brown universitypaul malloy, ph.d.butler hospital the frontal lobes function and dysfunction
TRANSCRIPT
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
The Frontal Lobes The Frontal Lobes Function and DysfunctionFunction and Dysfunction
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryThe frontal lobes as “silent areas”The frontal lobes as “silent areas”
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryPhineas Gage (Harlow, 1848)Phineas Gage (Harlow, 1848)
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryWartime Wartime TraumaTrauma
•Improvements in military medicine led to markedly improved survivability from head wounds in WWII and subsequent wars.•Low velocity shrapnel vs. high velocity projectiles.•Example: Luria and localization of function in Russian soldiers.
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryLeukotomy and lobotomyLeukotomy and lobotomy
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryAdvances in neuroimagingAdvances in neuroimaging
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: HistoryFrontal lobes: HistoryAdvances in neuroimagingAdvances in neuroimaging
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Comparative studiesFrontal lobes: Comparative studiesEvolutionEvolution
• Frontal lobes account for increasing proportion of cerebrum across phylogenetic spectrum (Fuster, 1980)
• Prefrontal areas are 33% of cerebral cortical surface in humans (Goldman-Rakic,1984)
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Comparative studiesFrontal lobes: Comparative studiesWorking memory paradigmsWorking memory paradigms
• Spatial working memory tasks– Delayed response– Delayed alternation
• Feature working memory tasks– Delayed matching to sample– Delayed object alternation
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Comparative studiesFrontal lobes: Comparative studiesWorking memory paradigmsWorking memory paradigms
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: DevelopmentFrontal lobes: DevelopmentAging and frontal functionsAging and frontal functions
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Functional zonesFrontal lobes: Functional zones
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Primary motor functionsFrontal zones: Primary motor functions
• Brodmann area 4
• Input from ventral lateral thalamic nucleus, primary somatosensory area in parietal lobe
• Output to internal capsule
• Pyramidal motor functions
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Primary motor dysfunctionFrontal zones: Primary motor dysfunction
• Initially flacid hemiparesis or hemiplegia on contralateral side
• Later spastic hemiparesis or hemiplegia
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Premotor functionsFrontal zones: Premotor functions
• Brodmann area 6• Input from ventral anterior thalamic
nucleus and secondary somatosensory area• Output to motor area and connections via
corpus callosum to contralateral premotor area
• Integration of sensory and motor information
• Praxis
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Premotor dysfunctionFrontal zones: Premotor dysfunction
• Apraxia• Preserved postural praxis via
basal ganglia• Contralateral fine motor
deficits• Difficulty using sensory
feedback
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Frontal eye field functionsFrontal zones: Frontal eye field functions
• Brodmann area 8• Volitional eye movement
in contralateral visual field
• Active visual search
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Frontal eye field dysfunctionFrontal zones: Frontal eye field dysfunction
• Failure to move eyes volitionally to contralateral visual field
• Intact passive eye movement• Poor visual search
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Dorsolateral functionsFrontal zones: Dorsolateral functions
• Brodmann areas 46, 45,47,8, 9
• Executive functions– Integration of multimodal sensory
information
– Generation of multiple reponse alternatives
– Selection of appropriate response
– Maintenance of set, persistence
– Set shifting, flexibility
– Spatial working memory
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Dorsolateral dysfunctionFrontal zones: Dorsolateral dysfunction
• Difficulty integrating sensory information
• Generation of few, stereotyped response alternatives
• Poor judgement in response selection
• Impersistence
• Perseveration
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Dorsolateral testsDorsolateral testsFigural fluencyFigural fluency
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Dorsolateral testsDorsolateral testsLuria’s reciprocal hand movements & graphic designsLuria’s reciprocal hand movements & graphic designs
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Dorsolateral testsDorsolateral testsPerseverations within and between Lurian tasksPerseverations within and between Lurian tasks
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Dysexecutive effects on other testsDysexecutive effects on other tests
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobesFrontal lobesPoor organization of learning and recallPoor organization of learning and recall
Copy Free recall
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Orbital functionsFrontal zones: Orbital functions• Brodman areas 10,11,12,13,14• Input from limbic and olfactory systems (amygdala,
temporal pole, entorhinal cortex, olfactory nerve); inferotemporal lobe areas, ventral visual pathways
• Output to autonomic musculature and endocrine system (basal forebrain cholinergic system, caudate, and autonomic system)
• Modulation of affective and social behavior; “...preservation of behavioral regulation by external stimuli and its dissolution in the absence of external stimulation.”
• Working memory for feature information• Integration of memory and emotional valence• Smell discrimination
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Orbital dysfunctionFrontal zones: Orbital dysfunction
• Disinhibition, socially inappropriate behavior
• Failure on feature working memory tasks
• Anosmia• Confabulation
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Orbital testsOrbital tests
• Go-NoGo tasks
• UPSIT
• Frontal Systems Behavior Scale (FrSBe)
• SIGO interview for behavior change
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Orbital testsOrbital testsChanges in smell with agingChanges in smell with aging
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Disinhibition and intrusion in drawingDisinhibition and intrusion in drawing
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Cingulate/SMA functionsFrontal zones: Cingulate/SMA functions
• Brodman areas 24, 32
• Connections with older cortical and deep limbic structures
• Drive and motivation
• Environmental exploration
• Complex attention
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal zones: Cingulate/SMA dysfunctionFrontal zones: Cingulate/SMA dysfunction
• Apathy, akinetic mutism
• Alien hand syndrome
• Complex attentional deficits, delayed habituation
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Alien hand syndromeFrontal lobes: Alien hand syndrome
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Subcortical connectionsFrontal lobes: Subcortical connections
• Parallel but separate connections to caudate and thalamus
• Topographic mapping of caudate and thalamus
• Subcortical white matter connections– Long tracts– Cortical U-fibers
• Small subcortical lesions can mimic large cortical lesions
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Subcortical connectionsFrontal lobes: Subcortical connectionsThalamusThalamus
dorsomedial
Dorsolateral prefrontal
Dorsolateralcaudate
Lateral dorsomedial
Globus Pallidus
VA & MDThalamus
Ventromedialcaudate
MedialGlobus pallidus
Anterior Cingulate
Nucleusaccumbens
RostrolateralGlobus Pallidus
MDThalamus
Orbital prefrontal
VA & MDThalamus
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Subcortical connectionsFrontal lobes: Subcortical connectionsThalamusThalamus
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Subcortical connectionsFrontal lobes: Subcortical connectionsWhite matterWhite matter
uncinate fasciculuslong tracts to posterior association areas
cortical u-fibers
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Cortical connectionsFrontal lobes: Cortical connections
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: Other signs and syndromesFrontal lobes: Other signs and syndromes
• “Frontal release” signs– Disappear with normal development, reappear
in aging or frontal systems dysfunction– Snout, suck, glabellar, grasp
• Gegenhalten vs. cogwheeling
• Frontal or magnetic gait
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Clinical examplesClinical examples
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: DementiaFrontal lobes: DementiaKorsakoff’s syndromeKorsakoff’s syndrome
This 42 year old man was admitted from a rest home, where he had been displaying a number of problematic behaviors, including compulsive eating of all the vegetables in the garden, and perseverative stuffing of toilets with paper. PMH = Severe alcohol abuse. He had impulsively gone to Florida with a barmaid, and spent all his money. He was “rescued” by his wife, but was unable to return to work as a bartender. He was eventually place in a rest home. NP testing = severe anterograde/retrograde amnesia, moderately severe deficits in executive abilities, marked inertia, abulia, and apathy.
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Korsakoff’s syndrome: Korsakoff’s syndrome: Intrusions and disinhibitionIntrusions and disinhibition
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: TraumaFrontal lobes: TraumaLocalization of TBILocalization of TBI
from Courville, 1941
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: TraumaFrontal lobes: TraumaContusion with hemorrhageContusion with hemorrhage
Case history: This 57 year old man was found unconscious by his family, and was thought to have struck his head in a fall. LOC x few hours, but remained confused for the next few days. Sent to a nursing facility, but had repeated arguments with staff, made sexually inappropriate and racist remarks, and was hospitalized. NP testing = severe dysexecutive and disinhibitory deficits, which affected his performance on other tasks.
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: TraumaFrontal lobes: TraumaContusion with hemorrhageContusion with hemorrhage
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Dementia of the frontal type vs. Alzheimer’s diseaseDementia of the frontal type vs. Alzheimer’s disease
• Early changes in behavior/personality
• Neuropsychological deficits in executive and inhibitory functions, no frank amnesia
• Relative sparing of posterior functions (must be dissociated from dysexecutive problems)
• Anterior atrophy
• Preservation of personality & social behavior
• Neuropsychological deficits in naming and construction, with frank amnesia after delay
• Relative sparing of anterior functions
• Generalized and hippocampal atrophy
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes:DementiaFrontal lobes:DementiaFrontal typeFrontal type
This 56 year old man presented with a one year history of progressive decline in memory and judgment, and several demotions at work. He had displayed a number of socially inappropriate behaviors, such as visiting a neighbor's swimming pool without invitation, neglect of his personal hygiene, and uncharacteristic episodes of anger dyscontrol. NP testing revealed prominent deficits on tests of executive and self-regulatory functions, failures on memory testing typical of frontal impairment (e.g. perseverative and intrusion errors).
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes:DementiaFrontal lobes:DementiaFrontal typeFrontal type
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
Frontal lobes: DementiaFrontal lobes: Dementia Frontotemporal dementiaFrontotemporal dementia
Normal elderlyFrontal dementia
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
5/29/2002
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
5/29/2002
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
5/29/2002
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Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
5/29/2002
![Page 54: Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction](https://reader036.vdocuments.net/reader036/viewer/2022081518/551c5b1d550346b1458b524a/html5/thumbnails/54.jpg)
Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
MMSE: 16
6/2002
![Page 55: Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction](https://reader036.vdocuments.net/reader036/viewer/2022081518/551c5b1d550346b1458b524a/html5/thumbnails/55.jpg)
Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
MMSE: 25
3/2003
![Page 56: Brown UniversityPaul Malloy, Ph.D.Butler Hospital The Frontal Lobes Function and Dysfunction](https://reader036.vdocuments.net/reader036/viewer/2022081518/551c5b1d550346b1458b524a/html5/thumbnails/56.jpg)
Brown UniversityBrown University Paul Malloy, Ph.D.Paul Malloy, Ph.D. Butler HospitalButler Hospital
6/2002 MMSE: 16
3/2003 MMSE: 25