LOBAR FUNCTION

TESTS
LOBES OF THE BRAIN
FUNCTIONAL AREA OF THE CEREBRAL 3

CORTEX

Brodmann (1909) had divided the

cerebral cortex into

47 areas

Indicated each of them by a number.

.
FUNCTIONAL AREAS

MOTOR AREAS

SENSORY AREAS

ASSOCIATION AREAS
 FUNCTIONAL AREAS OF
FRONTAL LOBE
Primary motor Voluntary Spastic paralysis
movements of C/L of extremities of
area part of body. opp. Half of body.

Successful
Premotor area- Difficulty In
performance of
performing skilled
6 voluntary motor
activities
movements

Supplementary B/L flexor

Assumption of
hypotonia with no
motor area posture
paresis/paralysis.
 Frontal controls voluntary
scanning
Eyes deviate to
side of lesion &
eye field movements of the
eyes.
unable to turn to
opposite side.

Motor Production of
speech excessive speech
or vocalization
Aphasia

area

Pre frontal Personality,

judgement, depth
Disinhibitory
behaviour/
area of emotions etc.
personality
changes.
FUNCTIONAL AREAS IN THE FRONTAL LOBE
7

1
 8

LESIONS IN PRIMARY MOTOR

AREA
• Lesions of primary motor area in one hemisphere: Produce
spastic paralysis of the extremities of the opposite half of the body
(hemiplegia).

• The masticatory, laryngeal, pharyngeal, upper facial and extra-

ocular muscles are spared for being represented bilaterally.
 PRE MOTOR AREA 9

Area 6 of Brodmann:

• The premotor area is responsible for successful performance of the voluntary

motor activities.

• The primary motor area receives numerous inputs from the sensory cortex,
the thalamus and the basal ganglia. It stores the programmes of motor
activity assembled as a result of past experience.

• The premotor area are responsible for programming the intended movements
of the primary motor area and controlling the movements in progress.

Lesions of premotor (secondary motor) area: Produce difficulty in the

performance of skilled movements
 10

SUPPLEMENTARY MOTOR AREA

• The body is represented from before backwards in craniocaudal

order.

• The stimulation of supplementary motor area produces complex

movements, some are described as 'assumption of posture' with
bilateral effects, including turning the head, assuming positions of
trunk and lower limb.

Lesions of supplementary motor area produce bilateral flexor

hypotonia with no paresis or paralysis.
 11

LESIONS OF FRONTAL EYE FIELD

• Lesions of the frontal eye field of one hemisphere:

Cause the two eyes to deviate to the side of lesion and an inability to
turn the eyes to the opposite side.

• The Involuntary tracking movement of the eyes when following moving

objects is unaffected since the lesion does not Involve the visual cortex
of the occipital lobe.
 12

MOTOR SPEECH AREA OF BROCA

Areas 44 and 45 of Brodmann:

• Broca's area is responsible for the production of expressive

speech/vocalization.

• It brings about the formation of words by its connections with the

adjacent primary motor area, which in turn appropriately stimulate the
muscles of the larynx, mouth, tongue, soft palate, and the respiratory
muscles.
 13

Lesions of motor speech area of Broca:

• Result In loss of ability to produce speech, I.e. expressive aphasia (also

called motor aphasia).

• The patients retain the ability to think about the words they wish to say,
they can write the words, and they can understand their meaning when
they see or hear them.

• Although the language is understood, it cannot be expressed in speech

even though there is no paralysis of muscles of lips, tongue, and vocal
cords.
 14

PREFRONTAL AREA
• Area is concerned with the individual’s personality.

• It exerts its influence in determining the initiative and judgement of

an individual.

• It is also concerned with depth of emotions, social, moral and ethical

awareness, concentration, orientation, and foresightedness.

• It is an area of the cerebral cortex that is capable of associating

experiences that are necessary for the production of abstract ideas.
 PRE FRONTAL CORTEX.
DLPFC VMPFC OFC
control of
Working memory and acquisition of
memory appropriate
provides
multimodal behaviors and
integration and the inhibition
executive of
function that inappropriate
underlies goal-
directed behaviors
behaviour based on
reward
contingencies
 17

LESIONS OF PREFRONTAL AREA

• Bilateral destruction of prefrontal area: (due to trauma or
tumours) results in profound change in personality.

• There is loss of concentration, initiative and judgement.

• The individual no longer conforms to the accepted mode of social

behaviour and becomes careless about his dress and appearance (i.e,
inappropriate social behaviour)

e.g. use of obscene language, urinating in public.

 Tests for
Executive Orbitofrontal tests attention.
function tests
[Link] SPAN TEST [Link]/NO GO TEST
[Link] DAYS OF [Link] TEST
WEEK BACKWARD Bender–Gestalt
[Link] OF
[Link] Test (Bender
ANIMALS, ETC
CARD SORTING Visual Motor
TEST Gestalt Test)
[Link] LURIA
TEST Visual Object
[Link] and Space
INTERPRETATION Perception
TEST Battery (VOSP)
[Link] GRAPHIC
TEST Behavioural
[Link] MAKING Inattention Test
TEST (line bisection,
star
cancellation)
Tests of
Everyday
Attention (TEA)
 19

EXECUTIVE FUNCTIONS TEST

(PREFRONTAL CORTEX)
The aim is to check the fund of information, motor sequencing, set shifting, problem solving,

judgement and abstract thinking.

1 .Ask and note how the patient had planned the visit to the doctor and his eagerness to reach on time.

2. Ask and note whether the patient is able to give the history properly and has preserved insight about his

problems.

3. Forward and backward digit span: Ask the patient to repeat the number sequences in the increasing

order

Eg., 3-7, 7-4-9,8-5-2-7,2-9-6-8-3and check whether the patient is able to repeat it correctly.

• Alternatively, days of the week or months of the year backwards can be used.

4. Ask the patient to produce as many words as possible in one minute, starting with any letter like F and S
 20

5. Ask to name animals, fruits or vegetables as many as he can in one minute-(more

than 10 is normal, abnormal is less than eight).

- Look for perseveration.

6. Motor Luria test (fist-edge-palm test):

- First explain the patient by doing it yourself. Make a fist and tap on flat surface with

your thumb upwards; then straighten out your fingers and tap with the ulnar border of

hand and then place your flat palm on the surface. Repeat this again.

-Once the patient has understood, ask the patient to repeat it. The hand motion may

be reinforced by counting from 1 to 3 along with each segment.

 21

[Link] interpretation test: Give five proverbs in the patient's own language in

the increasing order of difficulty keeping in mind social and educational background of

the patient.

-Ask him to explain what it means.

- Note the degree of abstract thinking shown by the patient to explain the

interpretation of the proverb

8. Luria graphic test. Patient is asked to draw alternating sequence like a triangle

and a square after being shown by the examiner.

 22

9. Trail Making Test-

Visuo-motor track, conceptualization, set shift

5 B
A 4

6
1
2
3
7

Various levels of difficulty:

1. “Please connect the letters in alphabetical order as fast as you
can.”
2. “Repeat, as in ‘1’ but alternate with numbers in increasing order”
Trail making test.
 24

ORBITAL AND BASAL AREAS OF

FRONTAL LOBE

The aim is to examine the patient's ability to inhibit his

responses, both social and motor.

1)Check for the inappropriate dressing sense and behaviour that

suggests lack of concern with the feelings of others or without
concern to accepted social customs.
) Go/No-go test:Ask the patient to make a response to one signal (the go signal) and
not to respond to another signal (the no-go signal).

• Direction: Patient is asked to tap once when examiner taps once and stop when
examiner tap twice

• Score (a) No error: 3 (b) 1-2 errors: 2 (c) > 2 errors: 1 (d) Patient taps like the
examiner at least four consecutive times: 0

• Significance: Difficulty in withholding a response - lesion in ventral part of frontal

lobes.
 26

3)The stroop test: This test examines the patient's ability to inhibit his
responses.

Patients are asked to state the colour in which words are printed rather than the
words themselves.

Example:

Red, Blue, Black, White, Orange, Violet

 Wisconsin Card Sorting Test
■ The material consists of 64 cards, each containing from one to four geometrical fi gures.
■ These consist of any one of four shapes (triangles, stars, crosses and circles) in any one of four
colours.
■ Four stimulus cards are set out before the subject who must sort the remainder beneath them.
■ His task is to discover by trial and error whether he is required to sort according to colour,
form or number, the clue being the examiner’s remark of ‘right’ or ‘wrong’ after each response
is made.
■ In administering the test the subject is required to sort first of all by colour, all other responses
being called wrong; then when he has achieved 10 consecutive correct responses to colour,
the required sorting principle shifts without warning to form.
■ Later it shifts to number, then back again to colour, and so on. The test thus combines the
requirement for shifting frames of reference with a need for empirical discovery of categories.
A total score can be obtained, also scores for perseverative and non-perseverative types of
errors
 Primary PARIETAL LOBE.
sensory
area

Sensory Secondary
Functional
association sensory
areas area
area

Sensory
speech
area of
wernicke
 30

Lesions of primary sensory area:

• Lead to the loss of appreciation of exteroceptive and proprioceptive

sensations from the opposite half of the body.

• The crude pain, temperature and touch sensations often return, but
this Is believed to be due to functions of the thalamus.
 31

SECONDARY SENSORY AREA

• The whole body is represented bilaterally.

• Area relates more to the pain perception.

• The ablation of this area may relieve intractable pain

 32

SENSORY ASSOCIATION AREA

Concerned with the perception of shape, size, roughness, and texture
of the objects.

• Enables the individual to recognize the objects placed in his/her hand

without seeing.

• Such ability is referred to as stereognosis.

• Lesions of sensory association area result in inability to

recognize or identify an object by its feel.

• Called tactile agnosia or astereognosis

 TESTS FOR PARIETAL LOBE
FUNCTIONS
• Ideational apraxia
• Right-left orientation Test
• Finger agnosia Test
• Visuo-spatial functions
• Cortical sensations
• Simple and complex calculations
• Geographical orientation
• Constructional ability tests
 34

TEST FOR PARIETAL LOBE FUNCTION

1)Ideational apraxia:

• Patient is unable to perform a task which involves a series of motor

activity or steps.

For example: Fold an envelope, apply a stamp and seal it.

Open a toothpaste, take the toothbrush and place the

paste on the brush
 35

2)Right-left orientation Test

can be done in four steps of increasing difficulty:

1. Identification on self (e.g. show your left hand)

2. Cross command on self (e.g. touch your left ear with right hand)

3 .Identification on examiner (e.g. show my right hand)

4. Cross command on examiner (e.g. touch my left hand with your right
hand)
 36

3)Finger agnosia Test

can be done in three steps of increasing difficulty:

[Link] finger recognition (touch the patient's finger in a closed-eye state and have eye opened
and ask the patient to point the same finger on the examiner's hand).

2. Identification of the named finger of the examiner.

3. Verbal identification (naming) of fingers of self and the examiner, for example, What is the name of
this finger?

-Both right-left disorientation and finger agnosia are part of Gerstmann syndrome due to
a lesion of dominant parietal lobe.
 37

4)Visuo-spatial functions

• Show the patient a drawn map of his or her house as told by the
caregiver. Now ask the patient to navigate the way in the house.

5)Cortical sensations

• Look for sensory extinction (tactile), astereognosis, graphaesthesia

 38

6)Simple and complex calculations

• Test both verbal and written in increasing order of difficulty –

• First verbal simple, then verbal complex and then written complex. Give verbal
simple calculations with single digit addition, subtraction, multiplication and
division.

• Next give verbal complex calculations (e.g. 12 + 19,42 - 36, etc.), and then
written complex calculation like 106 + 59; 405 - 75, etc.

• Adjust depending on the educational status of the patient.

 39

7)Geographical orientation

• Ask the patient to mark the important cities and towns on the map of
the country.

• Look for the correctness in terms of near the ocean, direction and
accuracy
 40

8) Constructional ability tests

Can done in two steps
1)Reproduction of two and three-dimensional diagrams: (at least two of each
type).Scoring - 0 ,1 ,2 ,3 for poor, fair, good and excellent, respectively.
This tests constructive praxis/visuo-constructive ability involving integration among parietal,
occipital and frontal lobe.
2) Drawing on command: Clock face drawing
Ask to draw a wall clock face by drawing a large circle, putting numbers from 1 to 12 and
two hands showing time ll:10.
If patient is unable to initiate drawing a circle, then ask again to do it
Scoring - give 3 for putting no. 12 in position, 1 for 12 numbers, 1 for hands and 1 for
correct time.
• Score of less than 4 suggests definite impairment.
• This tests constructional apraxia, visuo-spatial orientation, hemineglect, right-left
41
2) Drawing on command: Clock face drawing
Ask to draw a wall clock face by drawing a large circle, putting numbers from 1 to
12 and two hands showing time ll:10.
If patient is unable to initiate drawing a circle, then ask again to do it
Scoring - give 3 for putting no. 12 in position, 1 for 12 numbers, 1 for hands and 1
for correct time.
■ Score of less than 4 suggests definite impairment.
■ This tests constructional apraxia, visuo-spatial orientation, hemineglect, right-left
orientation, planning and sequencing.
 44

FUNCTIONAL AREA OF THE

TEMPORAL LOBE
• Sensory:- auditory and visual
perception

• Memory

• Comprehension & understanding

spoken language

• Emotion and behaviour

 45

TESTS FOR TEMPORAL LOBE

• Verbal Memory: four unrelated words

• Visual Memory: Hidden Objects

• Language Comprehension:
• Pointing Commands

• Yes-No Questions
 46

VERBAL MEMORY
• Four unrelated words

• Recall after few minutes

• Registration Distraction Recall

• Words : red , carrot , ankle , loyalty .

• Cued recall : “ one word was color” ( semantic cues ) , “hon…….

(instead of loyalty ). (Phonemic cues)
 47

VISUAL MEMORY
• Five small commonly used items (pen,keys,coin, comb, fork) are
hidden while the patient is watching.

• Name each item as it is hidden to ensure that patient is aware

where they are hidden .

• Registration Distraction Recall.

• Ask to name and indicate the location

 48

NEUROPSYCHOLOGICAL ASSESSMENT
1-Testing for auditory processing capacity-
• DICHOTIC TESTING TASK
2- Testing for visual processing capacities-
• Mc Gill picture anomalies tests
3—Test for verbal memory—
• Wechsler memory scale
4—Test for visual memory
• Rey complex figure/ Rey-Osterrieth Test
5—Test for language comprehension
• Token test
 49

APHASIAS
• Global :-M/C ,Spontaneous speech is absent or reduced to a few stereotyped words or
sounds. Comprehension is absent/reduced.

• Broca ‘s:- Nonfluent , comprehension good , poor repetition.

• Wernicke’s:- fluent, poor comprehension & repetition.

• Conduction:- poor repetition, paraphagic , fluent speech comprehension relatively spared

• Transcortical:- retained repetition but subdivided according to fluency & comprehension

as transcortical motor/ sensory

• Anomic Aphasia- There is word finding difficulty and an inability to name objects , speech
is spontaneous, fluent, grammatically rich but contains many word finding pauses

• Subcortical Aphasia- fluent/articulary disturbances Repetition is intact/impaired impaired

comprehension
 50

MEMORY ASSESSMENT
• Immediate memory:- 3 unrelated words ask to repeat , digit span
test.

• Recent /short term- recall of 3 words after 5 min , recent events of

day

* Orientation – time/place/person

* Verbal memory- word list test

* Visuo -spatial memory- reproduce drawings

• Remote /Long term:- personal / historic events of past.

 MEMORY TESTS
■ Paired associate learning tests
■ Object Learning Test
■ List learning tests
■ Recognition memory tests
■ Camden Memory Test
■ Benton Visual Retention Test
■ Rey–Osterrieth Test
■ Adult Memory and Information Processing Battery
 PAIRED ASSOCIATE TESTS
■ Paired associate learning involves
■ mastery of the appropriate response
■ when the first member of a
■ pair of words is present
 OBJECT LEARNING TESTS
■ Four cards are divided into 25 equal sections within which there are drawings of
familiar objects
■ The first card contains 10 items, the second 15, the third 20 and the fourth 25.
■ Six of the items are repeated across all four cards and are always in the same
position.
■ Some items form a category across the cards.
■ The cards are exposed to the subject for a standard length of time, and the
score represents the total number of correct items recalled
 Benton visual retention test

■ The subject must draw the designs from memory

after each card has been exposed for 10 seconds
and then removed.
■ The test can be varied by giving shorter exposures,
or by imposing delays before reproduction is required.
■ Copying of the designs while the card is in front of
the subject allows separation of memory difficulties from
visuoperceptual difficulties.
■ Performance is scored in terms of the number of
designs correctly reproduced and the number of errors made.
Rey–Osterrieth Test

• This involves the copying of a

single geometrical figure of
complex design, then testing
reproduction from memory
some time later
• The initial copying phase
therefore tests for attentional
neglect and praxic skills.
 OCCIPITAL LOBE
• FUNCTIONAL AREAS

• LESIONS

• TEST FOR OCCIPITAL LOBE FUNCTIONS

 57

Test for Occipital Lobe functions

• Prosopagnosia (inability to recognize familiar faces)

• The photographs of family members, popular figures like sportsmen,

political, historical or religious figures can be shown and patient can
be asked to identify the person in picture.

• Presence of any hemianopia with macular sparing also supports the

involvement of occipital lobe.
• Visual memory (five hidden objects):

• Direction - Name each item as it is hidden, provide interfering

stimuli for 5 minutes, ask the patient to name and indicate the
location,

• If the patient cannot locate, ask the name of the hidden

object.
 SECONDARY VISUAL AREA/VISUAL
59

ASSOCIATION AREA
Brodmann's Areas 18 and 19

• It relates the visual information received from primary visual area to

the past visual experiences,enabling the individual to recognize and
appreciate what he is seeing.

• Secondary visual area is responsible for recognition of the objects

seen.

• Lesions on the secondary visual area :Result in a loss of ability to

recognize objects (visual agnosia) seen in the opposite field of vision
FUNCTIONS OF FOUR LOBES OF BRAIN AND
RECOMMENDED TESTS 60
 References
• Bickerstaff’s Neurological Examination in Clinical Practice
• The Mental Status Examination in Neurology- Strub and Black
• Lishman’s Organic Psychiatry
• The Brain & Behaviour -David [Link] Nash N .Boutros