CORTICAL FUNCTION

dr. Paulus Anam Ong Sp.S

dr. Yustiani Dikot Sp.S(K)
Bagian I.P. Saraf RSHS FKUP
 Susunan saraf pusat

Cerebral
hemispheres

Batang otak Cerebellum

Brainstem

Spinal chord
Lobes of human cerebral cortex

PARIETAL
FRONTAL LOBE
LOBE OCCIPITAL LOBE

TEMPORAL
LOBE
 Neuron

axon

soma
Neuron Neuron

Synapse

dendrit
CEREBRUM / FOREBRAIN

p CONSIST OF 2 HEMISPHERE WHICH IS

NOT SYMETRICAL IN SHAPE AND
FUNCTION
p THE LARGEST PART OF THE HUMAN
BRAIN
p COVERED BY GRAY MATTER CALLED
CORTEX WHICH WAS FOLDED MADE GYRI
AND SULCI
Part Of Cerebral Cortex
CEREBRAL CORTEX
p CONSIST OF SIX LAYERS, THE THICHNESS VARIES IN
DIFFERENT REGIONS
p VIEWED LATERALLY COMPOSED OF FOUR LOBES,
BROODMAN DEVIDED IN 47 AREAS WHICH SPECIFIC PART
RESPECT FOR A CERTAIN ASPECT OF FUNCTION
p FUNCTION ARE INTEGRATION IN DISCRIMINATIVE AND
COGNITIVE PROCESSES RELATING TO AFFECTIVE
BEHAVIOR, MOTOR FUNCTION, SOMATOSENSORY
PERCEPTION, INTEGRATION AND MEMORY FUNCTION
p PERCEPTION
p MOTIVATION
p MOVEMENT
Functional Areas of The Cerebrum
INTEGRATION FIBRES
p INTEGRATION IN ONE HEMISPHERE

ASSOCIATION FIBRES

p INTEGRATION BETWEEN TWO HEMISPHERE

COMMISURE FIBRES/CORPUS CALLOSUM

p INTEGRATION WITH OTHER PART OF CNS

PROJECTION FIBRES
Right and Left Hemisphere Function
Right and Left Hemisphere Function
THE 47 AREAS
Consist of
p PRIMARY / PRINCIPLE RECEPTIVE AREA
p ASSOCIATION AREA
p INTEGRATION WITH OTHER PART
OF THE HEMISPHERE / BRAIN
Homonculus Cerebri
The Lateral Aspect of Cerebrum
The Medial Aspect of Cerebrum
Frontal Lobe Parts
 FRONTAL LOBE
FUNCTION
1. PRECENTRAL GYRUS (MOTOR CORTEX)
• Contralateral movement face, arm, leg, trunk
2. BROCA’S AREA (DOMINANT HEMISPHERE)
• Expressive centre for speech
3. SUPPLEMENTORY MOTOR AREA
• Contralateral head and eye turning
4. PREFRONTAL AREAS
• Personality and Initiative
5. PRECENTRAL LOBULE
• Cortical Inhibition of bladder and bowel voiding
 IMPAIREMENT OF FRONTAL
LOBE FUNCTION

1. PRECENTRAL GYRUS

Monoplegia or hemiplegia depending on extent of damage

2. BROCA’S AREA

Broca’s dysphasia
3. SUPPLEMENTARY MOTOR AREA

Paralysis of head and eye movement to opposite site

5. PRECENTRAL GYRUS

Incontinence of urine and fecal

Loss of cortical inhibition
 4. PREFRONTAL AREAS
Change personality with antisocial behavior
/ loss of inhibition

A.ORBITOFRONTAL SYNDROME
1. Poor judgement
2. Disinhibition
3. Emotional lability
B. FRONTAL CONVEXITY SYNDROME
p Apathy
p Indifference
p Poor abstract thought
C. MEDIAL FRONTAL SYNDROME
p Akinetic
p Incontinent
p Sparse verbal output
Associated with :
1. Primitive reflexes (gasp,pout, etc.)
2. Disturbance of gait (gait apraxia)
3. Resistance to passive movements of the limbs
(paratonia)
Parietal Lobe Parts
 PARIETAL LOBES
FUNCTION
1. POSTCENTRAL GYRUS (Sensory Cortex)
• Receives afferent pathways for appreciation of posture, touch
and passive movement
2. SUPRAMARGINAL AND ANGULAR GYRI
• DOMINANT HEMISPHERE
• Angular gyrus (Broadmann 39): Integration of auditory and
visual aspects comprehension
• Skill of handling numbers/calculation
• NON-DOMINANT HEMISPHERE
• Concept of body imaged and the awareness of the external
environment
• Ability to construct shape
 PARIETAL LOBE
IMPAIRMENT
1. DISTURBED
• Postural sensation
• Sensation of passive movement
• Accurate localisation of light touch
• Two point discrimination
2. As part of lesion extension from Wernicke language
area (posterior region of left superior temporal gyri
/Broadman area 21,42), this area involve in Wernicke
Aphasia

NON-DOMINANT
• Anosognosia, Dressing apraxia, Geographical
apraxia. Constructional apraxia
DOMINANT : (Gertman’s Syndrome)
• Right and left limbs disorientation, Finger agnosia.
Acalculation, Agraphia
Temporal Lobe Parts
 LOBUS TEMPORAL
FUNCTION
1. AUDITORY CORTEX (Heschl’s gyrus)
• Dominant è Hearing of Language
• Non-Dominant è Hearing of sound, rhythm and music
2. The superior temporal Gyrus, adjacent to Hesch’s gyrus,
§ auditory comprehension/ association area (left hemisphere: Wernicke
Language area/Broadmann are 21, 42)
3. THE MIDDLE AND INFERIOR TEMPORAL GYRI
• Learning and Memory
4. THE LIMBIC LOBE
• Sensation of olfaction
• Emosional
• Affective behavior
5. VISUAL PATHWAY
 TEMPORAL LOBE
IMPAIRMENT
1. AUDITORY CORTEX (Cortical deafness)
• DOMINANTè Difficulty in hearing spoken sounds
• NON-DOMINANT è Amusia
• Auditory hallucinations
2. Left posterior region of superior gyri (BA 21,42): Wernicke aphasia.
Lesion may extend to angular gyri of left temporal lobe/BA 39)
3. MIDDLE AND INFERIOR TEMPORAL GYRI
• Disturbed memory / learning
4. LIMBIC LOBE
• Olfactory hallucination with complex partial seizures
• Aggressive or antisocial behavior
• Inability to establish new memories
5. OPTIC RADIATION
• Upper homonymous qudrantanopia
Occipital Lobe Parts
 OCCIPITAL LOBE
FUNCTION

p Concerned with the perception of vision (The

visual cortex)
n Lies along the banks of the calcarine sulcus
p The Striate cortex èPrimary visual cortex
p Parastriate cortex è Association visual
cortex
 OCCIPITAL LOBE
IMPAIRMENT
1. HOMONIMOUS HEMIANOPSIA
2. CORTICAL BLINDNESS
• Extensive bilateral cortical lesions of the striate cortex
3. ANTON’S SYNDROME
• Involvement of both the striate and the parastriate cortices
affects the interpretation of vision
• Unaware of the visual loss and denies its presence
4. BALINT’S SYNDROME
• Simultanagnosia
5. VISUAL HALLUCINATIONS
• Elementary – unformed – appearing as patterns
6. VISUAL ILLUSIONS (Non-dominant)
• Micropsia / macropsia
• Disappearance of colour
7. PROSOPAGNOSIA
• Able to see a familiar face but cannot named it
Mental Status
5 basic element that build mental
status
1. Arousal Mechanism ( alertness, attention,
concentration)
2. Orientation
3. Language
4. Memory
5. Higher cortical function
Basic element of mental status

Higher cortical function Basic element of cogntion

(Marshall,Mayer.1997)

Memory Language • Arousal mechanism

• Bahasa & memori: well
developed and localized
basic element elemen

Concentration
• Higher cortical function:
depend on the 3 basic
Attentioni
element
Arousal
Language
p The basic tool of human communication and
crucial in assessing most cognitive abilities

p Must be establish early in the course of mental

status testing due to most of the mental test are
verbal oriented e.g verbal memory test, oral
calculation, proverb test
Terminology
p Dysarthria: specific disorder of articulation in which
basic language (grammar, comprehension & word
choice) is intact

p Dysprosody: an interruption of speech melody

(inflection and rhyme) that caused monotonal,
halting, can at times mimic a foreign accent

p Aphasia: a true deficit of higher integrative language

processing, patient produces errors of grammar and
word choice or has a defect in comprehension
Terminology
p Alexia: loss of (any level of) reading ability in
previously literate person.
p Dyslexia: a specific developmental learning disorders
of children who have normal intelligence, yet
experience unusual difficult in learning to read
p Agraphia: an acquired disturbance in writing.
Specifically refers to errors of language and not to
problem with the actual formation of letter or poor
handwriting
Aphasia
p Def: an acquired language impairment due to
damage to language areas of the brain (left
hemisphere)
p Characterized by defects of:
n Word selection
n language production
n language comprehension
p Affect not only spoken, but also written language
both comprehension (alexia) and production
(agraphia)
Etiology of aphasia
p Acute
n ischemic stroke (embolic/ thrombotic) in the distribution
of middle cerebral artery
n Cerebral hemorhage (hipertension, AVM, Aneurysm,
n Trauma

p Slowly progressive:
n brain tumor
n Degenerative process: Alzheimer disease, Primary
Progressive Aphasia

p Transient: TIA, epileptic seizures

Aphasia

p 95% result from left hemisphere lesions ‘cause

95% of right handed individual and 70% of left
handed are left hemisphere dominant for
language

p Crossed aphasia: aphasia after lesion of right

hemisphere in a right handed individual
Primary Language Area
(perisylvian area)

Girus Girus postsentralis

presentralis

Fasikulus
Arcuatus

Area Broca Area Wernicke

Girus temporalis superior

Sulkus lateralis
Language model of Wernicke-Geswind

kiri kanan
Perisylvian area
p Aphasia most often caused by damage of
perisylvian language, that comprises of:
n Broca’s area: motor programming of speech à Broca
aphasia
n Wernicke’s area: critical for auditory comprehension of
spoken words à Wernicke aphasia
n Arcuate fasciculus: links Broca’s and Wernicke’s areas,
important for repetition à Conduction aphasia
Extra perisylvian aphasias
p Aphasia may also caused by lesions that
do not directly damage the perisylvian
language area, but isolate them from
brain regions involved in semantic
processing and production of volitional
speech à Transcortical aphasias
Clinical evaluation

p Fluency
p Naming
p Repetition
p Auditory comprehesion
Fluency
p Fluent aphasias
n plentiful verbal output, well articulated, easy produced
utterances of relatively normal length and prosody (i.e.,
variation of pitch, loudness, rhythm).
n Lesions: post Rolandic cortex
p Non Fluent aphasia:
n sparse, effortful utterances of short phrase length and
disrupted prosody
n Lesion: pre-Rolandic cortex
Naming

p All aphasic patients exhibit naming

impairment, or anomia, usually in
combination with other language
deficits

p Isolated anomia à anomic aphasia

Auditory comprehension
p Most aphasic patients show auditory
processing defective

p Anterior lesions result in relatively mild

auditory comprehension impairment, whereas
posterior lesions (esp. Wernicke’s area) result
in significant impairment of auditory
processing
Repetition

p Requires intact perisylvian language area

p Perisylvian aphasias: repetition distrubed

p Extra-perisylvian aphasia: preserved of

repetition
Classification of Aphasia
Broca’s Area

Executive or motor for

production of language

Broca’s dysphasia Þ Motor

dysphasia
p Nonfluent / hesitant
speech
p Telegraphic speech
p Comprehension – relative
preserved
p Repetition – poor
p Handwriting- poor
Wernick’s Area–Receptive Area

Wernicke’s dysphasia
p Comprehension – Impaired
p Speech fluent but nonsensical
p Neologism
p Paraphasia – half right words
p Patient unaware of language
problems
p Repetition: relative preserved
p Hand writing poor
Conduction Aphasia

n Speech nonsensical
but fluent
n Comprehension -
normal
n Repetition - poor
Global Aphasia

p Non-fluent speech

p Comprehension impaired

p Repetition - poor
Boston Aphasia Classification

Aphasia syndromes Fluency Naming Repetition Auditory

Comprehen
sion
Broca aphasia Non-fluent - - +

Wernicke aphasia Fluent - - -

Conduction aphasia Fluent - - +

Gobal aphasia Non-fluent - - -

Transcortical motor aphasia Non-fluent - + +

Transcortical sensory aphasia Fluent - + -

Mixed transcortical aphasia Non-fluent - + -

Anomia aphasia Fluent - + +

+: relatively preserved -: relatively disturbed

Memory
Memory
p Involves :
1. Recognition
2. Registration
3. Recall – Retrieval
p Anatomical basis of memory
ß
Hippocampus
The Anatomical Basis of Memory
 Test of Memory

1. Immediate memory
2. Recent memory
3. Remote memory
Disorder of Memory
(Amnesia Syndrome)

1. Retrograde amnesia
Ø Impairment of memory for events that
antedate illness or injury

2. Anterograde amnesia
Ø Inability to learn new verbal or non-verbal
information from onset of illness or injury
Disorders of Memory Retrieval

p Senescence – AAMI (Age Associated Memory

Impairment) –retrieval of stored memory slow
but accurate
p Depression – disorder in motivation and
concentration
p Dementia – especially recent memories
p MCI- mild cognitive impairment amnestic type; a
pre-dementia stage
Constructional ability
p Capacity to draw or construct two or three
dimensional figures or shapes

p Task
n Copying line drawing
n Drawing to command
n Reconstructing block design

p Parietal lobe dysfunction

n Right hemisphere produces higher inciden and severity
than the left.
 Constructional Abilities
Copying Figures

Stimulus Results
Constructional Abilities
Copying Figures
Higher Cortical Function
p Attention Basic buiding blocks for
p Language development of higher
p Memory cortical function

Consists of :
p Manipulation of well learned material
p Abstract thinking
p Arithmatic computation etc
1. Evaluation

1. The fund of acquired information or the

store of knowlegde
• Assessed by :
1. Simple verbal test of vocabulary

2. General information/ knowledge

3. Proverb interpretation
2. Manipulation of old knowledge

p Ability to apply information to new or

unfamiliar situations
p Assessed by :
1. Calculation
2. Similarities and Differences
3. Conceptual Series completion
4. Social comprehension
Related cortical functions
p Apraxia
p Right-Left disorientation
p Acalculia Gerstmann’s
p Agraphia Syndrome

p Finger Agnosia
p Visual agnosia
p Geographic disorientation
APRAXIA

Loss of ability to carry out skilled

movement despite adequate
understanding of task and normal
motor power
Ideomotor apraxia
p Separation of idea of movement from execution
• Dominant hemisphere lesion
• Unable to carry out commands:
• Buccofacial apraxia: “Show me how to blow out a
match” ; “drink through a straw” –
• Limb apraxia: “flipping a coin”, “saluting”, “kicking a
ball”
• Truncal apraxia: “stand like a boxer”
Task: fail in commandà imitating à real object
Apraxia Ideomotor
Ideational apraxia

p Inability to carry out a sequence of

movements
p Higher order of complex motor planning than
ideomotor apraxia
p Difficulty in manipulating real object
p Sometimes show object agnosia: e.g. striking
candle to match box
p Bilateral diffuse cortex lesions especially
parietal cortex
Task: “ folding a letter, placing it in an envelope,
sealing it, and placing a stamp on the envelop”
Other apraxias

3. Constructional apraxia and dressing apraxia

(Non dominant parietal disease)
4. Gait apraxia (Frontal lobe/anterior corpus
callosum disease)
5. Occulomotor apraxia (Parieto-occipital
disease)
DISCONNECTION PATHWAY

1. INTRAHEMISPHERIC
• Linking part of the same hemisphere

2. INTERHEMISPHERE
• Corpus callosum link related parts of the two
hemisphere
Intrahemisphere Dysconnection Syndrome

CONDUCTION APHASIA

p Lesion of the arcuate

fasciculus
p Fluent dysphasia speech
p good comprehension, Broca’s speech area
poor repetition

Wernicke’s speech area

Intrahemisphere Dysconnection Syndrome

PURE WORD DEAFNESS

p Lesion beetween the primary

auditory cortex (Heschl’s
gyrus) and auditory
association cortex)
p Impaired comprehension of
spoken word, self initiated is
normal
p Patient seems deaf but
audiometry is normal
INTERHEMISPHERE DISCONNECTION SYNDROME
AGENESIS OF THE CORPUS CALLOSUM

p No connection between the

two hemisphere
p Failure to name an object
presented visually or by
touch to the non-dominant
hemisphere
Interhemisphere Dysconnection Syndrome
BUCCAL LINGUAL and SYMPATHETIC APRAXIA

p Involves the links between

left and right association
motor cortices Premotor motor
cortex Broca’s
p Right brachiofacial area
weakness and apraxia of
tongue, lip and left limb
movements
INTERHEMISPHERE DISCONNECTION SYNDROME

LEFT SIDE APRAXIA

p Lesion of the anterior

corpus callosum

p Apraxia of the left

sided limb move-
ment
INTERHEMISPHERE DISCONNECTION SYNDROME

ALEXIA WITHOUT AGRAPHIA

PURE WORD BLINDNESS

p Lesion of the posterior corpus callosum and

dominat occipital lobe (primary visual area)

p Inability to read, to name colours, to copy

writing and the ability to identify colours
n Inability to read letter (literal alexia)

n Inability to read word (verbal alexia)

Alexia without agraphia

Pure alexia Hemi alexia