Frontal Lobe Syndromes

Katalin Gymrey, Ph.D., M.D.

Outline
Functional anatomy of the frontal lobes Neurotransmitters in the frontal lobes Deficits resulting from frontal lobe insult Testing prefrontal cortical function Common causes of frontal lobe syndromes

Functional Frontal Lobe Anatomy

Largest of all lobes

SA: ~1/3 / hemisphere

3 major areas in each lobe

Dorsolateral aspect Medial aspect Inferior orbital aspect

Functional Frontal Lobe Anatomy

Premotor area
B6

Primary motor area

B4

Supplementary motor area

(medially)

Central sulcus

Frontal eye field

B8

Prefrontal area
B 9, 10, 11, 12

Lateral sulcus/ Sylvian fissure

Motor speech area of Broca

B 44, 45

Functional Frontal Lobe Anatomy

Motor cortex
Primary Premotor Supplementary Frontal eye field Brocas speech area

Prefrontal cortex
Dorsolateral Medial Orbitofrontal

Motor Cortex

Primary motor cortex

Input: thalamus, BG, sensory, premotor Output: motor fibers to brainstem and spinal cord Function: executes design into movement Lesions:/ tone; power; fine motor function on contra lateral side

Motor Cortex

Premotor cortex
Input: thalamus, BG, sensory cortex Output: primary motor cortex Function: stores motor programs; controls coarse postural movements Lesions: moderate weakness in proximal muscles on contralateral side

Motor Cortex

Supplementary motor
Input: cingulate gyrus, thalamus, sensory & prefrontal cortex Output: premotor, primary motor Function: intentional preparation for movement; procedural memory Lesions: mutism, akinesis; speech returns but it is non-spontaneous

Motor Cortex

Frontal eye fields

Input: parietal / temporal (what is target); posterior / parietal cortex (where is target) Output: caudate; superior colliculus; paramedian pontine reticular formation Function: executive: selects target and commands movement (saccades) Lesion: eyes deviate ipsilaterally with destructive lesion and contralaterally with irritating lesions

Motor Cortex

Brocas speech area

Input: Wernickes Output: primary motor cortex Function: speech production (dominant hemisphere); emotional, melodic component of speech (non-dominant) Lesions: motor aphasia; monotone speech

Prefrontal Cortex

Orbital prefrontal cortex

Connections: temporal,parietal, thalamus, GP, caudate, SN, insula, amygdala Part of limbic system Function: emotional imput, arousal, suppression of distracting signals Lesions: emotional lability, disinhibition, distractibility, hyperkinesis

Prefrontal Cortex

Dorsomedial prefrontal cortex

Connections: temporal,parietal, thalamus, caudate, GP, substantia nigra, cingulate Functions: motivation, initiation of activity Lesions: apathy; decreased drive/ awareness/ spontaneous movements; akinetic-abulic syndrome & mutism

Prefrontal Cortex

Dorsolateral prefrontal cortex

Connections: motor / sensory convergence areas, thalamus, GP, caudate, SN Functions: monitors and adjusts behavior using working memory Lesions: executive function deficit; disinterest / emotional reactivity; attention to relevant stimuli

Neurotransmitters

Dopaminergic tracts
Origin: ventral tegmental area in midbrain Projections: prefrontal cortex (mesocortical tract) and to limbic system (mesolimbic tract) Function: reward; motivation; spontaneity; arousal

Neurotransmitters

Norepinephrine tracts
Origin: locus ceruleus in brainstem and lateral brainstem tegmentum Projections: anterior cortex Functions: alertness, arousal, cognitive processing of somatosensory info

Neurotransmitters

Serotonin tracts
Origin: raphe nuclei in brainstem Projections: number of forebrain structures Function: minor role in prefrontal cortex; sleep, mood, anxiety, feeding

Frontal Lobe Syndromes

The Case of Phineas Gage (Harlow 1868)

tamping iron blown through skull: L frontal brain injury excellent physical recovery dramatic personality change: no longer Gage:stubborn, lacked in consideration for others, had profane speech, failed to execute his plans

Frontal Lobe Syndromes

Emotional make-up and personality Abstraction and judgment Attention and memory Language

Frontal Lobe Syndromes

Emotional make-up and personality

May be the only manifestation Apathy / euphoria / labile mood Decreased drive / poor impulse control Abulia; akinetic mutism Pseudobulbar palsy; Opercular syndrome Best assessed with Hx from family / friends & observation

Frontal Lobe Syndromes

Abstraction and judgment

Cognitive functions undisturbed Concrete thinking Diminished insight Defect in planning / executive control

Frontal Lobe Syndromes

Tests of abstraction and judgment

Interpret proverbs (e.g.the golden hammer opens iron doors) Explain why conceptually linked words are the same (e.g. coat & skirt) Plan & structure a sequential set of activities (how would you bake a cake?) Insight / reaction to own illness

Frontal Lobe Syndromes

Attention and memory

Inattentiveness Defect in working memory Defect in sequencing, perseverance

Frontal Lobe Syndromes

Tests of attention and memory

Alternative sequence (e.g. copying MNMN) Lurias fist-edge-palm test (show 3X) Go/no-go: tap once if I tap twice, dont tap if I tap once tap for A read 60 letters at 1/sec; N: < 2 errors

Frontal Lobe Syndromes

Tests of attention and memory cont

Digit span repeat 3-52; 3-52-8; 3-52-8-67.. N: >5 Visual grasp: look away from stimulus Recency test recall sequence of stimuli / events Imitation (of examiner) / utilization (of objects presented)

Frontal Lobe Syndromes

Language
Brocas / non-fluent aphasia Prefrontal/ transcortical motor aphasia Language-motor dissociation Akinetic mutism

Frontal Lobe Syndromes

Language tests
Thurstone / word fluency test (recite as many words beginning with F in 1 min as you can, then with A, S); N: >15 Repetition (Brocas vs transcortical)
Ball Methodist Methodist episcopal No ifs ends or buts Around the rugged rock the ragged rascal ran

Frontal Lobe Syndromes

Formal Tests
Wisconsin Card Sorting Test
abstract thinking and set shifting; L>R

Trail Making
visuo-motor track, conceptualization, set shift

Stroop Color & Word Test

attention, shift sets; L>R

Tower of London Test

planning

Wisconsin Card Sorting Test

Please sort the 60 cards under the 4 samples. I wont tell you the rule, but I will announce every mistake. The rule will change after 10 correct placements.

Trail Making Test

A
6

1
2 3 7

C
D

Various levels of difficulty: 1. Please connect the letters in alphabetical order as fast as you can. 2. Repeat, as in 1 but alternate with numbers in increasing order

Stroop Color and Word Tests

RED BLUE ORANGE YELLOW GREEN RED PURPLE RED GREEN YELLOW BLUE RED YELLOW ORANGE RED GREEN BLUE GREEN PURPLE RED
Please read this as fast as you can

Tower of London Tests

Various levels of difficulty: e.g. Please rearrange the balls on the pegs, so that each peg has one ball only. Use as few movements as possible

Diseases Commonly Associated With Frontal Lobe Lesions

Traumatic brain injury

Gunshot wound Closed head injury Widespread stretching and shearing of fibers throughout Frontal lobe more vulnerable Contusions and intracerebral hematomas

Diseases Commonly Associated with Frontal Lobe Lesions

Frontal Lobe seizures

Usually secondary to trauma Difficult to diagnose: can be odd (laughter, crying, verbal automatism, complex gestures)

Diseases Commonly Associated With Frontal Lobe Lesions

Vascular disease
Common cause especially in elderly ACA territory infarction Damage to medial frontal area MCA territory Dorsolateral frontal lobe ACom aneurysm rupture Personality change, emotional disturbance

Diseases Commonly Associated With Frontal Lobe Lesions

Tumors
Gliomas, meningiomas subfrontal and olfactory groove meningiomas: profound personality changes and dementia

Multiple Sclerosis
Frontal lobes 2nd highest number of plaques euphoric/depressed mood, Memory problems, cognitive and behavioral effects

Diseases Commonly Associated With Frontal Lobe Lesions

Degenerative diseases
Picks disease Huntingtons disease

Infectious diseases
Neurosyphilis Herpes simplex encephalitis

Diseases Commonly Associated with Frontal Lobe Lesions

Psychiatric Illness proposed associations Depression Schizophrenia OCD PTSD ADHD

Frontal Lobe Syndromes Summary

Personality and emotional changes Reflect prefrontal lesions Role of Dopamine and Norepinephrine Trauma > vascular, tumors

Functional Frontal Lobe Anatomy

Five frontal subcortical circuits

(Cummings,93)

1. 2. 3. 4. 5.

Motor Oculomotor Dorsolateral prefrontal Lateral orbitofrontal Anterior cingulate

Functional Frontal Lobe Anatomy

Frontal subcortical circuits

Striatum Caudate & Putamen Globus Pallidus & Substantia Nigra Thalamus DM & CM nuclei

Frontal cortex

Frontal subcortical Circuits:

1. Motor Circuit
VL Globus Pallidus Putamen

SMA, Premotor, Motor

VL, VA, CM Thalamus

Hypothalamus

Supplementary Motor & Premotor: planning, initiation & storage of motor programs; fine-tuning of movements Motor:final station for execution of the the movement according to the design

Frontal subcortical Circuits:

2. Oculomotor Circuit
DM Globus Pallidus

Frontal Eye Field

Central Caudate

Substantia Nigra

VA, MD Thalamus

Voluntary scanning eye movement Independent of visual stimuli

Frontal subcortical Circuits:

3. Dorsolateral Prefrontal Circuit
DM Globus Pallidus

Lateral Prefrontal

DL Caudate

Substantia Nigra

VA, MD Thalamus

Executive functions: motor planning, deciding which stimuli to attend to, shifting cognitive sets Attention span and working memory

Frontal subcortical Circuits:

4. Lateral Orbitofrontal Circuit
Inferolateral prefrontal DM Globus Pallidus

Orbitofrontal

VM Caudate

Substantia Nigra

VA, MD Thalamus

Emotional life and personality structure Arousal, motivation, affect Orbitofrontal cortex: consciousness

Frontal subcortical Circuits:

5. Anterior Cingulate Circuit
Anterior Cingulate Gyrus RL Globus Pallidus

Ventral Striatum

Substantia Nigra

MD Thalamus

Abulia, akinetic mutism