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lateral anosmia or optic atrophy, as occurs with a meningioma of the olfactory groove Our experience with frontal lobe lesions derived mainly from patients with trauma, in ltrating glioma, or ruptured anterior communicating aneurysms af rms most of the statements above Most apparent is the abulic-hypokinetic disorder that seems to slow the mental processes involved in all forms of cerebral performance Inattentiveness and impersistence in all assigned tasks are the other major features of this disorder; at the same time, seemingly paradoxically, there may be an impulsiveness in all responses and perseveration Such a state of slowness and inattentiveness cannot be speci cally ascribed to prefrontal lesions, since it may be a re ection of a more general impairment of the thalamolimbic or reticular activating thalamocortical system Indeed, bilateral medial thalamic lesions may give rise to the same syndrome, and Degos and colleagues have described a severe frontal lobe syndrome in association with bilateral lesions of the anterior cingulate gyrus It is noteworthy that these structures have close connections with the prefrontal cortices Although the frontal lobes are the subject of a vast literature and endless speculation (see reviews of Stuss and Benson and of Damasio), a uni ed concept of their function has not emerged probably because they are so large and include several heterogeneous systems There is no doubt that the mind is changed by disease of the prefrontal parts of the frontal lobes, but often it is dif cult to say exactly how it is changed Perhaps at present it is best to regard the frontal lobes as the part of the brain that quickly and effectively orients and drives the individual, with all the percepts and concepts formed from past life experiences, toward action that is projected into the future Psychologic tests of particular value in establishing the presence of frontal lobe disease are generally constructed to detect the ability to persist in a task and to switch mental focus on demand They include the Wisconsin card-sorting test, the Stroop colornaming test, sequencing of pictures, trail making (a two-part test in which the patient draws lines, rst connecting randomly arrayed numbers on a paper in order and then connecting numbers and letters that correspond in order) the verbal equivalent of trail making (see below), and the three-step hand posture test of Luria The last two tests are a popular part of the bedside neurologic evaluation of patients with suspected frontal lobe lesions The alphabet-number test requires the patient to give each letter of the alphabet followed by the corresponding number (A-1, B-2, C-3, etc) In the Luria test, the patient is asked to imitate, then reproduce on his own, a sequence of three hand gestures, typically slapping the opposite outstretched palm, hitting the palm with a closed st, and then by striking it with the side of the open hand Patients with frontal lesions on either or both sides have dif culty performing the test in correct sequence, often perseverating, balking, or making unwanted gestures Luria pointed out that the natural kinetic smoothness of transition from one hand position to the next is disrupted and there is a tendency to perseverate (He favored testing with the sequence of arm thrusting forward, clenching the st, and forming a ring with the rst two ngers) However, it should be kept in mind that similar impairments of performance may occur with all manner of confusional and inattentive states and with apraxias More complex mental acts that may be easily tested and betray frontal lobe disease but are less speci c, in that they are also disordered by lesions in other brain regions, include serial subtraction ( working memory ), interpretation of proverbs, tests of rapid motor response, and others
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Effects of frontal lobe disease may be summarized as follows: I Effects of unilateral frontal disease, either left or right A Contralateral spastic hemiplegia B Slight elevation of mood, increased talkativeness, tendency to joke inappropriately (Witzelsucht), lack of tact, dif culty in adaptation, loss of initiative C If entirely prefrontal, no hemiplegia; grasp and suck re exes or instinctive grasping may be released D Anosmia with involvement of orbital parts II Effects of right frontal disease A Left hemiplegia B Changes as in IB, C, and D III Effects of left frontal disease A Right hemiplegia B Motor speech disorder with agraphia, with or without apraxia of the lips and tongue (see Chap 23) C Sympathetic apraxia of left hand (see page 49) D Loss of verbal associative uency; perseveration E Changes as in IB, C, and D IV Effects of bifrontal disease A Bilateral hemiplegia B Spastic bulbar (pseudobulbar) palsy C If prefrontal, abulia or akinetic mutism, lack of ability to sustain attention and solve complex problems, rigidity of thinking, bland affect, social ineptitude, behavioral disinhibition, inability to anticipate, labile mood, and varying combinations of grasping, sucking, obligate imitative movements, utilization behavior D Decomposition of gait and sphincter incontinence
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