Ammar Alnajjar
Higher Cortical Functions
1- Consciousness 2- Orientation 3- Memory 4- Speech 5- Gait
1- Consciousness Level: response to external & internal stimuli
A- Conscious →respond spontaneously
B- Drowsy → respond to verbal stimuli ()هذا اذا نعوفه ينام
C- Stupor → respond to painful stimuli
D- Coma → no response
2- Orientation: awareness of time, place, person Ask direct questions
if he doesn’t know ask indirect
questions
3- Memory: أشياء و اكله عيدها3 انطي كشمولة.د
a- Registration (3 numbers)
a- Immediate → < 5 minراسا
b- Early memory (7 numbers)
b- Short term → > 5 min أيام) وره خمس دقايق/(ساعات c- Intermediate memory (5-3 min)
c- Long term → month/years اسئل شغالت قديمة كلش d- Late memory
Patient with Dementia → lose short term memory first
الن معظم الخلل يصير بالمنطقة المسؤولة عن الذاكرة القصيرة
Hippocampus in temporal lobe
4- Speech: شنو لغته؟ سمعه زين؟ التعليم؟ يمناوي لو يسراوي؟,الزم نتأكد من المريض
Notes
1- Auditory area (cortex) → receiving input from the ears in temporal lobe
2- Wernicke’s area → responsible for comprehension of speech (sensory part) يفسر الحجيin temporal lobe.
3- arcuate fasciculus → connect Wernicke’s to Broca’s
4- Broca’s area → responsible for production of speech (motor part) تحول الكالمin frontal lobe of the dominant hemisphere
- Aphasia is an inability to comprehend or formulate language
- Dysphasia is impairment of the power of expression by speech, writing, or signs, or impairment of the power of
comprehension of spoken or written language.
- Dysarthria is a motor speech disorder in which the muscles that are used to produce speech are damaged, paralyzed, or
weakened.
- anomia is a type of aphasia characterized by problems recalling words, names, and numbers
- Agnosia is an inability to recognize and identify objects or persons.
- Dysphonia → disorders of the voice
- Aphonia → the inability to produce voiced sound
1- Comprehension: فهم اللغة
Wernicke’s area → sensory part of speech
من احجي وياه الزم يكون مفتهم و أحاول اغطي حلكي من احجي بااليد,يحجي بطالقة و مفتهم
– أوامر3 ما اغطي حلكي او اوكف وره المريض و انطي
2- Fluency: جريان الكالم
Broca’s area → motor part of speech
- ( اخلي يحجي و يسولفfluent)
Damage to the Wernicke’s area: حجي مخربط ما بي أي معنى
Wernicke’s dysphasia (superior temporal gyrus *inferior branch of MCA)
- salad of words
- meaningless
- neologisms (invented words)
Damage to the broca’s area (Inferior frontal gyrus *superior branch of MCA)
- Broca's dysphasia → partial loss of the ability to produce language
(spoken, manual, or written
قليل يحجي بس يفهم األوامرeffortful speech
Global aphasia → no comprehension or fluency (both areas effected) stroke (Complete MCA
3- Reading: اقره جملةdo it not read it
4- Writing: اذا ميعرف يكتب خليرسم
- agraphia → inability to write, as a language disorder resulting from brain
damage.
- Dyslexia → ميكدر يقره
5- Repetition: عبارة يعيدها وراية مباشرة
Conduction aphasia is the inability to repeat words or phrases.
6- Naming: common object
a- شنو اسم هذا الشي
اذا ميعرف
anomia is a type of aphasia characterized by problems recalling words,
names, and numbers (angular gyrus lesion)
b- شنو نسوي بي
اذامعرف
Agnosia is an inability to recognize and identify objects
a- Visual agnosia
b- Auditory agnosia
c- Tactile agnosia
Q/Causes of aphasia & dysphasia?
A/problem in the speech center in cortex (Wernicke’s, Broca’s, Transcortical)
Dysphonia: problem in the phonation
vocal cord لحد الbrain يعني خلل من ال
:مثال
1- Laryngitis صوته مبحوح
2- Stroke in speech center
3- ممكنcranial nerves
Dysarthria: problem in articulation
lips & mouth الى حد الbrain يعني من ال
:مثال
1- Myasthenia gravis
2- Problem in brainstem
3- Facial palsy
Types of Dysarthria
1- Spastic (hot potato speech)
a- If lesion in one cortex → speech not effected
b- If lesion in both → Bilateral UMNL (pseudobulbar)
2- Scanning speech: is a type of ataxic dysarthria in which spoken words are broken up into separate
syllables, often separated by a noticeable pause, and spoken with varying force.
a- Cerebellum lesion (specific)
3- Slurred speech (Non specific)
4- Nasal speech (bulblar) LMNL
5- Slow monotonous speech: Parkinson’s & depression
6- Gait اذا متمدد يكوم يكعد
1- Walk forward, turn & return back to me (10m) ) (ثابتة لو يترنح:نشوف الكعدة مالته
Note: truncal ataxia يترنح
a- Time taken to complete first 10m نخلي يكوم يوكف (زين لو فاتح رجليه من
b- Stride length )يوكف
wide based gait اذا فاتح رجليه
c- Arm swing → no arm swing → extra-pyramidal tract
cerebellar lesion او
lesion (Parkinson’s disease)
d- Steadiness Parkinson’s disease
e- Turning → → اذا ميكدر يدور بسرعة
f- Any limbing
Cerebellar lesion
2- Tandem gait (Heel to toe walking) Cerebellar lesion → ipsilateral gait ataxia
This gait is useful for emphasizing
Damage to vermis (median segment of cerebellum) →ataxia
gait ataxia but it can not enable
on both sides (truncal ataxia)
me to differentiate between
cerebellar or sensory ataxia.
3- Walk on tip of toes
Useful in emphasizing simple lordosis (increased anterior curvature of spinal cord)
Seen in achondroplasia & peripheral neuropathy
4- Walk on Heels In foot drop the patient slaps his
Useful in emphasizing mild foot drop → mild motor foot on the ground as he walks so
that the gait in foot drop is called
peripheral neuropathy
slapping gait
Poliomyelitis → unilateral foot drop
5- Romberg’s test If unsteadiness is noticed before
closing the eyes → Cerebellar ataxia
a- Stand up straight
b- Feet close together
c- Arms straight forward & fingers separated If unsteadiness is noticed after
d- Keep this position few seconds then close his eyes closing the eyes → Sensory ataxia
(impaired proprioceptive or what is
called joint receptors)
6- Gower’s test Normally → stand up easily
a- Squat with the hands behind the head
Proximal myopathy → can’t, climb up using
b- Ask him to stand up nearby objects
DDx of proximal myopathy is wide, including:
a- Duchenne muscular dystrophy
b- steroid (drug-induced)
c- autoimmune polymyopathy
d- osteomalacia
Gait Abnormality
1- Hemiplegic Gait (Circumductive gait/spasticity)
a- Flexion of hand
b- Extension of the lower limb
Causes: after stroke (due to corticospinal lesion)
حيصيرupper بالpyramidal tract lesionالن عادة بال
flexor stronger than extensorال
extensor stronger than flexor الlower اما بال
2- Shuffling Gait
a- Small short steps
b- Loss of arm swing
Causes:
a- Parkinson’s disease
b- Extrapyramidal lesion
ينحني ليكدامrigid تكونtrunk هذا ينحني ليكدام الن عضلة ال
يكوم يمشي اسرع حتى ليوكع و يوزع الشغلgravity ويه
Small steps then large & fast steps
In parkinson’s → rigidity in proximal muscles
other than distal
3- Wide Based Gait Cerebellar ataxia:
يمشي خطوات جبيرة.ما يكدر يسد رجله a- Wide based gait
b- Ataxic gait
Causes: (lesion in the cerebellum) (broad stand, they can’t stand
a- Bilateral cerebellar hemisphere normally, tend to fall)
b- Vermis of the cerebellum is involved (Truncal ataxia) و همينipsilateral
4- Ataxic Gait
يترنح ويه المشي على جهة
Causes:
Cerebellum lesion (unilateral)
و يكون الترنح على الجهة المضروبةipsilateral
5- Waddling Gait (Myopathic gait)
يمشي مثل البطة
المريض يميل الن العضلة القريبة ضعيفة
فيحاول يخلي القوة على العضلة األعلى
فيميل من جهة بعدين يميل على الجهة
الثانية
Causes:
a- Pregnant
b- Proximal weakness
(hypothyroidism, osteoporosis,
osteomalacia)
6- Stomping Gait (foot drop) → sensory ataxia
يطب رجله بالكاع
Causes:
a- distal nerve injury
b- Loss of position & vibration
sensation → peripheral
neuropathy, B12 Deficiency
7- Steppage Gait (Neuropathic gait)
They can’t dorsiflex because their foot is very relaxed
Causes:
a- Peroneal muscle atrophy or peroneal nerve injury, as with a
spinal problem (such as spinal stenosis or herniated disc
b- Charcot mary tooth disease
