Neuropsychology - Case Study Example

Neuropsychology Case Studies Case Left temporal lobe tumor Introduction: Psychic symptoms or definite mental syndromes do not arise as a result of tumor of the temporal lobe, rather it may be emphasized that, psychic syndromes very rarely result from damage of a circumscribed part of the brain, but always as a functional damage of the brain as a whole. If the clinical symptoms are analyzed along with their connections with focal lesions, one can reach a conclusion that specific neuron groups from specific brain areas play greater part in specific brain activities. Better characterization of a temporal lobe tumor and prediction of prognosis of such a tumor after the appropriate therapy is instituted. It can be accomplished by paying more attention to the symptoms, such as, fits comprising of hallucinations, visual hallucinations, dreamy state, automatism, psychomotor equivalent, temporal lobe epilepsy; changes in personality; disordered mood; schizoform psychosis; parietal mental symptoms; and psycho-organic symptoms. Temporal lobes underlie the temporal bone. The temporal cortex is also termed as temporal lobes. Neurologically, these lobes, right and left respectively, serve as part of the verbal cortex. Apart from this, the temporal lobe handles many other actions necessary for day to day life. This lobe shares borders with occipital and parietal lobes, but the actual boundaries are very difficult to discern. Neural projections from thalamus and cortex enter this lobe. In a patient with left temporal lobe tumor, if one contemplates to predict the damage theoretically, it is necessary that the function of the temporal lobe is known. The functions of the temporal lobe are auditory, helping in the process of hearing and its understanding; ventral visual stream, processing the visual input for presenting it to the visual cortex; visual object recognition and categorization; long-term storage of sensory input; adding inputs and receiving outputs from amygdala that adds affective perspective and emotional significance to sensory inputs; and working hand in hand with hippocampus that generates spatial perspective, that is, allows us to navigate space and remember where the subject is. Functionally, the temporal lobe is divided into two parts, dominant and nondominant. The dominant side is usually the left lobe that conducts perception of words, processing of language as it relates to verbal expressions, sequential analysis, and perception of speech. It is also the centre of intermediate- and long-term memory, complex memory, auditory learning, retrieval of words, and visual and auditory processing (Bernstein, J.H., Prather, P.A., and Rey-Casserly, C., 1995). Focusing our attention to the patient who has been referred for a proven temporal lobe lesion, one can expect any to all of the symptoms that may happen as a result of the left temporal lobe tumor. These symptoms may include, decreased verbal memory for words, lists, or stories; difficulty or inability to place words or pictures in discrete categories; disability to understand the contextual significance of word; internally or externally driven aggressiveness; dark or violent thoughts; sight sensitivity; mild paranoia; problems with word finding; emotional destability; auditory processing problems; and reading difficulties. This patient may as well have temporal lobe personality, that is, they become egocentric, hyper-religious, may have aggressive outbursts, overemphasis on trivial things, and pedantic speech. Emotional instability is a very prominent feature of these patients, and frequently, they experience fluctuations in mood with inconsistency or unpredictability, and their behaviour becomes quite erratic. These have prominent psychosocial implications since mild paranoia or irritation or hypersensitivity to trivial things may cause serious problems in work or social relations. Reading in an efficient manner, remembering what is read, and integrating the knowledge are all very important, and inability to do so puts the person in severe distress if he was habituated to do so. Anger, irritability, and aggressiveness all increase to a considerable extent. All these patients are prone to develop temporal lobe epilepsy with aura and psychomotor seizures. A variety of symptoms may be associated with these seizures, such as, sensory illusions, such as, dj vu, jamais vu, irrational panic or anxiety, periodic confusion, and preoccupation with moral issues (Anastasi, A. 1996). While examining such a patient, the neuropsychologist usually approaches the subject with intent to examine the damage and assess the impairments due to the said left temporal lobe lesion. While evaluating the problem, the neuropsychologist also decides the possible remedy and assess the prognosis of such patients. Clinical neuropsychologist usually assess the patients with one of the three psychological tests. The first of this category is Halsted-Reitan Neuropsychological Battery. This is the most common test performed. This author plans to have brief descriptions of all the tests here and also intends to establish the reasons for selecting a particular test here. In this test, a fixed battery of tests are given to assess broadly the functions which are impaired and which are not. The second method is Luria - Nebraska test that is an assessment technique where there are fixed battery of tests, but there is a hierarchical arrangement of items within each subtest so that the level of impairment of function can be recognized. The third method is a flexible battery approach where a group of tests are picked up for a particular patient. Whatever may be the method, in summary, these tests target to have a comprehensive assessment of cognitive and behavioural functions with the use of a set of standardized procedures. Among many, mainly various mental functions are systematically tested. These are intellect, problem solving and conceptualization, organization and planning, attention and memory, learning and language, academic skills, perceptual and motor abilities, emotions, behaviour, and personality. In this patient, this author decided to use Halsted-Reitan Neuropsychological Battery since this is a comprehensive neuropsychological test battery and may be applied to a patient over age 15 with equal predictability. The score is expressed in terms of one combined score indicating impairment, Halsted impairment index. This predicts the neuronal damage and offers a comprehensive view of the patient's individual neuropsychological functions. This test, according to this examiner, will provide the referring clinician with data for inferring the nature and extent of the structural damage in the brain surrounding the left temporal lesion that may underlie and explain not only the distribution of the impaired function, but also will indicate the intact functions yielded by the qualitative information from the battery. This tests include Category Test, Tactual Performance Test, Seashore Rhythm Test, Speech-Sound Perception Test, Finger Tapping Test, Trail Making Test, Reitan-Indiana Aphasia Screening Test, Reitan-Klove Sensory Perceptual Examination, Strength of Grip Test, and Lateral Dominance Examination. Apart from these, this testing system also regularly employs Wechsler Adult Intelligence Scale (WAIS) and Minnesota Multiphasic Personality Inventory (MMPI) testing. This test is unique and appropriate in this setting of left temporal lobe disorder comprising of an array of possible deficits since it can help the neuropsychologist to have an accurate inferential decision making, level of performance allowing comparison of the individual with normative groups, pattern of performance allowing examination of intra-test performance and subtest scores, pathognomonic signs indicating specific behavioural deficits since this test has high sensitivity towards deviant or deficient performance that in turn points to a specific impairment, and comparison of two sides of the body indicating a lateralized impairment (Grant, I., and Adams, K.M., 1996). The Category Test is administered by visually presenting the subject with seven sets of slides, and he must press one of four levers in response to each slide. This test is related to abstraction, reasoning abilities, and concept formation. Seguin-Goddard Form Board is used to allow the subject to place blocks on the board without using vision, and the subject performs the task with dominant, nondominant, and both hands. The time serves as a score, and their sum gives the Tactual Performance Test (TPT) total time (TPT-T). Then, the subject is asked to recall the shape and location of the blocks yielding TPT-memory (TPT-M) and TPT-localization (TPT-L) scores. TPT measures manual dexterity, spatial memory, and tactile discrimination. The Seashore Rhythm Test (RT) measures non-verbal auditory discrimination as well as attention span and ability to concentrate, and the subject is required to discriminate between 30 pairs of rhythmic beats as eithersame or different. Speech-Sound Perception Test (SSPT) measures attention, verbal auditory discrimination, and auditory-visual integration. These tests usually produce poor performance in left temporal lobe lesion. A set 60 paralogues consisting of nonsense words based on vowel "ee" is played by tape recorder, and the patient is given a printed paper containing 4 alternatives, and he chooses the option which is heard. Finger Tapping Test or Finger Oscillation Test are administered by giving the subject multiple 10-second trials on manual tapping device using the index fingers of the nondominant and dominant hands. This test measures manual dexterity and motor speed. In Trail Making, the subject is asked to connect 25 numbered circles, which are distributed in a random fashion in numeric order. This test measures motor speed, visual scanning, and visual-motor integration. Reitan-Indiana Aphasia Screening Test is a collection of 32 tests where the subject is required to demonstrate abilities of naming, reading, writing, spelling, arithmetic, identifying body parts, identifying and copying shapes. As the name suggests, Reitan-Klove Sensory Perceptual Examination employs both unilateral and bilateral simultaneous stimulation across tactile, visual, and auditory channels; finger localization upon tactile stimulation, finger-tip number writing, and the tactile recognition of shapes. In Strength of Grip Test, the strengths of both dominant and nondominant hands are measured by a standard hand dynamometer. Lateral Dominance Examination tests preference between right and left involving hands, arms, legs, feet, and eyes (It is to be noted that this section would not be repeated in the next patient with stroke for reasons of space and repetition) (Grant, I., and Adams, K.M., 1996). To be honest from the remedial point of view, there is nothing much that a neuropsychologist can do to abolish the neuropsychiatric manifestations of a temporal lobe tumor. If there is apahasia, their treatment will stay on the hands of speech therapist, but this author appreciates the importance of establishment of a baseline neuropsychiatric status of this particular subject in question, since when the therapy of the tumor is employed by the surgeon or the physician, the residual deficit can be assessed again, and in the worst case scenario, the referring physician can be helped to prognosticate the patient's future disabilities post medical or surgical treatment so the adjustments in work, family, and patient's personal life can be done. Case 2: Occipitoparietal damage out of work accident Traumatic brain injury is more than a mere disintegration and derangement of nervous pathways to be labeled posttraumatic encephalopathy. Brain damage of any severity results in major disorganization of the personality with manifestations of overwhelming liabilities and deficits. Gross or subtle agnosic-apraxic disturbances set in. Higher social sensitivities and responsibilities become diminutive with general lapse to a more child- like level and pattern of thought process. There is gross paucity of interest and planning. Mood control is unstable or erratic so that either rebelliousness or passive acceptance of invalidism sets in. There may be a generalized intellectual slump that may progress to gross inability to handle abstract concepts. Psychological tests may reveal loss of intellectual ability to analyze and synthesize. Shifting of concepts or attitudes is hampered. Recent memory defects are manifest. Attention and concentration are impaired, although anxiety of the disease play a vital role in this. Thought process is stereotyped or repetitious. The occipitoparietal cortex subserves many important functions, such as, shifting and maintaining attention; directing eye movements and generating motor plans, both explicit and implicit; using working memory; coding and transforming space in retinotopic input or arm-centred output coordinates, and all these are vital components in many cognitive tasks. There is an array of other functions that might be impaired with damage of the brain in this area. These include motion processing, stereo vision, spatial and nonspatial working memory overlapping with visual attention activation, mental imagery, mental rotation, response inhibition, task switching, alertness, calculation, pain processing, swallowing, and meditation. To summarize this vast range of functions, it may be concluded that this area of the brain mainly associates between attention, visual and spatial representation, working memory, eye movements, and provides guidance for these actions by processing the sensory inputs. Simultaneous visual object recognition is affected since the right dorsal route from the occipitoparietal region to the right supramarginal region via the right angular region and the left ventral route from the left primary visual area to the left occipitotemporal region are involved in this simultaneous visual object recognition. Apart from these, there is possibility of post brain injury mania or depression (Feinberg, T.E.and Farah, M.J.,1997). Neuropsychological testing is mandatory in these cases for assessment of cognitive impairment. This is indicated for assessment of neurocognitive abilities following brain injury, to differentiate between psychogenic and neurogenic syndromes, for assessment of neurocognitive functions to assist in rehabilitations in case of residual or persistent dysfunctions, for prognostications of the illness, for adjustments in work or family, and for assessing progressions or improvements. In case of brain injury like occipitoparietal damage, neuropsychological testing was performed by this author with the intent of establishing a relation between observable deficits in the subject and damage to observable and quantifiable behavioural problems. The systemic testing can provide basic data about disabilities and abilities that are retained, can contribute to appropriate and final diagnosis, and will serve as a guide to clinical management and serve as a baseline for monitoring a change in the clinical status of this patient. As mentioned earlier, this author used Halsted-Reitan Neuropsychological Battery of tests to assess this patient, the details of which have been described earlier in the previous section. Along with that, Wechsler Adult Intelligence Scale (WAIS) and Minnesota Multiphasic Personality Inventory (MMPI) testing were utilized. These tests utilize a set of standard tests, and they are scientifically validated to produce consistent, reliable, and reproducible results. These tests are designed to produce accurate and unbiased analysis of the patient's overt cognitive and behavioural disturbances. The organic deficit that may be evident in occipitoparietal injury may be difficult to evaluate because the extent of anatomic injury is difficult to pinpoint and the extent of dysfunction more difficult to delineate by routine neurologic testing; whereas, accurate information regarding the deficits from a possibility list from the knowledge of involved anatomy, precise data regarding preserved function for treatment planning and disposition for rehabilitation is necessary. Systematic testing with the protocol above may be used to track the subject's progress in rehabilitation, to document the patient's rate of recovery or effectiveness of management or rehabilitation strategy, and can create the stage for patient's recovery sufficient to go back to work (Feinberg, T.E., Roane, D.M., Miner, C.R., et al. 1995). Conclusion: In both these patients, the same set of tests can be applied and interpreted, provided this examiner has enough knowledge of the disease as applied to the respective anatomic lesion. The usual practice is to plan the test after the subject fills up a neurocognitive questionnaire. This examiner could conceptualize the neuroanatomical and neurobehavioural implications of the diagnostic entities in both the patients and was capable of interpreting the test results in view of principles of lateralization and localization of cerebral functions, and this examiner strongly recommends followup neuropsychological testing in the both the patients in 3-month intervals. Reference List Bernstein, J.H., Prather, P.A., and Rey-Casserly, C., (1995). Neuropsychological Assessment In Preoperative And Postoperative Evaluation. Neurosurgical Clinics of North America;6(3):pp.443-454. Anastasi, A. (1996). Psychological Testing. 7th edition. New York, NY: Macmillan. Grant, I., and Adams, K.M., (1996). Neuropsychological Assessment of Neuropsychiatric Disorders. 2nd Ed. New York, NY: Oxford University Press. Feinberg, T.E.and Farah, M.J.,(1997). Behavioral Neurology and Neuropsychology, New York: McGraw-Hill. Feinberg, T.E., Roane, D.M., Miner, C.R., et al. (1995). Neuropsychiatric Evaluation In An Outpatient Setting. Journal of Neuropsychiatry and Clinical Neuroscience.;7(2):pp.145-154. Read More