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Clinical Effects of Parietal Lobe Lesions
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Within the brain, no other territory surpasses the parietal lobes in the rich variety of clinical phenomena exposed under conditions of disease Our current understanding of the effects of parietal lobe disease contrasts sharply with that of the late nineteenth century, when these lobes, in the classic textbooks of Oppenheim and Gowers, were considered to be silent areas However, the clinical manifestations of parietal lobe disease may be subtle, requiring special techniques for their elicitation; even more dif cult is the interpretation of these abnormalities of function in terms of a coherent and plausible physiology and psychology Close to the core of the complex behavioral features that arise from lesions of the parietal lobes is the problem of agnosia Allusion has already been made to agnosia in the discussion of lesions of the temporal lobes that affect language, and similar ndings occur with lesions of the occipital lobe as discussed further on In those contexts, the term refers to a loss of recognition of an entity that cannot be attributed to a defect in the primary sensory modality As a result of the extension of the term agnosia to a loss of more complex integrated functions as described below, a number of intriguing de cits arise These syndromes expose properties of the parietal lobe that have implications regarding a map of the body schema and of external topographic space, of the ability to calculate, to differentiate left from right, to write words, and other problems discussed below The fact that apraxia, an inability to carry out a commanded task despite the retention of motor and sensory
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NEUROLOGIC DISORDERS CAUSED BY LESIONS
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than one contact at a time; the disregard of stimuli on the affected side when the healthy side is stimulated simultaneously (tactile inattention or extinction); the tendency of super cial pain sensations to outlast the stimulus and to be hyperpathic; and the occurrence of hallucinations of touch Of these, the testing of sensory extinction by the presentation of two tactile stimuli simultaneously on both sides of the body has become a component of the routine neurologic examination for parietal lesions With anterior parietal lobe lesions there is often an associated mild hemiparesis, since this portion of the parietal lobe contributes a considerable number of bers to the corticospinal tract Or, more often, there is only a poverty of movement or a weak effort of the opposite side in the absence of somatic neglect The affected limbs, if involved with this apparent weakness, tend to remain hypotonic and the musculature may undergo atrophy of a degree not explained by inactivity alone In some cases, as noted below, there is clumsiness in reaching for and grasping an object under visual guidance (optic ataxia), and exceptionally, at some phase in recovery from the hemisensory de cit, there is incoordination of movement and intention tremor of the contralateral arm and leg, simulating a cerebellar de cit (pseudocerebellar syndrome) While relatively rare, it is authenticated by our own case observations With parietal lesions, the arm and hand may sometimes be held in a xed dystonic posture The Asomatognosias The term asomatognosia denotes the inability to recognize part of one s body The idea that visual and tactile sensory information is synthesized during development into a body schema or image (perception of one s body and the relations of bodily parts to one another) was rst clearly formulated by Pick and elaborated by Brain Long before their time, however, it was suggested that such information was the basis of our emerging awareness of ourselves as persons, and philosophers had assumed that this comes about by the constant interplay between percepts of ourselves and of the surrounding world The formation of the body schema is thought to be based on the constant in ux and storage of sensations from our bodies as we move about; hence, motor activity is important in its development Always, however, a sense of extrapersonal space is central to this activity, and this depends upon visual and labyrinthine stimulation The mechanisms upon which these perceptions depend are best appreciated by studying their derangements in the course of neurologic disease of the parietal lobes Anosognosia (Unilateral Asomatognosia; Anton-Babinski Syndrome) and Hemispatial Neglect The observation that a patient with a dense hemiplegia, usually of the left side, may be indifferent to the paralysis or unaware of it was rst made by Anton; later, Babinski named this disorder anosognosia It may express itself in several ways: The patient may act as if nothing were the matter If asked to raise the paralyzed arm, he may raise the intact one or do nothing at all If asked whether the paralyzed arm has been moved, the patient may say yes If the fact that the arm has not been moved is pointed out, the patient may admit that the arm is slightly weak If told it is paralyzed, the patient may deny that this is so or offer an excuse: My shoulder hurts If asked why the paralysis went unnoticed, the response may be, I m not a doctor Some patients report that they feel as though their left side had disappeared, and when shown the paralyzed arm, they may deny it is theirs and assert that it belongs to someone else or even take hold of it and ing it aside This mental derangement, which Hughlings Jackson referred to as a kind of imbecility, obviously includes a
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somatosensory defect that encompasses loss of the stored body schema as well as a conceptual negation of paralysis and a disturbed visual perception and neglect of half of the body It should be pointed out that the allied symptoms of loss of body scheme and the lack of appreciation of a left hemiplegia are seperable, some patients displaying only one feature The term anosognosia for hemiplegia has been used to describe the latter phenomenon The lesion responsible for the various forms of one-sided asomatognosia lies in the cortex and white matter of the superior parietal lobule but may extend variably into the postcentral gyrus, frontal motor areas, and temporal and occipital lobes, accounting for some of the associated abnormalities described below Rarely, a deep lesion of the ventrolateral thalamus and the juxtaposed white matter of the parietal lobe will produce a similar contralateral neglect Unilateral asomatognosia is seven times as frequent with right (nondominant) parietal lesions as with left-sided ones, according to Hecaen s statistics The apparent infrequency of right sided symptoms is attributable in part but not entirely to their obscuration by an associated aphasia Anosognosia is usually associated with a number of additional abnormalities Often there is a blunted emotionality The patient looks dull, is inattentive and apathetic, and shows varying degrees of general confusion There may be an indifference to performance failure, a feeling that something is missing, visual and tactile illusions when sensing the paralyzed part, hallucinations of movement, and allocheiria (one-sided stimuli are felt on the other side) Another common group of parietal symptoms consists of neglect of one side of the body in dressing and grooming, recognition only on the intact side of bilaterally and simultaneously presented stimuli (sensory extinction) as mentioned above, deviation of head and eyes to the side of the lesion, and torsion of the body in the same direction (failure of directed attention to the body and to extrapersonal space on the side opposite the lesion) The patient may fail to shave one side of the face, apply lipstick or comb the hair only on one side, or nd it impossible to put on eyeglasses, insert dentures, or put on a shirt or gown when one sleeve has been turned inside out (the problem dressing, when it is apparent on both sides of the body, is more of a dressing apraxia) Unilateral spatial neglect is brought out by having the patient bisect a line, draw a daisy or a clock, or name all the objects in the room Homonymous hemianopia and varying degrees of hemiparesis may or may not be present and interfere with the interpretation of the lack of application on the left side of the drawing A special type of spatial neglect is re ected in the patient s inability to reproduce geometric gures (constructional apraxia) A number of tests have been designed to elicit these disturbances, such as indicating the time by placement of the hands on a clock, drawing a map, copying a complex gure, reproducing stick-pattern constructions and block designs, making three-dimensional constructions, and reconstructing puzzles According to Denny-Brown and Banker, the basic disturbance in such cases is an inability to summate a series of spatial impressions tactile, kinesthetic, visual, or auditory a defect they referred to as amorphosynthesis In their view, imperception or neglect of one side of the body and of extrapersonal space is the essential feature and represents the full extent of the disturbance, which in lesser degree consists only of tactile and visual extinction They make the additional points that the disorder of spatial summation is strictly contralateral to the damaged parietal lobe, right or left, and must be distinguished from a true agnosia, which is a conceptual disorder and involves both sides of the body and extra-
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