Categorical classification of different mental status and their localization

1. Localizing Value
of
Altered Mental
Status
Yasser A. Alzainy MSc.

2. Introduction
Classification of the cerebral
cortex

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4. 1. Level of alertness, attention and
cooperation
2. Orientation
3. Memory
a) Recent
b) Remote
c) Implicit
4. Language
5. Calculations, right-left confusion, finger
agnosia, agraphia
6. Apraxia
7. Neglect and constructions
8. Executive funcitons
9. Logic and abstractions
10. Delusions and hallucinations
11. Mood
12. Complex sensory processing
13. Other notable syndromes
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Domains Covered

5. • Localization
• Areas of the brain that produce
symptoms in related domain if lesioned
• Arranged from most common to less
common
• Localizing Value
• Low
• Moderate
• High
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Mental Status Component

6. • Pontomesencephalic reticular
formation
• Thalami (bilateral)
• Cerebral hemispheres (bilateral)
• Frontoparietal association cortex
• Low
• Note: Memory and Language are
needed for orientation
• Mood disorders can affect co-
operation
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Alertness, Attention, Orientation and
Cooperation

7. • Easy
• Standardized
• Reflect Extent of the lesion
• Essential for the reliability for
the rest of mental status
examination
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Value?

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11. 02
Memory

12. • Medial temporal lobe
• Hippocampus
• Amygdala
• Medial diencephalon
• Mamillary bodies
• Fornix
• Anterior and mediodorsal thalamic nuclei
• High
• anterograde / retrograde
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Recent Memory

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14. • Unimodal and Heteromodal
Association Cortices
• Low
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Remote Memory

15. • Cerebellum
• Basal ganglia
• Heteromodal association areas of
temporal & parietal lobes.
• Low
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Implicit Memory

16. • Dominant (left) inferior parietal
lobule
• All 4 = Very High
• “Gerstmann’s Syndrome”
• One = Very Low
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Calculation, Right-left confusion, Finger
agnosia, Agraphia

17. • Dominant (left) Inferior parietal
lobule
• ~ Premotor cortex
• Moderate
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Apraxia

18. • Body of the corpus callosum
• High
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Apraxia of the left hand

19. • Non-dominant (right) parietal lobe
• Less common:
• Right frontal; Thalamic; Basal ganglia
• Rarely:
• Right midbrain
• In left parietal lesions, much milder forms
of neglect may be seen
• Moderate
• Presentation
• Sensory neglect
• Motor neglect
• Constructional apraxia
• Dressing apraxia
• Geographical agnosia
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Neglect and Visuospatial Constructions

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22. 05
Executive functions

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25. • Dorsolateral prefrontal cortex
• Severe = bilateral
• Mild = unilateral ( usually dominant)
• High
• Presentation:
• Impaired problem solving
• Poor judgement and
decision making
• Stubbornness
• Perseveration
• Bradyphrenia
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Planning, Judgement & Set Shifting /
Sequencing

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28. • Orbitofrontal cortex
• Severe = bilateral
• Mild = unilateral (usually dominant)
• ~ Temporal lobe
• Moderate
• Presentation:
• Disinhibition
• Impulsivity and
aggression
• Motor impersistence
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Inhibition of Behaviour

29. • Medial frontal cortex
• Severe = bilateral
• Mild = unilateral ( usually dominant)
• High
• Presentation:
• Apathy / Abulia
• Urinary incontinence
(non-intentional,
shameless)
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Motivation + urinary control

30. • Bilateral frontal lobes
• esp. Medial frontal cortex
• Bilateral Thalamic lesions
• Moderate
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Akinetic Mutism

31. • Prominent bilaterally = Bilateral Frontal
lobes
• More prominent on one side =
contralateral frontal lobes
• Orbitofrontal and medial frontal >
Dorsolateral prefrontal
• High
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Frontal Release Signs

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33. • Association cortices
• Low
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Logic and Abstraction

34. • Diffuse brain dysfunction
• Psychiatric disorders
• Frontal and temporal association
cortices
• Limbic system
• Low
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Delusions

35. • Diffuse brain dysfunction
• Psychiatric disorders
• Occipitotemporal association
cortices
• Visual
• Auditory
• Pontine tegmentum
• Low
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Hallucinations

36. • Left frontal lobe
• Bilateral dorsolateral frontal (flat
affect)
• Limbic system
• Low
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Depression

37. • Right Frontal
• Bilateral orbitofrontal
• Limbic system
• Low
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Mania / Elation

38. • Bilateral orbitofrontal cortex
• Limbic system
• Basal ganglia
• Corticospinal tract
• Low
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Emotional lability

39. • Medial frontal cortex (anterior
cingulate)
• Temporal lobe
• Limbic system
• Low
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Apprehension / Anxiety

40. • fMRI: hyper-frontality
• Increased activity in orbitofrontal and
anterior cingulate
• Temporal lobe
• Low
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OCD

41. • Lateral temporal lobe
• High
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Déjà vu, Jamais vu, Dissociative symptoms

42. • Bilateral Amygdala lesion
• High
• “Kluver-Bucy syndrome”
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Emotional placidity, Hyperorality and
Hypersexuality

43. • Hypothalamus
• As a part of hypothalamic syndrome
• Orbitofrontal cortex
• Moderate
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Hyperphagia

44. 07
Complex Sensory
processing

45. • Bilateral inferior occipitotemporal
cortex
• ~ left occipitotemporal cortex
• Moderate
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Visual object agnosia

46. • Bilateral inferior occipitotemporal
cortex
• ~ Right temporal lobe:
• Severe rare forms:
• Capgras syndrome
• Fregoli syndrome
• Moderate
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Prosopagnosia

47. • Hemifield:
• Contralateral inferior occipitotemporal
Cortex
• All filed:
• Bilateral inferior occipitotemporal Cortex
• Usually associated with prosopagnosia
• Moderate
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Achromatopsia

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49. • Lateral visual association cortex
• esp. occipitoparietal
• Moderate
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Macropsia, Micropsia and metamorphopsia

50. • Bilateral visual cortices or optic
radiations
• High
• “Anton syndrome”
• Usually temporary
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Blindness + denial

51. • Balint syndrome: Simultagnosia, optic ataxia &Ocular apraxia =
Bilateral occipitoparietal cortex.
• Alexia without agraphia = Dominant occipital + splenium of corpus
callosum
• Cerebellar cognitive affective syndrome
o ↓ Executive function & difficulty w/ visuospatial ability
o Flattened affect, inappropriate behavior
o Dysprosody, agrammatism.
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Other notable Syndromes

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Thank You