“Where’s the Lesion”?

AACN MeetingsAACN Meetings

June 17, 2005June 17, 2005

Russell M. Bauer, Ph.D.Russell M. Bauer, Ph.D.

Case S.J.

51-yo with 25-yr history of poorly 51-yo with 25-yr history of poorly controlled partial seizurescontrolled partial seizures

PMH: significant HTN, well-managed, PMH: significant HTN, well-managed, 2 minor CHI, both with brief LOC2 minor CHI, both with brief LOC

No prior psychiatric historyNo prior psychiatric history Employed as assistant principal in a Employed as assistant principal in a

local high school, having taught local high school, having taught science previouslyscience previously

Clinical examination – S.J.

Alert, oriented to person and place, not dateAlert, oriented to person and place, not date Intact language expression and Intact language expression and

comprehensioncomprehension Never recognized clinicians who worked with Never recognized clinicians who worked with

him; confabulated relationships with them (“I him; confabulated relationships with them (“I had dinner with you last night”); had dinner with you last night”); confabulation resolved quicklyconfabulation resolved quickly

Difficulty distinguishing dreams from realityDifficulty distinguishing dreams from reality Irritable, aggressive outbursts occasionallyIrritable, aggressive outbursts occasionally Amotivational, apathetic, inappropriateAmotivational, 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 headacheAwoke one day with severe headache Confused, had stiff neck and Confused, had stiff neck and

deceased memorydeceased memory Lumbar puncture: blood-stained CSFLumbar puncture: blood-stained CSF On admission, was somnolent and On admission, was somnolent and

oriented only to personoriented only to person Recalled 1/3 and had poor serial 7’sRecalled 1/3 and had poor serial 7’s Right homonymous hemianopiaRight homonymous hemianopia

Case T.R. – cont’d 15 days after admission15 days after admission

Alert and cooperaiveAlert and cooperaive Oriented for place, person, year, not monthOriented for place, person, year, not month Significant confusion about timeSignificant confusion about time Sometimes failed to read items in his intact left Sometimes failed to read items in his intact left

visual fieldvisual field Speech fluent without error, repetition and naming Speech fluent without error, repetition and naming

were normalwere normal Intact visuospatial abilitiesIntact visuospatial abilities Right superior quadrantanopia to confrontationRight superior quadrantanopia to confrontation Mild retrograde amnesiaMild retrograde amnesia ““Everything is becoming clearer, I feel like I woke Everything is becoming clearer, I feel like I woke

up day before yesterday”up day before yesterday”

Bauer, Grande, & Valenstein, 2003

Lesion involves left retrosplenial lesion

Additional Information – T.R. Had tendency to orient to contralateral Had tendency to orient to contralateral

space, and had significant temporal space, and had significant temporal memory disturbancememory disturbance

SPECT: SPECT: left thalamus hypometabolic, and left thalamus hypometabolic, and

anterior portion of left hemisphere anterior portion of left hemisphere was hypermetabolic when compared was hypermetabolic when compared to the rightto the right

no metabolic differences in MTLno metabolic differences in MTL

Case J.L.

44 y.o., R handed white male44 y.o., R handed white male Resides with wife & 2 teenage sonsResides with wife & 2 teenage sons B.A. in 1975 B.A. in 1975 Successfully employed as an Successfully employed as an

insurance agent for 20 years.insurance agent for 20 years. Medical history is unremarkableMedical history is unremarkable No history of alcohol/drug abuse, No history of alcohol/drug abuse,

psychological disorder, or psychiatric psychological disorder, or psychiatric illness.illness.

Mechanism of Injury & Acute Neurological Status On 8/22/97 unhelmeted rider of his motorcycle On 8/22/97 unhelmeted rider of his motorcycle

which crashed while he was travelling which crashed while he was travelling approximately 30 mphapproximately 30 mph

Initial GCS was 3 at OSH where he was paralyzed, Initial GCS was 3 at OSH where he was paralyzed, sedated, intubated and emergently transported by sedated, intubated and emergently transported by helicopter to Barnes-Jewish Hospital (BJH) in St. helicopter to Barnes-Jewish Hospital (BJH) in St. Louis Louis

Upon arrival, J.L. was still unresponsive. Hospital Upon arrival, J.L. was still unresponsive. Hospital records indicate contusions and abrasions of the records indicate contusions and abrasions of the distal upper extremities, bilaterally, R proximal distal upper extremities, bilaterally, R proximal lower extremity, and multiple facial abrasions. lower extremity, and multiple facial abrasions.

NNICU Course

J.L.’s level of consciousness gradually J.L.’s level of consciousness gradually improved. improved.

GCS reached 9 on 09/05 (14 days post injury)GCS reached 9 on 09/05 (14 days post injury)

At 24 days post-injury he was still confused At 24 days post-injury he was still confused and manifested paraphasic speech but was and manifested paraphasic speech but was considered neurologically stable and was considered neurologically stable and was transferred to the inpatient transferred to the inpatient neurorehabilitation unitneurorehabilitation unit

Inpatient Neuropsychological Status

Initial neuropsychological consultation at 7 weeks post Initial neuropsychological consultation at 7 weeks post injury revealed the following: injury revealed the following:

Ongoing post-traumatic amnesia (PTA; GOAT = 41)Ongoing post-traumatic amnesia (PTA; GOAT = 41)

Initial GCS = 3 (Severe range)Initial GCS = 3 (Severe range)Coma Duration = 2 weeks (Severe range)Coma Duration = 2 weeks (Severe range)PTA Duration = 7 weeks (Extremely severe PTA Duration = 7 weeks (Extremely severe

range)range)

Attentional and executive Attentional and executive dysfunctiondysfunction, anomic , anomic aphasia aphasia

Preserved auditory comprehension and perceptual Preserved auditory comprehension and perceptual reasoning abilities (PIQ = 113)reasoning abilities (PIQ = 113)

Neuropsychological Evaluation at 9 1/2 months post-injuryIntelligence:Intelligence:

WAIS-R: PIQ = 128; VIQ = 86; FSIQ = 101WAIS-R: PIQ = 128; VIQ = 86; FSIQ = 101RSPM: 87th %tileRSPM: 87th %tile

Attention:Attention:WMS-R DSFWMS-R DSF 50th %tile DSB50th %tile DSB 53rd 53rd

%tile%tileWMS-R VMSFWMS-R VMSF 88th %tile VMSB88th %tile VMSB 81st %tile81st %tile

PASAT: Trial #1 PASAT: Trial #1 1st %tile1st %tile #2#2 12th %tile12th %tile #3#3 31st %tile31st %tile #4#4 58th %tile58th %tile

Language:Language:COWATCOWAT 10th % tile10th % tileBNTBNT <1st %tile (profoundly impaired retrieval <1st %tile (profoundly impaired retrieval

functions (e.g. Globe = round map of the world)functions (e.g. Globe = round map of the world)WABWAB AQ = 92.60 - Anomic AphasiaAQ = 92.60 - Anomic AphasiaWRATWRAT Reading:Reading: 13th %tile (8th grade)13th %tile (8th grade)

Writing:Writing: 2nd %tile (5th 2nd %tile (5th grade)grade)

Arithmetic:Arithmetic: 32nd %tile (HS)32nd %tile (HS)

Visuoperceptual/visuomotor integration:Visuoperceptual/visuomotor integration:JLOTJLOT 72nd %tile72nd %tileTMT Part ATMT Part A 37th %tile37th %tile

Neuropsychological Evaluation (Cont.)

Neuropsychological Evaluation (Cont.)

Executive Functioning:Executive Functioning:WCSTWCST CategoriesCategories 66

Total ErrorsTotal Errors27th %tile27th %tilePersev. ErrorsPersev. Errors27th %tile27th %tile

Category TestCategory Test 4th %tile4th %tile

TMT Part BTMT Part B 2nd %tile2nd %tile

WAIS-R SimilaritiesWAIS-R Similarities 5th %tile5th %tile

Neuropsychological Evaluation (Cont.)

Verbal learning/Memory Functioning:Verbal learning/Memory Functioning:

CVLTCVLT TrialTrial %tile%tile

A1A1 <1st<1stA5A5 <1st<1stBB <1st<1stA6 (SDFR)A6 (SDFR) <1st<1stA7 (LDFR)A7 (LDFR) <1st<1stRecog. HitsRecog. Hits <1st<1stFalse Pos.False Pos.<1st<1stDiscrim.Discrim. <1st<1st

Neuropsychological Evaluation (Cont.)

WMS-RWMS-R TrialTrial %tile%tile

Log. Mem. ILog. Mem. I 9th9th

Log. Mem. IILog. Mem. II 1st1st

Vis. Repro. IVis. Repro. I 13th13th

Vis. Repro. IIVis. Repro. II 1st1st

RMTRMT WordsWords <1st<1st

FacesFaces <1st<1st

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.

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?

The falsification of memory occurring in The falsification of memory occurring in …association with an organically derived …association with an organically derived amnesia.amnesia.

Regardless of the etiology, frontal Regardless of the etiology, frontal dysfunction must co-occur with amnesia dysfunction must co-occur with amnesia to produce “spectacular” confabulation. to produce “spectacular” confabulation. Either one in isolation is not sufficient to Either one in isolation is not sufficient to account for this syndrome.account for this syndrome.

Berlyne, 1972

Stuss et al, 1978