in the primary gaze. If you
Difference bet. Occipital Lobe and Optic Nerve Lesion stimulate on the right the eyes goes to the left, and vice-
There is preservation of the Pupillary Light reflex in an versa. But if you DESTROY the one on the RIGHT SIDE, only
occipital Lobe Lesion compared to an optic nerve lesion. the left can stimulate so the eyes WILL LOOK TO THE
RIGHT – WHICH IS THE SIDE OF THE LESION. (Important
III. FUNCTIONAL AREAS OF THE BRAIN clinical sign in clinical neurology)
o Example: You see the patient has paralysis on one side of the
body, and the patient suffered a stroke. The patient looks to
the side of the lesion. One of the initial thing that a neurologist
would think, there is a preferential gaze and in most cases this
might be a big, massive lesion ON THE RIGHT.
 Determine which side first with sensory inattention
o Look first for the paralysis and the preferential gaze
o You start to stimulate on both sides of the body
 If the patient cannot answer for example, a comatose
patient, with right sided hemiparesis, the patient’s eyes
are deviated to the right. You want to verify if the patient
has really a paralysis. You stimulate the patient: put hard
pressure over the SUPRAFRONTAL AREA. Or you could put

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 deep pressure on the patient’s sternum manubrium area. sticks as stimulants.
The non-paralyzed side would move and the one with o Bilateral anosmia – not neurological, present in having colds
paralysis would not. o Unilateral anosmia – indicative of dementia which is an
 Visual inattention inferior frontal lobe lesion
o You present things to the patient, ask him to read.  Expressive dysphasia
 If the patient is stuporous, with right sided hemispheric  Urinary incontinence
lesion; the patient won’t see the left. When asked to read  Gait apraxia
A,B,C,D he will only read A,B – A,B without the C,D. o Apraxia – inability to learn former skilled movements in the
 Tactile Inattention absence of paralysis with the sensorium of the patient intact.
 Line bisection test (Parietal lobe) o In patients with gait apraxia, you assist the patient – initiate
o You draw a line, and ask the patient to bisect the line. the movement in the patient’s legs and you would see that the
o If the patient cannot see the left half of the visual field, the patient has no paralysis.
lesion is usually on the opposite side. (Right-sided parietal lobe
lesion) Temporal Lobe Function
 Superior quadrantonopsia
 Circling alphabets
o You write alphabets and you ask the patient to circle the letter  Receptive dysphasia
you’re asking for.  Short and long term memory
 Determine side Occipital Lobe Function
o Astereognosis (using common objects)  Cortical blindness
o Graphesthesia (writing numbers on the palm with eyes closed  Hemianopsia with macular sparing
– 3,4 and 8 is usually mistaken)  Look for contralateral upper motor neuron VII or ipsilateral XII
o Visual field for hemianopsia palsies.
 Gross confrontation test – compare visual field of patient o Central for face palsies (same side)
with doctor in the 6 areas of vision. o Brain stem paralysis (opposite side)
 Flick finger only once. Compare response with the patient.
 Check for pronator drift and minimal leg drag
 If you suspect LEFT side: o Gravity leads to heaviness of the arm if you ask the patient to
o Dysphasia assessment (expressive, receptive, nominal, extend his upper extremities.
conductive)
 If you suspect RIGHT side: VI. MENTAL STATUS EXAM
o Constructional apraxia (copy a cube or an intersecting  30 items, done in an individual to test memory and cognitive
pentagon) 
o Dressing apraxia (unbutton the shirt) Table 5. Psychiatric Interview VS. Mental Status Exam
 Usually patients would just grasp and crumple the shirt PSYCHIATRIC INTERVIEW MENTAL STATUS EXAM
o Spatial neglect (simultaneous stimulation)  Appearance  Attention and concentration
 Motor Behavior  Language
 Stand at the back of the patient and simultaneously touch
 Mood and affect  Memory
the patient, asking him where he was touched. Any  Verbal output  Constructions and praxis
stimulation given if a lesion is present will be neglected.  Stream of thought and  Calculation skills
talk  Abstraction
Parietal Lobe Function  Perception  Insight and judgment
 Gertsmann and nominal dysphasia vs apraxia and spatial neglect
o Patient will identify the position of the finger.
A. Folstein’s Mini-Mental Exam
Frontal Lobe Function (child/primitive reflexes)
 Grasp and palmomental reflexes; and glabellar tap Table 6. Folstein’s Mini-Mental Exam
o Stimulation of the palmar area of the patient would elicit PROCEDURE MAXIMUM SCORE
contraction in the mouth (mental). Orientation
o Grasp reflex present with a stimulus; not letting go of the hand - What is the day, date, month, 5
when one feels the hand is slipping away at the very end. season and year?
-Where are we? Country, state, city, 5
o Glabellar tap – usually using a neuro-hammer; keep on tapping
hospital, floor?
would elicit protruding of the lips. Registration
 In patients with Parkinson’s disease; if you keep on Name three objects: 1 second to say
tapping the glabella, eventually the patient would go into each. Then ask patient to repeat all
3
glabellar spasm or a Myerson's sign. three. Give 1 point for each correct
answer. Then repeat all three are
o Rooting reflex registered.
o Snout reflex
 Optic atrophy (tested via opthalmoscope)
 Anosmia
o Closing both eyes of the patient and use coffee or cigarette

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Attention and calculation
Serial 7s. One point for each correct.
Stop after 5 answers. Alternatively,
spell WORLD backwards.
Recall
Ask for the three objects you ask him
to remember. Give 1 point for each
correct answer.
Language
-Name a pencil and a watch.
-Repeat the following: “No ifs, ands,
or buts”
-Follow a three-step command:
“Take a piece of paper in your right
hand, fold it into half, and put it on
the floor.”
- Read and obey the following:
“Close your eyes.”
-Write a sentence.
Praxis
Copy Design (intersecting design)
o Capital of different countries or provinces
5 EXECUTIVE FUNCTIONS
 Collection of brain processes that are responsible for planning,
cognitive flexibility, abstract thinking, rule acquisition, initiating
appropriate actions and inhibiting inappropriate actions, and
3 selecting relevant sensory information.
CLOCK DRAWING TEST
 Complete 12 numbers
2
 Correct positioning of 12 numbers
1
 Correct placement of hands to designate the time asked
3  Correct proportion of the hand of the clock
TRAIL MAKING TEST
A. Connect numbers with randomly placed numbers. Must be done in
1
less than 120 seconds without lifting pen.
1

TOTAL 30
B. Connect letters with their corresponding number. More difficult
and must be done in 360 seconds.
From last year’s trans that were not discussed:

V. EXAMINATION OF MEMORY

BASIC MENTAL PROCESSES OF MEMORY

 Registration: the ability to perceive, recognize, and establish
information in the central nervous system
 Retention: the ability to retain registered information
 Recall: the ability to retrieve stored information at will

HISTORY AND CONVERSATION VI. APRAXIA

 The patient should be able to give a clear account of his/her life APRAXIA
from the remote to the recent past.  Inability to carry out on request a high-level, familiar, and
 Presenting complaint is important. purposeful motor act in the absence of any weakness, sensory
 Internal consistency of the personal history. loss, or other deficit involving the affected side.

SHORT TERM MEMORY (Immediate Memory) TYPES OF APRAXIA

 Recall of material within a period of up to 30 seconds after
presentation.
o Ask the patient to repeat sequences of digits (normal 7 digits)
LONG TERM MEMORY
 Recent memory: events occurring during the past few hours to the
past few months
o Ask the patient to learn three or four unrelated words said at
the rate of about one per second
o Ask to repeat each word after it has been said, to ensure that
each has been registered properly
o Distract, then ask to recall the words after 3 minutes or so
 Remote memory: events occurring in past years
o Name the current president and the two previous presidents
o Give name of children
o Birth date and place of birth
 Ideational / ideomotor: “wave good bye, blow me a kiss, show me
how to comb your hair, brush your teeth”
 Dressing apraxia: ask patient to button and unbutton shirt/blouse
 Gait apraxia: ask patient to walk
 Buccal apraxia: “stick out your tongue, lick your lips with your
tongue”
 Constructional apraxia: seen in posterior lesions of left or right
parietal or diffuse brain damage.
o Ask the patient to copy the Rey-Osterrieth complex figure.
 Kinetic limb apraxia:
o Interlocking finger test (entails limb praxis, visual-spatial, and
visuo-constructional skills, and poor performance is highly
correlated with parietal lobe pathology)

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 VII. AGNOSIA

AGNOSIA
 Loss of the ability to know or recognize the meaning of stimuli,
even though they have been perceived
 Absence of sensory deficit, sensorium intact
 Most frequently specific to one modality

VISUAL OBJECT AGNOSIA

 Inability to recognize a familiar object which can be seen.
 Seen in left occipital lobe lesions.
 Ask the patient to identify objects which make no noise, such as
pen, a coin or a dressing comb.

AGNOSIA FOR FACES (PROSOPAGNOSIA)

 Inability to recognize faces of people well known or newly
introduce to the patient.
 Most frequently the result of bilateral lesions of the mesial cortex
of occipital and temporal lobes.
TACTILE AGNOSIA (ASTEREOGNOSIS)
 Inability to recognize objects by touch.
 Result from unilateral or bilateral lesions of the postcentral gyrus.
 Ask the patient to identify by touch, items such as a key, a coin, or
a pen.
AUDITORY AGNOSIA
 Inability to recognize non-verbal acoustic stimuli.
 Associated with unilateral or bilateral temporal lesions.
 Ask the patient to identify the sound of keys jangling, water
running from a tap, or the clapping of hands.
SPATIAL AGNOSIA
 Include disorders of spatial perception and loss of topographical
memory. Some include spatial agnosia and constructional apraxia.
 Associated with bilateral cortical lesions.
 Ask the patient to locate significant geographical locations on an
unmarked map and orient him/herself in space using the available
cues.
Image 5.The positron emission tomography (PET) scan shows typical
patterns of brain activity associated with: reading words, hearing
words, thinking about words and saying the words.
APHASIA
 Disorder of language, including various combinations of
impairment in the ability to spontaneously produce, understand
and repeat speech, as well as defects in writing and reading.
EXPRESSIVE DYSPHASIA
 Caused by damage to a region of the inferior left frontal lobe.
 Manifestations:
o Slow, laborious non-fluent speech
o Difficulty in saying little words with grammatical meaning (e.g.
“a”, “the”, “some”, “in”)
o Words that they manage to say are almost entirely content
words (subject and verb)
 Speech deficits produced in and around the Broca’s area.
o Agrammatism: difficulty in using grammatical construction
o Anomia: word finding difficulty (omit words and/or use of
inappropriate words)
o Articulation difficulties
 Mispronounce words (lipsticks – likstip)
 Altering sequence of sounds

CORPORAL AGNOSIA AND ANOSOGNOSIA RECEPTIVE DYSPHASIA

 Corporal agnosia: inability to recognize parts of the body (one  Caused by lesion in the left superior temporal gyrus.
form of which is finger agnosia) or that a part of the body affected  Manifestations:
by disease (anosognosia). o Poor speech comprehension
 Agnosia limited to finger identification may be found in left o Production of meaningless speech
parietal lesions (in right handed people) o Fluent and unlaboured
 Anosognosia is associated with right parietal lesions. o Patient does not strain to articulate words
o Patient maintains a melodic line (prosody) with voice rising
VIII. LANGUAGE and falling normally
LANGUAGE EXAMINATION  Abilities disrupted includes:
 Spontaneous speech o Recognition of spoken words (pure word deafness)
 Comprehension o Comprehension of the meaning of words (transcortical sensory
 Naming aphasia)
o Ability to convert thought into words (conduction aphasia)
 Repetition
 Common co-morbid occurrence is unawareness of the deficit
 Writing
(anosognosia)
 Reading
BOSTON DIAGNOSTIC APHASIA TEST
 Conversational and expository speech
 Auditory comprehension

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 Oral expression
 Understanding written language
 Writing

TOKEN TEST
 Consist of 20 tokens with varying shapes, size and colour
 62 commands are given

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