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Handbook of Clinical Neurology 2023The motor phenomena accompanying frontal lobe disease are diverse, reflecting the various roles the frontal lobes play in the organization of motor control. The... (Review)
Review
The motor phenomena accompanying frontal lobe disease are diverse, reflecting the various roles the frontal lobes play in the organization of motor control. The principal frontal motor areas, the primary motor cortex, the premotor cortex, and the supplementary motor area, have different but interrelated functions in motor control. The principal efferent pathway of the primary motor cortex is the corticospinal tract which conducts fine motor control. Damage to the primary motor cortex and the corticospinal tract results in paralysis and loss of skilled, particularly distal, motor function. Lesions of the premotor cortex interfere with the preparation for the execution of movements and coordinating sequences of limb movement. Mediated through cortico-reticulospinal pathways, the premotor cortex adjusts axial and limb muscle activities. The fine motor skills of the corticospinal tract are superimposed upon these stabilizing movements. Supplementary motor area lesions interrupt self-initiated movements, release alien limb behaviors, and result in grasping. Paralysis, primitive reflexes, and frontal gait disorders are readily observed on examination, but difficulties initiating and sequencing movements are more subtle signs of perturbed higher motor control and require special examination procedures. Prefrontal motor syndromes include motor behaviors that only become apparent when the subject performs spontaneous or self-directed activities, unconstrained by instructions from the examiner. Clinical observation also reveals a slowness to respond to instruction with long delays before initiating action (inertia), but once underway they may be unable to stop (perseveration). Patients sit motionless without spontaneous movement or interest in their surrounds (apathy), yet exhibit distractibility, diverting attention to an incidental peripheral stimulus or an object with which they may then fiddle (environmental dependency and utilization behavior). Little spontaneous speech is initiated (abulia) but echolalia may be stimulated by the examiner's conversation. Restlessness, distractibility, perseveration, and environmentally dependent utilization behaviors coexist with apathy, inertia, and abulia. Mutism and akinesia may alternate with stereotypies and agitation in catatonia. These paradoxical combinations are of considerable diagnostic significance in recognizing frontal lobe motor syndromes.
Topics: Humans; Syndrome; Frontotemporal Dementia; Apathy; Motor Cortex; Paralysis
PubMed: 37620084
DOI: 10.1016/B978-0-323-98817-9.00008-9 -
Practical Neurology Oct 2019The three cardinal qualities necessary for the ideal neurologist are observation, the ability to reason backwards inferentially and specialist knowledge. Modern...
The three cardinal qualities necessary for the ideal neurologist are observation, the ability to reason backwards inferentially and specialist knowledge. Modern medical technology has greatly increased the ability to diagnose and treat disease but it has also encouraged a benign variant of abulia, which is killing off the art and science of clinical reasoning. Intent gazing at the unfamiliar with old eyes or a long look at the familiar with new eyes offers the neurologist an opportunity to discover hitherto unnoticed diagnostic signs far beyond the resolution of the brain scanner and even the light microscope. While there may be nothing new under the sun, there are plenty of old things that no one has observed, which have the potential to greatly improve clinical practice.
Topics: History, 19th Century; Humans; Neurologists; Neurology; Patients; Practice Patterns, Physicians'
PubMed: 30948556
DOI: 10.1136/practneurol-2018-002176 -
Psychosomatics 2020The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health... (Review)
Review
BACKGROUND
The pandemic of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has emerged as one of the biggest health threats of our generation. A significant portion of patients are presenting with delirium and neuropsychiatric sequelae of the disease. Unique examination findings and responses to treatment have been identified.
OBJECTIVE
In this article, we seek to provide pharmacologic and treatment recommendations specific to delirium in patients with COVID-19.
METHODS
We performed a literature search reviewing the neuropsychiatric complications and treatments in prior coronavirus epidemics including Middle Eastern respiratory syndrome and severe acute respiratory syndrome coronaviruses, as well as the emerging literature regarding COVID-19. We also convened a work group of consultation-liaison psychiatrists actively managing patients with COVID-19 in our hospital. Finally, we synthesized these findings to provide preliminary pharmacologic recommendations for treating delirium in these patients.
RESULTS
Delirium is frequently found in patients who test positive for COVID-19, even in the absence of respiratory symptoms. There appears to be a higher rate of agitation, myoclonus, abulia, and alogia. No data are currently available on the treatment of delirium in patients with COVID-19. Extrapolating from general delirium treatment, Middle Eastern respiratory syndrome/severe acute respiratory syndrome case reports, and our experience, preliminary recommendations for pharmacologic management have been assembled.
CONCLUSIONS
COVID-19 is associated with neuropsychiatric symptoms. Low-potency neuroleptics and alpha-2 adrenergic agents may be especially useful in this setting. Further research into the pathophysiology of COVID-19 will be key in developing more targeted treatment guidelines.
Topics: Adrenergic alpha-2 Receptor Agonists; Antipsychotic Agents; Betacoronavirus; Brain Diseases; COVID-19; Central Nervous System Depressants; Coronavirus Infections; Delirium; Dopamine Agonists; GABA Modulators; Humans; Lorazepam; Melatonin; Pandemics; Pneumonia, Viral; Practice Guidelines as Topic; SARS-CoV-2
PubMed: 32828569
DOI: 10.1016/j.psym.2020.05.013 -
Behavioural Pharmacology Apr 2023Schizophrenia is a serious neuropsychiatric disorder characterized by the presence of positive symptoms (hallucinations, delusions, and disorganization of thought and... (Review)
Review
Schizophrenia is a serious neuropsychiatric disorder characterized by the presence of positive symptoms (hallucinations, delusions, and disorganization of thought and language), negative symptoms (abulia, alogia, and affective flattening), and cognitive impairment (attention deficit, impaired declarative memory, and deficits in social cognition). Dopaminergic hyperactivity seems to explain the positive symptoms, but it does not completely clarify the appearance of negative and cognitive clinical manifestations. Preclinical data have demonstrated that acute and subchronic treatment with NMDA receptor antagonists such as ketamine (KET) represents a useful model that resembles the schizophrenia symptomatology, including cognitive impairment. This latter has been explained as a hypofunction of NMDA receptors located on the GABA parvalbumin-positive interneurons (near to the cortical pyramidal cells), thus generating an imbalance between the inhibitory and excitatory activity in the corticomesolimbic circuits. The use of behavioral models to explore alterations in different domains of memory is vital to learn more about the neurobiological changes that underlie schizophrenia. Thus, to better understand the neurophysiological mechanisms involved in cognitive impairment related to schizophrenia, the purpose of this review is to analyze the most recent findings regarding the effect of KET administration on these processes.
Topics: Humans; Ketamine; Schizophrenia; Cognitive Dysfunction; Memory Disorders; Receptors, N-Methyl-D-Aspartate
PubMed: 36094064
DOI: 10.1097/FBP.0000000000000689 -
British Journal of Neurosurgery Feb 2022Falcine meningiomas present significant surgical challenges because they often involve the falx bilaterally, are concealed by a significant amount of normal brain...
INTRODUCTION
Falcine meningiomas present significant surgical challenges because they often involve the falx bilaterally, are concealed by a significant amount of normal brain parenchyma and are frequently deep in location and in close proximity to the anterior cerebral arteries. Many prefer the interhemispheric approach for these lesions, but this operative corridor is not without risk as venous infarctions and cortical injury can occur.
CLINICAL PRESENTATION
We present an alternative technique utilizing a transcortical approach to resect a giant, bilobed falcine meningioma in a 68-year-old female who presented with progressive abulia, urinary incontinence, and bilateral lower extremity weakness over 2 years. A unilateral right frontal craniotomy and a corticectomy through the right superior frontal gyrus was used to safely resect the entire tumor. The patient tolerated the procedure well and was discharged home without issue. Pathology demonstrated that the lesion was an atypical meningioma and she subsequently received adjuvant fractionated radiotherapy. At 2-year follow-up, she has no neurologic deficits, never developed any postoperative seizures and has not had any evidence of tumor recurrence.
CONCLUSION
The transcortical approach can be used as a safe alternative for resecting falcine meningiomas without adding significant undue risk to the patient.
PubMed: 35174752
DOI: 10.1080/02688697.2022.2034744 -
Cancers May 2022Background: Gliomas infiltrating the corpus callosum (G-I-CC) majorly impact patient quality-of-life, but maximally safe tumor resection is challenging. We... (Review)
Review
Background: Gliomas infiltrating the corpus callosum (G-I-CC) majorly impact patient quality-of-life, but maximally safe tumor resection is challenging. We systematically reviewed the literature on G-I-CC. Methods: PubMed, EMBASE, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients with G-I-CC. Clinicopathological features, treatments, and outcomes were analyzed. Results: We included 52 studies comprising 683 patients. Most patients experienced headache (33%), cognitive decline (18.7%), and seizures (17.7%). Tumors mostly infiltrated the corpus callosum genu (44.2%) with bilateral extension (85.4%) into frontal (68.3%) or parietal (8.9%) lobes. Most G-I-CC were glioblastomas (84.5%) with IDH-wildtype (84.9%) and unmethylated MGMT promoter (53.5%). Resection (76.7%) was preferred over biopsy (23.3%), mostly gross-total (33.8%) and subtotal (32.5%). The tumor-infiltrated corpus callosum was resected in 57.8% of cases. Radiation was delivered in 65.8% of patients and temozolomide in 68.3%. Median follow-up was 12 months (range, 0.1−116). In total, 142 patients (31.8%) experienced post-surgical complications, including transient supplementary motor area syndrome (5.1%) and persistent motor deficits (4.3%) or abulia (2.5%). Post-treatment symptom improvement was reported in 42.9% of patients. No differences in rates of complications (p = 0.231) and symptom improvement (p = 0.375) were found in cases with resected versus preserved corpus callosum. Recurrences occurred in 40.9% of cases, with median progression-free survival of 9 months (0.1−72). Median overall survival was 10.7 months (range, 0.1−116), significantly longer in low-grade tumors (p = 0.013) and after resection (p < 0.001), especially gross-total (p = 0.041) in patients with high-grade tumors. Conclusions: G-I-CC show clinicopathological patterns comparable to other more frequent gliomas. Maximally safe resection significantly improves survival with low rates of persistent complications.
PubMed: 35626112
DOI: 10.3390/cancers14102507 -
The Journal of Neuropsychiatry and... 2022The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and...
OBJECTIVE
The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored.
METHODS
An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018.
RESULTS
Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke.
CONCLUSIONS
Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.
Topics: Cognitive Dysfunction; Dementia; Humans; Memory Disorders; Neuropsychological Tests; Stroke
PubMed: 35040661
DOI: 10.1176/appi.neuropsych.21030086 -
Cognitive and Behavioral Neurology :... Dec 2021Individuals with the behavioral variant of frontotemporal dementia (bvFTD) exhibit various levels of abulia, disinhibition, impaired judgment, and decline in executive...
BACKGROUND
Individuals with the behavioral variant of frontotemporal dementia (bvFTD) exhibit various levels of abulia, disinhibition, impaired judgment, and decline in executive function. Empirical evidence has shown that individuals with bvFTD also often exhibit difficulty using honorific speech, which expresses respect to another party or addressee.
OBJECTIVE
To analyze differences in the ability to use honorific speech among individuals with bvFTD, individuals with dementia of the Alzheimer type (AD dementia), and individuals with normal cognition (NC).
METHOD
A total of 53 native Korean speakers (13 bvFTD, 20 AD dementia, and 20 NC) completed an experimental honorific speech task (HST) that involved both expressive and receptive tasks. We analyzed the number of correct responses and error patterns separately for an expressive task and for a receptive task.
RESULTS
The bvFTD group had significantly fewer correct responses on the HST compared with the AD dementia and NC groups. The bvFTD group exhibited more misjudgment errors in identifying nonhonorific speech as honorific speech in the expressive task, and significantly longer response times in the receptive task, than the AD dementia and NC groups. Significant associations were identified between HST scores and cortical atrophy in the temporal and frontotemporal lobes.
CONCLUSION
A decline in the ability to use honorific speech may be a diagnosable behavioral and psychiatric symptom for bvFTD in Korean-speaking individuals. This decline in individuals with bvFTD could be attributed to multiple factors, including social manners (politeness) and impaired social language use ability (pragmatics).
Topics: Alzheimer Disease; Executive Function; Frontotemporal Dementia; Humans; Neuropsychological Tests; Speech
PubMed: 34851865
DOI: 10.1097/WNN.0000000000000284