BEHAVIOR DISORDER FOLLOWING ANTERIOR CEREBRAL ARTERY OBSTRUCTION

Isnawan Widyayanto

INTRODUCTION Pierre Paul Broca (28 June 1824 9 July 1880) a French physician, surgeon, anatom ist, and anthropologist.

Suggested that certain regions of the brain were responsible for certain functions. His Hypothesis then supported by John Hughlings Jackson, Carl Wernicke, and Korbinian Broadmann

STROKE
Stroke is a form of cardiovascular disease affecting the blood supply to the brain. Also referred to as cerebrovascular disease or apoplexy. In order to function properly, nerve cells within the brain must have a continuous supply of blood, oxygen, and glucose (blood sugar). If this supply is impaired, parts of the brain may stop functioning temporarily. If the impairment is severe, or lasts long enough, brain cells die and permanent damage follows.

Because the movement and functioning of various parts of the body are controlled by these cells, they are affected also.

The symptoms experienced by the patient will

depend on which part of the brain is affected. Thats why important to localize lesion to determine topical diagnosis.

There are two broad categories of stroke:

Hemorrhage and Ischemic

Hemorrhagic strokes are caused by bleeding into
the brain or adjacent tissues.

Ischemic strokes are caused by a lack of blood flow to

the brain and account for about 70 percent of all strokes.

Type : - Atherothrombic stroke - Embolic stroke - Lacunar stroke

ANATOMY : CEREBRAL CIRCULATION

Blood flow to the brain

The territory of the anterior cerebral artery

Includes the whole of the medial aspect of the

frontal

and parietal lobes, as far back as the parietooccipital fissure and the subjacent white matter; genu

corpus callosum; the septum lucidum, anterior pillars of the fornix and part of the anterior commissure; part of the head of the caudate nucleus, the anterior part of the two
and anterior four-fifths of the outer segments of the lenticular nucleus, and the

anterior half of the fore-limb of the internal

capsule.

FRONTAL LOBE

FRONTAL LOBE

FRONTAL LOBE
The frontal lobes are considered our emotional control center and home to our personality. There is no other part of the brain where lesions can cause such a wide variety of symptoms (Kolb & Wishaw, 1990). The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language,

initiation, judgement, impulse control, and social and sexual behavior.

SYNDROMES OF THE ANTERIOR CEREBRAL ARTERY CRURAL MONOPLEGIA (Contralateral lower limb Weakness and Sensory loss) IDEO-MOTOR APRAXIA/ CALLOSAL APRAXIA TRANSCORTICAL MOTOR APHASIA GRASP REFLEX SNOUT REFLEX HEMISPATIAL NEGLECT VISUOCONSTRUCTIVE DISORDER DISEXECUTIVE SYNDROMES AKINETIC MUTISM APHATY ALIEN HAND

Callosal apraxia (CA)

Often concerns the left hand. It is characterized by an inability to correctly perform movements to verbal command with the left hand, contrasting with preserved right-hand movements.

In most spontaneous cases, CA is caused by infarctions in the territory of the anterior cerebral artery.

the the anterior part of corpus callosum is damaged.

In these cases,

Transcortical motor aphasia is characterized

by poor spontaneous speech but good repetition and comprehension. There is a variable naming deficit and the written output is also poor. The localization of lesions is characteristically in the

superior mesial frontal region or the

supplementary speech area in the dominant hemisphere

Damage to the medial frontal lobe tends to reduce initiative, motivation, and spontaneous activity, leading to abulia or, in the acute stage, akinetic mutism (Nagaratnam et al., 2004). Different disturbances of speech (mutism, a tendency to speak in whispers, acquired stuttering) (Hamano et al., 2005; Kakishita et al., 2004)

And motor behavior (perseveration, forced grasp and groping, compulsive motor behavior, intermanual conflicts, alien hand phenomenon) may occur independently of lesion side.

Alien hand

phenomenon and loss of bimanual coordination, involving the right hand, have been described following left ACA infarcts (McNabb et al.,1988)

If the infarct extends to the anterior corpus callosum it may produce disconnection syndromes, the left hand (without access to the left hemisphere verbal information) becomes agraphic, apraxic to verbal commands and anomic to tactile stimuli, while the right hand has no such impairment. However, complete callosal disconnection syndromes are rarely observed following ACA stroke (Bogousslavsky and Regli, 1990).

Hemispatial neglect
is generally defined as a failure to detect and orient to stimuli in the space contralateral to a focal brain lesion (i.e. the contralesional side), which cannot be explained by primary sensory or primary motor disturbances, nor by any general intellectual loss or confusion. Neglect can be apparent in responses to external stimulation as well as during spontaneous behavior. Typically, across a

behave as if a portion of the contralesional space did not exist and could not be conceived any longer.
variety of situations and tasks, these patients

DISEXECUTIVE SYNDROMES The early description of clinical consequences of frontal damage has documented a large variety of behavioral disturbances such as: Abulia, apathy, aspontaneity, akinetic mutism, pseudodepressive state, lack of drive, poor motivation, inattention, indifference, euphoric state, distractibility, impulsivity, disinhibition, irritability, restlessness, moria, pseudopsychopathic state, anosognosia, indifference,confabulation, and perseveration

Akinetic mutism
is also called abulia major, and was formerly called coma vigile. Patients with akinetic mutism appear alert or at least wakeful, because their eyes are open and they have active gaze movements. They are mute and immobile, but they are able to follow the observer or moving objects with their eyes, to whisper a few monosyllables, and to have slow feeble voluntary movements under repetitive stimuli. The patients can answer questions, but otherwise never voluntarily start speaking.

ALIEN HAND
A person with alien hand syndrome can feel normal sensation in the hand and leg, but believes that the hand, while still being a part of their body, behaves in a manner that is totally distinct from the sufferer's normal behavior. They lose the 'sense of agency' associated with the purposeful movement of the limb while retaining a sense of 'ownership' of the limb. They feel that they have no

control over the movements of the 'alien' hand, but that,

instead, the hand has the capability of acting autonomously

TERIMA KASIH