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Frontal lobe signs

Dr. Abdul Aziz Salar

The Frontal Lobe

Causes of Frontal Lobe


Disorders

Cerebrovascular disease
Anterior cerebral artery
Supplies medial surface of the brain
B/L ACA infarct causes quadriparesis legs worse than arms, and
akinetic mutism

Occlusion of artery of Huebner


Borderzone infarction between ACA/MCA
Wedge shaped lesion between superior and middle frontal gyri
Man-in-the-barrel syndrome proximal weakness at shoulder and hip,
intact cranial nerves and preservation of leg function symmetrical
proximal brachial amyotrophic diplegia

Tumours
Olfactory groove meningioma

Anosmia
Loss of inhibition
Headaches
Memory impairment
Visual symptoms
Metastatic brain tumours

Trauma

Frontotemporal lobar degenerations


(FTLD)
Frontotemporal dementia
Orbitobasal disinhibition
Mediofrontal mutism
Dorsolateral Classical FTD apathy, psychomotor retardation
Primary Progressive Aphasia

Logopenic Progressive Aphasia


Semantic Dementia (Fluent PPA)

Other causes

Hydrocephalus
NPH
Tourette syndrome
Infections

HIV
Abscesses
Tuberculoma
Neurocysticercosis

The Frontal Lobe Signs


According to the area of involvement

Precentral gyrus
Monoparesis
Hemiparesis
Seizures
Focal
GTCS

Brocas area
Motor dysphasia/aphasia if in the dominant hemisphere

Supplementary motor area


Paralysis of head and eye movement to opposite side
Head and eyes deviated to same side of lesion

Prefrontal area
Personality change

Disinhibition
Inappropriate jocularity
Loss of initiative and concern
Akinetic mutism
General retardation

Prefrontal area (contd)


Primitive reflexes (frontal release responses)

Grasp
Pout
Palmar-mental
Brisk jaw jerk
Contralateral DTR changes
Unsteady gait upright posture with short stride, hesitant, widened
base gait
Ignition apraxia
Poor balance
Paratonia

Paracentral lobule
Incontinence of urine or faeces cortical disinhibition

Orbital surface
Anosmia unilateral or bilateral

Physical examination
Frontal lobe specific cognitive screening
Frontal assessment Battery (FAB)
Montreal Cognitive Assessment (MoCA)

Tests for frontal lobe


dysfunction

Go/No-Go task
Test of echopraxia
Ask patient to hold up 1 finger if the examiner holds up 2
fingers and 2 fingers if the examiner holds up 1
10 trials should be done
Failure to respond correctly suggests lack of normal
response inhibition

Antisaccade task
Ask patient to move eyes opposite to the direction of the
stimulus
Failure to do so reflects dysfunction of the prefrontal
cortex

Trail-Making Test
Part A connect 25 numbered circles
Part B connect numbers and letters in alternating
progression

Thurstone Test (lexical fluency)


Ask the patient to generate as many words as possible

beginning with the letter F in 1 minute, excluding proper


nouns (names)
Normal score for a native English speaker is 8 words
This tests design fluency, not semantic category fluency
Marked impairment lateralizes to the left frontal lobe
Mild to moderate impairment has poor localizing value

Alternating sequences task


Lurias three step motor program
Fist-edge-palm test

Applause test

Examiner claps 3 times, and asks patient to do the same


Positive applause sign is clapping 4 times or more
This is a manifestation of perseveration
Highly specific for parkinsonian disorders with frontal
involvement

Moderately specific cognitive


tests/signs
Aphasia

Brocas aphasia
Apraxia
Left premotor and supplemental motor cortices
Buccofacial apraxia cannot perform movements with the mouth
or lips, and is localized near Brocas area
Callosal apraxia unilateral apraxia ACA stroke

Contd
Neglect
Patients may neglect to draw one side of a drawing or to read
words on one side of a page Neglect dyslexia
Motor neglect
Sensory neglect
Anosognosia (denial of illness)

Anosodiaphoria (minimization of illness)

Contd
Utilization behavior
Using, touching or playing with an object that is inappropriate to
the scenario
E.g. A patient taking a physicians stethoscope and listening to his
heart sounds while the physician is talking to him

Alien hand syndrome


The patients hand assumes complex positions that are not under
volitional control

Other signs
Lack of originality
Inability to plan, initiate, organize or form and maintain
personal relationships
Thes patients lack insight and are dependent on
caregivers despite normal intellect
Witzelsucht addiction to joking patients tell
inappropriate jokes or pointless stories in socially
inappropriate situations

Thank You