Final Exam Flashcards
Orientation Terms
- Superior: top
- Inferior: bottom
- Anterior: front; towards nose/face
- Posterior: back; towards back of head
- Dorsal: top of the brain
- Ventral: bottom of brain
- Lateral: away from the middle
- Medial: towards the middle
- Rostral/anterior: front/toward the nose/anterior/front of the brain head end of the body
- Caudal/posterior: back/toward the tail end of the body
Brain Lobes
Forehead/blue: Frontal
Back of skull/yellow: parietal
Side/temple/green: temporal
Back just above neck/red: occipital
Brain Planes
Coronal: divides into back and front
Horizontal: divides into top and bottom
Midsaggital: divides into right and left
Language Regions
Neuroanatomy: Language and regions
• Broca’s Area (frontal lobe)-Expressive Language
• Wernicke’s Area (temporal lobe)- Receptive Language
• Arcuate Fasiculus (bundle of white matter)-Connection between Broca’s and Wernicke’s
• Primary Auditory Cortex (temporal lobe)
• Primary Visual Cortex (occipital lobe)
• Primary Motor cortex (frontal lobe)
• Primary Somatosensory cortex (parietal lobe)
*****Motor is anterior/rostral to somatosensory
Language Lateralization/Dominance
Language tends to be left side dominant; only damage to left side of brain will cause an aphasia
• Right sided damage doesn’t tend to cause aphasia
o Can cause pragmatic problems (not always)
• Some people can have language on right
o Very rare
o More common in left-handed people
• Also bilateral language, also very rare
Hippocampus function
*episodic memory, especially long-term
*Spatial awareness and processing
*
The blood to the brain comes from two major arteries
o The carotid artery
o The vertebral artery
Circle of Willis
• Located on the ventral/inferior side of the brain
• Connects the carotid and vertebral arteries
• Creates the 3 major arteries of the brain
1. Anterior Cerebral Artery-
• Anterior communicating artery connects them
2. Middle Cerebral Artery: most important for sending blood to areas of brain imperative for language
3. Posterior Cerebral Artery- connects middle cerebral artery and posterior cerebral arteries
• Also contains the communicating arteries (Anterior and Posterior communicating arteries), which help compensate in case there is a blockage in one of the major cerebral arteries; if there is a blockage blood can go around
Cerebrovasculature and aphasia
- Wernicke’s Aphasia (left), Broca’s Aphasia (right) IMPORTANT FOR LANGUAGE FUNCTIONING; left side of brain most important for language
- Middle cerebral artery are inside of that area (profused by middle cerebral artery)
- Wernicke’s area: posterior superior portion of temporal lobe
- Broca’s area: inferior posterior portion of frontal lobe
- To have broca’s aphasia- have to have blockage/rupture in left MCA, in the superior division
- Inferior division damage to left MCA cause damage to wernicke’s area, causes wernicke’s aphasia
Brain imaging Techniques important for “Where” (spatial resolution)
- Postmortem correlations: Broca (1844): Leborgne: Lesion models (done through post-mortem correlation)
- Transcranial Magnetic Stimulation (TMS)
• More Lesion Models
o Intracarotid Sodium Amobarbital Procedure (ISAP)/WADA test- put it in carotid artery to find out which side of brain is dominant for language or memory- very invasive
o Pre-surgical planning
o Invasive- minimize damage to language and memory
• Single pulse; Repetitive (rTMS) (transcranial magnetic stimulation) = lasting effects; no lasting effects from single procedure; creates a virtual lesion through magnetic stimulation (turn neurons off/stops them from firing for a second)
o Migraine headaches
o Nonfluent aphasia
o Major depression
o Electroconvulsive therapy popular for people with manic/major depression; put electric leads on temples and start a seizure - SPECT
- Positron Emission Tomography (PET)
- Computed Tomography (CT)
• Often used clinically – cheaper and faster than MRI
• Radiation exposure significant (3D xray; can cause a lot of cancer; lead coat helps reduce exposure to xrays)
• Left CVA/Infarct (loss of blood to area of brain) ; with imaging, left is right and right is left
Vasculature/cerebral aneurism images
6. Magnetic Resonance Imaging (MRI) o Structural o Functional o Diffusion Tensor Imaging (DTI) (new) Rely on facts that: • Every tissue of body has water in it • Hydrogen molecules • Huge magnet aligns them all • They all fall/relax at different rates (depending on what tissue they are in) Differing rates of relaxation produce • contrast in different tissue types • T1 relaxation produces a high resolution structural image of frontotemporal dementia • White matter, gray matter, bone DTI: * Way of imaging neural tracts (connect 2 different gray matter areas together); does not care about structure as much • Creates beautiful pictures of white matter (very colorful)
PET vs. SPECT
Both rely on fact that
o Metabolic activity requires glucose
o Useful for oncology as tumors have high glucose uptake
Uses gamma radiation and gamma cameras (nuclear), good for finding tumors
Brain imaging Techniques important for “When” (temporal resolution)
- Electroencephalography (EEG)/ERP
• Real‐time neural activity- measures electrical signals in brain
• Limited spatial sensitivity- not good at “where”
• Messy movement artifact- will mess up if you blink move or wrinkle forehead - Magnetoencephalography (MEG)
• Electrical current produces a magnetic field
• Close to real-time, but not quite
• Better spatial resolution than EEG; where seizure activity is starting
• Used for seizure; localize issue and remove that part of the brain
MRI vs. CT Scan
CT scan is better for stroke because MRI will not detect acute CVA (cerebro-vascular accident/stroke)
MRI is a lot slower and more expensive than CT
MRI has highest spatial resolution
CT scan best for muscle/bone issues, fractures, blod clots, bleeding from the brain; MRI for tendons, ligaments, spinal cord
Differential diagnosis for aphasia
Aphasia is a language difficulty worse than, NOT, and not due to a cognitive difficulty
Communication also shouldn’t be affected by
o Dysarthria- difficulties with articulating speech
o Apraxia- inability to perform purposive action
o Agnosia- inability to name things in a certain modality (disconnect between sensory system and semantic knowledge)- can still recall info when shown in a different modality
o Sensory Disorder
o Dementia
Problems in aphasia
- Stereotypic Utterances
- Anomia
- Circumlocution
- Paraphasia
- Nonfluency
- Jargon
- Agrammatism
Stereotypic utterance
- Usually seen in very severe aphasia
- May not be able to say anything other than one utterance
- Can be a real word or a non real word like “tono”
- Prosody may be intact
- Say the same word over and over again
Anomia
- Word finding issues
- Unable to come up with word
- Can be perfectly fluent but may have difficult coming up with words in constrained situations
- Does not mean you are fluent or non-fluent
- May only occur in constrained/difficult situations
Circumlocution
- Difficulty coming up with word
- Circle around idea
- Usually lengthy responses
Paraphasia
- Semantic paraphasia- replace word with another of a similar semantic class
- Phonemic paraphasia- replace word with another with similar phonology (do not have to be real words)
- Mixed paraphasia- replace word with another of similar semantic class and phonology
- Unrelated paraphasia- replace with completely unrelated real word
- Neologistic paraphasia- replace with completely unrelated non real word
Nonfluency
- Rate and naturalness of speech
- Slow and labored speech
- A lot of uhm’s, ah’s stops
- Very effortful
- Common with Broca’s aphasia
Jargon
- Semantic jargon- producing real words but done in a manner which does not make sense
- Neologistic jargon- same as semantic jargon but with the non real words as opposed to real words
- Essentially meaningless speech that is spoken as if it had meaning
Agrammatism
- Loss of grammar skills in speech
- Telegraphic speech-mostly content words
- Loss of complexity of sentences, not a lot of fillers
- Can get point across, but words are very simplistic and do not follow grammar rules
- This video does a nice job summing up agrammatism
Aphasia/stroke risk factors
- High Blood Pressure
- High Cholesterol
- A-Fib (atrial fibrillation- abnormal beating of heart)
- Diabetes
- Atherosclerosis
- Tobacco Use
- Alcohol Use
- Obesity
F.A.S.T.
o Face- drooping
o Arms – if one arm is lower than the other when you ask them to lift them above head
o Speech – slurred, nonsensical
o Time – the quicker you call 911 and get person to services the less possibility of disability
Ischemic stroke
• A block in the arteries either due to blood clot or more commonly the buildup of plaque
• About 87% of all strokes are ischemic
• The brain needs blood
o After only 10-15 seconds without blood you pass out
o 2-3 minutes without blood leads to permanent brain damage
Types of Ischemic Stroke:
1. Thrombosis- blood clot or blockage occurs locally
2. Embolism- blood clot forms elsewhere and travels to brain and causes blockage
Hemorrhagic stroke
- 13% of all strokes are hemorrhagic strokes
- Occur when a blood vessel in the brain breaks and blood begins to leak in the brain
- Blood accumulates quickly and can put a dangerous amount of pressure on brain
- More likely to cause death than ischemic stroke – because it so quickly causes brain loss to happen, pressure causes brain damage
Types of hemorrhagic stroke
- Epidural hemorrhage- bleed occurs between the bone and the dura mater
- Subdural hemorrhage- bleed that occurs between the dura and arachnoid
- Subarachnoid hemorrhage- bleed that occurs between arachnoid and pia mater
- Cerebral hemorrhage- any bleed that occurs in the brain
Ischemic stroke treatments (list)
Thrombolysis, Thrombectomy, other management/drugs
Hemorrhagic stroke treatments (list)
Surgery
Thrombolysis
- Clot busting
- rTPA
- Must be administered close to the onset of the stroke (within three hours) (thrombolysis)
- Better outcomes have been found although these are controversial (some studies found not much difference in outcomes with/without TPA)
- Increase in chance of hemorrhage
- At first a lot of people were in love with it, now seen to not do as much as they thought and point above
Thrombectomy
- Surgical removal (ectomy) of the thrombi
- Much more invasive and risky (than thrombolysis)
- Really only done if there is significant threat of (impending) death
Other management/drugs
- Antiplatelet drugs – reduce likelihood of clots forming (aspirin, Plavix)
- Vasodilator – drugs that help arteries/blood vessels to open up wider
- Anticoagulants – reduce coagulation/clotting of blood (coumadin, warfarin) – after stroke, higher incidence of embolism/thrombus, will knock blood clots loose, used as preventative measure
- Blood pressure medications – reduce blood pressure
- Beta blockers – reduce pulse rate
- Reduce risk factors – improvements in diet, exercise, reduce tobacco/alcohol use, quitting tobacco use after just 1 year gives you same chance of stroke as someone who never smoked
- Carotid Endarterectomy
Carotid Endarterectomy
- Remember the carotid artery (main artery that sends blood to brain, along with vertebral artery)
- Catch it early!
- If it is very blocked this procedure will occur
- Reduces risk of second stroke
- Risky surgery so only done if a significant blockage is present
- Invasive/dangerous- once you open up a vessel the strength and stability of that vessel are reduced
- Can be scarring in the artery which leads to more narrowing
Surgery for hemorrhage
- Closing off ruptured vessel (or dilate another vessel) to move blood to another area)
- Draining pools of blood
- Craniotomy
- Very large brain compared to size of skull, not a lot of space for brain to move, pressure will build up if any liquid gets in the brain; if hemorrhages are epidural/subarachnoid/subdural, they can do craniotomy (removal of a portion of the cranium) to relieve pressure and pool of blood; if cranium is left off for a period of time they actually store the cranium in the gut; open the abdomen and but cranium in the stomach and keep it there until they have to put it back; relatively common but controversial
Areas of brain affected by each aphasia
- Broca’s Aphasia- Broca’s area (frontal lobe)
- Wernicke’s Aphasia- Wernicke’s area (border of parietal and temporal lobe)
- Global Aphasia- Wernicke’s area, Broca’s area, and arcuate fasciculus (white matter track that connects Wernicke’s area and Broca’s area)
- Conduction Aphasia- Arcuate fasciculus
- Transcortical Motor aphasia- ACA-MCA watershed areas
- Transcortical Sensory aphasia- MCA-PCA watershed areas
- Transcortical-mixed aphasia- both ACA-MCA and MCA-PCA watershed areas
Bilingual aphasia is an acquired language disorder that results in problems in both languages for:
Production/Speech, Comprehension/Listening, Reading, Writing
Bilingual aphasia affects all areas of language including
o Phonology (Sounds) o Grammar (rules of language) o Morphology (sounds that carry meaning) o Semantics (meaning of words ) o Pragmatics (rules of social discourse)
Impairment in bilingual aphasia occurs
in both languages in varying degrees; however, all of these areas are not necessarily impaired.
Pathological code switching
Difficulty staying in target language and code switching ; involuntary language mixing
Bilingual aphasia and proficiency
• Can occur even when there is minimal proficiency in the second language.
o For example, people who spend the summer in another country.
o Language is still disordered
Bilingual aphasia is not
a way to miraculously wake up speaking a new language from
Patterns of impairment for bilingual aphasia
Proficiency • Primary Language (L1) • Secondary Language (L2) Age of Acquisition • Heritage Speakers • Second Language Learners Use • L1 Dominance • L2 Dominance
Parallel vs. differential impairment
Parallel impairment
o Both languages are equally impaired
Differential impairment
o different degrees of impairment for each language (one language is more impaired than the other)
o Differential aphasia: aphasia symptoms differ across languages Example: Broca’s aphasia in one language and Wernicke’s in the other language.
Blended or mixed patterns
o mixed language patterns at any linguistic level (phonological, morphological, syntactic, lexical, or semantic)
Selective aphasia
o impairment of only ONE language
Example of mixed patterns
patient no longer recognizes what words or features belong to each language (not the same as code switching which is voluntary).
Patterns of bilingual aphasia recovery
• Parallel: Both improve together, same rate. (Most common.)
• Differential: one language recovers better than the other regardless of premorbid levels
• Selective: Only one language recovers.
• Blended: Inappropriate blending of languages.
• Successive: One improves, then the other. One language may plateau before the other can recover.
• Antagonistic: one language improves and the other regresses. Improvement in one language negatively affects the other language.
* Recovery can occur in both language or one more than the other.
• Language recovery can be either the L1 first or L2 first, no specific order regardless of native language, familiar language or language of the environment.
Relationship between aging and disease
• As age increases the incidence of disease increases as well
Why are so many diseases mostly seen in old age?
• We are copies of copies- you have none of cells you had 7 years past
• The selection shadow- diseases show up after 40 because it doesn’t matter if you die because you already had your children
Brain changes in normal aging
Normal aging is associated with structural and functional changes in the brain (between 18-25 brain volume begins to shrink)
o Global changes
o Regional changes
• Frontal (executive function, emotion, perception/behavior. judgment) and temporal (semantics, memory, content) regions are most affected
o Observable in neuroimaging studies
There are corresponding declines in cognitive functioning
o Executive functions and (processing) speed most affected
o Also changes in memory and other domains (multitasking not good)
Declines in gray and white matter (volume)
Normal vs. Abnormal aging
• The abnormal is dementia
• Not everyone is destined for dementia
• Please let people know this
o There are things they can do to help prevent dementia
MCI
Transitional zone between dementia and normal aging
o Aging → MCI → Dementia
Proposed Criteria (Winblad et al., 2004)
o Not normal, not demented by DSM-IV criteria
o Cognitive decline (self- and other-reported)
o Preserved ADLs (activities of daily living)
Can be difficult to tease apart form normal cognitive decline; executive functioning, memory, processing speed; not homogeneous diagnostic label- people are very different
Can improve, remain stable, or evolve to AD or another form of dementia (most commonly remains stable)
3 MCI categories
Amnestic o Mostly memory o Most likely to become AD Multiple Domain o Spatial & Language, partially memory Non-Memory Domain o Language