Signs and Symptoms
This is a 68 year old female with difficulty speaking and mid-paralysis of her lower face, right side. Her symptoms have included headaches and nausea for approximately two years and personality changes over past six to 8 months. She displayed problems with expressive language, specifically word generation, slowed rate of speech, and difficulty attempting to write a sentence. No difficulty with receptive language or comprehension was noted. Short term and immediate memory was moderately impaired for verbal information only. She has become irritable, impulsive, and verbally combative with little concern about her behaviors. An increase in intracranial pressure was noted.
Relevance
The patient’s current signs and symptoms in combination with her past history are indicative of a localized brain injury and possibly brain issues that are more generalized as well. Specifically, the sudden onset of paralysis on the lower face on her right side indicates an issue that is localized to the left side of her brain. There are significant expressive language issues and memory problems that appear to be localized to semantic memory. Her irritability, impulsivity, reduced inhibitory functions, and personality changes point to frontal lobe involvement. Her acute memory problems involve deficits in short term and immediate semantic memory (Smith, 2007). The findings of increased intracranial pressure could be reflective of the aftereffects of this recent problem but could also have been present for a longer period and would account for the premorbid headaches, nausea, memory, and personality changes.
Other necessary information
In addition to the neuropsychological findings and medical tests already performed, an MRI and EEG will be necessary to explore evidence of visible damage to the brain. However, a much more detailed family and personal history is necessary to be able to identify pre-morbid issues and the course of her condition to date. Many physical and psychological problems that are related to memory problems, word finding issues, and psychiatric problems seem to be present in families. This includes high blood pressure, obesity, age-related dementias and other heart problems that may result in a stroke.
Areas of the brain involved
Semantic fluency involves retrieval of words from the conceptual or semantic memory and lexical memory. This process involves several areas of the brain that must operate within a limited period. Word retrieval involves the neural and sensorimotor networks that connect the cortical and sub-cortical portions of the brain that decode information stored in long term memory. The development of these networks are developed and adjusted over time and require both functional and structural brain plasticity. These functions involve the left lateral neocortex in the temporal lobe (Lah & Smith, 2013).
However, the frontal lobe, specifically Broca’s area or the ventrolateral prefrontal cortex, is involved with retrieving a limited set of words appropriately and correctly. The process requires planning, judgment, decision-making, and monitoring. Frontal lobe functioning (especially the left frontal cortex) and frontal-subcortical neural pathways are involved in the retrieval process (Lah & Smith, 2013).
Diagnostic considerations
Immediate considerations would include a CVA (stroke) that has damaged the left temporal lobe and adjacent sections of the frontal and parietal lobe that would account for the word retrieval problems, facial paralysis, and behavioral issues. It may also cause or be the result of the increased intracranial pressure noted by the physician.
However, given her age, the behavioral changes, and apparent memory weaknesses displayed prior to this episode, it will be important to consider Alzheimers Disease or other age-related dementia (Wostin, 2004, pg. 925). Parkinson’s and Huntington’s can be ruled out because of the lack phonetic recall. While schizophrenia can produce semantic memory problems, this condition usually becomes evident in late teens and early twenties. There is no evidence of the presence of this condition (Smith, 2007).
If the source of her word finding problems and behavioral issues is damage due to a CVA, she may begin to regain some function with rehabilitation. The brain has the capacity to create new pathways but these are created through relearning, practice, and repetition. Her mood related problems may be permanent as they often are with individuals who have experienced a head injury. However, if she has Alzheimers, her memory and behavioral issues are likely to become more pronounced overtime, extending into her episodic memory functions and more complex frontal lobe activities.
- Lah, S., & Smith, M. Semantic and Episodic Memory in Children With Temporal Lobe Epilepsy: Do They Relate to Literacy Skills?. Neuropsychology,2004
- Smith; Kosslyn. Cognitive Psychology: Mind and Brain. New Jersey: Prentice Hall. pp. 21, 194–199, 2007
- Wostin, P (2004). Can chronic increased intracranial pressure or exposure to repetitive intermittent intracranial pressure elevations raise your risk for Alzheimer’s disease? Medical Hypotheses Volume 62, Issue 6, 2004, Pages 925–930
