EXAMINATION

NEUROLOGY
Definitions chapter 3 and 11
 DEFINITIONS
• The frontal eye field- is a specialized area situated in the middle zone of the dorsolateral surface
which includes the prefrontal and premotor cortex.
• Cytoarchitecture- refers to the arrangement of cells in organs and tissues particularly in the cortex
area.
• Aphasia – refers to a language disorder that affects a person's ability to communicate.
• Confabulation- refers to the tendency of the patient to produce inaccurate information on being
questioned about the past either recent or remote
• Momentary confabulation- refers to the most common form of confabulation that consist of the
production of autobiographic material of the habitual nature in response to being questioned.
• Fantastic confabulation- less common form of confabulation which consist of material around
grandiose theme , often arising spontaneously and frequently repeated
• Utilization behavior- describes the form of behavior where patients with a frontal lesion give an
instrumentally appropriate but exaggerated response to objects that were introduced to them
 DEFINITIONS

1. cerebral angiography is used to refer to the radiological investigation of both the arterial and
venous channels of the brain and us often used interchangeably with the term arteriography.
2. Electroencephalography- this is the technique of recording the electrical activity of the brain
through the skull by means of electrodes placed on the scalp.
3. Anoxia- reduction of oxygen supply to the tissue
4. Ischemia- reduction of blood supply
5. Oedema- brain swelling
6. Coup’ injuries refer to damage beneath the site of impact,
7. Contre-coup’ injuries refer to lesions at some distance from the site
8. Glasgow coma scale is a simple standardized chart of eye opening, motor response and verbal
response.
9. Neoplasm is defined mass of cells, it is normally present in the body but arranged atypically,
which grow at the expense and independently of the organism without subserving any useful
purpose therein
● Transient ischaemic attack- Refers to recurrent attacks of short-lived local neurological deficit
produced by temporary ischaemia.
● Aphasia- refers to an acquired impairment in the reception manipulation or expression of the
symbolic content of language due to brain Damage.
● dysarthria - speech difficulties due to interference with the peripheral speech mechanisms,
larynx pharynx and tongue.
● paraphasia - is the expressive difficulties manifested by errors in word or phrase selection.
● Alexia- inability to understand written language
● conduction aphasia- abnormality in speech with the preservation of comprehension of both
written and spoken speech.
 DEFINITIONS
1. Transient global amnesia- is a sudden, temporary interruption of short-term memory
2. Retrograde amnesia-patient has lost the ability to recall events that happened just before the onset of
amnesia
3. Anterograde amnesia- refers to a decreased ability to retain new information
4. The cocktail-party effect- refers to the ability of normal individuals to note information, such as one’s
name
5. Sound agnosia- refers to the inability to discriminate accurately a sound produced by a perceptual
discriminative
6. Associative auditory agnosia- refers to the inability to associate the auditory stimulation with its
meaning
7. Primary effect- the reproduction of the first word that was given in a given word series.
8. Recency effect- the reproduction of the last word given in a given word series
 DEFINITIONS
1. Topographical agnosia- inability to recognize and use visual cues from ones surrounding
to guide them to a particular direction
2. Topographical amnesia- impairment of memory for places and spatial layout.
3. Unilateral spatial neglect- inability to pay attention to people and things on the affected
side.
4. Tactile agnosia- inability to identify objects by touch in the absence of visual input
5. Spatial apraxia- The patient can recognize letters and words but may be unable to read.
 DEFINITIONS
1. Visual agnosia- refers to a failure to recognise objects through the visual sense where
there is neither a primary sensory loss nor mental deterioration
2. Visual object agnosia- refers to the failure to recognize objects when presented via the
visual perceptual modality with preservation of recognition by other modalities such as
touch
3. Simultanagnosia- This form of visual agnosia consists of an inability to appreciate more
than one aspect of stimulus configuration at a time.
4. Alexia without agraphia- Patient has reading difficulties due to the failure of recognizing
words

5. Prosopagnosia ( agnosia for faces)- inability to recognize faces

CHAPTER 3
Study notes
METHODS OF
INVESTIGATION
Neurological examination, radiological investigation and electrical investigation
 NEUROLOGICAL EXAMINATION

• Entails gathering a detailed history from the patients and those around him. Much valuable
information such as the types of neurological test to be employed can be obtained from the
patients case file.
• Where the anamnesis is insufficient, the neuropsychologist should develop careful questioning .
• Neurological investigations aim to obtain information on the changes specifically changes on
human functioning that occur with lesion in the nervous system.
• The information obtained can be used to add on to the method already in use for the diagnosis of
the nature and location of lesions
 RADIOLOGICAL INVESTIGATION

• It relies on the detection of differences of electron density between tissues for a differential effect
on the X-ray attenuation which is then used to create a visual image
• Imagining techniques
1. Computerized tomography (CT scan)
2. Positron electron computerized tomography( PET scan)
3. Arteriography
4. Single photon emission computed tomography
5. Digital subtraction angiography
6. Magnetic resonance imaging (MRI
 PROCEDURES / TECHNIQUES

1. Computerized tomography ( CT Scan)

• this technique measures the morphological changes of the brain by scanning the brain using a narrow
beam of X-ray. The photon data is processed by a computer and the Information is converted to a
visual image of the internal structure of the head and brain.
• Pathological processes are indicated by alterations of normal density and by deformation of brain
structures. It increases the sensitivity by using intravenous injection of iodine containing material.
• Its values lies in the clear delineation of the morphology of neurological lesions in vivo against which
to correlate behavioural indices.
• This procedure is safe and easy to carry out on both in-patient and out-patient cases.
2. Positron emission computerized tomography ( PET scan)
• The technique can provide a cross section of the brain and also it is capable of providing dynamic
information on a wide range of cerebral functions such as local cerebral blood flow, local cerebral
glucose and oxygen metabolism as well as blood volume and other measures.
• It produces an image of brain radioactivity following the Intravenous injection of a labelled indicator.
The biologically active compounds used include positron emitting isotopes of elements such as
carbon, fluorine, nitrogen and oxygen.
• It proved useful in demonstrating altered cerebral function of a lasting nature in tissues that appear
normal with computed tomography.
• Its value lies in the ability of the , PET tracers being able to chemically attached to many normal and
abnormal brain neurotransmitters, receptors, peptides and intermediate molecules.
• Examples include labelling of the amyloid protein that accumulates in Alzheimer's disease, muscarinic
receptors and dopaminergic systems in Parkinson's disease and Dementia with Lewy Bodies.
3. Single photon emission computerized tomography (SPECT)
• The technique records regional differences such as those of cerebral blood flow as it consists of a
gamma camera that is used to record emissions after the injection of a radiotracer that is taken up
differently by normal and pathological tissue.

• One of the most fruitful areas has been the study of epileptogenic foci, where the possibility exists
of surgical excision of the affected area with cure or amelioration of the condition. In this instance
comparison measurements are made between the interictal state of the brain and the activity during
a period of electrical abnormality.
• It can be used to study other conditions such as Alzheimer's disease, head injuries and amnestic
disorders. It has been used to study a patient who suffer from complex partial seizures and the three
phases of activity were shown.
4. Arteriography
• Technique is used to outline the circulation by means of a rapid series of radiographs taken during the
passage of radiopaque material that has been injected into the blood stream. Formerly the injection
was made directly in to the artery, most commonly the internal carotid artery, but it is now customary
to pass a catheter via the femoral artery.
• This allows injection of material into the arch of the aorta to display the origins of all vessels or
selective catheterization of chosen vessels to study the extracranial and intracranial circulation.
• Its value lies in the investigation of structural abnormalities of the blood vessels themselves.
• The risks have been associated with sensitivity to the injected radio-opaque materials.
5. Digital subtraction angiography
• Technique used for scanning the output from an x-ray image-intensifying tube with a video camera and
this video signal is then amplified and stored in digital form in the imager’s memory.
• Further images are taken after the arrival of contrast materials at the site then the first set of data, which
is the mask image, is then subtracted from the second by the computer to produce the final image.
• Contrast material is introduced intravenously thus avoiding the rik=sks associated with intra-arterial
injections. When contrast material can be introduced intravenously so that it is possible to visualise
either the extracranial or intracranial circulation on an outpatient.
• The material is of particular value in detection of extracranial vascular pathology such as stenosis
occlusion and ulceration and that performs a valuable role in the prevention of stroke.
6. Magnetic resonance imaging
• MRI measures both structural and physiological abnormalities. It provides rapid non-invasive depiction of
vascular anatomy . It does not employ x-rays and does not require the injection of contrast media and images
are usually superior to those obtained with CT scanners and it has the ability to produce images in all planes.
• MRI-demonstrated hypoperfusion correlates well with neuropsychological deficits as exemplified by “cortical”
deficits in the presence of subcortical infarction
• Retarded diffusion of water molecules can detect probable irreversible ischemic damage in acute stroke within
minutes, whilst influx of injected contrast material can show reduced blood perfusion around the diffusion
lesion indicating further “at risk”, some of which appears salvageable with clearing of blocked arteries.
• There has been a recent MRI innovation with considerable potential for neuropsychology which is said to be the
functional magnetic resonance imaging (fMRI) which is based on image signal intensity varying with regional
blood volume in which increases in neuronal activity can be visualised during specific cognitive tests.
• The MRI signal can be altered by using the blood oxygenation level dependent (BOLD) contrast technique
which uses paramagnetic properties intrinsic to deoxygenated hemoglobin. Cognitive paradigms are constructed
with at least two states varying ideally by only one cognitive parameter and steady state BOLD images from
each state are compared to determine those areas uniquely active.
 ELECTRICAL INVESTIGATION

1. Recording
• Uses electroencephalography which is the technique of recording the electrical activity of the brain through the skull
by means of electrodes placed on the scalp.
• As the difference between two points on the skull are very small before they can be used to drive a recording device
they need to be amplified multiple times. The brain potentials are recorded in waveform from 1 to 100 Hz, with an
amplitude ranging from about 5 to several hundred microvolts.
• The scalp electrodes are usually placed in a standard pattern, and the activity between any pair of electrons is
recorded as a single channel, of which there are usually about 16 at any given time. The "montage" can be varied by
switching the outputs between pairs of electrodes. Newer digital systems allow for simultaneous recording from all
sides, allowing for different montages to be created to view transient changes.

• The technique is often valuable in neurological diagnosis particular in the investigation of epilepsy, the abnormal
electrical activity may be recorded in the period between the patient's clinical seizures. Unfortunately any one EEG
record taken from an epileptic patient may prove to be normal and serial recordings are often needed.

• Latent abnormalities may be brought out by using various activation procedures such as: i) recording during sleep; ii)
over breathing for 2 or 3 minutes; iii) photic stimulation in the form of repetitive light flashes; and iv) administration
of drugs this may be effective in evoking the epileptic discharges so that they may appear on the record though the
patient may not have any clinical manifestations.
• Recent advances in electronic technology have made it possible to record EEG actively in ambulatory
patients in their normal environment for periods of 24 hours or more. Recordings from depth electrodes
form an essential part of the inpatient investigation in patients with intractable epilepsy in home surgical
treatment is projected. The electrodes may remain in situ over many days while recording is made from
cable or radiotelemetry with concurrent video monitoring of the patient's behaviour.
• Apart from its primary role in the study of epilepsy, the EEG is also of diagnostic value in the
localisation of organic lesions of the brain such as cerebral tumor, abscess or infarction but it is of much
less value in determining the nature of pathological process.
• It is a safe and relatively simple procedure routinely used in most larger hospitals.
 STIMULATION

• Modern electronic stimulators permit investigators to control such parameters of stimulation as the frequency,
duration, shape and intensity of the pulses used.
• Opportunities for study of human beings are restricted to patients undergoing neurosurgical procedures under
local anesthesia. There are very few positive responses which have been evoked with stimulation outside the
primary motor and sensory areas; the major exception is the evolution of complex experiences from the temporal
lobe.

• On the other hand, negative responses, i.e. the destruction of functions is much more common. A typical example
would be the disruption of language functions such as the ability to name objects when certain areas of the
Cortex are stimulated.
• The early work was largely associated with the neurosurgical treatment of epilepsy and thus was much concerned
with the cerebral cortex. More recently stereotaxic operations and subcortical regions particularly the thalamus
for the treatment of dyskinesia have revealed a specific dissociation of effects according to the site of stimulation.
• It is also clear that the timing of stimulation is crucial, for example stimulation at the time of input of information
made actually enhance retrieval, whereas stimulation on the same side at the time of retrieval may worsen
performance compared with the normal state
NEUROLOGICAL
DISORDERS
 Cerebral trauma Intracranial tumour Cerebrovascular disorders
1. Cerebral contusion 1. Cerebral ischemia
2. Concussion 2. Cerebral infraction
3. Traumatic haemorrhage 3. Cerebral haemorrhage
3.1 hypertensive intracerebral haemorrhage
3.2 Ruptured aneurysm
3.3 ruptured arteriovenous malformation
CEREBRAL TRAUMA
Types
• Physical injury can disrupt the functions of the brain and the efforts of penetrating wounds
of the brain resulting from high velocity projectiles. Cerebral damage may be defined as
primary or secondary, primary lesions are associated with the trauma itself and secondary
lesions arise from reduction of blood supply, reduction of oxygen to the tissues and brain
swelling.
 CEREBRAL CONTUSION

• The location of lesions is unknown however tow terms are used to descripte the locations ‘Coup’
injuries which refer to damage beneath the site of impact, while ‘contre-coup’ injuries refer to lesions
at some distance from the site.
• The greatest zone of brain contusion following a head injury was invariably opposite to the impact.
Identical lesions of the subfrontal and anterior temporal regions result from contact of either the frontal
region or the occipital region of the moving head.
• The fact that neither gross coup nor contre-coup lesions occur in the occipital region suggests that the
anatomic relation of the brain and the portion of skull proximate to it is essentially responsible for the
nature and distribution of the lesion.
• The damage to the anterior portion of the temporal lobe and sometimes the frontal lobe may be so great
that it produces subdural hemorrhage, brain contusion, laceration and intracerebral bleeding which is
termed exploded pole.
• It is important to understand the mechanism of cerebral contusion so as to be able to understand why
some patients present with psychological deficts such as uninhibited behaviours and lack of planning
which are frequently seen in injury to the frontal lobe.
 CEREBRAL CONCUSSION

• The impairment of consciousness is a prominent symptom of head injury.

• In a simple concussion there may be only a brief clouding of consciousness or a temporary stress. Injury
to the brain-stem reticular formation leads to the temporary loss of consciousness.
• Retrograde amnesia occurs when the patient does not remember the incident causing the concussion and
has a loss of memory for events preceding.
• Anterograde or post-traumatic amnesia is memory loss for the period subsequent to the injury.
• Comparisons of an individual’s own performance post-injury to a pre-season baseline are advanced to
aid determination of complete recovery
• Computerized measures have been found more sensitive than traditional techniques
• Measure of severity
• Coma- the usefulness of employing length of coma measure as a measure of severity against
which to correlate clinical and social sequelae was lessened by the variable and uncertain ways in
which coma was defined in early studies. The Glasgow coma scale is a simple standardized chart
of eye opening, motor response and verbal response.
• Post-traumatic amnesia- measures using the length of time from injury to the time the patient
become aware that he had regained consciousness. This corresponds to the time the patient
begins to retain a stable record of ongoing events. Measures of PTA are demonstrated to be
superior to duration of coma in predicting outcome . The Westhead scale differs from the
Galveston Orientation and Amnesia Test in that both correct orientation and the ability to recall
newly learned information are required to define the emergence from PTA
 TRAUMATIC HAEMORRHAGE

● Small haemorrhages may occur in virtually any part of the brain after any form of head injury,
but the more extensive haemorrhages occur from the laceration of blood vessels inside the skull.
● For example, fracture of the skull may tear the middle meningeal artery which by bleeding under
considerable pressure into the space outside the covering of the brain, greatly compress the
central hemisphere and later the basal portions of the brain
● Bleeding from blood vessels beneath the dura mater produces a subdural haematoma which may
be less dramatic and in elderly patients may follow an injury so trivial that the patient does not
even recall the incident.
● This condition may produce changes that develop over days or even weeks after the injury often
simulating the picture of dementia, with loss of concentration, episodes of confusion and
memory loss.
INTRACRANIAL TUMOUR
INTRACRANIAL TUMOURS
● The word tumour literally means swelling. When referring to intracranial tumors is often
labelled cerebral tumours, the term usually means a neoplasm or new growth.
● Neoplasm is defined mass of cells, it is normally present in the body but arranged atypically,
which grow at the expense and independently of the organism without subserving any useful
purpose therein.
● These neoplasm in the brain may be benign or malignant. Benign neoplasm frequently grow
from the covering of the brain.
● These coverings are termed meninges and tumours arising from them meningiomas.
● Such benign tumours may grow slowly and attain a large sized before they cause symptoms
from their pressure effect on the brain or they may be symptomless and only be discovered at
autopsy.
INTRACRANIAL TUMOURS CONTINUE
● They can be successfully removed in their entirety as they do not usually invade the brain
substance.
● unfortunately , benign tumours are much less frequent than malignant types, which invade the
tissue of the brain. The latter can rarely be removed fully by surgery because of the extent to
which they infiltrate the surrounding tissue.
● Most malignant brain tumours arise from the glial or supporting cells and not from the nerve
cells or fibres themselves. They are termed primary neoplasms
● The smaller portions of the brain are called secondary neoplasms since they multiply from cells
of malignant tumours in other parts of the body. These cells of origin of cerebral secondary
neoplasms have become detached from their parent tumours and been carried by the blood
stream to lodge in the brain to begin independent growth there. Tumours of lung or breast often
give rise to such metastatic tumours
INTRACRANIAL TUMOURS CONTINUE
● Conditions that are not neoplastic may give rise to very similar signs and symptoms, for
example an abscess in the brain.
● Tumours , abscesses and other mechanically similar conditions are given the title of space-
occupying lesions
● Small lesion in a strategic situation may have disastrous early effects because it interferes
with vital centres or cuts a large number of interconnections between different areas of the
brain while a large lesion in another area may be almost silent for a relatively long period
● It is this failure to take into account the nature and location of cerebral lesions that defeated
many of the earlier attempts to draw conclusions from psychological studies of heterogeneous
populations of brain-damaged people.
 THE GLEA

• Function
• Is to support the neurons
• provide nutrients to the neurons
• clean up the neurons of any filth in them
CEREBROVASCULAR
DISORDERS
CEREBRAL ISCHENMA
CEREBRAL INFRACTION
CEREBRAL HAEMORRHAGE
 CEREBRAL ISCHAEMIA

• The patient experiences sudden loss of neurological function. This may be loss of power, sudden
sensory loss particularly loss of vision in one eye or loss of speech, memory or the functions
referable to the cerebral hemisphere territories supplied by the internal carotid system. It is unusual
for the brain and the eye to be affected simultaneously in one attack.
• Two major types of surgical procedure have been devised to prevent strokes and ischaemic attacks
by reconstituting the arterial blood flow
• The most common is the operation of endarterectomy which aims at correction of stenosis,
removal of atheromatous plaques and other conditions compromising the circulation. Surgery for
asymptomatic lesions remains controversial
 CEREBRAL INFARCTION

• The basic pathological process, this is not uniform process that affects certain parts of the
arterial system more than others. The deposition of materials, mostly cholesterol causes
plaques which narrow the artery and thus restrict the flow
• This may progress to complete occlusion of the affected vessel.
• The most common sides are the origin of the internal carotid artery. The upper end of the
vertebrals and the lower portion of the basilar, the stem of the middle cerebral and the
posterior cerebral though other vessels are also commonly affected.
• The other common cause of cerebral embolism is from thrombi forming in the heart due to
arrhythmias
• A dramatic embolic phenomenon is amaurosis fugax which means fleeting blindness and is
most commonly due to emboli blocking retinal arterioles
 CEREBRAL HAEMORRHAGE

• There conditions of haemorrhage are

• Hypertensive intracerebral haemorrhage-a burst of blood into the cerebral hemisphere's substance or
parenchyma If the bleeding continues, it destroys brain tissue and puts pressure on nearby tissues
through compression or displacement. Large hemorrhages can cause vital organs to be displaced to the
point of death. The function of adjacent or nearby tissues may be disrupted by less severe pressure. The
penetrating branches of the middle cerebral, posterior cerebral, and basilar arteries are the main sources
of haemorrhage.
• Ruptured aneurysm
• The thin-walled protrusions are most common on the vessels that form the arterial circle.
• In rupturing, blood may be spurted into the subarachnoid space or into the adjacent brain substance
producing an intracerebral haematoma.
• 3.Ruptured arteriovenous malformation
• The blood vessels forming the mass interposed between the feeding arteries and the draining veins are
pathologically thin willed and liable to rupture. Rupture of the larger malformations may produce
intracerebral as well as subarachnoid bleeding
DEGENERATIVE DISODERS
 dementia
Dementia is a genetic term that refers to
a complex set of changes of known or
unknown etiology, which are reflected in
widespread dissolution of human mental
capabilities and social functions.
Dementia can be reversible or
irreversible. Dementias can be divided
into primary types due to
parenchymatous cerebral degeneration
and secondary types associated with
known conditions
The primary type which is Alzheimer’s
disease, while the secondary type feature
of neurological or other systemic
disorder may manifest themselves before
the onset of intellectual decline.
Alzheimer's disease
Symptoms
memory loss, disorientation and gross
intellectual dissolution.
This intellectual loss is accompanied by
personality changes, disappearance of
insight and worsening difficulties with the
task of everyday living.
The deterioration in self-care is often the
most notable feature. As with most ill
understood it is possible that subtypes of
Alzheimer’s disease exist.
The most important factor in the diagnosis
of the condition is the personal history. It
will also become apparent very often that
changes have been taking place for a
considerable time before professional
attention is sought. As means of arresting if
not reversing the disorder emerge, early
detection will become paramount
Frontotemporal dementia
It predominantly associated with anterior
lesions, e.g. loss of social grace, disinhibition or
apathy and frequently, aphasia.
The first sign is usually a series of changes that
are associated with a change in mood and
personality.
There is a loss of interest in activities, including
work, as well as a bland indifference, which is
followed by a loss of self-care and emotional
unconcern. The individual shows
uncharacteristic rudeness to others. The patient
exhibits both a lack of concern and a lack of
understanding.
The patient may appear depressed at times, but
he or she is usually responsive to therapy. Self-
neglect is frequently present.
Another feature is the variable and idiosyncratic
preservation of orientation and memory
disturbance. Forgetfulness frequently fluctuates
as a function of lack of attention, and formal
testing has revealed preserved ability to learn
some new materials for quite some time.
INVESTIGATION
• The differentiation between Alzheimer's and pick's disease is greatly improved by CT and
MRI scanning, and made even clearer by positron and mission tomography. With growing
interest in frontotemporal dementia, studies of blood flow coma and of glucose and oxygen
metabolism using PET and SPECT have typically shown a differential fall-off in the anterior
brain region compared with the parental and occipital lobes in such cases while the reverse has
been true in patients with Alzheimer's disease.
• The correlation of imaging findings with clinical neurological and neuropsychological
evaluations will further delineate the disorder. Histological changes appear to be very similar in
FTD and pick's disease with the same regional differentiation noted in the imaging studies.

• Moreover, epidemiological and neuropathological similarities have been noted between FTD and
several other degenerative conditions, Specifically primary progressive aphasia. Motor neuron
disease with dementia and an akinetic rigid syndrome called Cortical basal ganglion degeneration
• These conditions demonstrate similar pathological changes, though Initially in different
regions of the brain, and not infrequently can occur in the same person, or first-degree
relatives. An underlying common genetic defect as reported in some cases in which
abnormalities of a microtubule stabilization tau protein contribute, though the conditions
may still be Heterogeneous. Another focal cortical dementia and posterior cortical atrophy is
distinct clinically and pathologically, Commonly showing isolated parieto occipital
Alzheimer pathology. It has been known for some time that, in contrast to patients with
Alzheimer's disease the ECG tends to be normal in the FTD group
• Dementia with lewy bodies (DLB)
• New neuropathological antibody-based staining Techniques have led to the differentiation of the entity
from other dementias. logically DLB is distinguished By the presence of ubiquitin positive cortical
neuronal inclusions, termed lewy bodies. these inclusions are similar to those seen in typical parkinson’s
disease within cells of the substantia nigra in the midbrain, though staining less noticeably with older
histological stains. clinically DLB patients may have Permanent attentional disturbances, with
fluctuating confusion over minutes, hours, days or longer. These dominant test performances, and may
lead to highly variable results both within and between test sessions. memory deficits may also be highly
variable. vivid visual hallucinations are common, and at times the patient may act in such a strange
manner towards decision as to suggest delusional ideation.
• Ischaemic vascular dementia (IVD)
• This is the term for intellectual loss brought about by multiple cerebral infarctions, formerly called
multi- infarct dementia. Its incidence is variable, mainly due to differences in definitions, though in the
elderly it has been stated as the second most common cause of dementia. Recent conceptions emphasize
strategic infarctions which each cause-specific recognisable deficits, but whose some disability fulfills
criteria for dementia. Unlike the steadily progressive cause of Alzheimer's disease, IVD is characterized
by sudden onset followed by a stepwise decline, which is often marked by remissions and exacerbations.
The infections of IVD May be either predominantly cortical, or subcortical or as a combination of the
two which means that the clinical picture may vary widely. The relation between the lesions and
• Mild cognitive impairment
• Attempts to define features characteristic of very early stages of dementia and predictive of
conversation to dementia have led to numerous definitions and proposed criterias currently,
the definition of Peterson termed mild cognitive impairment, has been most widely used
with emphasis on subjective complaint of memory disturbance, memory impairment below
expected levels with respect to age and education based innovative performance without
other features of dementia. This has some predictive values common in that approximately
10 to 15% of Patients who fulfill MCI criteria on a single occasion may convert to
alzheimer’s disease by research criteria annually.
DISRUPTION OF HIGHER
FUNCTIONING
APHASIA • MOTOR
• SENSORY- AUDITORY AND VISUAL
• GLOBAL OR MIXED APHASIA
AGNOSIA • AUDITORY
• VISUAL
• TACTICE
• SPATIAL
NEGLECT SYNDROM • UNILETERAL SPATIAL NEGLECT
• HEMI-INATTENTION
• SENSORY INATTENTION
• AKINESIA
BODY AGNOSIA • FINGER AGNOSIA

AMNESIA • ANTEROGRADE
• RETROGRADE
• PORT TRAUMATIC AMNESIA
APRAXIA UNILETERAL APRAXIA
MOTOR
IDEOMOTOR
UNILETERAL IDEOMOTOR
IDEATIONAL
CONSTRUCTIONAL APRAXIA

MEMORY DISORDERS HYSTERICAL FUGUS

PSYCHOGENIC AMNESIA

EPILEPSEY GERERALISED SEIZURE- TONIC AND CLONIC PHASE

PARTIAL SEIZURES- SIMPLE AND COMPLE
UNILETERAL SEIZURES
 APHASIA
• The various forms of aphasia developed as a result of lesions in the so-called dominant
hemisphere. The importance of aphasia lies in its great localisation value in diagnosis and no
neuropsychological examination is complete without a careful examination of the patient's
language functions.
• Motor aphasia or Broca’s aphasia - generally result from a lesion in the posterior part of the
inferior frontal convolution.
• The disability may vary from a complete loss of speech to a mild deficit in which the patient has
difficulty in finding the appropriate word and also have difficulty with grammatical construction.
The patient tends to use sentences of a very simple structure with a predominance of nouns,
verbs, and a paucity of adjectives, adverbs and joining words.
• The difficulties also extends to written language where the aphasic patient shows the same
difficulty as in verbal expression. On rare occasions this agraphia has been described in cases
with no obvious difficulties of verbal expression. The second Frontal gyrus has been
implemented in some of these cases.
• Sensory aphasia- generally results from a lesion in the region of Wernicke's area of the dominant
hemisphere. the prime difficulty is a loss of the association between words and their meaning,
particularly for spoken nouns and verbs, but often of the written word as well.
• two major forms of sensory aphasia may be separated,
• auditory receptive aphasia are usually related to lesions in The Superior temporal convolution.
Patient has trouble with understanding what is said to them. The problem is due to a failure in
comprehension, since Auditory acuity as tested by audiometry remains adequate. Patient presents
with paraphasia which is the expressive difficulties manifested by errors in word or phrase
selection.
• visual receptive aphasia related to more posteriorly placed parieto- temporal lesions. patient’s
ability to understand written language is impaired. this difficulty is referred to as Alexia or
sometimes word blindness. while patients may be able to identify individual letters they are
unable to receive words and meaningful wholes. Alexia may occur together with difficulty in
recognising objects under the syndrome of Visual objects agnosia and the inability to name
colours (colour anomia). While the ability to read number may be preserved the ability to read
letters and words is lost.
• global or mixed aphasia- refers to cases where they are both motor and sensory elements present.
• These cases are usually severe in their symptoms and present extensive Lesions on pathological
examination. Amnestic, amnesic, anatomic or nominal aphasia is characterized by the patient's
inability to identify people or objects by their proper names. If shown a hairbrush, the patients will be
Unable to evoke the name ‘brush’ , though they will demonstrate both with words and actions that
they are well aware of the nature of the object and will recognise the correct word when it is given.
• Some authors consider amnestic aphasia to be essentially a form of sensory aphasia, and the
responsible Lesion usually found in the posterior region of The Superior temporal convolution on the
dominant side
 THE ANATOMICAL DISCONNECTION MODEL

1. With a lesion of Wernicke’s area incoming auditory information will not be understood since a
lesion in this region may interrupt the passage of Visual information traveling forward from the
visual Association Cortex, isolating this information from the anterior speech area, patients
will be unable to describe in words what they see. they no longer understand the written
language.
2. A lesion in the principal connection link between the comprehension area and the expressive
area, the arcuate fasciculus, leads to abnormality in speech with the preservation of
comprehension of both written and spoken speech. Such disorder is termed conduction
aphasia. Since Wernicke’s area is intact, patients can understand what is said to them. On the
other hand, with Broca’s area also intact they will be able to speak spontaneously. The speech
is often copious but is abnormal because of the isolation between the two major areas. Since
the connection has been broken between the receptive area and the motor speech area they will
be unable to repeat what the examiner says.
3. When a lesion is damaged the left visual Cortex and the posterior portion of the corpus
callosum known as the splenium, the patient is able to see stimuli in the left visual field
corresponding to the Intact right visual cortex though not in the right visual field.
However, the information perceived by the right hemisphere can no longer reach the left
hemisphere language areas so that patients cannot understand written language though, with
the preservation of both Wernicke’s and Broca’s areas they can both comprehend and speak
spontaneously. This disorder is termed Alexia or agnostic Alexia.
 AGNOSIA
• retrorolandic lesions is the second major unit of the higher nervous system, the one concerned
with the reception, analysis and storage of information.
• it is divided into three major types of cortex. first,
1. primary projection areas- which are modality specific, that is serve only one that is plaid out
in a somatotopic manner as described.
2. projection Association Cortex -that is adjacent to a primary projection area and while still
concerned with only one sensory mode, recognizes the incoming information into meaningful
wholes.
3. area of cortex that is concerned with the integration of information- from all sensory
channels and, in the integrative sense, is supramodal.
• Agnosia- refers to a failure to recognise familiar objects perceived via the senses where the
inability does not rest on sensory impairment, intellectual deterioration or other causes. where it
is associated with only one modality.
 FORMS OR TYPES

1. auditory agnosia- is the term used to refer to the inability to recognise speech. The failure to
recognise melodies is referred to as sensory amusia.
2. visual agnosia has been classified according to the class of visual perceptual material with
which the patient has difficulty. They may be visual object agnosia, where the patient without
disturbances of Visual acuity or Visual field defects fails to recognize the object for what it is or
may be unable to recognise pictorial representation of objects.
3. Spatial agnosia this form of disorder is sometimes referred to as visual or spatial
disorientation. The patient is unable to find their way around in a familiar environment such as
their own District or even their own home, though they may recognise separate objects in the
home quite well. There may also be defect in Visual and topographical memory, so that patients
with this disorder are unable to find their way on a map or if asked to draw a map will produce
one with topographical distortions and omissions.
4. Tactile agnosia refers to the inability to recognize objects by feeling them. The relation of
tactile agnosia to sensory defects is discussed in relation to lesions of the parietal lobes
 THE NEGLECT SYNDROM
• A patient with neglect syndrome fails to report, respond, or orient to novel or meaningful
stimuli presented to the side opposite a brain lesion.
1. Unilateral spatial neglect, also termed hemispatial neglect, hemispatial agnosia and
visuospatial agnosia.
• patients neglect the half of space contralateral to the lesion,
• e.g. when asked to bisect a line they may neglect the presence of one side of the lesion, or
they may fail to cross out lines on one side of a page which has lines scattered randomly
over it.
• -In real life, patients may fail to eat food on on side of the plate and bump into objects to one
side which they appear not to notice.
2. Hemi-inattention -refers to a failure to report stimuli of various kinds presented unilaterally.
Obviously it may be difficult to distinguish unilateral inattention from hemianopia or hemianesthesia.
However the subject with hemi-inattention may be able to detect the stimulus with related is if attention is
directed specifically to its presence
3. Sensory inattention, sensory extinction, sensory suppression or perceptual rivalry- Denotes a failure to
appreciate a stimulus when a similar stimulus is applied to a corresponding part of the body or to both halves
of the visual field simultaneously.
The patient is quite able to see and recognise things in any part of the visual field when they are presented
alone or to report a tactile stimulus from either side of the body. it is only when the stimuli are presented
simultaneously that the disorder comes to light. The inattention is for the stimulus opposite the opposite side
of the lesion.
4. akinesia- Some patients with unilateral lesions may show a slowing of movement or an inability or delay
in initiating movement of the limb contralateral to the lesion. -Attempt at bilateral movements may worsen
the contralateral limb akinesia, a condition akin to sensory extinction and actually termed motor extinction
BODY AGNOSIA
● Body agnosia, corporeal agnosia or autotopagnosia is a lack of awareness of the body’s
topography and inability to recognise or localise parts of the patient's own body.
● A special form of autotopagnosia, is finger agnosia where the patient cannot point to show
the examiner the various fingers of each hand.
● It forms one of the four classical features of Gerstmann’s syndrome, which, because of its
important bearing on the notion of cerebral dominance or lateralisation is discussed in chapter
8.
● Body agnosia is often associated with lack of awareness of disease or disability known as
anosognosia, e.g. the patient fails to perceive or denies that the arm or legs are paralyzed.
APRAXIA
● Apraxia is the inability to carry out purposive or skilled acts due to brain damage.
● It does not result from numerous other reasons that may result in imperfectly executed
movements, e.g failure to comprehend what to do weakness or paralysis or sensory loss
● In the first of a number of works on apraxia or motor asymbolly, Liepmann (1900)
commented on the case of an individual who had suffered a stroke and who acted with his
right extremities as if he were a total imbecile, as if he understands neither questions nor
commands, as if he could neither understand the value of objects nor the sense of printed or
written words, yet prove by an intelligent use of his left extremities that all of those
seemingly absent abilities were in reality present.
● Liepmann termed this “unilateral apraxia”.
● The patient was globally aphasic and as a result of his lack of correct responses also had been
considered to be demented.
APRAXIA CONT...
● Motor apraxia Is believed to be due to loss of kinaesthetic memory patterns or engrams necessary for the
performance of the skilled act as first suggested by Liepmann.
● This form of apraxia usually affects the final movements of one upper extremity movements such as doing-up
buttons,Opening a safety pin and placing a letter in an envelope. Where there is associated weakness the
clumsiness of the movement is out of proportion to the loss of power. This form of apraxia usually results
from a lesion of the precentral gyrus contralateral to the side of the body affected .
● Ideomotor apraxia Is the most common type of motor apraxia. It is a condition in which the patient finds it
difficult to carry out an action on verbal command with either hand but may do so automatically or almost
fortuitously
● They are usually unable to imitate actions that are demonstrated to them. The kinetic engram is preserved but
it is not available to the patient's voluntary recall.This form of apraxia is usually associated with a lesion in the
posterior part of the left or dominant hemisphere, particularly in the region of supramarginal gyrus
APRAXIA CONT…
● In the case of carrying out a skilled movement on verbal command
● first, the auditory information is organised in Werniecke’s area
● From here the information travels to the motor association cortex in the frontal lobe and then to the
motor cortex,
● which sends impulses to the appropriate muscle groups on the right side of the body to execute the
command.
● left-sided apraxia, unilateral limb apraxia or callosal apraxia, in essence, it is a unilateral ideomotor
apraxia- the patient incapable of carrying out verbal commands with the left hand while still able to
carry them out with the right.
● Ideational apraxia- Is the difficulty in executing the correct sequence of steps that makes up a complex
act through the individual components acts as may be carried out successfully.
● Is associated with dominant hemisphere parietal lobe lesions and is thus often accompanied by fluent
aphasia and elements of Gerstmann’s syndrome
● Constructional apraxia - the patient is unable to put together parts to make a whole
AMNESIA
● Memory disorders are frequent accompaniment of cerebral disorders and have given rise to countless studies
reported in literature.
1. Anterograde amnesia is characterized by an inability to retain or at least report spontaneously ongoing
events it is synonymous with a known learning difficulty material which is clearly apprehended as measured
by the ability of the patient to repeat it immediately cannot be reported a short time later it is common after
cerebral trauma for this condition to improve with the passage of time but Lesions in certain anatomical sites
may lead to a lasting memory impairment.
2. Retrograde amnesia refers to the difficulty in recalling events that occurred prior to the injury. With the
passing of time retrograde amnesia shrinks so that well a few days after the injury patients may not recall
events that happened weeks or even months before, they may be able to recall events much closer to the
injury sometime later so that the gap left in the memory may be very short.
3. Post-traumatic amnesia (PTA) is the period from the time of injury to the time when the patient begins to report
ongoing events, i.e. where anterograde amnesia stops. Its duration has been used as a guide to the severity of the
damage. The longer the period of PTA the more severe the damage is likely to be although there are some striking
exceptions.
TYPES OF MEMORY DISORDER
● Amnesic syndromes may accompany neurological or psychological disorders, They may be transient or lasting and
they may be specific or general.
1. hysterical fugue - consists of a series of events whereby the patient often may remove himself from his current
situation which is almost invariably disagreeable, and move to another.
● This may involve travel to distant parts and even a change from customary occupation. The behaviour is often
described as dissociation and patients may appear to be unaware of their past while in the fugue state, i.e they have
total amnesia and on return to their “former self” will be amnesic for the period occupied by the fugue. behaviour
appears to be fairly well integrated and consistent in each of the states.
2. Psychogenic amnesia or pseudo-neurological amnesias may mimic those of a neurological etiology but will be
differentiated by their lack of concordance with the characteristics of the organic varieties.
Characteristically the period extends over several hours and the patient is permanently amnestic for the duration of
the attack
EPILEPSY
● The term epilepsy means a seizure,that is the sudden disruption of the patient's sensors.
1. Generalized seizures may be primary or may be precipitated from a localised Focus. The primary form of
epilepsy was often referred to as centrencephalic epilepsy.
● The principal feature of many generalized seizures is disorganised muscular contraction.
● The term tonic-clonic seizures describe the two main phases of a paroxysm which were previously termed grand
mal seizures.
● In the tonic phase the muscles contract and the subject often falls to the ground. Contraction of respiratory
muscles may produce a grunt or cry. swallowing is lost and the patient becomes cyanosed from lack of oxygen.
Contraction of muscles often produced incontinence of urine and less commonly of feces.
● The clonic phase follows after a brief time (a few seconds to a minute) and is marked by rhythmic contraction of
limb and trunk muscles. After a variable time the clonic phase ceases and the patient passes from stupor, through
confusion, to a normal conscious state.
● On some occasions one generalized seizure may follow another in rapid succession the so-called status
epilepticus
2. Partial seizures
● These seizures have also been termed focal seizures since they reflect a neuronal discharge,
which is more or less localised to one area of the brain.
● They are divided into two main types: 1. Those with elementary; and 2. Those with complex
symptomatology.
● The former type occurs without any loss of consciousness, while some impairment of the
conscious stage is found with complex partial seizures.
2.1 Simple partial seizures
● Motor symptoms may take many forms and point to the localisation mainly in portions of the
region in front of the central or rolandic fissure, though the focal abnormality may lie in the
temporal or parietal region.
● Sensory symptoms may take the form of any of the sense modalities. There may be a fine line
between the designation of a symptom as a simple sensory seizure, a sensory illusion, or even a
sensory hallucination but a careful examination may be of value in localisation.
2.2 complex partial seizure- The portions of the cortex that may be involved are the frontal,
temporal and parietal neocortex and the subcortical structures associated with them.
• The main types can be grouped as follows
1. Cases where impairment of consciousness is the principal or even the sole symptom.
2. Psychomotor attacks where the principal symptoms are confusion and automatic behaviour.
Confusional automatisms may be merely a mechanical prolongation of the behaviour in which the
patient was engaged at the onset of the attack.
3. Seizures with sensory illusions or hallucinations. The nature of these seizures varies with the
region of cortex that is the site of discharge
UNILATERAL SEIZURES
● n this type of disorder, the discharge, while spread over a wide area, is restricted to one hemisphere
and demonstrates itself by clinical phenomenon on the opposite (contralateral) side of the body.
● The excessive neuronal discharge causing the seizure may arise in the centrecephalon where it spreads
exclusively or mainly to the hemisphere on one side or the discharge me originate in a local region of
the cerebral cortex of one hemisphere and spread to the centrecephalon from which it projects in turn
to the whole of that Hemisphere.
● The reason for considering these unilateral seizures as separated from partial seizures is that there are
no signs in the period between the seizure of Clinical or EEG features of localised brain impairment
and such seizures may alternate from side to side, from one attack to another, or even during the
course of a single attack.
● As with generalized seizures unilateral seizures have been classified into a number of subtypes
according to the symptomatology.
CHAPTER11
Study notes
 ROLES OF CLINICAL NEUROPSYCHOLOGY

Evaluation
• The major features of evaluation turn on diagnosis and measurement of function.
• Clinical neuropsychologist is seldom in the position of being asked to provide a definitive diagnosis
although it will be argued that if neuropsychologist accept the role of applied scientist rather than
technician, they will be in a position of offering what at times is crucial information regarding
diagnosis.
• Neuropsychological examination is an integral part of the neurological examination and must be seen in
this context. It would be valuable if sensitive behavioral measures could be refined to promote the
earlier diagnosis of some cerebral lesions.
• There is an encouraging evidence that behavioral measures may be able to detect impairment that is too
subtle to be detected by many current neurological procedures e.g., CT scan that depends on the
detection of structural alteration in the brain
 ROLE CONTI..

• Another role of neuropsychology is based on the assessment cases where the diagnoses has
been verified. All the information on the patient's mental function is of importance
especially with following the progress of those suffering from crania-cerebral trauma,
cerebrovascular disorders and other neurological conditions in which mental symptoms form
part of.
• It should not be viewed as that its main role is of documentation only, but can be viewed as
another way in which understanding can be provided on how a neurotically condition has
affected a patient and provide more information on medical managements, rehabilitations as
well as counselling for both the patient and the relatives.
• Other roles that can be seen include education of other professionals about the ways in
which neuropsychology has developed and the ways in which it can provide useful
information for patient management
 ROLES OF CLINICAL NEUROPSYCHOLOGY

 THERAPY
• Therapeutic intervention
• With this role of therapeutic intervention, more rehabilitation and treatment centres need to be introduced.
• Whitby (1990), stated that psychotherapeutic methods have remained popular along with its professionals despite the fact
that subjective and objective criteria's were used and the success obtained was either moderate or immoderate.
• He further stated that the effect that is produced should be useful, be it through high self esteem, persisted and directed
activity and good humour.
• Another characteristic of this role is to produce a mind frame in which change and progress will become hard that it leads to
a deep communication with those of opposite views.
• With regard to medicine it contained scattered opinions on clinical appraisals with effective therapeutic procedures which
were later regarded as being ineffective.
• Like cognitive appraisals, they can be used to encourage objective based appraisal .
 ROLES OF CLINICAL NEUROPSYCHOLOGY

• Forensic psychology
• It involves the application of neuropsychological assessment methods to the examination of
criminal and civil litigants.
• A forensic neuropsychologist expert presents reliable/valid psychological and
neuropsychological assessment data pursuant to one’s emotional/cognitive/behavioural
functioning as applied to legal proceedings and specific forensic questions posed by attorneys
and courts.
• Neuropsychologists are called mainly when advice is needed on medico-legal issues.
• Mostly when it came to the issue of moderate to severe head injury.
 THE NEUROPSYCHOLOGIST AS EXPECT
WITNESS
• An expert witness encounters difficulties when it comes to the legal processes. The arguments on their
own are based on winning rather than establishing the truth. Most of the neuropsychologists need to
familiarise themselves with the system even though it will be different from their scientific
methodology.
• Legal vs Scientific argument
• The difference between these two is mainly the mode of operation.
• With psychologists the argument is based on the probability estimates as well as confidence limits
where as with lawyers arguments revolve around yes or no, true or false responses.
• Law is the body of practice and science is the body of knowledge and the expert witness occupies an
uncertain position between these two where as the neuropsychologist has to provide evidence that that
will not show much of the difference between them.
• The rules that are of science are not of the law/ courtroom, where lawyers use one or more statements to
reach a logical conclusion and doctors observe the body to come up with a general principle.
 THE NEUROPSYCHOLOGIST AS EXPECT
WITNESS

• Expert evidence vs expert opinion

• Expert evidence refers to the body of a specialised knowledge or information that is related
to the practice of a particular profession, where as Expert opinion refers to the conclusion
that are drawn from the expert evidence.
• There may be an agreement with regard to the evidence that is acquired by the experts so
will there be differences of opinions.
• Some of these differences arise due the variations with regard to those who have
qualifications and those with more experiences in the field
 THE NEUROPSYCHOLOGIST AS EXPECT
WITNESS

• Inherent dangers and bias

• Most of the lawyers see the expert witness as someone who does not help the judge to make conclusion but as
someone who helps the lawyers to produce the best out of the case.
• They also help with regard of formulating the questions that will be asked in the cross examination. With regard
to this there is a possibility that they might be paid by one party to assist the counsel.
• This already leads to the occurrence of bias as it leads to the conclusion that lawyers might have looked for their
specific individual to work for their purpose.
• Here witnesses need to be made aware that their opinions and inputs will be regarded as crucial evidence that
will be used to conclude on the case.
• Experts should not only give their opinions but confidence in which they hold those opinions, giving their
opinion in favour of this degree of confidence when needed to do so.
• Where expects will be needed to indicate whether asked or not, what their evidence suggests or doesn’t approve
 THE NEUROLOGIST AS AN EXPERCT
WITNESS

• Biased sampling
• This is seen when experts are not allowed to give a balanced account of matters since of the facts that
are regarded as relevant aren’t brought out by the counsel in the examination.
• Meaning that they can not give facts that are of unbiased presentation and that favour a certain point
of view.
• This lead to some of the scientists not wanting to take part on cases.
• Hence the experts need to ensure that they aren’t personally involved in the case to make clear
opinions.
• Meaning that the expect has to be able to accept possible, reasonable alternatives while still firmly
maintaining the thrust of his or her opinion.
 EXPERCTS IN NEUROLOGY
Clinical psychology, psychiatry and neuropsychology
Clinical psychologists and psychiatrists have aided in cases of brain damage as well as medico-
legal roles.It is extended into the effects of brain impairment in civil suits with clinical
neuropsychology.
It has been observed that the interactions between psychology and psychiatrist complement each
other, but this is no longer the case due to the well qualified and experienced neuro-psychologist
who assists brain damage plaintiffs.
Neuropsychologists have now taken the place of both the psychiatrist and clinical psychologists
who were called by the court to assess a person of interest's cognitive behavior.
Clinical psychologists and psychiatrists are not physically or mentally fit to serve as legal
representatives. The court is more concerned with the contribution of understanding an
individual's behavior and ability to function in certain situations than with the individual's
diagnoses.
• Courts mainly use professionals that are impressive, with good qualifications and with good
standard to perform a forensic role and it should not be like that.
• It is also seen that they reject neuropsychologists as well as psychologists who lack medical
knowledge or lack experience when it comes to neuropathology. ( generally having no
formal training when it comes to brain damage
CRITERIA NEEDED TO BE CALLED A CLINICAL
NEUROPSYCHOLOGISTS ARE:

• Understanding neuropsychological disorders, their functions and the distinctions from non-
neuropsychological disorders.
• The effects of other medical disorders on the functioning of the brain
• The methods that are employed in certain cases
• And lastly , the help with rehabilitation planning on the basis of assessment
 KEEPING OUT OF COURT
The pre-trial report
This is where psychologists may be asked to either write a report that will be used in court
or to appear in court to test the effectiveness of the report.Neuropsychologists primarily
contribute to the examinations and histories of others. In some cases, the writing of a report
is given little consideration, but they would prefer to open a cross-examination.
This is due to the fact that the information documented may be read and explained
differently by different training professionals.As a result, a close relative or someone who
has been close to the person of interest may be the one targeted for further investigation.
 NATURE OF EXAMINATION
• Neuropsychological tests are tasks that are specifically designed to measure a psychological
function that is known to be associated with a specific brain structure or pathway.
• Tests are used in research into brain function as well as in clinical settings to diagnose deficits.
• Most lawyers and doctors are unaware of what neuropsychology tests are, how they differ from
other tests, and in what ways they differ.In real life, there is no such thing as a
neuropsychological test.
• All tests/mechanisms involving the investigation of how the mind functions can be used to
improve neurological function.
• More information about how the mind works can be gathered by using Wechsler Scales and
careful observation of the qualitative features.
• Weakness in the examination
• The faults that may be seen are a collection of tests that may irrelevant to the answers needed by the
legal counsel as well the misplacement of the examination in an appropriate context. Another fault that
may be seen is of lacking history/ background with the stated statements .
• Weakness in reporting
• Many reports read as though the writer had no expectation that the opinion would be queried let alone
taken apart with surgical precision by those adept at finding weaknesses in the reporting of facts and the
sustainability or otherwise of the ensuing arguments.
• With regard to the data themselves there is often a failure to present the specific test information upon
which certain, often crucial opinions are made. On the other hand, findings may be reported that are not
referred to at all or are only dealt with in passing
 COURTROOM PERFORMANCE
• Communication skills.
• The nature of court proceedings is such that not only do expert witnesses need to provide evidence in their area of expertise,
but also, they must be an expert at presenting their evidence.
• The language that is being used should be clear and as free as possible from technical terms. It may be necessary at times to
retain some technical terms but these should be explained in a language that an average person can understand.
• The essence of good communication is to keep the audience always in mind.
• Cross examination
• Cross examination is at once the backbone of the adversarial system and the bugbear of many experts who differ enormously
in their attitude to the process, many seeing its sole purpose as being to discredit the individual giving evidence, and there is a
good deal of truth in this.
• Three main areas are usually the focus of cross examination, though skillful examiners may not approach them as separate
entities nor in any systematic way, at least until the later part of the legal process.
• They are: the adequacy of the individual as an expert;
• deficiencies in the factual evidence presented, usually the thoroughness of the expert’s examination;
• the credibility with which the opinions derived from the data can be accepted.
• The criminal forensic setting.
• Neurobehavioral disorders such as those associated with closed head injuries appear to have a higher incidence in the criminal
versus normal population. Since such deficits may impact on sundry legal questions such as the variety of issues to do with
 TRAINING IN NEUROLOGY

Clinical reasoning
• Recent medical literature has included much discussion of the various models used to achieve diagnostic reasoning and the
relative effectiveness of each. Not only may different models be used by different clinicians, but the models may differ
depending on the nature of the questions being asked, and the clinician may use different methodologies in different situations,
or even more than one in a given case. Clinical reasoning, clinical problem solving, and clinical decision making all refer to the
same thing.
• Their study stretches back decades and has been to a large degree in medical journals and texts but also in psychology.
• The hypothetico-deductive systems are methods that are widely being used in psychological research as well as in clinical
practices and forms the framework of the present text.
• The preparation of skills for future clinicians in neuropsychology depends on at least three factors:
1. The background provided in basic neuroscience concepts which provide the foundation for the neurology- psychology linkage.
2. The richness of available case material.
3. Clinical teaching and supervision.
Behavioral neuroscience
• While all postgraduate programs provide some neurological foundation, behavioral neuroscience is
seeing the emergence of specialized primary degrees. This could result in the clinical orientation being
strengthened even more.
• A few world centers with a large number of neuroscience departments are able to hold regular
multidisciplinary case conferences that include neuropsychology on a regular basis.
• Many of them are aimed at determining the best treatment and rehabilitation program.The dialogue at
such meetings sharpens each specialist's expertise, and the debates allow collaboration to clarify the
benefits and risks of treatment, as well as to outline management strategies.
• Enriching the background
• One suggestion, which might greatly improve clinical evaluation, would be production of readily accessible internet
site for an encyclopedia neuropsychological containing ‘video-case’ material.
• He encyclopedia would help to fill several roles
1. To cover all disorders from the more frequently met to met to the less common.it is a truism to say that ‘you can only diagnose
what you know
2. It would encompass sundry examples of each symptom and sign. These would range in each category from examples of the
more readily detected to the subtler. The latter have been very difficult to express in writing.
3. To illustrate patterns of disorders, i.e. syndromes. Such cases would be accompanied by case data including history, clinical
neurology including neuroimaging, and psychometric data.
4. The reference Centre could provide particular instances of hypothesis testing in specific situations.
Such video-case material would have numerous advantages:
1. It could be donated from world-wide sources thus assisting with the increase problem of cross-cultural difficulties in
assessments.
2. It would be constantly enriched by the addition of new illustrative cases and the situation of better examples as they come to
hand.
3. It would allow repetition of viewing to reinforce learning. It is not unusual foe even experienced clinicians to note new aspects
of behavior on replay.
4. It would allow teachers to explain in even greater detail about the conditions being viewed
Clinical development
Unlike other measures of the development of clinical competence over time whose results have been largely
negative, the script concordance test seems to offer promise. The term ‘’script’’ is used to signify the organization of
network of clinical knowledge.
The test material is varied according to the specialty under consideration, the items being produced by two or more
experts in the field.
A similar procedure could be relevant to neuropsychology.
Details of the test construction and scoring are given by the designers. Several studies of the test given to
individuals in separate specialties at different levels, from novice to expert, reveal that scores increase from group to
group.
Such tests might also help to provide a measure of individual difference in clinical development