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HIGHER MENTAL FUNCTION EXAMINATION(PART2)
- 1. DR. ASHUTOSH RATH GMCH,GUWAHATI
- 2.
- 3. SUPERIOR TEMPORAL GYRUS ANTEROLATERAL TEMPORAL LOBE& ANGULAR GYRUS(39) CLASSICAL WERNICKES AREA & SUPRAMARGINAL GYRUS OF PARIETAL LOBE(22 & 40)
- 4. READING AND WRITING: ALEXIA and AGRAPHIA • VWFA-visual word form area • Equivalent to Auditory phoneme perception area. • Left occipito-temporal sulcus & left fusiform gyrus.
- 5.
- 6. Reading with comprehension •Visual information from the left occipital lobe reaches directly the left fusiform gyrus. • From the rt occipital lobe has to cross over to (corpus callosum)reach the left fusiform GYRUS. • ANGULAR GYRUS- interpretation of visual- verbal materials.
- 7.
- 8. •THE PROBLEM OF READINGWITH COMPREHENSION ALEXIA •THE PROBLEM OF READING ALOUD PARALEXIA
- 9. Reading CONDITIONS FEATURES BROCA’S APHASIAOFTEN IMPAIRED(THIRD ALEXIA) WERNICKE’S APAHSIA IMPAIRED FOR COMPREHENSION, READING ALOUD GLOBAL IMPAIRED CONDUCTION APHASIA INABILITY TO READ ALOUD, SOME COMPREHENSION TRANSCORTICAL MOTOR INTACT TRANSCORTICAL SENSORY IMPAIRED TRANSCORTICAL MIXED IMPAIRED ANOMIC APHASIA INTACT
- 10. ALEXIA WITHOUT AGRAPHIA •PURE/POSTERIOR ALEXIA • CAN NOT : read and understand • CAN UNDERSTAND: words spelled aloud, written on the palm • Visual function intact(Naming objects) • left occipital lobe with splenium • Left PCA infarcts ALEXIA WITH AGRAPHIA • CENTRAL ALEXIA • Aquired illiteracy • Unable to read or write • Dominant ANGULAR gyrus
- 11.
- 12.
- 14.
- 15. THIRD ALEXIA • Inabilityto comprehend syntax • “Ravana was killed by rama” vs “ Rama killed Ravana” • Seen in Broca’s aphasia
- 16. OTHER ALEXIAS SURFACE ALEXIA •Grapheme to phoneme conversion problem • Irregular orthography • CAN read: mint,dog,cat • CAN NOT read: pint, dough, laugh • PARALEXIA(DEEP) • Problem of READIN ALOUD • SEMANTIC paralexia –m.c • Eg: infant read as baby
- 17. WRITING CONDITIONS FEATURES BROca’s APAHSIAIMPAIRED(DYSMORPHIC, AGRAMMATICAL) WERNICKE’S APHASIA WELL FORMED PARAGRAPHIC GLOBAL APHASIA IMPAIRED CONDUCTION APHASIA VARIABLE TRANSCORTICAL MOTOR APHASIA INTACT TRANSCORTICAL SENSORY APHASIA IMPAIRED TRANSCORTICAL MIXED APHASIA IMPAIRED ANOMIC APHASIA INTACT (EXCEPT FOR ANOMIA)
- 18.
- 19. APRAXIA CENTRAL ALEXIA ACALCULIA ANDCOMPONENTS OF THE GERSTMANN SYNDROME
- 20.
- 21. TYPES CONCEPTUAL APRAXIA IDEATIONAL APRAXIA IDEOMOTORAPRAXIA LIMB KINETIC APRAXIA
- 22. PRAXIS CONCEPTUAL ANDPRODUCTION SYSTEMS INF.PARIETAL LOBULE SUP.PARIETAL LOBULE
- 23. PARIETO-FRONTAL PRAXIS PATHWAYS •IMAGE 4.2 CRUDE REACHING MOVEM MEDIAL PATHWAY LATERAL PATHWAY FINE GRASPING MOVEMENTS
- 24. CONCEPTUAL AND IDEATIONAL APRAXIA(Ochipa’smodel) • PRAXIS conceptual system has 3 types of knowledge Knowledge of objects and tools Knowledge of actions Knowledge of organization of actions in a sequence • 1st two impaired in conceptual A. • 3rd knowledge in ideational A.
- 25. Transitive movements • Movementsor pantomimes where an object is used 1. Act of omission(forgets to spread the Paste) 2. Act of misuse(uses key instead of hammer) 3. Act of mislocation(holds the pen upside down)
- 26. IDEOMOTOR • ABNORMALITIES ofthe action production system • Perform poorly on pantomime • Significant improvement with object.
- 27. LIMB KINETIC APRAXIA •PREMOTOR CORTEX • Deficit confined to finger and hand movements c/l to the lesion regardless of the hemispheric side, with preservation of power
- 28. OTHER APRAXIA’S • Eg.how to drink using a straw, whistle , cough • Ventral pemotor cortex BUCCO-FACIAL APRAXIA • Genu and body • Unilateral apraxia of the non dominant limb CALLOSAL APRAXIA • Inability to generate voluntary saccades to a visual target OCULOMOTOR APRAXIA • High level gait disorder • NPHGAIT APRAXIA
- 29. TESTING CONCEPTUAL APRAXIA • TOOLSELECTION TASK : appropriate tool to complete a task. eg hammer for a partially driven nail.
- 31. • ALTERNATIVE TOOLSELECTION TASK : eg. What will u do if hammer is not available
- 33. • GESTURE RECOGNITIONTASK Gesture performed by examiner Name them or match a card corresponding to it
- 35. IDEATIONAL APRAXIA • Preparea letter for mailing • Use the toothbrush and paste to brush.
- 37. IDEOMOTOR APRAXIA • PANTOMIMEusing a hammer or a screw driverTRANSITIVE • Wave good bye, salute INTRANSITIVE MOVEMENTS • Imitation of meaningful and meaningless posturesIMITATION ACTUAL TOOL USE
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- 39.
- 43. LIMBKINETICAPRAXIA Ask thepatient to oppose their thumb to their index , middle , ring and little fingers in rapid succession Ask the patient to imitate some random hand position
- 45. GERSTMANN’S SYNDROME 1. ACALCULIA(anarithmia) 2.AGRAPHIA 3. FINGER AGNOSIA 4. RIGHT-LEFT CONFUSION
- 47. ACALCULIA• PRIMARY acalculia •A basic defect in computational ability • Left angular gyrus ANARITHMIA • SECONADRY ACALCULIA • Alexia for numbers • Also in central alexia & alexia without agraphia ALEXIC ACALCULIA • Difficulty in Written arithmetics • Carrying over problem • Mental arithmetics better than written calculation • Rt . PARIETAL pathology SPATIAL ACALCULIA
- 48. Testing procedure 1. FORWARDand backward counting 2. Symbolic transcoding 1. Numerical to verbal: 109---- one hundred nine 2. Verbal to numerical: vice versa 3. Reading and writing arithmetic signs 4. Mental calculation(add,subsract,multiply,divide) 5. Written calculation 6. Aligning numbers in columns for adding.(eg. 32+333+3456+2) 7. Arithmetic problems requiring planning. (perform the ebove calculation)
- 50. FINGER AGNOSIA • Inabilityto recognise , distinguish or name fingers 1. patients own hand 2. examiners hand 3. Drawing of a hand. • m.C problems index, middle and ring fingers
- 51. Testing procedure 1. Handsvisible: identification of fingers touched by the examiner 2. Hands visible: identification of examiners fingers 3. Hands hidden: identification of fingers touched by the examiner 4. Hands hidden: identification of pairs fingers simultaneously touched by the examiners.
- 52. RIGHT LEFT DISORIENTATION •Inability to identify right & left sides of 1. Own body 2. Person seated opposite 3. Photograph/drawing • Patients also have problems with 1. Up & down 2. Above & below 3. Over & under
- 53. Testing procedure ORIENTATION TOWARDSOWN BODY 1. Naming single lateral body parts touched 2. Pointing to single lateral body parts on verbal command 3. Executing double uncrossed movements on command(touch left ear with left hand) 4. Executing double crossed movements on verbal command(touching left ear with right hand)
- 54. ORIENTATION TOWARDS CONFRONTING EXAMINEROR PICTURE 1. Naming single lateral body parts shown by the examiner 2. Pointing to single lateral body parts on verbal command 3. Imitating double uncrossed movements on command(touch left ear with left hand) 4. Imitating double crossed movements on verbal command(touching left ear with right hand)
- 55. COMBINED ORIENTATION TOWARDSONE’S OWN BODY AND CONFRONTING PERSON. Placing the right hand of the patient on confronting persons left ear
- 56. AGRAPHIA • Aquired abnormalitiesof writing • called apraxic agraphia • Not associated with alexia • The usual missing element in incomplete gerstmann
- 57. AGRAPHIA • anterior(BROCA’s)-agrammatism withspelling mistakes • Posterior(WERNICKE’S)-unintelligible & non- sensical Aphasic agraphia • Correct letters and words • Problem with orientation on a paper • eg,. Moving on to the next line, wider space on one side Visuospatial agraphia • Language formation is correct along with spatial arrangement • Handwriting loses its personal characters(becomes a scrawl) Apraxic agraphia
- 58. Testing procedure A. Spontaneouswriting: 1. Interpretation of cookie theft picture 2. Why have u come here? B. Writing to dictation C. copying
- 64.
- 65.
- 66. HEMINEGLECT • PERSONAL NEGLECT: askthe pt. 1. Comb your hair 2. Shave 3. Put on a makeup (cream/powder)
- 67. REPRESENTATIONAL HEMINEGLECT • Drawa clock face from memory
- 69. NEGLECT TO EXTERNALSPACE 1. Cancelling targets among distractors.
- 70. why does everyonein these pictures seem to have a left hemineglect?? A coincidence!!
- 72. 2. Horizontal linebisection
- 73. Hemianopic patients Direct moreeye movements towards Their contralesional blind side during Visual sear
- 74. 3. marking locationsof objects with respect to the patient • Ask the patients to report ten objects in the room seating him in the middle of the room. 1. Neglect: report items items from only one side 2. Hemianopia: try to compemste by moving their head a7 eyes to the contralesional space.
- 75. CONSTRUCTIONAL APRAXIA • Inabilityto copy drawings or three dimensional constructions accurately. • No difficulty in making relevant individual movements. • commonly used diagrams: 1. Necker’s cube 2. Intersecting pentagons
- 77. EXPLOSION OF THECONSTITUENT PARTS SIMPLIFICATION OF THE DRAWINGS
- 78. DRESSING APRAXIA(DA) • Automaticspontaneous capacity for dressing oneshelf is lost • Not a true DA if due to ideational or ideomotor apraxia • TEST: put on a jacket given to the patient upside down with its sleeves deliberately turned upside down.
- 80. TOPOGRAPHICAL DISORIENTATION(TOPOGRAPHOGNOSIA) 1. EGOCENTRIC DISORIENTATION 2.LANDMARK AGNOSIA 3.HEADING DISORIENTATION 4. ANTEROGRADE DISORIENTATION
- 81. EGOCENTRIC DISORIENTATION • Dysfunctionof localization in space by vision • Can identify objects • Have trouble reaching for them & navigating around them • Can localize auditory stimuli • Judge relative location btw objects using proprioceptive inputs
- 82. Examples(egocentric d.) • Bumpinto things • Unable to negotiate paths even in familiar territory • May walk directly into an obstacle even when he can see it • While going towards towards the door the patient towards the wall & then search for the door
- 83. Testing 1. Ask thept to point in the direction of the object 2. Touch an object in the visual field 3. Judge the distance of an object 4. Count the no.of objects on a paper placed on the table
- 85. Count thenumber of dots without pointing at them(ACE)
- 86. HEADING DISORIENTATION • Allocentric orientation lost •Can localize objects wrt their body • Unable to describe route fam. Places • Can not Draw maps familiar places • POSTERIOR CINGULATE LANDMARK AGNOSIA • Inability to recognize landmarks • LINGUAL GYRUS ANTEROGRADE DISORIENTATION • Inability to aquire novel topographic memory • Getting lost easily in unfamiliar places • Eg. Tell me the way to the bathroom to a hospitalized patient • PARA- HIPPOCAMPUS • Common in AD
Editor's Notes
- #5 ALSO important in color integration and facial recognition.
- #7 Visual information from the left occipital lobe reaches directly the left fusiform gyrus. From the rt occipital lobe has to cross over to (corpus callosum)reach the left fusiform GYRUS. Or the grapheme perception sysytem ANGULAR GYRUS- interpretation of visual-verbal materials.
- #8 paralexia
- #10 Third alexia is agrammatism or difficulty understanding grammars
- #11 ALEXIA’S ARE OF TWO TYPES WE LL HAVE A LOOK AT THE CENTRAL ALEXIA IN PARIETAL LOBE FUNCTION Copies written language as if it was a foreign language. Color naming impaired Which means he has alexia and not aphasia
- #13 Explaination: a disconnecgion between the rt intact visual cortex and the left angular gyrus.
- #15 Like wernicke’s where reading is impaired more than auditory perception
- #23 INFERIOR PARIETAL LOBULE : CONCEPTUAL SYSTEM SUP. PARIETAL LOBULE: PRODUCTION SYTEM FAILURE TO RESPOND TO AVERBAL COMMAND FAILURE TO IMITATE FAILURE TO HANDLE AN OBJECTY CORRECTLY FAILURE TO IDENTIFY MOVEMENT PERFORMED BY THE BY THE EXAMINER
- #24 MEDIAL PATHWAY : REACHING THE OBJECT LATERAL PATHWAY: GRASPING AND MANIPULATION THE OBJECT
- #25 Transitive movements: activities requiring objects Act of omission ,misuse and mislocation
- #27 Transitive poor in ideational Improvement with transitive in ideomotor Spatial errors are the most characteristic
- #31 What is the device will u use to put this nail through
- #35 For example I m brushing my teeth
- #36 Mistakes have been discussed
- #38 PANTOMIME MEANS TO EXPRESS MEANINGS WITH GESTURES TRANSITIVE DOES NOT MEAN WE HAND OVER AN OBJECT TO THE PATIENT
- #42 HE KNOWS THE SEQUENCE BUT SEEMS TO HAVE A PROBLEM USING PREVIOUSLY USED THINGS
- #46 Posterior part of the dominant inferior parietal lobule.
- #48 Carrying over in additions and multiplications Aquired loss of the ability to perform calculation task
- #58 Aquired abnormalities of writing: agraphia
- #60 They have been asked to describe the cookie jar picture. Just like the speech
- #62 Handwriting a scribble(APRAXIC AGRAPHIA)
- #63 APRAXIC AGRAPHIA
- #64 Orientation on a page(VISUOSPATIAL AGRAPHIA)
- #66 Multiple streams of sensory data to form a body schema which determines relationship of our body parts to ourselves and to other objects in extra personal space.
- #68 Rt-represenattional
- #69 One thing we must have noticed is that in all of these cases it’s the keft side of the hemifield that’s neglected.
- #70 Important clue could be ……neglect start scanning the page from the right in contrast to normal persons who do so from the left side (bcoz of the writing)
- #72 Cortical brain region –angular gyrus of the rt parietal lobe
- #73 Despite their visual loss, hemianopic patients direct more eye movements towards their contralesional blind side during visual search [2], [8]. In contrast, the scanpaths of hemineglect patients typically ignore contralesional space [2], [3]. During line bisection, when subjects have to indicate the middle of a line segment [9], hemianopic patients bias their perceived midpoint slightly towards the contralesional side [10], [11], [12], [13] whereas hemineglect patients make large bisection errors towards the ipsilateral side [14], [15]. Studies of eye movements during line bisection show that hemianopic patients cluster fixations at both the contralesional end of the line and a second central location just contralesional to the true midpoint, while hemineglect patients fail to explore the contralesional space and show a broad ipsilesional distribution of fixations
- #74 Lets see how does a person with left hemianopia bisects the lines. Contrary to belief ………………….
- #85 Remembering routes from one place to another