Hemispheric disconnection syndrome persisting after anterior cerebral artery aneurysm rupture

FMRI of working memory impairment after recovery from subarachnoid hemorrhage

Recovery from aneurysmal subarachnoid hemorrhage (SAH) is often incomplete and accompanied by subtle but persistent cognitive deficits. Previous neuropsychological reports indicate these deficits include most prominently memory impairment, with working memory particularly affected. The neural basis of these memory deficits remains unknown and unexplored by functional magnetic resonance imaging (fMRI). In the present study, patients who experienced (SAH) underwent fMRI during the performance of a verbal working memory paradigm. Behavioral results indicated a subtle but statistically significant impairment relative to healthy subjects in working memory performance accuracy, which was accompanied by relatively increased blood-oxygen level dependent signal in widespread left and right hemisphere cortical areas during periods of encoding, maintenance, and retrieval. Activity increases remained after factoring out inter-individual differences in age and task performance, and included most notably left hemisphere regions associated with phonological loop processing, bilateral sensorimotor regions, and right hemisphere dorsolateral prefrontal cortex. We conclude that deficits in verbal working memory following recovery from (SAH) are accompanied by widespread differences in hemodynamic correlates of neural activity. These differences are discussed with respect to the immediate and delayed focal and global brain damage that can occur following (SAH), and the possibility that this damage induces subcortical disconnection and subsequent decreased efficiency in neural processing.

Conflict of intentions due to callosal disconnection

OBJECTIVES

Three patients with callosal syndrome manifested a peculiar symptom in that they were unable to perform intended whole body actions because another intention emerged in competition with the original one. Attempts were made to clarify the symptomatology of this manifestation and its possible mechanism is discussed.

METHODS

The three patients are described and previous reports on patients with callosal damage were reviewed. Four additional patients with similar symptoms were found and the clinical features common to all seven patients were examined.

RESULTS

This symptom could not be attributed to unilateral movement disorders such as unilateral apraxia, intermanual conflict, or compulsive manipulation of tools. The manifestations included marked hesitation in initiating actions, interruption of actions, repetitive actions, and performance of unintended actions with difficulty in correcting them. All patients, except one, had a lesion in the posterior half of the body of the corpus callosum, and there was no significant involvement of the cerebral cortex. The symptom became manifest later than 4 weeks after callosal damage. It occurred during spontaneous actions, but not during well automated actions nor when following instructions.

CONCLUSION

This symptom, tentatively named "conflict of intentions", can be regarded as a fragment of diagonistic dyspraxia originally described by Akelaitis, although it can occur independently of intermanual conflict. Normally, the right and left cerebral hemispheres may be complementarily modifying automated whole body actions in order to adapt behaviour to changes of the environment as well as to the intention. Partial callosal disconnection without significant cortical involvement would exaggerate the disparity between the role of each hemisphere through the reorganisation of neural systems after callosal damage. Such double, often contrary, behavioural tendencies may sometimes simultaneously enter the patient's awareness.

Alien hand phenomena: a review with the addition of six personal cases

This is a comprehensive literature review of the motor abnormalities that have come to be included under the designation of Alien Hand Phenomena (AHP). Some of the disorders are dyspractic in nature - intermanual conflict, mirror movements, interference etc., while others - groping, grasping with inability to release, utilization etc. are frontal lobe reflexes. AHP are mainly associated with two pathological processes: 1) Infarction or hemorrhage in the territory of the anterior cerebral arteries; and 2) Corticobasal degeneration. Included in the review is a description of AHP in six personal cases of corticobasal degeneration. The summary includes a short discussion of the possible anatomy of 'free will' based on AHP.

Long-term cognitive deficits in patients after surgery on aneurysms of the anterior communicating artery

The long term recovery of a series of 27 patients who had undergone rupture and repair of an aneurysm of the anterior communicating artery was assessed using a number of neuropsychological measures. Testing took place 12 to 84 months post surgery. On the basis of the results from tests of intellect, memory, and conceptual learning, three subgroups of patients were identified: those with persuasive cognitive defects, those with evidence of residual frontal lobe damage and those who showed no evidence of dysfunction. The occurrence of cerebral vasospasm was the most consistent predictor of long term cognitive deficit.

The MR equivalents of cerebral hemispheric disconnection: a telencephalic commissuropathy

Since the original observations of cerebral disconnection in experimental conditions with animal models, the surgical division of the cerebral commissures for control of seizure activity has led to the description of a human hemispheric disconnection syndrome. More recently, MR has revealed a spectrum of conditions of the forebrain responsible for the natural development and acquired occurrence of this unique commissural syndrome. Acutely, nonspecific expressions of disconnection may be observed; however, there are no explicit behavioral manifestations of this syndrome in the chronic state. The signs of stabilized hemispheric disconnection are only elicitable via sophisticated, neuropsychological testing performed by experienced technicians. Included in the present series of callosal pathology were individuals with agenesis, surgical section, infarction, trauma, glioma, and Marchiafava-Bignami disease. On specialized examination, the surgical "split-brain" patients illustrated the classic syndrome of a halt of interhemispheric transfer of information, a block of nondominant hemisphere access to language functions and an inhibition of dominant hemisphere access to superior visuospatial capacity. The nonsurgical subjects with developmental callosal agenesis and acquired pathologic processes involving the callosum revealed a varied, nonspecific reduction in cognitive function most probably related to associated extracallosal hemispheric pathology. No external abnormalities in behavior which could be attributed specifically to the callosal findings were identified chronically, although some progressive diseases suggested the presence of a subacute symptomatic phase of the disconnection syndrome. Any condition which causes the division, destructive insult, or primary ontogenic nondecussation of commissural axons will produce an interference in interhemispheric, interneuronal communication. This is manifested by individual degrees of covert interhemispheric data transfer arrest and of reduced bidirectional dominant-nondominant hemispheric access and telencephalic integrative capacity, consistent with a cerebral commissuropathy. This study reveals the MR equivalents of the hemispheric disconnection syndrome which occur in many nonspecific pathologic conditions of the cerebrum, but which result in few if any overt behavioral aberrations in the stabilized state.