FRONTAL LOBE

AND DISORDERS
DR.MEERA.S

JUNIOR RESIDENT
Frontal Lobe Anatomy

• Largest of all lobes

• SA: ~1/3 / hemisphere

• 3 major areas in each lobe

• Dorsolateral aspect
• Medial aspect
• Inferior orbital aspect
Frontal Lobe Anatomy

Premotor area Primary motor area

B6 B4

Central sulcus
Supplementary
motor area
(medially)

Frontal eye field

B8

Prefrontal area
B 9, 10, 11, 12
Lateral sulcus/Sylvian fissure

Motor speech
area of Broca B 44, 45
Functional Frontal Lobe Anatomy

• Motor cortex  Prefrontal cortex

• Primary – Dorsolateral
• Premotor
• Supplementary
– Medial
• Frontal eye field – Orbitofrontal
• Broca’s speech area
VASCULAR SUPPLY

• Derived from ACA and MCA

• Superolateral – MCA ( except for thin medial strip by ACA)
• Medial – cortical branches of ACA
• Inferior – medial by ACA
lateral by MCA
MOTOR CORTEX

• Located in precentral gyrus(area 4)

• Matures by the age of 4 years
• Betz cells
• Low intensity of current required to elicit
movements
• Representation of human body
• Striking disproportion for hand and face
 Motor
• Primary Cortex
motor cortex

• Input: thalamus, BG, sensory,

premotor

• Output: motor fibers to

brainstem and spinal cord

• Function: executes design into

movement

• Lesions:/ tone;  power; 

fine motor function on contra
lateral side
 Primary (Somatic) Motor Cortex
• Somatotopy
• The entire body is
represented spatially in the
primary motor cortex, i.e., in
one region we have neurons
controlling hand movements
and in another region leg
movements, etc.
Motor Cortex

• Premotor cortex
• Input: thalamus, BG, sensory
cortex

• Output: primary motor cortex

• Function: stores motor programs;

controls coarse postural
movements

• Lesions: moderate weakness in

proximal muscles on contralateral
side
 Motor Cortex
• Supplementary motor area

• Input: cingulate gyrus, thalamus, sensory & prefrontal cortex

• Output: premotor, primary motor

• Function: intentional preparation for movement; procedural

memory

• Lesions: mutism, akinesis; speech returns but it is non-spontaneous

•
Frontal Eye Fields
Input: parietal / temporal (what is
target); posterior parietal cortex (where
is target)

• Output: caudate; superior colliculus;

paramedian pontine reticular
formation,caudate nucleus, midbrain

• Function: executive: selects target and

commands movement (saccades)

• Lesion: eyes deviate ipsilaterally with

destructive lesion and contralaterally
with irritating lesions
 Motor
• Broca’s Cortex
speech area
• Input: Wernicke’s

• Output: primary motor

cortex

• Function: speech
production (dominant
hemisphere); emotional,
melodic component of
speech (non-dominant)

• Lesions: motor aphasia;

monotone speech
ORBITAL PREFRONTAL
CORTEX
• Part of limbic social cognition
system • Lesions: emotional
• Function: lability,
emotional input, disinhibition,
arousal, distractibility,
suppression of impulsivity
distracting signals,
MEDIAL PREFRONTAL CORTEX

• Functions: motivation,
initiation of activity
• Lesions: apathy; decreased
drive/ awareness/
spontaneous movements;
akinetic-abulic syndrome &
mutism
 DORSOLATERAL PREFRONTAL
CORTEX
• Functions: executive functions using ‘working memory’

• Lesions: executive function deficit; disinterest / emotional reactivity;  attention to

relevant stimuli
 Subdivisions of pfc

• DLPFC: promotes goal-setting and task monitoring through the processes of working
memory
• VLPFC: reconciles stimuli and potential responses with the stored representations of past
experiences
• ACC: motivates for choosing the best goal-oriented response from the available choices
• DMPFC: engages the perspective of the self and considers feedback on the outcomes
• VMPFC: provides meaning by linking emotion to experiences, context-updating
• OFC: learning from reward and punishment and for controlling immediate responses to
environmental events before considering the options
Functional Frontal Lobe Anatomy

• ‘Frontal subcortical circuits’

Globus
Striatum Thalamus
Fronta Pallidus &
Caudate & nuclei
l Substantia
Putamen
cortex Nigra
Frontal Subcortical Circuits:
1. Motor Circuit

VL Globus
SMA, Pallidus Hypo-thalamus
Premotor, Putamen
Motor VL, VA, CM
Thalamus

• Supplementary Motor & Premotor: planning, initiation & storage of motor

programs; fine-tuning of movements
• Motor:final station for execution of the the movement according to the design
Frontal subcortical Circuits:
2. Oculomotor Circuit

DM Globus
Frontal Pallidus
Caudate VA, MD
Eye Field
Thalamus
VL Substantia
Nigra

• Voluntary scanning eye movement

• Independent of visual stimuli
Frontal subcortical Circuits:
3. Dorsolateral Prefrontal Circuit
DM Globus
Lateral Pallidus
DL VA, MD
Prefronta
Caudate Thalamus
l Substantia
Nigra
 Frontal subcortical Circuits:
4. Lateral Orbitofrontal Circuit
Lateral DM Globus
orbital Pallidus
gyrus VM VA, MD
Caudate Thalamus
Medial Substantia
inferior Nigra
FG

• Integration of limbic and emotional information into

contextually appropriate social behaviour
• Emotional life and personality structure
Frontal subcortical Circuits:
5. Anterior Cingulate Circuit

Anterior Globus
Ventral Pallidus
Cingulate Striatum MD
Gyrus Substantia Thalamus
Nigra
Frontal Lobe Syndromes
The Case of Phineas Gage (Harlow 1868)
 Tamping iron blown through
skull: L frontal brain injury
 Excellent physical recovery
• Dramatic personality
change:
• ‘no longer
Gage’:stubborn, lacked
in consideration for
others, had profane
speech, failed to
execute his plans
Diseases Commonly Associated With
Frontal Lobe Lesions
 Traumatic brain injury
– Gunshot wound

– Closed head injury

• Widespread stretching and shearing of fibers
throughout
• Frontal lobe more vulnerable

– Contusions and intracerebral hematomas

Diseases Commonly Associated with
Frontal Lobe Lesions

 Frontal Lobe seizures

– Usually secondary to trauma
– Difficult to diagnose: can be odd (laughter, crying,
verbal automatism, complex gestures)
Frontal lobe Epilepsy
•Nonspecific aura
•Begin and end abruptly
•Brief duration, usually less than 60 seconds
•Frequently in series, rapid secondary generalization,tendency to status
epilepticus
•Semiology variable in individual patients
•Complex motor automatisms
•Complex vocalizations
•Nocturnal preponderance
•May be misdiagnosed as psychogenic seizure.

of contact, consciousness)  motor activity (massive

(Loss
movements of body, limbs) vocalization automatisms
abrupt end of seizure with full consciousness
Frontal lobe Epilepsy
 Frontotemporal lobar degenerations (FTLD) and other
dementias of the frontal lobe
behavioral variant of frontotemporal dementia
•Orbitobasal or pseudopsychopathic FTD
•Mediofrontal (anterior cingulate) FTD
•Dorsolateral prefrontal or pseudodepressive FTD

primary progressive aphasia (PPA), a.k.a progressive

nonfluent aphasia (PNFA)

logopenic progressive aphasia (LPA)

semantic dementia (SD), also known as fluent PPA

Diseases Commonly Associated With
Frontal Lobe Lesions
 Vascular disease
– Common cause especially in elderly
– ACA territory infarction
• Damage to medial frontal area

– MCA territory
• Dorsolateral frontal lobe

– ACom aneurysm rupture

• Personality change, emotional disturbance
Diseases Commonly Associated With
Frontal Lobe Lesions
 Tumors
– Gliomas, meningiomas
– subfrontal and olfactory groove meningiomas:
profound personality changes and dementia

 Multiple Sclerosis
– Frontal lobes 2nd highest number of plaques
– euphoric/depressed mood, Memory problems,
cognitive and behavioral effects
Diseases Commonly Associated With
Frontal Lobe Lesions
 Degenerative diseases
– Pick’s disease
– Huntington’s disease

 Infectious diseases
– Neurosyphilis
– Herpes simplex encephalitis
Diseases Commonly Associated with
Frontal Lobe Lesions
 Psychiatric Illness – proposed associations
– Depression
– Schizophrenia
– OCD
– PTSD
– ADHD
Executive dysfunction seen in

• Huntingtons disease
• Parkinsons disease
• PSP
• Wilsons disease
• Neuro acanthocytosis
• Psychiatric disorders- Schizophrenia, Depression, ocd,
ADHD, Tourettes syndrome, Korsakoff syndrome
Lesion of OFC

• Pseudopsychopathic personality
• disinhibition, emotional lability, irritability, explosive aggressive
outbursts, impulsive behaviour
• Inappropriate social behaviour-lack of interpersonal sensitivity,
improper sexual remarks, lack of empathy, inappropriate jocular
affect
• Euphoria
• Distractibility
• Poor judgement and insight
• Impaired reponse inhibition- impaired go-no-go

• OCD
DISINHIBITION SYNDROMES
OCCUR IN
• Frontotemporal dementia
• Closed head injury
• Frontal lobe tumors
• Focal vascular lesions
• Pseudo-depressive syndrome
• Amotivation
• Akinetic mutism
• bilateral lesions of the ACC; a wakeful state with prominent apathy,
indifference to pain, thirst or hunger; lack of motor and psychic initiative,
spontaneous movements, verbalization and response to commands
• Abulia
• a less severe form of akinetic mutism; apathy, lack of responsiveness, poor
initiative and inertia
• Apathy: affective/emotional, cognitive, motor
• reduced response to pain; impaired motor initiation
Akinetic mutism described in

• Cerebrovascular d/s-mesencephalic infarction

• Craniopharyngiomas
• Obstructive hydrocephalus
• Tumours in region of 3rd ventricle
• Conditions inv. Ventral striatum
• Circumscribed SMA lesion

Apathy- B/l lesion of VL &DM thalamic nuclei

- GP lesion
 CLINICAL EVALUATION

History

Observation and Interview

Frontal Lobe Functions

Insight

Judgement

 Similarities

Digit Span test

 CLINICAL EVALUATION
Frontal Lobe Functions

Random “A” Letter test

LTPEAOOASCZAAACFDPRA
 CLINICAL EVALUATION
Frontal Lobe Functions

Trail making test

Part A and B
 CLINICAL EVALUATION
Frontal Lobe Functions
Conceptual Series completion
 A B C D…….
 1 4 7 10 …….
 AZ BY CX D….
Problem Solving
Controlled Oral Word Association Test (COWAT)
Category fluency
Fund of knowledge
Proverbs
 CLINICAL EVALUATION
Frontal Lobe Functions
Alternating motor patterns test (kinetic melody)

Fist –Palm-Side test

Go-No test
 CLINICAL EVALUATION
Frontal Lobe Functions
Assessing speech and language by
checking fluency
looking for paraphasic-phonic and semantic errors
word finding difficulties
comprehension
naming
 repetition of words and phrases
reading aloud
performing written instructions
asking the a patient to write a sentence
 CLINICAL EVALUATION
Frontal Lobe Functions

Stroop test
 CLINICAL EVALUATION
Frontal Lobe Functions
THANK YOU