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Cerebral lobe syndromes

LAYERS OF CORTEX
1. Molecular: horizontal axons, golgi 2 cells 2. Ext. Granular: granule cells 3. Ext. Pyramidal: 4. Int. Granular: 5. Int. Pyramidal:
commisural fibers

stellate cells, ext. band of Baillarger Largest cells

6. Multiform Layer

LAYERS OF CORTEX
1 & 2: receive diffuse afferent fibers from lower brain to control excitability of region 3: connect two hemispheres and ipsilateral cortico-cortico association fibers main sensory afferent input (in sensory cortex) main efferent to brain stem and spinal cord (in motor cortex) efferent fibers to thalamus

4: 5:

6:

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GENERAL ANATOMY ‡ ‡ ‡ ‡ ‡ Frontal Lobe Temporal Lobe Parietal Lobe Occipital Lobe Insula .

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Frontal lobe .

Frontal lobe ‡ Highest level of brain evolution ‡ Involved in many functions ‡ Lesions in different parts lead to different syndromes .

Frontal lobe .

pallilalia ± Premotory areas lesions: diminishment of spontaneous movements. akinesia.Frontal lobe syndrome ‡ ‡ Lesions of the motor area lead to motor deficits of the opposite half of the body ± Irritative lesions ± jacksonian motor seizures Lesions of premotor areas ± less important motor deficit ± Irritative lesions in premotor areas ± ³adversive´ seizures. frontal ataxia . or supplementary motor area seizures ± Supplementary motor area seizures: cessation of all activity. repetitions. eventually hyopkinesia. tonical contractions of proximal muscles. tremor ± Forced prehension ± Gait and posture abnormalities. delay of voluntary actions (movements).

11 ‡ Plays a role in affective behavior and judgment .10.PREFRONTAL CORTEX ‡ Frontal pole ‡ Areas 9.

PREFRONTAL CORTEX
‡ Pts with bilateral lesions neglect their appearance, act inappropriately, have no appreciation of social norms for conduct. They are uninhibited and highly distractable ‡ Perseveration

Frontal lobe syndrome
‡ Prefrontal areas lesions
± Alteration of personality ± Diminishment of spontaneous activity - the patient does not feel the need to do anything, is not able to plan the future events, may be agitated ± Attention deficits ± memory is normal, but the patient doesn¶t bother to use it ± Loss of abstract thinking ± Perseveration ± Afffective changes ± either apathic, ³flat´, either excessively exuberant and childish; may show lack of inhibition, eventually sexually improper actions

Frontal lobe syndrome
± Prefrontal dorsolateral cortex lesions
‡ Diminished fluency (verbal & nonverbal), reasoning problems, reduction of spontaneous responses inhibition, perseveration, attention deficits

± Orbitofrontal cortex lesions ± desinhibition, anosmia ± Mezial frontal cortex, anterior cingullary cortex lesions ± apathy, abulia, memory impairments

Cognitive function testing in frontal lobe lesions ± MMS does not approach these problems ± Frontal lobe tests: ‡ ³go-no go´ tests ± patient is told to lift 2 fingers. but the evaluator lifts only 1 ‡ Speech fluency ± patient is asked to produce as many words he can starting with letter ³Z´ ± normally more than 8 words/ 1 min ‡ Motor tests for perseveration ± patient is asked to execute series of 3 movements (fist. edge-palm tests ± Luria) .

Parietal lobe .

7. 39. 2 areas ± primary somatosensory cortex 5. 40 areas ± somatosensory association areas. areas 5 and 7 are important for stereognosis Parietal regions have appeared when the fingers were used for more than just mobility (catching.Parietal lobe ‡ ‡ Anterior somatosensory area. throwing) ‡ ‡ . 1. posterior association area 4th neuron of sensory tracts (3.

despite having the desire and the physical ability to perform the movements ± Finger agnosia ± Left-right agnosia . anosognosia. anosodiaforia. neglect of left body half) ‡ Right parietal lobe ± spatial component of activities ± Apraxia ± loss of the ability to execute or carry out learned purposeful movements.Parietal lobe syndromes ‡ Controlateral hemihypestesia (diminished sensation) ‡ Astereognosis (5 & 7 areas lesions) ‡ Sensory epilepsy (paresiae and sometimes paroxistical pain) ‡ Asomatognosia (left hemisphere lesions lead to one side asomatognosia.

"pick up this pen and write down your name") ± Inability to use the informations on spatial relations ‡ Constructive apraxia ‡ Topographic agnosia ‡ Prosopagnosia . or wink).. e.Parietal lobe syndromes ‡ Left parietal lobe ± symbol and experiences comprehension ± ideomotor (inability to carry out a motor command or a learned gesture. ‡ nonverbal-oral or buccofacial (inability to carry out facial movements on command. cough. ± ideational (inability to create a plan for or idea of a specific movement. for example. lick lips. for example.g. whistle. "act as if you are brushing your teeth" or "salute") ‡ limb apraxia when movements of the arms and legs are involved.

purposeful motor acts correctly despite intact motor and sensory systems. an activity that can be performed spontaneously Summary of path activated when pt. and normal attention and comprehension Ideomotor Apraxia ‡ Inability to carry out. asked to move his left hand .APRAXIA Apraxia = inability to perform skilled. learned. on verbal command.

APRAXIA Ideational Apraxia ‡ Abnormality in the conception of movement so that the the pt. although more common and severe in nondominant lesions . has difficulty sequencing the different components of a complex motor task ‡ Lesion in dominant temporo-parieto-occipital area Constructional Apraxia ‡ Inability of the pt to put together or articulate component parts to form a single shape or figure. eg assembling blocks to form a design ‡ Can be seen with either dominant or nondominant posterior parietal lesions.

Constructive apraxia .

syncynesia) ‡ Balance problems ‡ Taste problems (area 43) ‡ Hemianopia . unstable hand.Parietal lobe syndromes ‡ Speech problems ± frequently associated with writing problems ‡ Motor abnormalities (diminishment of spontaneous movements.

Parietal lobe syndromes ‡ Gerstmann syndrome (left angulary girus) ‡ Digital agnosia ‡ Left-right confusion ‡ Agraphia ‡ Acalculia .

Parietal lobe .

‡ Adaptative possibilities of parietal lobes ± blind boy ³reads´ with the tip of his nose .

Temporal lobe .

TEMPORAL LOBE
‡ Two transverse sulci divide into ‡ Superior Temporal Gyrus ‡ Middle Temporal Gyrus ‡ Inferior Temporal Gyrus ‡ Transverse (Heschl¶s) Gyrus runs anterolaterally over superior aspect of first temporal Gyrus

Temporal lobe
‡ Underneath the lateral sylvian fissure, continues with occipital and parietal lobes ‡ Primary and associative auditory areas (41, 42), association areas (38, 20, 21, 22); ‡ Area 38 ± involved in taste perception ‡ Areas 41, 42 sound perception and interpretation ‡ Limbic system (hypocampal uncus and gyrus, girus cinguli, subcalossal areas, olfactory areas) ± critical role in emotions and affect ‡ Optic radiations ‡ Dominant temporal lobe ± perception and decoding of words/language ‡ Nondominant temporal lobe ± perception of intonation, music, conversation

Temporal lobe syndromes
‡ Temporal lobe lesions
± Troubles of hearing, balance, taste, smell, language, sight, memory, dietary comportment, sexual behaviour ± Epilesy with temporal lobe generators ± reason troubles, halucinations, abnormal behaviour

‡ Hearing loss ± area 41 ± unilateral lesion; bylateral lesions ± cortical deafness; iritative lesions lead to auditory illusions, auditory hallucinations ‡ Taste and smell problems: olfactory halucinations as part of epileptic crysis. Destruction of olfactory areas in the hippocampal uncus and hypocampic gyrus lead to anosmia. Olfactory hallucinations may precede seizures (aura) ‡ Visual damage ± hemianopia, visual memory impairment

APHASIA .

Circumlocution ‡ ³Empty speech´ or ³word-salad´ ‡ Cannot comprehend ‡ Lesion in Wernicke¶s area= posterior part of Superior Temporal gyrus (22) .WERNICKE¶S APHASIA ‡ Fluent. Neologism. Receptive ‡ Normal to supranormal speech output ‡ Paraphrasia. Substitutions.

APHASIA TYPE BROCA¶S TRANSCORTICAL MOTOR GLOBAL FLUENCY COMPREHESION REPETITION + + - - + - - WERNICKE¶S TRANSCORTICAL SENSORY CONDUCTION + - + + + - .

aphasia.Temporal lobe syndromes ‡ Memory impairment ± Recent memory ± in billateral inferior hypocampic lesions ± Short term memory ± bilateral lesions of mamillary bodiesAfectarea memoriei pentru cuvinte ± Long time memory ± mamillothalamic or cortical bilateral lesions ± Storage of new memories and comprehension of those elements is performed by the Papez circuit (hypocampus. thalamus. deja pense. girus cinguli) ‡ ‡ Sexual and feeding behaviour Temporal lobe epilepsy ± EEG ± Simple or complex psychosensorial halucinations. jamais vu . olfactory or auditory halucinations ± Recall and recognition impairment ± déjà vu. mammilary bodies.

. Role in storing memory.Papez circuit ‡ ‡ ‡ ‡ James Papez in 1937 One of the major pathways of the limbic system Chiefly involved in the cortical control of emotion.

KLUVER. Paul Bucy. 1939 Bilateral temporal lobectomy Blunted Affect with Apathy Psychic Blindness or visual agnosia with inability to distinguish between friends and strangers Hypermetamorphosis = hypersensitivity to minute/fine visual stimuli Hyperorality Bulemia or unusual dietary habits Hypersexulaitity ‡ ‡ ‡ ‡ .BUCY SYNDROME ‡ ‡ ‡ ‡ Heinrich Kluver.

Occipital lobe .

18. transparency) ± 18th area (parastriate) and 19th area (peristriate) ± association cortex ‡ Disorders of the occipital lobe can be the result of distruction (defficit) or irritation. and symptoms may be uni. movement. light. shape.Occipital lobe ‡ Small part of dorsolateral part of the hemispheres ‡ Visual function ± ± ± ± Visual perception Recognition in relation to spatial and temporal parameters 17. size.or bylateral . 19 Brodmann areas 17th area ‡ Near the calcarine sulcus ‡ Reception center for visual information (colour.

PRIMARY VISUAL CORTEX .

reverse sight. lights. reappariton of images after the source has ceased to exist in the visual fields. with sensory and cognitive aspects ± Elementary hallucinations:stars. mobile/fixed in the visual fields . ± Loss of spatial sight. moving objects ± Abnormal colours (erithropsia). or believe that they are real ‡ Visual illusions (metamorphopsia) ± objects have abnormal visual properties: shape. animals of normal or abnormal size. colours ± Images may be related to previous experiences ± Mycropsia. lack of colour (acromatopsia). geometric figures ± Complex hallucinations: objects. poliopia (one object appears in multiple instances). size. megalopsia. patients may perceive those object as unreal. macropsia. persons. colours. monocular diplopia. flashes. false orientation of objects in space ‡ Occipital lobe epilepsy ± elementary visual hallucinations.Occipital lobe syndromes ‡ Irritative pathology: ‡ Visual hallucinations ± simple (elementary) or complex.

g.PRIMARY VISUAL CORTEX ‡ Occipital lobe syndromes ± Lesions produce visual field defect in contralateral visual field ‡ e. lesion of inferior calcrine cortex = contralateral quadrantanopsia ± Lesions of the whole visual cortex in one hemishpere result in a loss of vision in the contralateral visual field ± If lesion is vascular (eg occlusion of PCA) results in macular sparing because macula area receives collateral blood supply from the MCA .

and acts as in the case of a peripheral blindness ± Some patients try to act as if they were seeing ± Anton syndrome (associates parietal lesions and sensory neglect) . impossibility of colour naming and identification ‡ Cortical blindness ± Both primary visual areas are damaged ± Patient cannot interpret visual information.Occipital lobe syndromes Deficit syndromes ‡ Colour agnosia ± loss of correct perception of colours.

Ocular Apraxia ± Inability to direct eyes to a certain point in visual fileld despite intact vision and eye movements ± Seen with Bilateral Parieto-Occipital lesions .‡ Balint¶s syndrome ± Bylateral lesions of occipital lobes ± Optic Ataxia.

auditory or tactile Visual Agnosias ± ± ± ± Visual Object Agnosia= inability to recognize visually presented objects Prosopagnosia= inability to recognize faces Visual color agnosia= inability to recognize colors Simultanagnosia= inability to recognize the whole ‡ Auditory Agnosias ± Auditory Verbal Agnosia= inability to recognize spoken language ± Auditory Sound Agnosia= inabiltiy to recognize non-verbal sounds ± Sensory Amusia= inability to recognize music ‡ Tactile Agnosias ± Astereognosia= inability to judge form of object by touch .AGNOSIA ‡ ‡ ‡ Agnosia = the inability to recognize perceived sensory informaton Often modality specifiv: visual.

Epilepsy .

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± Convulsion: Sudden attack of involuntary muscular contractions and relaxations.Definition ‡ Epilepsy: A group of recurrent disorders of cerebral function characterized by both seizures and convulsions. ‡ Sezures are generated by abnormal synchronous electrical brain activity . ± Seizure: Abnormal central nervous system electrical activity.

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Etiology ‡ Idiopathic ± genetic conditions ‡ Acquired: ± Trauma ± Brain tumors ± Stroke ± Infections ± Degenerative diseases .

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pH and cell volume . Ca.Ion channels ‡ Proteins that are organised into small pores in the cell membrane ‡ They allow selective passage of ions (Na. Cl). ‡ Intercelular signals. with an important contribution in maintaining the membrane potential and in forming the trans membranare electric flow. transmembrane transport. K.

Calcium channel .

Natrium channel Na channel .

Potassium channel .

Classification Partial (focal) ‡ Simple ± Motor ± Sensitive ± Vegetative ± Psichical Generalized ‡ ‡ ‡ ‡ ‡ ‡ Tonic Atonic Clonic Tonic-clonic Mioclonic Absence ‡ Complex ‡ Secondary generalized unclassifiable International Classification of Seizures (ILAE. Epilepsia 1981) .

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‡ Epileptogenesis ‡ The abnormal discharge originates usually in a definite area .

Investigatii ‡ ‡ ‡ ‡ Electroencefalogrphy ± spectral analysis Cerebral Computed Tomography (CT) MRI Functional imagistics techniques: ± PET ± fMRI ± SPECT ‡ Magnetoencephalography ‡ video ± EEG monitoring .

Scalp EEG Data Acquisition .

1010-second EEGs: Seizure Evolution Normal Pre-Seizure Seizure Post-Seizure .

normal .EEG .

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- Spike-wave complexes .

fMRI .

PET .

MagnetoMagnetoencefalography .

TYPES OF SEIZURES .

Generalized Seizures ‡ ‡ ‡ ‡ ‡ Grand Mal Absence Tonic seizures Atonic seizures Mioclonic seizures .

‡ Usually originates in the thalamus or brainstem. ‡ Affects the whole body. ‡ Loss of consciousness is common.Generalized Seizures ‡ Excessive electrical activity in both cerebral hemispheres. .

jpg . arms. or legs ‡ Clonic Seizures: rhythmic jerking movements of the arms and legs without a tonic component ‡ Tonic-clonic (grand mal): ± Tonic phase followed by clonic phase http://www. ‡ Tonic Seizures: sudden stiffening of the body.gov/medlineplus/ency/images/ency/fullsize/19076.Generalized Seizures ‡ Myoclonic: Brief shock-like muscle jerks generalized or restricted to part of one extremity. ‡ Atonic: Sudden loss of muscle tone.nih.nlm.

Generalized Seizures ‡ Absence (petit mal): Person appears to ³blank out´ . or 3 seizures without a normal period in between ± May be fatal ± Emergency intervention required .³Daydreaming´ ± Simple Absence (primarily effects consciousness only) ± Complex Absence ± Atypical Absence (Includes physical symptoms like eye blinking or lip movements) ‡ Status Epilepticus: A seizure lasting longer than 30 min.

Grand Mal epilepsy .

Absences .

± Motor ± Sensory ± Autonomic ± Key feature: preservation of consciousness. .Partial (focal) Seizures ‡ Excessive electrical activity in one cerebral hemisphere. ‡ Simple Partial: Person may experience a range of strange or unusual sensations. -Affects only part of the body.

Partial (focal) Seizures ‡ Complex Partial: ± Loss of awareness at seizure onset.g. Person seems dazed or confused and exhibits meaningless behaviors. ± Typically originate in frontal or temporal lobes (e. Temporal lobe epilepsy) .

Motor partial seizures ‡ ‡ ‡ ‡ ‡ Motor (Jacksonian) seizures Oculo-cefalogiric seizures Adversive seizures Supplementary motor area seizures Tonic seizures .

Sensory partial seizures ‡ ‡ ‡ ‡ ‡ ‡ Jacksonian sensory seizures Visual Auditive Vestibulary Olfactive & gustative Vegetative .

‡ Jamais vu ‡ Anger. ‡ Déjà vu. fear. joy crisis .Partial complex seizures Association areas are involved: ‡ Partial loss of awareness ‡ Dream state.

Partial motor & sensory seizures .

Complex partial seizures .

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‡ Drugs ‡ Cetogenic diet ‡ Surgery ‡ Vagal stimulation .

Treatment principles ‡ Monotherapy ‡ Politherapy ‡ Titration ‡ Treatment cessation .

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Absence seizures ‡ Etosuximide ‡ Oxazolidindione .

Drugs that work in seizures other than absence ‡ Phenobarbital ‡ Phenitoin ‡ Carbamazepine ‡ Primidone .

Drugs efficient in all types of seizures ‡ Sodium valproate ‡ Clonazepam .

Status epilepticus ‡ Prolonged seizure or seizures without remission periods between ‡ Parenteral treatment: ±Clonazepam ±Diazepam ±Phenitoin .

Antiepileptics: efficacy range Large range of efficacy ‡ Sodium valproate ‡ Levetiracetam ‡ Phenobarbital ‡ Benzodiazepines ‡ Topiramate ‡ Lamotrigine ‡ Zonisamide* * Based on preliminary evidence Narrow range ‡ Phenytoin ‡ Carbamazepine ‡ Ethosuximide ‡ Gabapentin ‡ Oxcarbazepine ‡ Tiagabine ‡ Pregabalin .

Modern Antiepileptics ‡ ‡ ‡ ‡ ‡ Topiramate Vigabatrin Oxcarbazepine Lamotrigine Clobazam ‡ ‡ ‡ ‡ ‡ Gabapentin Pregabalin Tiagabine Levetiracetam Zonisamide .

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Adverse efects ‡ ‡ ‡ ‡ Gingival hyperplasia Hirsutism/ Transient hair loss Vitamine/folate deficiency Polycystic ovary syndrome and menstrual disturbances ‡ Bone loss .

Surgery ‡ Resection of epileptic abnormal discharge source ‡ Lobectomiy ‡ Hemispherectomy ‡ Calosotomy .

Vagal stimulation ‡ Electrodes are attached to the vagus nerve ‡ Intermittent stimulation ‡ Indication in treatment resistent epilepsy .

Special issues ‡ Driving ‡ Extreme/risky sports ‡ Special professions ‡ Pregnancy and breast feeding .

Julius Caesar Sokrates Gustave Flaubert Hermann von Helmholtz Alfred Nobel Margaux Hemingway Jeanne d'Arc Lord Byron Vincent van Gogh Wladimir Iljitsch Lenin F.´ Napoleon Bonaparte G.M. Dostojewskij Kardinal Richelieu .³People with epilepsy have excelled in every area.