Where s the Lesion AACN Meetings June 17 2005

“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 n PMH: significant HTN, well-managed, 2 minor CHI, both with brief LOC n No prior psychiatric history n Employed as assistant principal in a local high school, having taught science previously n

Clinical examination – S. J. n n n 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

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

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

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

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

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

Case J. L. n n n 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.

Mechanism of Injury & Acute Neurological Status n On 8/22/97 unhelmeted rider of his motorcycle which crashed while he was travelling approximately 30 mph n 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 n 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.

NNICU Course n J. L. ’s level of consciousness gradually improved. n GCS reached 9 on 09/05 (14 days post injury) n 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

Inpatient Neuropsychological Status Initial neuropsychological consultation at 7 weeks post injury revealed the following: i 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) i i Attentional and executive dysfunction, anomic aphasia Preserved auditory comprehension and perceptual reasoning abilities (PIQ = 113)

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

Neuropsychological Evaluation (Cont. ) Language: COWAT BNT WAB WRAT 10 th % tile <1 st %tile (profoundly impaired retrieval functions (e. g. Globe = round map of the world) AQ = 92. 60 - Anomic Aphasia Reading: 13 th %tile (8 th grade) Writing: 2 nd %tile (5 th grade) Arithmetic: 32 nd %tile (HS) Visuoperceptual/visuomotor integration: JLOT 72 nd %tile TMT Part A 37 th %tile

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

Neuropsychological Evaluation (Cont. ) Verbal learning/Memory Functioning: CVLT Trial %tile A 1 A 5 B A 6 (SDFR) A 7 (LDFR) Recog. Hits False Pos. Discrim. <1 st <1 st

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

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.

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.

Delayed Nonverbal Memory: WMS-R VR

Acute CT Scan Findings

CT Scan Findings at 8 Months Post-injury

Why Confabulation? n The falsification of memory occurring in …association with an organically derived amnesia. Berlyne, 1972 n 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. Stuss et al, 1978