BIOLOGICAL BASIS OF BEHAVIOR
Psychology 321
Spring, 2005 HGH 225
Dr. John M. Morgan MWF, 8am to 9:00
The Temporal Cortex
Monica Wood
PJ Hall
Kathryn E. Martinez
Justin Clarke
Kristen Kelly
Miranda Cook
Introduction
The temporal cortex, also known as the temporal lobes, is
the part of the verbal cortex in the left and right hemispheres
of the brain lying inside the temples. In general the temporal
lobes handle a wide variety of task that are essential to every
day functioning.
Patient him/herself
Monica Wood
The temporal lobes are readily recognizable brain
structures with a thumb like appearance when viewed from the
side. Their name reflects their location beneath the temporal
bone on the side of the head. In some ways, the temporal lobes
are more a convenient fiction than anatomical entities. They
share borders with the occipital and parietal lobes, but the
precise boundaries are not clearly defined by landmarks. A
better definition of the anatomical limits of the temporal lobe
would come from thalamic and intracortical projections and a
functional analysis of the various subunits within the lobe.
Because excision of the anterior temporal lobe is often used to
help control medically intractable seizure disorders, much of
our knowledge of the effects of damage to this area comes from
studies of persons with epilepsy (Encyclopedia of the Human
Brain).
The functions of the temporal lobe are: auditory, ventral
visual stream, processing of auditory input, visual object
recognition and categorization, long term storage of sensory
input, Amygdala (adds affective or emotional tone to sensory
input and memories), and Hippocampus (cells code places in space
and allow us to navigate space and remember where we are)
(www.brain place.com/bp/brain system/temporal.asp).
The temporal lobe is separated into two sides: dominate and
non-dominate. The dominate side of the temporal lobe is usually
the left side and is involved in the perception of words,
processing language related to sounds, sequential analysis,
increased blood flow during speech perception, processing
details, intermediate term memory, long term memory, auditory
learning, retrieval of words, complex memories, and visual and
auditory processing.
A patient who is experiencing dominant temporal lobe
problems may be suffering from one or more of the following
symptoms: decreased verbal memory (words, lists, stories),
difficulty placing words or pictures into discreet categories,
trouble understanding the context of words, aggression;
internally or externally driven, dark or violent thoughts,
sensitivity to slights, mild paranoia, word finding problems,
auditory processing problems, reading difficulties, as well as
emotional instability (www.brain place.com/bp/brain
system/temporal.asp).
The non-dominate side of the temporal lobe is usually the
right side and is involved in perception of melodies,
pitch/prosody, social cues, reading facial expressions,
increased blood flow during tonal memory, decoding vocal
intonation, rhythm, and visual learning. A patient who is
experiencing non-dominate temporal lobe problems may be
suffering from one or more of the following symptoms: difficulty
recognizing facial expressions, difficulty decoding vocal
intonation, implicated in social skill struggles, trouble
processing music, decreased social cues/context, poor visual
imagery, decreased selective attention to visual input, and
decreased recall of nonverbal items-shapes, faces, tunes
(www.brain place.com/bp/brain system/temporal.asp).
Individuals with a temporal lobe tumor or lesion are often
said to have a temporal lobe personality. Aspects of this
particular personality are that they may be more likely to have
aggressive outbursts, overemphasis on trivia, pedantic speech,
egocentric, preoccupation with religion (www.brain
place.com/bp/brain system/temporal.asp).
Research has found that emotional stability is heavily
influenced by the dominant (left side) of the temporal lobe.
Optimal activity in the temporal lobes enhances mood stability,
while increased or decreased activity in this part of the brain
leads to fluctuating, inconsistent or unpredictable moods and
behaviors. An individual who has a tumor or lesion on this side
of the temporal lobe may be moody and often aggressive. The
following is an example of a patient who came to see a doctor
because he was sure he had a temporal lobe problem:
Blain, age 60, had memory problems and was moody and often
aggressive. Blain also frequently saw shadows out of the corner
of his eyes and had an annoying “buzzing” sound in his ear,
which his previous doctor could not find a cause for. “The
temper problems just seem to come out of the blue. The littlest
things seem to set me off. Then I feel terribly guilty,” he
said. When Blain was 5 years old he fell off a porch headfirst
into a pile of bricks. As a schoolboy he had a terrible time
learning to read and he frequently got into fights. His brain
SPECT study showed significant abnormalities in his left
temporal lobe. It was decreased in both the front and back of
the temporal lobe and there was an area of increased activity
deep within the left temporal lobe. Seeing this abnormality, it
was clear to the doctor that many of Blain’s problems came from
the instability of his left temporal lobe, likely from his
childhood accident. Blain was placed on Depakote, an
antiseizure medication known to stabilize activity in the
temporal lobes. When the doctor spoke with Blain three weeks
later he was elated. The buzzing and shadows went away and he
had not lost his temper since he started the medication. He
said, “That was the first time in my life I can remember going
three weeks and not screaming at someone.” Four years later his
temper remains under control (www.brain place.com/bp/brain
system/temporal.asp).
In addition to aggression, individuals with a tumor or
lesion on their left temporal lobe may be more sensitive to
slights and even appear mildly paranoid. Unlike people with
schizophrenia who can become frankly paranoid, temporal lobe
dysfunction often causes a person to think others are talking
about them or laughing at them when there is no evidence for it.
This sensitivity can cause serious relations and work problems
for the individual (www.brain place.com/bp/brain
system/temporal.asp).
Reading and language processing problems are also common
when a tumor or lesion occurs on the left temporal lobe. Being
able to read in an efficient manner, remember what you read and
integrate the new information relies heavily on the dominant
temporal lobe. This is an essential skill in the modern-day
world and can cause sever distress for individuals who are
unable to perform such tasks sufficiently (www.brain
place.com/bp/brain system/temporal.asp).
While a tumor or lesion on the left temporal lobe is more
frequently associated with externally directed discomforts (such
as anger, irritability and aggressiveness), a tumor or lesion on
the right temporal lobe is likely to be associated with internal
discomforts (such as anxiety and fearfulness) (www.brain
place.com/bp/brain system/temporal.asp).
An individual with a tumor or lesion on the non-dominate
temporal lobe is likely to experience social skill trouble,
especially in the areas of reading, recognizing facial
expressions and recognizing voice intonations. The following
illustrates the difficulties experienced by a patient who had a
dysfunction in this part of the brain:
Mike, age 30, came to see the doctor because he wanted a
date. He had never had a date in his life and was very
frustrated by his inability to meet and successfully ask a
woman on a date. During the doctors evaluation Mike said he was
at a loss as to what his problem was. His mother, who was in
the room at the time, had her own ideas as to Mike’s problem.
“Mike“, she said, “misreads situations. He has always done
that. Sometimes he comes on too strong, sometimes he is
withdrawn when another person is interested. He doesn’t read
the sound of my voice right either. I can be really mad at him
and he doesn’t take me seriously. Or he can think I’m mad, when
I’m nowhere near mad.” Mike’s SPECT showed marked decreased
activity in his right temporal lobe; his left temporal lobe was
fine. The intervention that was most effective for Mike was
intensive social skills training. He worked with a psychologist
who coached him on facial expressions, voice tones, and proper
social etiquette. He had his first date 6 months after coming
to the clinic (www.brainplace.com/bp/brain system/temporal.asp).
A tumor or lesion on either or both temporal lobes can
cause a wide variety of other symptoms for an individual as
well, including: abnormal perceptions (sensory illusions),
memory problems, feeling of déjà vu (that you have been
somewhere before even though you haven‘t), jamais vu (not
recognizing familiar places), periods of panic or fear for no
particular reason, periods of confusion, and preoccupation with
religious or moral issues. Unexplained headaches and
stomachaches also seem to be common in temporal lobe
dysfunction. Likewise, temporal lobe epilepsy is common in
individuals who have a tumor or lesion on their temporal lobe
(www.brain place.com/bp/brain system/temporal.asp).
Temporal lobe epilepsy (TLE) is the most common cause of
partial seizures and aura. TLE often begins in childhood.
Repeated TLE seizures can damage the hippocampus, a part of the
brain that is important for memory and learning. Although the
damage progresses very slowly, it is important to treat TLE as
early as possible. Recurrent partial seizures are sometimes
called psychomotor seizures. The term “psychomotor” refer to
the interaction between brain and muscle, and in this case
refers to the twitches and hallucinations that characterize the
seizure. Some people who have partial seizures experience
unusual sensations that warn them that they are about to have a
seizure. This premonitory state is called aura. Aura takes
several different forms: sometimes it is perceived as a sinking
feeling in the pit of the stomach or a sense of “déjà vu”,
sometimes it takes the form of an auditory hallucination, like
an advertising jingle. A person experiencing aura is having a
simple partial seizure without losing consciousness
(http://yourmedicalsource.com/library/epilepsy/EPI_kinds.html).
A tumor or lesion on the temporal lobe is very serious and
can cause severe health concerns. It is important for
individuals who are experiencing any of the before mentioned
symptoms, for no obvious reason, to go see their physician.
For individuals who have a temporal lobe tumor or lesion
and still attend school, the following are some learning hints
to help alleviate the negative side effects of associated with
the dysfunction: In detail oriented classes sit on the left
side of the classroom to process information with the right ear
(information will go preferentially to the right ear and
subsequently left hemisphere). In creative or music classes sit
on the right side of the classroom to process information with
the left ear (information will go preferentially to the left ear
and subsequently right hemisphere).
References
Brain Function And Physiology. Retrieved: April 29, 2005. From:
http://www.brainplace.com/bp/brainsystem/temporal.asp.
Buchtel, Henry A. (2002). Encyclopedia of the Human Brain.
California: Academic Press.
Feldman, Robert S. (2005). Essentials of Understanding
Psychology. New York: McGraw-Hill Co.
Kalat, James W. (2004). Biological Psychology. Canada:
Wadsworth.
Psychological Sequelae: Postconcussion, Frontal Lobe, and
Temporal Lobe Syndromes. Retrieved: May 2, 2005. From:
http://calder.med.miami.edu/pointsis/tbiprov/NEUROPSYCHOLOGY/psy
ch1.html.
Speyrer, John A. Retrieved: May 2, 2005. From: http://primal-
page.com/penfield.htm.
What are the Different Kinds of Epilepsy. Retrieved: May 2,
2005. From:
http://yourmedicalsource.com/library/epilepsy/EPI_kinds.html
Family Member Perspective
PJ Hall
The temporal lobe has several functions. Among these
functions are auditory, memory, and emotional tone to sensory
input. In these ways temporal lobes allow us to not only hear,
but to comprehend what we hear and put it in to the proper
context to effectively remember. (Columbia Encyclopedia, 2005)
Because of the functions of the temporal lobe, someone who
suffers from damage to this area due to either a lesion or tumor
can also suffer from a major change in personality. Drastic
personality changes are one of the primary reasons it can be
difficult to live with a family member who is experiencing
temporal damage. One important role a family member of a person
who suffers from temporal lobe lesions or tumors plays is
helping the person recognize that there is a problem.
Recognizing that there is a problem can be achieved
through understanding the various symptoms associate with
temporal lobe damage. One major area of symptoms deals with the
drastic personality changes. The predominate symptom associated
with personality changes experienced as a result of temporal
damage is an extreme increase in aggression. Other symptoms of
personality changes deal primarily with personal behavior, such
as a change in sexual behavior, and a major shift in general
personality as well as affective behavior. A second major group
of symptoms associated with temporal damage is in the area of
sensation and perception. These symptoms include different
disorders of visual perception, difficulty perceiving auditory
stimuli, and difficulty paying attention to visual and auditory
stimuli. A final group of temporal lobe damage symptoms includes
difficulty with long term memory, as well as problems with
language comprehension and organization and categorization of
verbal material. (“The Temporal Lobe,” 2005) Once symptoms have
been recognized, a family member can assist in testing for
damage.
Personality Changes
As mentioned above, personality changes, particularly
aggressiveness, are a major side effect of damage to the
temporal lobes. Aggression can be described as “a form of
behavior characterized by physical or verbal attack.” (Columbia
Encyclopedia, 2005) This aggressiveness can be expressed either
externally or internally. In other words, some patients with
temporal lobe damage acts out physically towards other people,
while some patients aggressiveness is directed at themselves,
through harsh and violent thoughts or physically hurting
themselves. (Amens, 2005)
Family members of those who suffer from temporal lobe
damage due to lesions or tumors are primarily affected by the
type of aggressiveness directed outward, toward others. One
patient, a thirteen-year old girl named Denise, went to a
neuroscience clinic and was found to have temporal lobe damage
after she had pulled a knife on her mother, as well as having
school problems. According to Dr. Amen, founder of the Amen’s
Clinics, the type of aggression experience by Denise and others
who direct their aggression outward is generally associated with
damage to the right side of the temporal lobe. (Amens, 2005)
Another case study of aggression as a result of temporal lobe
damage is a five year old boy who suffered for twenty-two months
before anyone could exactly pinpoint what was causing his
behavior. Over the twenty-two month period the boy displayed his
aggression through unprovoked screaming fits, and episodic
attacks of rage and violence against other children. It wasn’t
until the boy began complaining frequently about feeling his
skin was on fire, and episodic nonsensical speech, did he
receive a diagnoses of chronic sinus disease. Through treatment
for his sinus diagnosis he received an MRI where doctors found a
large mass on his right temporal lobe. (Nakaji, et. al, 2003)
Although the family members of those with temporal damage
that leads them to inward aggression may not have to deal with
the outburst as described above, inward aggression is as, if not
more, serious. Dr. Amen, reports that sixty-two percent of her
temporal damage patients had suicidal thoughts or actions.
(Amens, 2005)Along with inward aggressiveness, depression is
also prevalent, which may help in explaining the high percentage
of suicidal thoughts or actions as reported by Dr. Amen. In
general depression is characterized by those suffering as having
feelings of despair and sadness, as well as a lack of interest
in activities of previous enjoyment, for an extended period of
time. (Weiten,p.437)Whatever the cause, having close contact
with a person who suffers from depression is never easy. Many
patients who suffer from depression have family members that
report that although they have not physically lost their loved
one, they feel as though they have because the depressed person
lacks characteristics they had before the depression.(National
Institute of Mental Health, 2000)
Treatment is essential in the alleviation of both types of
aggressiveness patients with temporal damage experience. One
common treatment is Depakote. This drug is in the
anticonvulsants drug class, specifically in the category of
valproates. Depakote is a mood stabilizer that is generally
given in the time-release capsule form and is known generically
as divalproex sodium. The most common side effects of this drug
are weight gain, menstrual changes hair loss,
drowsiness/weakness, headache, tremors/shaking, and anemia.
Other more serious side effects include difficulty breathing,
hives/rashes, unusually bleeding or bruising, double vision or
back-and-forth movement of the eyes, liver failure, and
pancreatitis Aside from the major personality changes, such as
those that lead to the use of Depakote, as mentioned above,
temporal lesions or tumors can also result in major difficulties
perceiving stimuli. (Micromedex, 2005)
Perceptual and Learning Changes
Language is one of the major areas of perceptual difficulty
a person with a temporal tumor or lesion may experience.
Depending on what side of the brain the temporal lobe containing
the lesion/tumor is located, it can impact language differently.
For instance, a person who suffers impairment on the right side
of the temporal lobe may result in the loss of the ability to
talk, while the left temporal lobe if damaged may result in
difficulty recognizing words. (Amens, 2005) In general, the
temporal lobe contains an area devoted to auditory processing,
and when damaged can lead to aphasia. Aphasia is defined as “a
sever impairment of language.”(Kalat, p.443)
The Wernicke’s area of the brain is believed to be strongly
associated with language. This area is housed with in the left
temporal lobe, and include part of the supramarginal gyrus, the
angular gyrus,the superior temporal gyrus, and the middle
temporal gyrus. (McPherson, 2005) When damage occurs to the
temporal area containing Wernicke’s area, the patient having
difficultly in comprehending speech, specifically in
understanding spoken words. (Weiten, p.75) This condition is
also sometimes called Wernicke’s aphasia, or fluent aphasia.
Wernicke’s aphasia although still deals with the impairment of
language, specifically is associated with the ability to
continue to speak smoothly. Wernicke’s aphasia also leads to
the inability to comprehend language that is either read or
heard. In addition, those with Wernicke’s aphasia have
difficulty finding the proper words to use when speaking, and
often make up names as substitutes for the names they cannot
remember. (Kalat, p.443)
Difficulty with language can have a profound impact on the
family members of those who suffer from temporal lesions or
tumors because it impairs the patient’s ability to communicate
fully. Communication in general is an essential part of family
functioning, and difficulties with communication can make daily
interactions with the patient a major struggle. As a family
member of someone with aphasia, it is important to recognize
that outside support is available. The National Aphasia
Association is one of the organization geared at helping those
who suffer from aphasia as a result of brain injury. Essentially
the National Aphasia Association, is a non-profit organization
that’s goal is to educate the community about aphasia as well as
research, rehabilitate and provide services to assist those with
aphasia including their families.(National Aphasia Association,
2005) One of the major resources created by the National Aphasia
Association is a book they have created called The Aphasia
Handbook, which is a guide for those who suffer from Aphasia. In
addition to the handbook, the National Aphasia Association has a
website available with a variety of other resources ranging from
a pen-pal program so families of those with aphasia can
communicate, to support groups, and even suggestions for helping
diagnose aphasia.
Memory is another major area difficulty those who suffer
from temporal lobe lesions/tumors experience. The type of memory
most commonly affected by temporal lobe lesions or tumors is
long term memory. Long term member is classified as memories of
events that are not currently taking place, and that are from a
previous time. (Kalat, p291) Problems with long term memory can
be difficult for family members to cope with because like
communication, it impacts the general functioning of the family.
Different types of long-term memory impairment impacts the way a
family copes with such difficulty. How exactly memory is
impaired as a result of a brain tumor/lesion to the temporal
area is influenced by the specific area within the temporal
cortex that is damaged.
One of the major areas leading to memory problems when
damaged is the hippocampus. The hippocampus is named for its
shape, the sea horse, and is one of the oldest parts of he
brain. (McPherson, 2005) Generally, the hippocampus is believed
to contain cells that “code places in space and allow us to
navigate space and remember where we are.” (Amens, 2005)
However, how exactly the hippocampus contributes to memories is
debatable, although multiple theories exist that attempt to
explain the exact contribution of the hippocampus to the
declaration and recall of memories. The data existing regarding
patients, who have memory problems as a result of temporal lobe
damage most, supports the Hippocampus and Declarative Memory
hypothesis. The Declarative Memory hypothesis, as its name
suggests, holds that the hippocampus is essential for
declarative memory, which contains memories that the patient
conveys to others regarding specific instances that have
previously occurred. This type of memory contains single events,
and is known as episodic memory. (Kalat, p398) In addition,
researchers believe that the hippocampus is linked with
“encoding face-name associations, the encoding of events, and
the recall of personal memories in response to smells,” and
possibly even memory consolidation during sleep. (McPherson,
2005)
Coping with the challenges temporal lesions or tumors
present can be difficult for any family. However, seeking help
for problems that are being presented to the individual is only
half the battle, and understanding the classic symptoms is
essential in discovering, and eventually treatment of temporal
damage. Dr. Amen from the Amen’s clinics understands the
challenges of the diagnosis process and puts multiple screens in
place to alleviate some of the difficulty associated with
diagnosis. One of these screens is the way she gathers
background information regarding previous experiences resulting
in brain injury. According to Dr. Amen, many of the patients
don’t even remember that they previously had suffered from brain
injury, and therefore do not suspect they would have a brain
tumor/lesion. (Amens, 2005)
Works Cited
Amens, Daniel (2005) The Temporal Lobes. Retrieved March 24,
2005 from
http://www.brainplace.com/bp/brainsystem/temporal.asp
Columbia Encyclopedia, Sixth Ed. (2005)
Feldman, Robert S. (2005) Remembering: A Phenomenological Study.
IN: Indiana University Press.
Gorfein, David S.; Hoffman, Robert R. (1987) Memory and
Learning: The Ebbinghaus Centennial Conference. Hillsdale:
Larence Erlbaum Associates, Inc.
Human Memory. n.d. Retrieved April 22, 2005, from
http://www.cc.gatech.edu/classes/6751_97_winter/Topics/huma
n-cap/memory.html
Kalat, James W. (2004) Biological Psychology.(8th ed.) Belmont:
Wadsworth
McPherson, Fiona. (2005) About Memory. Retrieved April 3, 2005
from http://www.memory-key.com/MemoryGuide/glossary-
brain.htm
Micromedex Corp. (2005) Depakote. Retrieved on May 1, 2005 from
http://www.drugs.com/depakote.html
Nakaji, Peter; et. al. (2003) Improvement of Aggressive and
Anitsocial Behavior After Resection of Temporal Lobe Tumors
[Electronic version]. Pediatrics, 121
National Institute of Mental Health (2000) Depression. Retrieved
on May 4, 2005 from
http://www.nimh.nih.gov.punlicat.depression.cfm#ptdep1
The Temporal Lobe. N.D. Retrieved March 25, 2005 from
http://www.wfu.edu/users/perrtk2/temporallobepage.htm
Weiten, Wayne. (2002). Psychology: Themes and Variations.
(5th ed.) Belmont: Wadsworth
Employer/Social Worker
Kathryn E. Martinez
Going Home after a brain tumor or lesion can be exciting,
joyous, and fearful for the whole family. It can be hard to
leave the security of your doctors and nurses, even though they
are only a phone call away. Luckily social services can help
homecoming along with the many laws protecting people with
disabilities.
Employment
The workforce includes many individuals with psychiatric
disabilities who face employment discrimination because their
disabilities are stigmatized or misunderstood. Congress
intended Title I of the Americans with Disabilities Act (ADA)
(1990) to combat such employment discrimination as well as the
myths, fears, and stereotypes upon which it is based. The Equal
Employment Opportunity Commission ("EEOC" or
"Commission")(2005)receives a large number of charges under the
ADA alleging employment discrimination based on psychiatric
disability. These charges raise a wide array of legal issues
including, for example, whether an individual has a psychiatric
disability as defined by the ADA and whether an employer may ask
about an individual's psychiatric disability. People with
psychiatric disabilities and employers also have posed numerous
questions to the EEOC about this topic. The purpose of the ADA
is to: (1) provide a clear and comprehensive national mandate
for the elimination of discrimination against individuals with
disabilities; (2) provide a clear, strong, consistent,
enforceable standard addressing discrimination against
individuals with disabilities; (3) ensure that the Federal
Government plays a central role in enforcing the standards
established in this chapter on behalf of individuals with
disabilities; and (4) invoke the sweep of congressional
authority, including the power to enforce the fourteenth
amendment and to regulate commerce, in order to address the
major areas of discrimination faced day to day by people with
disabilities.
The first employment lawsuit filed under the Americans with
Disabilities Act of 1990 (ADA) was on behalf of a brain tumor
survivor. In July 1992, Charles L. Wessel, Executive Director of
AIC Security Investigations, was fired with one day’s notice
after telling his company he had inoperable brain metastases
from lung cancer. The Chicago-based company’s owner told Mr.
Wessel that his position had been eliminated. On November 5,
1992, the EEOC filed this first federal ADA “test case” with
their Chicago district office. The EEOC claimed Mr. Wessel was
able to perform the essential functions of his role of executive
director and that his firing violated Title I of the ADA. EEOC
lawyers described the case as “a classic example of the type of
discrimination” the ADA was intended to prevent. On March 18,
1993, the Chicago jury awarded Mr. Wessel $22,000 in back pay,
$50,000 in compensatory damages, $250,000 in punitive damages
against AIC, and $250,000 in punitive damages against the
company owner. The court later reduced the punitive damage
awards the jury had made because they exceeded the amount
allowed.
Insurance
The Brain Tumor Foundation (2005) explains the employment issues
faced by brain tumor patients in their article The Truth About
Insurance Companies and HMOs. Insurance is based on a simple
concept: the many help the few. The many employers pay premiums
to the company which establishes a cash reserve. The cash
reserves are used to settle claims from the few. There is an
administrative cost and everything left over is profit. The goal
of most health insurance companies is to make a profit. Profits
are made by collecting more in insurance premiums than they pay
out in administrative costs, dividends and, oh yes, the
settlement of claims. Insurers look at money the employer has
faithfully paid them in monthly premiums as their money, which
they begrudgingly have to pay out from time to time to settle a
claim. Patients expect good service from the doctor. Their
employer has been paying for good service in the form of hefty
insurance premiums each year while they've been healthy.
However, delay on the payment of claims means that reserves
drawing interest or earning money in investments can earn more
money for just a little bit longer. Sometimes the "red tape"
involved in getting a claim settled discourages the enrollee
bringing the claim altogether. That's good news for the
insurance company; it's one less claim they have to pay out. The
longer the company can hold off paying a claim as it waits for
further information, proper documentation, internal review by
the "medical director", fee negotiations, computer glitch
repairs, etc., the more interest the undisturbed capital
reserves earn. The more paperwork an insurance company insists
on having completed prior to processing a claim, the greater
number of possibilities for claim payment delay or claim denial.
Employers get sick and tired of paying what they consider to be
huge premiums to insurance companies. These costs get passed on
to employees and result in higher prices for their goods and
services. Brain tumor and lesion patients expect health
insurance from their employers. U.S. employers are "stuck". By
subscribing to a Managed Care Plan, an employer can give the
illusion of providing health insurance to employees while saving
significant money. The employees won't know the difference until
they get some serious disease. They then find out that one gets
what one pays for.
School Issues
The Children’s Brain Tumor Foundation (2005) provides
information on three main federal laws that may apply to
children returning to school who have or had a brain tumor or
lesion. The first is the Individuals With Disabilities Education
Act (IDEA), which applies to all public schools and to children
with specified disabilities or special needs. A child with a
brain tumor might be classified as having “traumatic brain
injury” or other health impairment, which adversely affect their
performance. All children are entitled to an evaluation,
resulting in an “Individualized Education Plan” (IEP), detailing
the child’s needs and accommodations the school will make. The
second is Section 504 of the Rehabilitation Act of 1973 (Section
504). Section 504 applies to schools receiving federal funds,
public or private. It prohibits discrimination against a child
or individual with disabilities, and a child with special needs
is entitled to appropriate education with accommodations. Early
intervention programs entitle children up to age three, who are
experiencing life threatening illness and treatments to free
services such as physical and occupational therapy, speech
therapy, and special instruction. The family may be entitled to
services as well. Following assessment, the early intervention
team will develop an Individualized Family Service Plan (IFSP)
with the parent or guardian. The third is the American with
Disabilities Act (ADA, passed in 1990. ADA is the most general
of the federal laws. While it does not deal directly with
schools or children’s educational needs, it may help in
guaranteeing that a child gets the required support.
The effects of a tumor or lesion may compromise cognitive and/or
sensory functions, resulting in learning difficulties. Special
education services may be appropriate for children whose
treatment interferes with education and learning. Many children
can continue to attend school while they are in treatment. Some
medical centers provide an “education team” who can help prepare
the child’s class for the child’s return. Social workers working
with the child and classmates can ensure that the child is
treated as normally as possible. They can also help educate
teachers about the consequences or side effects of the child’s
treatment and disease. The following accommodations in school
may be needed: wheel chair accessibility for classroom and
toilet facilities, special bathroom privileges, playground or
gym exemptions or adaptations, opportunities to rest, classroom
seating arrangements for hearing, vision or attention problems,
homework and test modifications because extra time may be
needed, and arrangements to take medications during the day.
The Association of Oncology Social Work (AOSW)
Oncology social work is the primary professional discipline that
provides psychosocial services to patients, families and
significant others facing the impact of brain tumors or lesions.
The Association of Oncology Social Work (AOSW) (2005) is a non-
profit, international organization dedicated to the enhancement
of psychosocial services to people with brain tumors or lesions.
Created in 1984 by social workers interested in oncology and by
existing national cancer organizations, AOSW is an expanding
force of psychosocial oncology professionals. The scope of
oncology social work includes clinical practice, education,
administration and research. The Masters in Social Work degree
provides oncology social workers with theoretical knowledge,
clinical expertise and practical experience with patients. In
addition, oncology social workers often receive specialized
training in cancer care through continuing education, in service
training and on the job experience. The AOSW’s mission is to
advance excellence in the psychosocial care of persons with
tumors or lesions, their families, and caregivers through:
networking, education, advocacy, research, and research
development.
Psychosocial services provided by oncology social workers
include individual, family and group counseling, education,
advocacy, discharge planning, case management and program
development. These services are designed to maximize the
patient's utilization of the health care system, foster coping,
and mobilize community resources in order to support optimal
functioning. Oncology social work services are available to
patients and families throughout all phases of the continuum,
including prevention, diagnosis, survivorship, terminal care,
and bereavement. Services are delivered in a wide variety of
settings including specialty cancer centers, general hospitals
and health systems, ambulatory centers, home health and hospice
programs, community based agencies, and private practice
settings. Oncology social workers are an integral part of the
health care team and contribute to the development and
coordination of the overall treatment plan. In addition to
services to patients and families, oncology social workers
address organizational and community needs through professional
practice. Services are provided to institutions, voluntary
health organizations, and community agencies with the overall
aim of promoting health and improving the delivery of care to
individuals at risk for or affected by cancer.
Coping
There are many organizations for brain tumor patients and their
families that provide up to date educational information about
this multi faceted disease. One of the most beneficial programs
of The Brain Tumor Society (2005) has been the one t one support
provided to thousands of patients and their families. Through a
toll free telephone line support is given to callers to help
them make informed decisions about treatment and help them
regain a sense of control, which is so often lost under the
circumstances. Bereavement support, including information about
the late stages of the illness, is available to families facing
the loss of a loved one. Because long term survivors represent
an ever growing number of The Brain Tumor Society’s callers,
they have developed resources where none existed before,
including long term survivorship stories in their newsletter,
survivorship panels at their conferences, and articles
addressing some of the ongoing and unresolved concerns of this
group.
The Brain Tumor Society (2005), American Brain Tumor Association
(2005), Acoustic Neuroma Association (2005), and the Brain Tumor
Foundation for Children Inc.(2005) to name a few all provide
support groups. These groups address all the associated features
of this life threatening disease and problems it may cause with
memory, perception, behavior, personality, and overall health.
Often, affected persons have played a pivotal family role.
Sometimes the illness necessitates an immediate shift in family
roles without allowing time for negotiation. Experience has
shown that providing information and education, as well as
psychological support and advocacy, helps patients and families
cope with the ongoing situation. A group setting led by a social
worker offers a ready made support network and furthers the
chances that others will have shared one’s particular
experience. For those who are currently homebound, alternatives
to group meetings include patient/family telephone networks and
computer-based support groups such as BRAINTMR or a chat room on
the Internet.
References:
(2005). Support Groups. Retrieved April 25, 2005, from
Acoustic Neuroma Association. http://www.anausa.org.
(2005). Care And Support. Retrieved April 25, 2005, from
American Brain Tumor Association. http://www.abta.org.
(2005). Mission & Positions. Retrieved May 1, 2005, from
Association Of Oncology Social Work. http://www.aosw.org.
(2005). Support Programs. Retrieved April 25,2005, from
Brain Tumor Foundation for Children, Inc.
http://www.brfcgainc.org.
(2005). School Issues. Retrieved April 25, 2005, from
Children’s Brain Tumor Foundation. http://www.cbtf.org.
(2005). The Truth About Insurance Companies and HMOs.
Retrieved May 3, 2005, from The Brain Tumor Foundation.
http://www.braintumorfoundation.org.
(2005). Employment and Financial Issues. Retrieved April
25, 2005, from The Brain Tumor Society.
http://www.tbts.org.
(2001). EEOC Enforcement Guidance on the Americans with
Disabilities Act and Psychiatric Disabilities. Retrieved
May 2, 2005, from U.S. Equal Employment Opportunity
Comission. http://www.eeoc.gov.
Justin Clarke
Perspective from a Neuropsychologist
Emphasis on the Temporal Lobe and its Effects on Language
My paper has to due with the duties of a Neuropsychologists
when examining damage or abnomalities to the Temporal lobe of
the human brain and the various impairments that can happen to
language. The temporal lobe is a vital area of the brain for
many of the humans abilities such as memory and auditory
processing, an also language. The neuropsychologist
responsibility is for evaluating problems in this area when
dealing with a client and implementing therapy solutions. Also
the duties of a neuropsychologist are in the aspects of research
and developing tools to assist people with temporal lobe
malfunctions and other areas of the body too. This paper will
delve into these functions of a neuropsychologist and how the
practitioner uses these tools to assist people with the various
afflictions that arise from problems in the human temporal lobe.
A pivotal area of the temporal lobe and language comprehension
is the Wernike’s area. When theirs damage to this section of the
brain a condition related to language problems is known as
Wernike’s Aphasia. Aphasia is known as a severe language
impairment but with this version the person is still able to
speak fluently but are unable to comprehend written and spoken
language. (Kalat, 2005) The principal signs of aphasia are
impairments in the ability to express oneself when speaking,
trouble understanding speech, and difficulty with reading and
writing. Aphasia is most often the result of stroke or head
injury, but can also occur in other neurological disorders, such
as brain tumor or Alzheimer's disease. The effects of aphasia
differ from person to person, and can sometimes benefit from
speech therapy. (Aphasia.org, 2005)
Neuropsychologists have extensive training in the anatomy,
physiology, and pathology of the nervous system so when
examining a patient with symptoms dealing with aphasia a battery
of tests are performed. Clinical neuropsychologists evaluate
patients using one of three general methods. The first method is
to use an assessment technique in which a fixed battery of tests
is given and in which we only want to know what functions are
impaired and what functions are not impaired. The most commonly
used representative of this type of test is the Halstead -
Reitan Neuropsychological Battery. The second method is to use
an assessment technique in which a fixed battery of tests is
given but in this method there is a hierarchical arrangement of
items within each subtest so that if a function is impaired, the
level at which it is impaired can be determined. The most common
representative of this type of test is the Luria - Nebraska.
Common to both of these tests is a long history of research
studies examining the ability of the two batteries to measure
dysfunction of the brain and to accurately identify why that
dysfunction is occurring. The third method used by
neuropsychologists is the flexible battery approach. By
definition, the flexible approach is not a battery because when
one uses this approach one gives a group of tests allegedly
picked for just the particular patient. (Appel, 2005) A
neuropsychological evaluation is a comprehensive assessment of
cognitive and behavioral functions using a set of standardized
tests and procedures. Various mental functions are
systematically tested, including, but not limited to:
· Intelligence
· Problem solving and conceptualization
· Planning and organization
· Attention, memory, and learning
· Language
· Academic skills
· Perceptual and motor abilities
· Emotions, behavior, and personality (Aphasia.org, 2005)
In the Wierneke’s area problems with language related to
Aphasia has been found to be most detrimental when the damage is
focused on the left temporal lobe. This side of the brain is
highly correlated with language and comprehension, more so than
its counterpart on the right side. Right handed people process
most basic language tasks in the left brain area, making recover
of language effecting the left hemisphere more difficult for
right-handed people. One limitation to this idea is the exact
definition of the Wierneke’s area, which is not as widely agreed
upon as the Broca’s area. The most common definition is the
posterior third of the superior temporal gyrus is the location
of the Wierneke’s area and the when damaged is the cause of
Wierneke’s Aphasia. However there is evidence that a lesion
restricted to this area does not elicit permanent symptoms of
Wierneke’s Aphasia, and that a wider lesion is needed. (Martin,
2003) Patients have been reported having symptoms of Wierneke’s
Aphasia but the lesions are outside of the Wierneke’s area.
(Martin, 2003)
There is little treatment by neuropsychologists in regards
to aphasia. The disorder can be treated using speech therapy,
but it depends on the severity of the condition. The
neuropsychologist is really only responsible for diagnosing the
problems or for coming up with methods for diagnosing and
evaluating the various complexities of a disorder like aphasia.
Neuropsychologists are responsible for evaluating aphasia,
which is derived very commonly from people who have a stroke.
Each year 3/4 of a million people suffer a temporary loss of
blood flow to the brain, known as an ischemic stroke.
(NewsRX.com, 2005) This results in damage to the left temporal
lobe and effects the person’s ability of speech and language.
Many people recover the majority of their language abilities
within six to twelve months of their recovery. Not all aphasia
diagnosis are a result of stroke, so in some cases recovery is
not an option, and this can even be true with strokes too.
Another predominate disorder treated by neuropsychologists
is temporal lobe epilepsy. A lesion known as the mesial
temporal sclerosis is the most commonly found lesion with this
disabilitating condition. This lesion is associated with the
severe and complicated febrile convulsions that are experienced
with young children. (BMA, 2003) I personally work with a young
man who suffers from this disabilitating illness, and I see
first hand the complications this condition has with his ability
to process and articulate language. Neuropsychologists monitor
his frequency, severity, and the overall toll these seizures
have on his health. His speech has slowly deteriated over the
years causing him to barely be able to utter complete sentences
and to only be able to comprehend very simple commands and
statements. This illness has slowly stolen the ability for him
to function on any substantial level of language and oratory
skills. The neuropsychologists in his case have been really
unsuccessful in alleviating any of the symptoms of the
continually compounding illness.
There have been devices devised by neuropsychologists and
other professionals. The tool that they used on my cohort was a
implant in his chest that signaled and stimulated an implant in
his temporal lobe to help circumvent the buildup of tension or
electrical causes that elicit a seizure. The neuropsychologists
are responsible for monitoring its effects and maintaining the
rate of activation (which stimulates him at a certain rate).
However with my client’s condition and the condition of many
others, there is only so much that a professional can due with
illnesses that affect people’s temporal lobe and other areas of
the brain. Unfortunately my client’s condition has not improved
from the help of these professionals, and treatments for him are
almost to a stand still or non-existent.
Works Cited
Aphasia.org (2005). Introduction to Aphasia. Retrieved May
2,2005. From Aphasia.org.
Appel, A. (1997) What is a Neuropsychologist. Retrieved April
23, 2005. From tbidoc.com.
British Medical Association. (2003). Mesial temporal sclerosis
lobe epilepsy. Retrieved April 24, 2005. From
WWW.info-trac.com.
Kalat, J. (2004). Biological Psychology. 8Th edition, Chapter
15.3.
Martin, R.C. (2003). Language processing: functional
organization and neuroanatomical. Annual Review of Psychology.
Annual 2003 p55(35).
NewsRX. (2001). Area of Language Recovery in Brain Imaged.
Pain & Central Nervous System Week. Jan 13, 2001 p14.
Kristen Kelley
The Neurologist
Language is a vital part of both verbal and non-verbal
communication. Each of us uses language everyday in a variety of
ways. When our language skills are in jeopardy, it can affect
our entire lives. The consequences of a loss of language can be
more restricting then that of loss of sight or hearing.
Communication is a matter of survival and independence, without
it ones life will change drastically.
There is almost complete agreement that there are four main
language areas in the left cerebral hemisphere of most people.
Two of these areas are considered receptive while the other two
carry out the actual task. These two receptive areas take on
very different tasks, one involving the perception of written
language and the other of spoken language. The area that helps
to regulate written language is located in the angular gyrus,
while the other occupies the Heschl’s gyri.
Although language and speech are usually considered
synonymous functions, this is not the case in all aspects of
their roles. Unlike an impairment of speech, language impairment
always occurs due to an abnormality of the cerebral hemisphere.
Speech on the other hand may be effected by the same sort of
abnormality but it also can be effected by damage to other parts
of the brain.
Loss of communication and language can be a result of
damage to the temporal lobe of the brain. The type of language
loss is dependent of what specific area of the temporal lobe has
been damaged. Possible types of damage to the brain can be a
lesion or a tumor. It is the job of the neurologist to locate
the area of damage and to assess the level of impairment.
Neurologist use a variety of test to asses the possible damage
to the brain or spinal cord including CAT scans, Magnetic
Resonance Imaging (MRI) and a wide variety of functional, skill
assessments. One of the most popular verbal memory assessments
used in the field is the Wechsler Memory Scale, the most
recently revised version has been a useful tool for neurologist
to determine severity and location of the temporal damage.
One of the first signs of a lesion to the temporal lobe is
a change in behavior. Behavior changes can vary dependant on the
injured area. When the change in behavior is analyzed in
conjunction with skill assessments the Neurologist can make
rather accurate predictions about the area of the temporal lobe
that is effected by a lesion.
When the Anterior Temporal Lobe has been injured, very
specific behaviors are prevalent in the patient. Such behaviors
are auditory memory disturbance, auditory and/or visual
hallucinations and difficulty with short-term auditory memory. A
neurologist is also able to pin point possible points of injury
in the anterior temporal lobe by specific behavior changes. For
instance, if the left side of the anterior is damaged the
patient may display difficulty with the learning and retention
of verbal material presented to them. This same patient though
will be able to retain information about places, faces and
melodies. Impairment of these skills are an indication of a
lesion on the right anterior temporal lobe. Neurologist will
also seek out information regarding the patients recent social
judgement, and conduct memory assessments verbally, visually and
auditory to make a proper assessment.
Since the temporal lobes are involved in the primary
organization of sensory input (Read, 1981) individuals with
temporal lobes lesions may have a difficult time placing words
or pictures into their correct categories.
Frequently temporal lobe lesions also effect ones verbal
language. Left temporal lesions impair recognition of words
while right temporal damage can cause a loss of verbal skills
and verbal cognition. While visual impairments are also noticed
the diminished verbal skills are more common.
Middle temporal lobe lesions will show different changes in
ones behavior and language memory as well as use. When a patient
suffers a middle temporal lesion, they are still able to
comprehend individual words, but have a very difficult time
retaining two or more at a time. In addition, patients suffering
from a lesion in this area of the temporal lobe cannot retain
series of syllables or words. The above disorder is called
Acoustico-mnestic disorder. In mild cases of mid-temporal
lesions, the patient suffering may be able to retain elements of
word series but not remember what order they belong. For all
patients stressful situations cause a further difficulty with
reproduction of word and word series. Phonemic learning is an
area of language not effected by mid-temporal damage.
One of the most important discoveries in the understanding
of the behavior changes associated with temporal lobe lesions
was Carl Wernickes aphasia. The aphasia syndrome discovered by
Wernicke in the early nineteen hundreds was a huge breakthrough
for neuroscience. As Wernicke explained, the aphasia syndrome,
which is caused by a lesion to the now called Wernicke area,
will cause dramatic behavior changes pertaining to language in
patients. The Wernicke area is located right at the tempro-
parietal junction, which is where the temporal lobe and the
parietal lobe join.
The aphasia syndrome consists of much impairment of both
verbal and now verbal language. Not only is the verbal aspect
impaired but the comprehension of language has also been
effected. A neurologist will notice impairments of comprehension
of spoken language meaning that the patient will have a
difficult time understanding what is being said in his or her
surrounding, or even directly to them. Other compromised skill
would be that of reading silently and writing.
A lesion in this area of the temporal lobe also impairs
articulate speech. The affected persons may speak fluently with
a natural language rhythm, but the result has neither
understandable meaning nor syntax. A way to assess this skill
would be simply to ask the patient to describe a picture they
are given. The patient will quickly be able to start verbalizing
but the context of their words will not be applicable to the
situation. Despite the loss of comprehension, the word memory is
preserved and words are frequently chosen correctly.
Another result of a lesion to Wernickes area that has been
noticed in some patients is euphoria and/or paranoia. This
specific aspect of the disorder can be attributed to a cortical
lesion in the posterior portion of the left first temporal
convolution.
Any damage to the temporal lobe will carry with it a high
probability of diminished language and memory skills. Each
patient will display behavior changes that will lead to a change
in lifestyle and both verbal language as well as comprehension.
Lesions to different area of the brain will effect each patient
differently. Some again may show very few verbal skills after a
lesion has occurred while others are able to speak freely but
with little of it being coherent. The temporal lobe is a very
vital part to our communication and any damage to it is life
altering.
Works Cited
Read, D. (1981) Solving deductive-reasoning problems after
unilateral temporal lobectomy. Brain and Language.
Milner, B. (1968) Visual recognition and recall after right
temporal lobe excision in man. Neuropsychologia
Queensland Health
www.health.qld.gov.au
Long, CJ Neuropsychology and Behavioral Neuroscience
www.neuro.psyc.memphis.edu/neuropsyc
Kalat,J.W.(1998) Biological Psychology
Sixth Edition, Brooks Cole Publishing
Miranda Cook
The Neurosurgeon
The temporal lobe comprises all the tissue that lies below
the Sylvian fissure and anterior to the occipital and parietal
cortex. The temporal regions can be divided on the lateral
surface into those that are auditory (Brodmann’s area) and those
that form the ventral visual stream on the lateral temporal
lobe. The visual regions are referred to as either
inferotemporal cortex or by von Bonin and Bailey’s designation,
TE. The sulci of the temporal lobe contains most of the cortex.
The superior temporal sulcus (STS) which separates the superior
and middle temporal gyri can be divided into many sub regions.
It receives input from auditory, visual, and somatic regions as
well as the frontal and parietal regions and the paralimbic
cortex. The medial temporal region includes the hippocampus
(and surrounding cortex) and the fusiform gyrus. The posterior
end of the temporal lobe is referred to as the parahippocampal
cortex and includes areas known as TH and TF. The fusiform
gyrus and interior temporal gyrus are part of the lateral
temporal cortex. The uncus refers to the anterior extension of
the hippocampus. The hippocampus, as well as the amygdala, are
buried deep within the temporal lobe.
The temporal lobes have many internal connections which
project to the sensory systems, to the parietal and frontal
regions, to the limbic system, and to the basal ganglia. The
neocortex of the left and right lobes is connected to the
archicortex. Studies have demonstrated four projection pathways
of information in the temporal lobe which each form separate
functions. First, auditory and visual information processes
from the primary regions ending in the temporal pole form the
ventral stream of visual processing. Its function is thought to
be stimulus recognition. Second, auditory, visual, and somatic
project into the superior temporal sulcus whose function is
stimulus categorization. Third, auditory and visual information
is projected to the medial temporal regions including the
hippocampus (called the preforant pathway) and the amygdale.
This pathway is crucial to long term memory. Fourth auditory
and visual information goes to the area of the frontal lobe
which is necessary for various aspects of movement, control,
short term memory, and affect.
Three basic functions of the temporal cortex are known: the
processing of auditory input, visual object recognition, and
long-term memory storage of sensory input. This implies that
damage to the temporal cortex leads to deficits in identifying
and categorizing stimuli. The amydgala functions to exhibit
affective response such as associating positive, negative, or
neutral stimuli. The hippocampus functions to allow us to
navigate space and remember where we are. Considering these
functions of the temporal lobe, the loss of these functions
would have devastating consequences for behavior.
Temporal damage causes eight different symptoms associated
with different parts of the temporal lobe: (1) damage to
Brodmann’s Areas causes disturbance of auditory sensation and
perception, (2) damage to Areas TE and STS cause disturbance of
selective attention of auditory and visual input, (3) damage to
Areas TE, STS, and amygdale cause disorders of visual
perception, (4) damage to TE and STS cause impaired organization
and categorization of verbal material, (5) damage to Brodmann’s
area 22 cause disturbance of language comprehension, (6) damage
to areas TE, TF, TH, and Brodmann’s area 28 cause impaired long-
term memory and amnesia, (7) damage to TE and amygdale cause
altered personality and behavior, and (8) damage to amygdala
(plus other unknown areas) cause altered sexual behavior.
Studies done by Milner and her colleagues show specific
effects of the left and right temporal lobes which revealed that
specific memory defects vary according to the side the lesion is
on. Damage to the left temporal lobe is associated with
deficits in verbal memory such as processing speech sounds and
damage to the right temporal lobe is associated with deficits in
nonverbal such as processing music. In addition the left and
right temporal lobes are associated with behavior. Observations
show that left and right temporal lobe lesions appear to have
different effects on personality and that only right temporal
lesions lead to impairments in interpretations of facial
expressions.
In reviewing studies, bilateral temporal lobe removal
produces more dramatic effects than unilateral temporal lobotomy
which shows that although the temporal lobes have different
functions, they often overlap.
Sometimes neurosurgeons perform a temporal lobotomy to
intentionally remove parts of the temporal cortex for patients
with medically intractable epilepsy. Epilepsy is defined as a
condition of recurrent seizures. Patients with temporal lobe
epilepsy require surgical resection of a lesion in the temporal
lobe. The goal of temporal epilepsy surgery is to identify an
abnormal area and remove it without causing any significant
functional impairment.
A variety of strategies are used to optimize surgical
resection while minimizing risk of injury to functional cortex.
Magnetic resonance imaging (MRI) can detect abnormalities of the
brain with exceptional anatomical detail by creating a model of
an individual's brain. The use of an electroencephalograph (EEG)
can provide evidence of focal electrical dysfunction. For
example, intracerebral depth electrodes can be placed through
small holes in the skull and secured with some form of cranial
fixation. Electrodes are targeted towards the amygdala or
hippocampus and can locate a focal area of seizure.
Neuropsychological testing and psychosocial assessment along
with the MRI and EEG provide the most favorable results for
patients
The typical temporal lobectomy always includes the anterior
temporal cortex, and, in some neurosurgeries, the amygdala and
varying amounts of the hippocampus and parahippocampal gyrus are
also removed. The extent of excision from the hippocampal
region is often individually based either because of the
presence of documented abnormalities or because of the risk of
memory damage. The severity of memory deficits is dependent
upon how much of the hippocampus region in removed. Such
decisions are based on the surgeon’s drawings and report at the
time of the operation.
Precise identification of anatomy allows the surgeon to
navigate to the amygdala, hippocampus, or gyrus. The amygdala
projects into the anterior aspect of the temporal and is
connected to the hippocampus. Careful dissection of the amygdala
will avoid postoperative memory deficits. The amygdala is not
well defined because it blends with the white matter. The
amygdala has a grayish hue and care must be taken in resecting
lesions in the superior portion. The hippocampus can be easily
distinguished from the other structures by its shiny white
color.
The use of neurosurgical navigational systems is becoming
more popular as the technology advances. These systems are
especially helpful in the resection of deep-seated lesions.
Anatomical landmarks are used to guide dissection to the
location of interest. The advantage is that resection of
temporal neocortex is not necessary. The pathway to the temporal
structures through this approach is relatively straight and
short, with minimal dissection.
The majority of temporal lobectomies are safely performed
under general anesthesia. The patient is positioned on the
operating table with the head fixed by a three-point Mayfield
holder. A skin incision is made behind the hair line. Temporal
lobe removals usually extend back 4.5 - 5 cm. but can extend
beyond 7 or 8 cm.
Much research has been done on the temporal lobes in
relation to memory and seizures including the famous
observations in the 1950’s of the patient known as H.M. who had
undergone bilateral medial temporal lobe removal to treat severe
epileptic seizures. The resection extended 8 cm along the
medial surface of both temporal lobes, destroying the amygdala,
the uncus, and the anterior two-thirds of the hippocampus and
the parahippocampal gyrus, but spared the lateral neocortex.
H.M.’s surgery was successful in treating his seizures but
manifested severe anterograde and retrograde amnesia.
More recent clinical data shows that lesional surgery for
the treatment of temporal lobe epilepsy is less detrimental.
With modern imaging techniques, surgery in the temporal lobe
offers well to excellent results in 75 - 85% of the cases and
seizure free rates are now approaching 90%. A few examples are
worth noting:
A patient suffering from seizures showed a small lesion of
the left parahippocampal gyrus. The seizures caused the
inability to speak. A left temporal craniotomy was performed for
resection of the lesions. Postoperative imaging documented
complete removal of the lesions. Eighteen months after the
operation, the patient remained seizure free with the help of
medication.
A patient had seizure disorder as well as paresis. Imaging
of the head revealed two lesions, one in the left gyrus and one
in the right frontal gyrus. The patient underwent a temporal
craniotomy for resection of the lesions. Postoperative MR
imaging demonstrated removal of both lesions. The paresis
improved with physical therapy and after radiation therapy the
follow-up MR imaging showed no evidence of disease in the brain.
At his 6-month follow-up examination, the patient was seizure
free.
A patient had relieved chemotherapy for cancer and soon
after developed memory loss. Imaging of the brain showed two
large lesions in the right temporal lobe. A right temporal
craniotomy was performed for resection of the two lesions.
Postoperative MR imaging showed removal of both lesions however
she died of a hemorrhage 3 months after the surgery.
The two reasons for surgical treatment of epilepsy are to
abolish the seizures and to entirely remove the lesion for a
maximal therapeutic benefit. There is major controversy in
lesional epilepsy surgery whether just removing the lesion
(lesionectomy) is adequate to achieve these goals or if surgical
removal of the lesion as well as the identification and
resection of surrounding cortex (lesionectomy plus corticectomy)
provides better seizure control.
The long-standing debate over lesionectomy versus
lesionectomy plus corticectomy began with the observation that
many patients do become seizure free or have a dramatic
reduction in seizures after simple excision of a structural
cortical lesion. The patient may be cured of seizures even
though scalp EEG abnormalities remain. These observations
suggest that a structural lesion does not necessarily result in
permanent changes in the surrounding cortex and that
lesionectomy alone may be able to reverse the epileptic
condition in certain cases. On the other hand, there are cases
where resection of the lesion alone without removal of the
functionally independent epileptogenic cortex would result in a
surgical failure.
One alternative surgical approach is to suggest that
patients with lesional epilepsy should undergo resection of the
structural lesion after appropriate non-invasive presurgical
evaluation. In many instances, 70 to 80% of patients will remain
seizure free after surgery. If the seizures persist after
lesionectomy, then a more detailed and comprehensive evaluation
could be undertaken with intracerebral electrodes. This approach
would minimize the expense and risk of invasive intracranial
monitoring in all patients and seems a cost-efficient and
effective compromise.
Bibliography
Handbook of Clinical Neurology
Elsevier Science Publishers 1985
Neuropsychological Assessment
Muriel Deutsch Lezak
Oxford University Press 1995
Research Publications of the Association for Research in Nervous
and Mental Disease
B. Milner, 1958
Location and Neuroimaging in Neuropsychology
Andrew Kertez (Editor)
Dept. of Clinical Neurological Sciences, Canada
Academic Press 1985
Neuropsychology
Stuart J. Dimond, BSC, MA, PhD
University College, Cardiff, Wales, UK
Butterworth & Co. 1980
Surgical Treatment of Epilespy
G. Rees Cosgrove, M.D., F.R.C.S.(C) and Andrew J. Cole M.D.,
FRCP(C)
Departments of Neurology and Neurosurgery, Massachusetts General
Hospital Epilepsy Center, Harvard Medical School, Boston,
Massachusetts
American Assoication of Neurological Surgeons
www.NeurosurgeryToday.org
Congress of the Neurobiological Surgeons
www.neurosurgeon.org
Go back to the beginning
Copyright © 2005, Dr. John M. Morgan, All rights
reserved -
This page last edited 1-3, 2005
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