CORTICAL FUNCTION

dr. Paulus Anam Ong Sp.S dr. Yustiani Dikot Sp.S(K) Bagian I.P. Saraf RSHS FKUP

CEREBRUM / FOREBRAIN

CONSIST OF 2 HEMISPHERE WHICH IS NOT SYMETRICAL IN SHAPE AND FUNCTION THE LARGEST PART OF THE HUMAN BRAIN COVERED BY GRAY MATTER CALLED CORTEX WHICH WAS FOLDED MADE GYRI AND SULCI

Part Of Cerebral Cortex

CEREBRAL CORTEX

CONSIST OF SIX LAYERS, THE THICHNESS VARIES IN

DIFFERENT REGIONS

VIEWED LATERALLY COMPOSED OF FOUR LOBES, BROODMAN DEVIDED IN 47 AREAS WHICH SPECIFIC PART RESPECT FOR A CERTAIN ASPECT OF FUNCTION

FUNCTION ARE INTEGRATION IN DISCRIMINATIVE AND COGNITIVE PROCESSES RELATING TO AFFECTIVE BEHAVIOR, MOTOR FUNCTION, SOMATOSENSORY

PERCEPTION, INTEGRATION AND MEMORY FUNCTION

PERCEPTION MOTIVATION MOVEMENT

Functional Areas of The Cerebrum

INTEGRATION FIBRES

INTEGRATION IN ONE HEMISPHERE ASSOCIATION FIBRES

INTEGRATION BETWEEN TWO HEMISPHERE COMMISURE FIBRES/CORPUS CALLOSUM

INTEGRATION WITH OTHER PART OF CNS PROJECTION FIBRES

Right and Left Hemisphere Function

Right and Left Hemisphere Function

THE 47 AREAS
Consist of

PRIMARY / PRINCIPLE RECEPTIVE AREA ASSOCIATION AREA

INTEGRATION WITH OTHER PART

OF THE HEMISPHERE / BRAIN

Homonculus Cerebri

The Lateral Aspect of Cerebrum

The Medial Aspect of Cerebrum

Frontal Lobe Parts

FRONTAL LOBE FUNCTION

1.

PRECENTRAL GYRUS (MOTOR CORTEX)

Contralateral movement face, arm, leg, trunk

BROCAS AREA (DOMINANT HEMISPHERE) Expressive centre for speech A.SUPPLEMENTORY MOTOR AREA and B. frontal eye field

2. 3.

A.More involved in providing drive for initiation of movement than executing movement B.Voluntary eyes movement on opposite stimulation
4.
5.

PREFRONTAL AREAS
Personality and Initiative PRECENTRAL LOBULE Cortical Inhibition of bladder and bowel voiding

IMPAIREMENT OF FRONTAL LOBE FUNCTION

1.

PRECENTRAL GYRUS

Monoplegia or hemiplegia depending on extent of damage

2.

BROCAS AREA

Brocas dysphasia
3.

SUPPLEMENTARY MOTOR AREA and frontal eye field

Lack of initiation and Paralysis of head and eye movement to opposite site
5.

PRECENTRAL GYRUS

Incontinence of urine and fecal Loss of cortical inhibition

Change personality with antisocial behavior / loss of inhibition

A.ORBITOFRONTAL SYNDROME 1. Poor judgement 2. Disinhibition 3. Emotional lability B. FRONTAL CONVEXITY SYNDROME Apathy Indifference Poor abstract thought C. MEDIAL FRONTAL SYNDROME Akinetic Incontinent Sparse verbal output Associated with : 1. Primitive reflexes (gasp,pout, etc.) 2. Disturbance of gait (gait apraxia) 3. Resistance to passive movements of the limbs (paratonia)

4. PREFRONTAL AREAS

Parietal Lobe Parts

PARIETAL LOBES FUNCTION

1.

POSTCENTRAL GYRUS (primary sensory Cortex) and Superior Parietal Lobule (secondary sensory association area)

Receives afferent pathways for appreciation of posture, touch and passive movement
Coordination, integration and refinement of sensory input, tactile localization, discrimination, sterognosis Inferior parietal lobule: posterior tertiarry are that combines information from 3 posterior lobes: parietal, temporal, occipital SUPRAMARGINAL AND ANGULAR GYRI

2.

DOMINANT HEMISPHERE Language: From wernickes language area Integration of auditory and visual aspects comprehension in Skill of handling numbers/calculation NON-DOMINANT HEMISPHERE

Concept of body imaged and the awareness of the external environment and ability to construct shape

PARIETAL LOBE IMPAIRMENT

1.

2.

DISTURBED in Postural sensation Sensation of passive movement Accurate localisation of light touch Two point discrimination WERNICKES DYSPHASIA
NON-DOMINANT

Anosognosia Dressing apraxia Geographical apraxia Constructional apraxia Right and left limbs disorientation Finger agnosia Acalculation Agraphia

DOMINANT : (Gertmans Syndrome)

Temporal Lobe Parts

LOBUS TEMPORAL FUNCTION

1.Primary AUDITORY CORTEX (Heschls gyrus, BA 41,42)

Dominant Hearing of Language

Non-Dominant Hearing of sound, rhythm and music Wernicke area: stretch over tertiary association of parietal, temporal, occipital

Dominant: language comprehension

Non dominant: perception of music Learning and Memory Sensation of olfaction, Emosional, Affective behavior

2.THE MIDDLE AND INFERIOR TEMPORAL GYRI

3. THE LIMBIC LOBE

4.VISUAL PATHWAY

TEMPORAL LOBE IMPAIRMENT

1.

AUDITORY CORTEX (Cortical deafness)

DOMINANT Difficulty in hearing spoken sounds NON-DOMINANT Amusia Auditory hallucinations

2.

MIDDLE AND INFERIOR TEMPORAL GYRI

Disturbed memory / learning

3.

LIMBIC LOBE
Olfactory hallucination with complex partial seizures Aggressive or antisocial behavior Inability to establish new memories

4.

OPTIC RADIATION
Upper homonymous qudrantanopia

Occipital Lobe Parts

OCCIPITAL LOBE FUNCTION

Perception of vision (The visual cortex)

1. 2.

Lies along the banks of the calcarine sulcus

The Striate cortex: Primary visual cortex (BA 17) Parastriate cortex: Association visual cortex (BA 18): Synthesize visual impression, integrate them with other sensory modalities and aid in formation of visual memory traces.

Area where parietal and occipital lobes meet:

perception of spatial relationship,

visuokinesthetic motor engrams prepositional consruction in language comprehension and speech

OCCIPITAL LOBE IMPAIRMENT

1. 2.

3.

4.

5.

6.

7.

HOMONIMOUS HEMIANOPSIA CORTICAL BLINDNESS Extensive bilateral cortical lesions of the striate cortex ANTONS SYNDROME Involvement of both the striate and the parastriate cortices affects the interpretation of vision Unaware of the visual loss and denies its presence BALINTS SYNDROME Simultanagnosia VISUAL HALLUCINATIONS Elementary unformed appearing as patterns VISUAL ILLUSIONS (Non-dominant) Micropsia / macropsia Disappearance of colour PROSOPAGNOSIA Able to see a familiar face but cannot named it

Balints syndrome

Synonim: Balinnt-Holmes syndrome (1909), Occularr apraxia ; optic ataxia

Bilateral parieto-occipital disease Inability to direct the eyes to a certain point in the visual field despite intact eye

movement.

End of Session

Mental Status

5 basic element that build mental status

1. Arousal Mechanism ( alertness, attention, concentration) 2. Orientation

3. Language
4. Memory

5. Higher cortical function

Basic element of mental status

Higher cortical function

Basic element of cogntion

(Marshall,Mayer.1997)

Memory

Language

Arousal mechanism Bahasa & memori: well developed and localized basic element elemen Higher cortical function: depend on the 3 basic element

Concentration Attentioni

Arousal

Language

The basic tool of human communication and crucial in assessing most cognitive abilities Must be establish early in the course of mental status testing due to most of the mental test are verbal oriented e.g verbal memory test, oral calculation, proverb test

Terminology

Dysarthria: specific disorder of articulation in which basic language (grammar, comprehension & word choice) is intact Dysprosody: an interruption of speech melody (inflection and rhyme) that caused monotonal, halting, can at times mimic a foreign accent Aphasia: a true deficit of higher integrative language processing, patient produces errors of grammar and word choice or has a defect in comprehension

Terminology

Alexia: loss of (any level of) reading ability in previously literate person. Dyslexia: a specific developmental learning disorders of children who have normal intelligence, yet experience unusual difficult in learning to read Agraphia: an acquired disturbance in writing. Specifically refers to errors of language and not to problem with the actual formation of letter or poor handwriting

Aphasia

Def: an acquired language impairment due to damage to language areas of the brain (left hemisphere) Characterized by defects of:

Word selection language production language comprehension

Affect not only spoken, but also written language both comprehension (alexia) and production (agraphia)

Etiology of aphasia

Acute

ischemic stroke (embolic/ thrombotic) in the distribution of middle cerebral artery Cerebral hemorhage (hipertension, AVM, Aneurysm, Trauma
brain tumor Degenerative process: Alzheimer disease, Primary Progressive Aphasia

Slowly progressive:

Transient: TIA, epileptic seizures

Aphasia
95% result from left hemisphere lesions cause 95% of right handed individual and 70% of left handed are left hemisphere dominant for language Crossed aphasia: aphasia after lesion of right hemisphere in a right handed individual

Primary Language Area

(perisylvian area)
Girus presentralis Girus postsentralis Fasikulus Arcuatus

Area Broca Sulkus lateralis

Area Wernicke Girus temporalis superior

Language model of Wernicke-Geswind

kiri kanan

Perisylvian area

Aphasia most often caused by damage of perisylvian language, that comprises of:

Brocas area: motor programming of speech Broca aphasia Wernickes area: critical for auditory comprehension of spoken words Wernicke aphasia Arcuate fasciculus: links Brocas and Wernickes areas, important for repetition Conduction aphasia

Extra perisylvian aphasias

Aphasia may also caused by lesions that do not directly damage the perisylvian language area, but isolate them from brain regions involved in semantic processing and production of volitional speech Transcortical aphasias

Clinical evaluation
Fluency Naming Repetition Auditory comprehesion

Fluency

Fluent aphasias

plentiful verbal output, well articulated, easy produced utterances of relatively normal length and prosody (i.e., variation of pitch, loudness, rhythm). Lesions: post Rolandic cortex
sparse, effortful utterances of short phrase length and disrupted prosody Lesion: pre-Rolandic cortex

Non Fluent aphasia:

Naming
All aphasic patients exhibit naming impairment, or anomia, usually in combination with other language deficits Isolated anomia anomic aphasia

Auditory comprehension
Most aphasic patients show auditory processing defective Anterior lesions result in relatively mild auditory comprehension impairment, whereas posterior lesions (esp. Wernickes area) result in significant impairment of auditory processing

Repetition

Requires intact perisylvian language area

Perisylvian aphasias: repetition distrubed

Extra-perisylvian aphasia: preserved of repetition

Classification of Aphasia

Brocas Area
Executive or motor for production of language Brocas dysphasia Motor dysphasia Nonfluent / hesitant speech Telegraphic speech Comprehension relative preserved Repetition poor Handwriting- poor

Wernicks AreaReceptive Area

Wernickes dysphasia

Comprehension Impaired Speech fluent but nonsensical Neologism Paraphasia half right words Patient unaware of language problems Repetition: relative preserved Hand writing poor

Conduction Aphasia

Speech nonsensical but fluent Comprehension - normal Repetition - poor

Global Aphasia
Non-fluent speech Comprehension impaired Repetition - poor

Boston Aphasia Classification

Aphasia syndromes Fluency Naming Repetition Auditory Comprehen sion

Broca aphasia
Wernicke aphasia Conduction aphasia

Non-fluent
Fluent Fluent

+
+

Gobal aphasia
Transcortical motor aphasia Transcortical sensory aphasia

Non-fluent
Non-fluent Fluent

+ +

+ -

Mixed transcortical aphasia

Anomia aphasia

Non-fluent
Fluent

+
+

+: relatively preserved

-: relatively disturbed

Memory

Memory

Involves :
1. 2. 3.

Recognition Registration Recall Retrieval

Anatomical basis of memory Hippocampus

The Anatomical Basis of Memory

Test of Memory
1.

2.
3.

Immediate memory Recent memory Remote memory

Disorder of Memory
(Amnesia Syndrome)
1.

Retrograde amnesia

Impairment of memory for events that antedate illness or injury Inability to learn new verbal or non-verbal information from onset of illness or injury

2.

Anterograde amnesia

Disorders of Memory Retrieval

Senescence AAMI (Age Associated Memory Impairment) retrieval of stored memory slow but accurate Depression disorder in motivation and concentration Dementia especially recent memories MCI- mild cognitive impairment amnestic type; a pre-dementia stage

Constructional ability

Capacity to draw or construct two or three dimensional figures or shapes Task

Copying line drawing Drawing to command Reconstructing block designs Right hemisphere produces higher inciden and severity than the left.

Parietal lobe dysfunction

Constructional Abilities
Copying Figures
Stimulus Results

Constructional Abilities
Copying Figures

Higher Cortical Function

Attention Language Memory

Basic buiding blocks for development of higher cortical function

Consists of : Manipulation of well learned material Abstract thinking Arithmatic computation etc

1. Evaluation
1.

The fund of acquired information or the store of knowlegde

Assessed by : 1. Simple verbal test of vocabulary 2. General information/ knowledge 3. Proverb interpretation

2. Manipulation of old knowledge

Ability to apply information to new or unfamiliar situations Assessed by :

1. 2. 3. 4.

Calculation Similarities and Differences Conceptual Series completion Social comprehension

Related cortical functions

Apraxia Right-Left disorientation Acalculia Agraphia Finger Agnosia Visual agnosia Geographic disorientation

Gerstmanns Syndrome

APRAXIA
Loss of ability to carry out skilled movement despite adequate

understanding of task and normal motor power

Ideomotor apraxia

Separation of idea of movement from execution Dominant hemisphere lesion Unable to carry out commands:
Buccofacial apraxia: Show me how to blow out a match ; drink through a straw Limb apraxia: flipping a coin, saluting, kicking a ball

Truncal apraxia: stand like a boxer

Task: fail in command imitating real object

Apraxia Ideomotor

Ideational apraxia
Inability to carry out a sequence of movements Higher order of complex motor planning than ideomotor apraxia Difficulty in manipulating real object Sometimes show object agnosia: e.g. striking candle to match box Bilateral diffuse cortex lesions especially parietal cortex Task: folding a letter, placing it in an envelope, sealing it, and placing a stamp on the envelop

Other apraxias
3.

Constructional apraxia and dressing apraxia (Non dominant parietal disease) Gait apraxia (Frontal lobe/anterior corpus callosum disease) Occulomotor apraxia (Parieto-occipital disease)

4.

5.

DISCONNECTION PATHWAY
1.

INTRAHEMISPHERIC
Linking part of the same hemisphere

2.

INTERHEMISPHERE
Corpus callosum link related parts of the two hemisphere

Intrahemisphere Dysconnection Syndrome

CONDUCTION APHASIA

Lesion of the arcuate fasciculus Fluent dysphasia speech good comprehension, poor repetition

Brocas speech area

Wernickes speech area

Intrahemisphere Dysconnection Syndrome

PURE WORD DEAFNESS

Lesion beetween the primary auditory cortex (Heschls gyrus) and auditory association cortex) Impaired comprehension of spoken word, self initiated is normal Patient seems deaf but audiometry is normal

INTERHEMISPHERE DISCONNECTION SYNDROME

AGENESIS OF THE CORPUS CALLOSUM

No connection between the two hemisphere Failure to name an object presented visually or by touch to the non-dominant hemisphere

Interhemisphere Dysconnection Syndrome BUCCAL LINGUAL and SYMPATHETIC APRAXIA Involves the links between left and right association motor cortices Right brachiofacial weakness and apraxia of tongue, lip and left limb movements

Premotor motor cortex Brocas area

INTERHEMISPHERE DISCONNECTION SYNDROME

LEFT SIDE APRAXIA

Lesion of the anterior corpus callosum Apraxia of the left sided limb movement

INTERHEMISPHERE DISCONNECTION SYNDROME

ALEXIA WITHOUT AGRAPHIA

PURE WORD BLINDNESS

Lesion of the posterior corpus callosum and dominat occipital lobe (primary visual area) Inability to read, to name colours, to copy writing and the ability to identify colours

Inability to read letter (literal alexia) Inability to read word (verbal alexia)

Alexia without agraphia

Pure alexia

Hemi alexia