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“Where’s the Lesion”?

“Where’s the Lesion”?. AACN Meetings June 17, 2005 Russell M. Bauer, Ph.D. Case S.J. 51-yo with 25-yr history of poorly controlled partial seizures PMH: significant HTN, well-managed, 2 minor CHI, both with brief LOC No prior psychiatric history

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“Where’s the Lesion”?

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  1. “Where’s the Lesion”? AACN Meetings June 17, 2005 Russell M. Bauer, Ph.D.

  2. Case S.J. • 51-yo with 25-yr history of poorly controlled partial seizures • PMH: significant HTN, well-managed, 2 minor CHI, both with brief LOC • No prior psychiatric history • Employed as assistant principal in a local high school, having taught science previously

  3. Clinical examination – S.J. • Alert, oriented to person and place, not date • Intact language expression and comprehension • Never recognized clinicians who worked with him; confabulated relationships with them (“I had dinner with you last night”); confabulation resolved quickly • Difficulty distinguishing dreams from reality • Irritable, aggressive outbursts occasionally • Amotivational, apathetic, inappropriate

  4. Lesion involves right diagonal band of Broca, including preoptic area. Septal area and nucleus basalis appear to have been spared.

  5. Case T.R. • Awoke one day with severe headache • Confused, had stiff neck and deceased memory • Lumbar puncture: blood-stained CSF • On admission, was somnolent and oriented only to person • Recalled 1/3 and had poor serial 7’s • Right homonymous hemianopia

  6. Case T.R. – cont’d • 15 days after admission • Alert and cooperaive • Oriented for place, person, year, not month • Significant confusion about time • Sometimes failed to read items in his intact left visual field • Speech fluent without error, repetition and naming were normal • Intact visuospatial abilities • Right superior quadrantanopia to confrontation • Mild retrograde amnesia • “Everything is becoming clearer, I feel like I woke up day before yesterday”

  7. Lesion involves left retrosplenial lesion Bauer, Grande, & Valenstein, 2003

  8. Additional Information – T.R. • Had tendency to orient to contralateral space, and had significant temporal memory disturbance • SPECT: • left thalamus hypometabolic, and anterior portion of left hemisphere was hypermetabolic when compared to the right • no metabolic differences in MTL

  9. Case J.L. • 44 y.o., R handed white male • Resides with wife & 2 teenage sons • B.A. in 1975 • Successfully employed as an insurance agent for 20 years. • Medical history is unremarkable • No history of alcohol/drug abuse, psychological disorder, or psychiatric illness.

  10. Mechanism of Injury & Acute Neurological Status • On 8/22/97 unhelmeted rider of his motorcycle which crashed while he was travelling approximately 30 mph • Initial GCS was 3 at OSH where he was paralyzed, sedated, intubated and emergently transported by helicopter to Barnes-Jewish Hospital (BJH) in St. Louis • Upon arrival, J.L. was still unresponsive. Hospital records indicate contusions and abrasions of the distal upper extremities, bilaterally, R proximal lower extremity, and multiple facial abrasions.

  11. NNICU Course • J.L.’s level of consciousness gradually improved. • GCS reached 9 on 09/05 (14 days post injury) • At 24 days post-injury he was still confused and manifested paraphasic speech but was considered neurologically stable and was transferred to the inpatient neurorehabilitation unit

  12. Inpatient Neuropsychological Status Initial neuropsychological consultation at 7 weeks post injury revealed the following: • Ongoing post-traumatic amnesia (PTA; GOAT = 41) Initial GCS = 3 (Severe range) Coma Duration = 2 weeks (Severe range) PTA Duration = 7 weeks (Extremely severe range) • Attentional and executive dysfunction, anomic aphasia • Preserved auditory comprehension and perceptual reasoning abilities (PIQ = 113)

  13. Neuropsychological Evaluation at 9 1/2 months post-injury Intelligence: WAIS-R: PIQ = 128; VIQ = 86; FSIQ = 101 RSPM: 87th %tile Attention: WMS-R DSF 50th %tile DSB 53rd %tile WMS-R VMSF 88th %tile VMSB 81st %tile PASAT: Trial #1 1st %tile #2 12th %tile #3 31st %tile #4 58th %tile

  14. Neuropsychological Evaluation (Cont.) Language: COWAT 10th % tile BNT <1st %tile (profoundly impaired retrieval functions (e.g. Globe = round map of the world) WAB AQ = 92.60 - Anomic Aphasia WRAT Reading: 13th %tile (8th grade) Writing: 2nd %tile (5th grade) Arithmetic: 32nd %tile (HS) Visuoperceptual/visuomotor integration: JLOT 72nd %tile TMT Part A 37th %tile

  15. Neuropsychological Evaluation (Cont.) Executive Functioning: WCST Categories 6 Total Errors 27th %tile Persev. Errors 27th %tile Category Test 4th %tile TMT Part B 2nd %tile WAIS-R Similarities 5th %tile

  16. Neuropsychological Evaluation (Cont.) Verbal learning/Memory Functioning: CVLT Trial%tile A1 <1st A5 <1st B <1st A6 (SDFR) <1st A7 (LDFR) <1st Recog. Hits <1st False Pos. <1st Discrim. <1st

  17. Neuropsychological Evaluation (Cont.) WMS-R Trial%tile Log. Mem. I 9th Log. Mem. II 1st Vis. Repro. I 13th Vis. Repro. II 1st RMT Words <1st Faces <1st

  18. Immediate: Anna Thompson was working at the high school, was on her way with her four kids and somebody robbed her and took her money from her purse and she met at the police office, told them everything that had happened. And they listened, they appreciated her being so honest and telling everything. They planned on doing everything they could and find the guys who robbed her. Immediate: Anna Thompson was working at the high school, was on her way with her four kids and somebody robbed her and took her money from her purse and she met at the police office, told them everything that had happened. And they listened, they appreciated her being so honest and telling everything. They planned on doing everything they could and find the guys who robbed her.

  19. Delayed: This woman was working five days a week, usually Monday through Friday and after work Friday, she went looking for something for the boys. She bought 2 shirts and 1 pair of pants and thought they would fit perfectly. She came home, she pulled in the garage, she opened up the door and went into the house. Didn’t know if something bad was going on, she went into the living room down in the basement, and there a guy unfortunately was in there robbing the house. He had the boys tied up and he pointed the gun at her and just told her “ma’am, gotta stand right there; if you start to run, I will definitely shoot.” He went over and he put her down on that sofa and he tied her hands up and said, “now you stay right here, I’m going to yell up stairs”. So he yelled upstairs “the wife is home now, and she’s tied up with the boys too, come on lets hurry it up.” And the guy started carrying everything down. They got the television, the radio, and they found a little bit of cash in one of the drawers. They looked in her purse and they did find another twenty dollars. They didn’t take her credit cards or nothing like that. And they said o.k. now, someone is going to be in the garage there looking for some tools out in the garage and if you start making a noise or we think you’re on the telephone, we’ll come and shoot you and look later and see if you’re actually doing it. And they went out, the three of them went out the front door, he went out through the kitchen and they went out the backdoor and they all got in the car down the road, and they drove away. And it took her about twenty minutes to realize they had gone. She just got up, went over and called the police, and they were there in about five minutes. (Examiner asks, “What did the police do? Do you know?”). Police got the description of the guys. One of them had been in a robbery before, and they thought they knew who he was, and they put the alarm out to let the other police know he was driving. His car was a Ford pick-up truck. They don’t know that’s what he’s in, but just look for a Ford pick-up truck and it’s brown and should be on the western end of Belleville and heading back towards the eastern end of Belleville.

  20. Delayed Nonverbal Memory: WMS-R VR

  21. Acute CT Scan Findings

  22. CT Scan Findings at 8 Months Post-injury

  23. Why Confabulation? • The falsification of memory occurring in …association with an organically derived amnesia. • Regardless of the etiology, frontal dysfunction must co-occur with amnesia to produce “spectacular” confabulation. Either one in isolation is not sufficient to account for this syndrome. Berlyne, 1972 Stuss et al, 1978

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