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A few retrospective studies have other things allergy treatment kochi purchase seroflo with mastercard, how an epileptogenic focus arises distant from a favored the use of valproic acid when compared to allergy xyzal discount seroflo 250 mcg otc phenytoin tumor (30) allergy shots for poison ivy seroflo 250 mcg on-line, and why a procedure that would not basically or carbamazepine in view of the promptness of it achieving a affect this desynchronization and deafferentation allergy levels nyc discount 250 mcg seroflo, such as with therapeutic level, its enzyme-inhibiting properties that may a simple removal of the tumor via a lesionectomy, may not increase the effectiveness of concomitant chemotherapy, and achieve optimal seizure freedom (36). However, it It has been suggested that in almost one third of patients may cause significant bone marrow suppression, especially with brain tumors and epilepsy, the epileptogenic focus does given its combination with chemotherapy. This phenomenon is called several prospective studies have recently suggested that either secondary epileptogenesis, implying that an actively discharging gabapentin (38), levetiracetam (39,40), or topiramate (41) epileptogenic region induces similar paroxysmal activity in may be effective options for add-on therapy. This process is mostly tive series of 26 patients with primary brain tumors who seen with low-grade brain tumors located in the temporal lobe, received add-on levetiracetam, usually in combination with which may have associated hippocampal sclerosis (21). In those valproic acid, a seizure reduction of more than 50% was cases, the secondary focus becomes a completely independent observed in 65% of patients (40). In a small prospective series epileptic generator that needs to be also removed to achieve of 14 patients with intractable seizures and brain neoplasms, seizure freedom in intractable patients. Since young age and gabapentin was added to phenytoin, carbamazepine, or long disease duration have been proposed as being the main clobazam. Reduction in seizure frequency was seen in all risk factors for this secondary epileptogenesis (37), early resecpatients, and more than 50% became seizure-free (38). In tion of the primary focusthe tumorhas been promoted to another prospective observational study of 47 glioma patients, avoid the development of an irreversible secondary focus and initial or add-on therapy with topiramate achieved complete was actually shown to correlate with better rates of seizure freeseizure freedom in 56% of patients with a seizure reduction in dom following resective epilepsy surgery (10,15,37). Very often, adequate treatment of seizures Special Issues Pertaining to Medical in such a setting requires a multidisciplinary approach, including the patients neuro-oncologist, neurosurgeon, and epilepTreatment of Epilepsy in Brain Tumors tologist. Goals of treatment need to be clarified early on in the treatment course, as well as a clear determination of the Medical Intractability of Epilepsy in Brain Tumors riskbenefit ratio of various medical and surgical therapeutic While 20% to 25% of epilepsy patients in general continue options. This has been attributed to a variety of counterproductive, worsening the patients quality of life. Overexpression of proteins belonging the other hand, a simple reduction in seizure frequency would to the multidrug resistance pathway is a frequently discussed likely be an unacceptable treatment goal in a patient with a mechanism of refractoriness. Carbamazepine, phenyfor nor against seizure prophylaxis, in people with brain toin, phenobarbital, and primidone, and to a lesser extent tumors (23). Similarly, individual risk factors and careful discussion with patients, enzyme inhibition or induction by anticancer drugs can lead keeping in mind that there is no strong evidence that any of to toxicity or loss of seizure control (34,43). In another series of adult tumor-related epilepsy Surgical Treatment patients, the epileptogenic focus as determined by interictal and ictal recordings agreed with the involved lobe in 72% of In general, the following questions are considered when evaluthe cases (14). First, Should any kind of neurophysiological testing be performed it is important to acknowledge that even though the aboveprior to surgeryfi Will mentioned studies showed seizures arising from the same a lesionectomy be appropriate, or is a more aggressive reseclobe as the tumor, electrocorticographic recordings usually tion requiredfi How can this patient be counseled about show that the tumors themselves are electrically inert and that his/her seizure outcome following surgeryfi Despite extensive epilepsy often arises from the tissue surrounding the tumor literature available on these topics, such decisions remain very (31). Some have even suggested that seizures arise distant much patient-dependent, and a careful consideration of all from the tumor in up to a third of patients with brain tumors treatment options, as well as a clear and educated patient and epilepsy (3,9,30). Second, not A critical piece of information that determines the answer to all brain tumors are epileptogenic and not all spells are this question is the type and grade of the tumor in question. Third, some studies have reported better seizure with a high risk of malignant transformation such as ganglioutcomes with the use of intraoperative electrocorticography ogliomas, surgical removal is an essential part of the tumor in tumor surgery and the resection of intraoperatively identitreatment, and should be performed regardless of whether it is fied zones of interictal spiking and ictal onsets (3,13,45). On the other hand, most developmental postoperative seizure-free incidences for the group that undertumors and many low-grade tumors may be observed for years went lesionectomy plus additional spike-positive site resection from a tumor treatment perspective, or be treated with equated to 90. However, such results need to be reproduced mainly depend on whether a patients seizures are controlled in larger scale randomized studies. Many epileptologists usually wait until in proximity to eloquent cortex, intraor extraoperative funcseizures are medically intractable before pursuing surgical tional mapping is often essential in determining the extent of tumor removal. For all the above reasons, it is recepilepsy duration at the time of tumor resection is an imporommended to perform a neurophysiological evaluation, tant predictor of postoperative seizure freedom. Such observations, together with the high risk of rates ranging from 65% to 80% (21,26,27,47). There is eviintractability in low-grade tumors (1,3,4), support early dence, however, to support more aggressive resections in removal of low-grade brain tumors associated with epilepsy, certain situations. This issue has been investigated most especially when the tumor is easily surgically accessible (3). An extensive lesionectomy was performed to include areas of identified epileptogenicity rendering the patient seizure-free (follow-up of 2 years). Such findings have been attributed to the high prevalence of dual pathology in Seizure Outcome temporal lobe tumors (28,29,49), and to the risk of associIn both temporal and extratemporal epilepsy surgery, a ated secondary epileptogenesis. This is supported by the tumoral etiology carries usually a favorable prognosis and is persistence of interictal spiking recorded with intraoperative associated with a favorable seizure outcome in as many as electrocorticography in the hippocampus of 86% of cases 65% to 87% of the cases (10,15,21,26,27,47,50). The practice of resecting the complete tumor resection and short epilepsy duration at the mesial temporal structures while resecting the tumor is easy time of surgery. In another review above-mentioned outcome data prompt most surgical cenof 332 adults with low-grade glioma, patients with a grossters to resect the hippocampus, especially if neuropsycholototal resection were 16 times more likely to achieve seizure gial testing suggests a low risk for postoperative functional freedom than after subtotal resection/biopsy alone (10). Currently, it is There is little doubt currently then that a complete resection is difficult to justify resecting a dominant normally appearing the crucial determinant of seizure freedom. Seizure recurrence hippocampus unless there is compelling evidence, such as should prompt an evaluation for tumor recurrence (24,29). This finding may support early tumor removal in with temporal lobe tumours and medically refractory focal epilepsy. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Our knowledge of the tumors in childhood: long-term outcome and prognostic features. Optimal seizure management in brain tumor ditions has grown exponentially over the past few years, but patients. Several medical and surgical epilepsy: characteristics and predictors of surgical outcome. Frontal lobe tumoral epilepsy: clinical, neurophysiologic features and predictors of surgical outproposed. Coexistence of neoplasia and cortical plete view of the true disease pathophysiology and likely be dysplasia in patients presenting with seizures. Gangliogliomas: characteristic imaging findings and role in the temporal lobe epilepsy. Gene expression profile analysis of patients with newly diagnosed brain tumors: a retrospective review. Seizures as the presenting symptom of brain in glioma patients: who, when, why and how longfi Array analysis of epilepsy-associtumours: epidemiology, mechanisms, and management. Outcome and tolerability of topifollowing resection in 332 patients with low-grade gliomas. Neuropathological findings in epilepsy and mechanisms underlying multidrug resistance in refractory 224 patients with temporal lobe epilepsy. Efficacy of intraoperative electrocorticogassociated with medically intractable epilepsy. Prospective study of awake craniotomy used routypes encountered in the Cleveland Clinic epilepsy surgery program. Surgical outcome in patients with ing surgery for dysembryoplastic neuroepithelial tumor. Presurgical seizure frequency newly diagnosed glioblastoma patients: update on the Lombardia experiand tumoral etiology predict the outcome after extratemporal epilepsy ence. Factors contributing to resectability and case-control study using electronic primary care records. Nearly 40% of these late seizures trauma or subsequent complications and have to be differentiappear within the first 6 months after injury; more than 50% ated from late, unprovoked post-traumatic seizures defining a appear by 1 year and 70% to 80% appear by 2 years after the diagnosis of epilepsy (10). Most of these early post-traumatic seizures population has not changed in the past 30 years, the number occur within the first week after injury (10). Only six patients had clinically witnessed infections can cause symptomatic seizures several weeks after generalized tonicclonic seizures, another four patients the injury (Table 29. Moderate to severe head injury, in particular the status epilepticus, more often seen in children (23,42).

This leads us to allergy testing san francisco generic seroflo 250mcg on-line think that either the parents in the current study were a unique group based on their proactive nature allergy symptoms mold cheap seroflo online, or it might be possible that general awareness amongst the public about autism has increased along with improvements in accessibility to allergy medicine keeps me awake buy generic seroflo from india 71 services allergy forecast plano tx discount 250mcg seroflo, thus leading parents to seek help early. Early identification of developmental disorders, including autism, has become a best practice since it helps families gather information and begin treatment early (Filipek et al. The majority of parents coped with the diagnosis of autism through social support from family, friends and parent support groups. Moreover, 77% of the parents reported being affiliated to an autism organization, parent group or a parent network. Research has shown that social support in families with disabilities is significantly related to child behavior characteristics which in turn are significantly related to child progress (Kazak & Marvin, 1984). Overall, the parents in this sample were well-educated (67% of the parents had a college degree or higher), were well-off (77% of the families had an annual household income of $40,000 and above) and had a strong social support (77 % were affiliated to an autism organization, parent group or a parent network, 61% sought support from family, and 39% sought support from friends) which may have affected the early diagnosis and early intervention for their children. It may be argued that in this sample, early identification and intervention may have affected the progress that their child had made up till now, which most of the parents reported to be moderate to excellent. Resources Spent on Diagnosis and Intervention the average amount of money spent by parents on diagnosis was $ 759. It was interesting that almost 65% of the parents spent nothing or less than $ 100 on the diagnosis. This is comparable to 60% of the parents who spent none or less that $100 on current intervention. Although a majority of parents (77%) in this sample had an annual household income of $40,000 and above, 23. However, socioeconomic status of the parents should be considered relative to the area of the country where they reside and the associated cost of living. Thus, two possibilities arise with the groups of parents on both ends of the spectrum. It may be possible that parents, who were on the middle to higher end of the spectrum of household income, may have had adequate insurance plans to cover the expenses of their services. The other possibility is that parents on the lower end of the spectrum may not have had good insurance plans to support services for their child. They may have taken advantage of the National Health Plans such as Medicaid to pay for their childs treatment. This may be another reason why most of the parents in this sample may have spent nothing or less than $100 on diagnosis and interventions. Even though spending 10-40 hours may seem more than sufficient for children in general, it may not be adequate for children with autism given the research about remarkable gains after intensive behavioral interventions (Lovaas, 1987). Only 3% of the parents noted that they spent more than 40 hours a week on intervention. When asked about their opinion about whether their children should receive 40-hours of therapy every week, 45. First, even though some parents may wish to provide 40 hours of therapy, they may not have time to provide intensive behavioral treatment. Second, it may be possible that children may be receiving 40 hours of therapy per week across home and school/private settings. However, since the question only sought to ask about the time spent by parents on intervention, the number of hours reported may not be the total number of hours of therapy that their children receive per week. Third, some parents may not feel that their children need intensive behavioral treatment (more than 40 hours of therapy per week) because their children may be high functioning and making progress even with less than 40 hours of therapy. Issues of Assessment and Diagnosis the majority (61%) of the children in the sample were diagnosed as having Autistic disorder, followed by some (28. In this sample, some parents (35%) reported worrying about the child before the age of 1 year. Therefore, it could be argued that since 84% of the parents (of whom 41% were concerned before the age of 1 year) reported being worried before the age of 2 years; the problems were severe enough to be concerned that early. The severity of the problems may be evident in the fact that parents reported noticing transition difficulties (44. As a result, these children may have received the diagnosis earlier than the children with other diagnoses under the umbrella of Pervasive Developmental Disorders. This may be confirmed by the results of the exploratory analysis, that the group with Autistic disorder (M = 2. Although there were no significant differences in the age of diagnosis of the Autistic group (M = 2. In children with Aspergers disorder, there are no clinically significant delays or deviances in language acquisition before the age of 3 years, in contrast to children with Autistic disorder. Although these children are usually described as using adult-like language, they may have difficulties in communication due to social dysfunction. Parents may not be concerned about their child until the child begins pre-school or is exposed to same-age children, at which point their social skill deficits may become apparent. In most of the school-age children with Aspergers disorder, good verbal abilities may mask the severity of social dysfunction. This may mislead parents to focus on the childs good verbal abilities, while being insufficiently unaware of the deficits in the social aspects of language development. This may suggest that parents may not be concerned about their child until later, thus receiving a diagnosis at a later age than the other diagnosis. First, it was found that this label is often used as a default diagnosis when inadequate information about the symptom presentation is available to make a specific diagnosis. Second, this diagnosis is given to children whose symptoms are severe enough to warrant a diagnosis on the autism spectrum, but do not meet criteria for Autistic disorder. When the childs social skill deficits become apparent at about the time that he/she goes to pre-school, he/she may meet criteria for a diagnosis of Aspergers disorder. The first concerns that the parents noticed were speech delays and insufficient amount of speech. This is consistent with the fact that a larger portion of our sample (61%) was diagnosed as having Autistic Disorder. A relatively lower percentage of the sample was diagnosed with Aspergers disorder and therefore only a few parents were first concerned that their child was using language much higher for his/her age. This characteristic of children with Aspergers disorder distinguishes them from the children with Autistic disorder. Self-injurious behaviors observed in children with autism are more closely linked to the mental retardation that often accompanies autism than to autism per se (Dawson, Matson, & Cherry, 1998). Noticing lack of pointing may be especially important because joint attention (shared attention between social partners through non-verbal gestures such as pointing or eye gaze) differentiates children with autism from the typically developing or delayed children (Dawson et al. Some aspects of joint attention typically emerge by 912 months of age (Brooks & Meltzoff, 2002), with some aspects emerging as early as 6 months of age (Morales, Mundy, & Rojas, 1998). By 12 months of age, most typical infants display all aspects of joint attention, including sharing attention. Thus, it may be important for parents to understand that pointing is a critical skill that most children should develop before the age of 1year, in order to have a successful speech and language development. When asked about the personnel who referred their child for a diagnostic evaluation, some (15%) parents reported referring their child on their own. Very few reported that a teacher, school psychologist or day care personnel referred the child. It is 78 impressive to find that a substantial number of children were referred for further testing by a pediatrician and only 15% of the parents referred their own child. In the Howlin and Moore (1997) study, about 10 % of the parents reported that although a cause for concern was acknowledged, some were told to return if problems persisted; while others were reassured that their children will outgrow their problems. This suggests that professionals are being aware of symptoms of autism and rather than overlooking parents concerns, they are taking active steps towards early diagnosis and intervention. It may have been possible that parents did not know the type of tool that was used to diagnose their child (31. Furthermore, professionals who diagnosed most of the children were clinical child psychologists (35. Very few mentioned that psychiatrist, school psychologist, state department case worker, primary care physician, neurologist, infant developmental specialist, neuropsychologist, and speech therapist diagnosed their children for the first time. From this, it is evident that others who diagnosed the children may have used brief observations during office visits, clinical judgment, and general awareness about autism and parent reports to diagnose autism.

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The child typically holds his or her arms out and shows an involuntary shiver or shudder sometimes involving most of the body allergy testing what to expect discount 250mcg seroflo with visa. Hyperekplexia this is a rare differential of neonatal seizures in its severe form allergy medicine xanax buy generic seroflo on line. Typically due to allergy forecast reston va seroflo 250mcg mastercard mutations in glycine receptor genes allergy symptoms 1 month order seroflo online pills, with failure of inhibitory neurotransmission, it causes a marked susceptibility to startle. Sudden sounds, and particularly being touched or handled, precipitate episodes of severe total body stiffening. The spells (and apnoea) can be terminated by forcibly fiexing the neck: a manoeuvre family and carers should be taught. Event severity tends to lessen with time and so long as hypoxic complications are prevented, prognosis is good. Paroxysmal tonic upgaze of infancy this involves prolonged episodes lasting hours at a time of sustained or intermittent upward tonic gaze deviation, with down-beating nystagmus on down gaze. Benign myoclonus of early infancy this is a rare disorder of early infancy with spasms closely resembling those of West syndrome. Onset is between 1 and 12 mths, and movements settle by the end of the second year. Recurrent episodes of cervical dystonia occur resulting in a head tilt or apparent torticollis. Events typically last several hours to a few days in duration and are accompanied by marked autonomic features (pallor and vomiting). The condition typically starts in infancy, resolving within the pre-school years, but such children often go on to develop hemiplegic migraine in later life. There is usually a family history of (hemiplegic) migraine and many cases are associated with calcium channel mutations. Children present with sudden onset signs consistent with vertigo (poor coordination and nystagmus). Children are often strikingly pale and may be nauseated and distressed but not encephalopathic. The condition should not be confused with the similarly named benign paroxysmal positional vertigo, a condition of adults caused by debris in the utricle of the inner ear. Self-comforting phenomena (self-gratification, masturbation) Witnessed self-comforting phenomena are common in normal toddlers, and in older children with neurological disability. A common setting is in high chairs or car travel seats fitted with a strap between the legs and with a tired or bored child. Older children often lie on the fioor, prone or supine, with tightly adducted or crossed legs. This may continue for prolonged periods, the child often becoming fiushed and quite unresponsive to attempted interruption. Parents sometimes require considerable reassurance that such behaviour is commonplace, normal and simply a source of comfort, not a sign of sexual deviancy. Tics these are isolated fragments of gestures or movements repeated compulsively, sometimes in conjunction with vocal tics as part of Tourette syndrome (see b p. Older children can by definition at least briefiy suppress the desire to tic, although they will often report a sense of rising tension, which only resolves by releasing the movements. Ritualistic movements and behavioural stereotypies these are relatively common in young children and older children with neurological disability particularly autistic spectrum disorders. Hyperventilation and anxiety attacks the respiratory alkalosis resulting from hyperventilation is a potent cause of sensory phenomena (particularly peri-orally) and tetanic contraction of the muscles of the forearm and hand resulting in carpopedal spasm. Onset of paroxysmal attacks is from 5 yrs of age; sudden weakness, unsteady, and blurred vision, lasting minutes to hours. Attacks become milder and less frequent with age, but cerebellar signs may persist (cerebellar vermis atrophy on imaging); usually acetazolamide responsive. Paroxysmal dyskinesias A range of individually rare paroxysmal movement disorders is recognized including paroxysmal dystonias and choreoathetosis. They are generally grouped into kinesiogenic (movement induced) and non-kinesiogenic forms. Dyskinesias occurring before meals or after fasting should raise suspicion of glucose transporter deficiency (see b p. May be Dystonia often with Dystonia or chorea Dystonia, chorea or ballism unable to communicate during episode. As stressed in Chapter 3, seizure-like jerking limb movements and even incontinence of urine can result in the late phases of a syncopal episode, raising the risks of a misdiagnosis of epilepsy. The context in which the episode occurred and its earliest features are the most telling. Cardiac disease the importance of correctly identifying an intermittent cardiac dysrhythmia or structural cardiac disease as the cause of episodic loss of awareness is self-evident. Historic clues will include the relationship to exercise and, as stressed, prominent early pallor. The phenomenon has also been referred to as pallid syncope and in the old paediatric literature extremely confusingly as a pallid breath-holding spell (a complete misnomer for reasons that should be apparent). A sudden unexpected shock or pain results in a vagally mediated severe bradycardia or even asystole with consequent hypotension, pallor and loss of consciousness that may then lead to episodes of limb stiffening or clonic jerks. An accurate history identifies the triggers that consistently precede these episodes. Occasionally, severely affected children have come to cardiac pacemaker implantation. Common triggers include intercurrent illness, hot weather, missed meals, inadequate fiuid intake, and prolonged standing. It is typically a disease of adolescents who will be able to report a prodromal awareness of feeling cold, clammy, and unwell. If the event is not terminated by lying down in the prodromal phase, the child goes on to fall stiffiy to the ground or slump, and may exhibit brief tonic or clonic movements, or urinary incontinence. Blue breath-holding spells are primarily hypoxic in origin due to disordered respiration. Typically, a toddler who has become angry or frustrated begins to cry and becomes stuck at the end of a period of prolonged sobs. As a result, the child becomes predominantly blue, limp, and may briefiy lose consciousness; again, this may result in subsequent jerking limb movements. Daydreaming Daydreaming enters the differential of absence seizures as a cause of vacant spells. The fiavour is very different from absence or other seizure that actively interrupts and cuts across normal activity. Movements may include pelvic thrusting, rolling or reciprocating kicking or fiailing movements. None of these occur as part of the repertoire of a generalized tonicclonic seizure. Narcolepsy and cataplexy Narcolepsy is an under-recognized cause of excessive daytime sleepiness (see b p. Cataplexy is a sudden loss of muscle tone typically precipitated by laughter or startle that is a common feature of narcolepsy particularly by early adulthood (although there are other causes). Recognition and appropriate management of functional symptoms is an important skill for the child neurologist. There are some adult data suggesting that pre-existing brain disease increases the risk of functional symptoms, but little evidence that neurological presentations are more common than other presentations of functional disease. Terminology this is a sensitive and important issue if a successful outcome is to be achieved. It is important to be aware that families may be accessing professional or patient support group material on the internet, and they need to understand that, although a variety of terms are in widespread use they are referring to essentially the same clinical problem. It may be helpful to refer to the understanding implied in the term conversion that anxiety can be converted into physical symptoms. Although psychiatric diagnostic schemes emphasize distinctions between deliberate and subconscious intent, and possible motivations. Generally, such distinctions are not relevant to successful resolution (see b p. Diagnostic pointers to functional basis include the following: Paralysis Variable loss of function. Even if the movement is not performed there is usually an involuntary postural adjustment anticipating the lifting of the leg, felt as increased downward pressure of the held heel into the couch, which would not occur if legs were truly paralysed.

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However allergy medicine for juniper purchase cheap seroflo online, as a general rule allergy symptoms latex cheap seroflo 250mcg on-line, the slower the growth of the tumor allergy medicine you can take during pregnancy order seroflo master card, the milder the symptomatology allergy forecast rhode island buy seroflo 250 mcg overnight delivery. Although there are different types of tumors affecting the brain, gliomas (tumors originated from the glia) represent close to 50% of all brain tumors. Secondary tumors (metastatic tumors) represent a relative small percentage, close to 10% (Table 2. Percentage of brain tumors Aphasia Handbook 40 Infections An infection appears when the body is invaded by a pathogenic microorganism. Infectious agents include viruses (a small infectious agent that can replicate only inside the living cells of an organism), bacterias (microorganisms with a small size some few micrometershaving a wide range of shapes, ranging from spheres coccito rods bacilliand spirals spirilla and spirochaetes-); fungi (member of a large group of eukaryotic organisms that includes yeasts, molds, and mushrooms); and parasites (type of non mutual relationship between organisms of different species where one organism, the parasite, benefits at the expense of the other, the host) Infections can affect the brain tissue because they interfere with the cerebral blood flow and alter the metabolic capacity of the cells, or the characteristics of the cell membrane, changing its electric properties. Nervous system infections are frequently secondary to infections in other parts of the body. Acute confusional state is frequently found in cases of brain infections: temporal-spatial disorientation, memory difficulties, naming defects, and psychomotor agitation also are found. It is interesting to refer in particular to two infections: Herpes simplex encephalitis is a severe viral infection of the central nervous system that is usually localized to the temporal and frontal lobes. Herpes simplex encephalitis is thought to be caused by the retrograde transmission of virus from a peripheral site on the face, along a nerve axon, to the brain. The virus lies dormant in the ganglion of the trigeminal cranial nerve, but the reason for reactivation, and its pathway to gain access to the brain, remains unclear. Most individuals show a decrease in their level of consciousness and an altered mental state presenting as confusion, and changes in personality. Intracerebral abscess results from the invasion of infectious organisms into the brain tissue. It is a consequence of the spread of contiguous infection from nonneural tissue, the result of hematogenous introduction from a remote site, or direct mechanical introduction as a result of penetrating trauma or a surgical procedure. A wide range of microorganisms have been recovered from intracerebral abscesses, including most types of bacteria and certain types of fungi and parasitic organisms ure 2. An intracerebral abscess can result in a focal symptomatology: when located in the brain areas supporting language, and aphasia manifestations will be evident. Degenerative conditions A degenerative condition refers to a disease in which the function or structure of certain tissues or organs will progressively deteriorate over time. In this chapter, Alzheimerfis disease, progressive aphasia (as a special subtype of Alzheimerfis disease), and some other degenerative conditions will be examined. The specific language characteristics in different types of dementia will be examined in Chapter 8 (Associated Disorders). Alzheimers disease Alzheimers disease is the most common cause of dementia among older people. Dementia is understood as the loss of cognitive functioning such as thinking, remembering, and reasoningand behavioral abilities, to such an extent that it interferes with a persons daily life and activities. One or more of the following cognitive disturbances: (a) aphasia; (b) apraxia; (c) agnosia; (d) disturbance in executive functioning. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. Dementia ranges in severity from the mildest stage, when it is just beginning to affect a persons functioning, to the most severe stage, when the person must depend completely on others for basic activities of daily living. During normal aging, brain atrophy and ventricular enlargement are also observed, but in Alzheimerfis disease they are notoriously more pronounced. Language disintegration follows a particular sequence: initially, word-finding difficulties and anomia are found, associated with difficulties in understanding complex language; active and passive vocabulary progressively decreases. Semantic paraphasias (semantic substitutions such as table instead of chair) become more and more abundant. Later on in the disease evolution, phonological paraphasias (phonological substitutions due to phoneme additions, omissions or substitutions) also are observed. However, some language abilities may remain intact even in advances stages of dementia. People with primary progressive aphasia may have trouble naming objects or may misuse word endings, verb tenses, conjunctions and pronouns. Symptoms of primary progressive aphasia begin gradually, frequently before the age of 65, and tend to worsen over time. Eventually, the patient will present an Alzheimerfis disease, including not only language defects, but also memory impairment and other disturbances in cognition (Mesulam, 1982, 2001). Subtypes of primary progressive aphasia have been described, in particular a non-fluent type similar to Brocafis aphasia (so-called progressive nonfluent aphasia) associated with frontotemporal lobar degeneration and a fluent subtype, in occasions referred as semantic dementia (Grossman & Ash, 2004). In progressive nonfluent aphasia, agrammatism (impairment in use of grammatical and syntactic constructs of language), phonological paraphasias, apraxia of speech, and articulatory difficulties are found. In semantic dementia, word-finding difficulties, anomia, impaired comprehension and more verbal paraphasias are observed. Not only disturbances in oral language can appear as the initial manifestation of an Alzheimers disease (progressive aphasia). For instance, Ardila, Matute and Inozemtseva (2003) reported a case of a 50-year-old, right-handed female who, over approximately two years, presented with a progressive deterioration of writing abilities associated with acalculia and anomia. The ability to read words was preserved, but the ability to read pseudowords was lost. However, in these two conditions there is a subcortical dementia characterized by slowness in cognition, retrieval defects in memory, and executive functioning defects. Dysarthria is evident (hypokinetic dysarthria in Parkinsonfis disease, and hyperkinetic dysarthria in Huntingtonfis disease) but aphasia is mild. In general, decreased verbal fluency, difficulty in the comprehension of complex commands, and wordfinding difficulties (anomia) are identified. In other degenerative conditions, speech and language impairment also may be observed. This disease belongs to a group of disorders known as motor neuron diseases, which are characterized by the gradual degeneration and death of motor neurons. Dementia, however, has been occasionally reported (problem solving, attention, memory, naming defects). Summary Any abnormal condition affecting the brain areas involved in language processing can result in aphasia. The specific symptoms of the language impairment depend upon the particular brain area that is affected. Pathological conditions affecting the posterior frontal areas of the left hemisphere usually result in a nonfluent disorder of language, characterized by agrammatism with an accompanying apraxia of speech, whereas pathological conditions affecting the temporal and partially the parietal lobe in the left hemisphere are associated with disturbances in language understanding, word-finding difficulties, and paraphasias. Different etiologies of brain damage are recognized, but the vascular disorders and traumatic brain injury represent the two major causes of aphasia. Brain tumors, infections, and some degenerative conditions also may be associated with aphasia. Progressive Agraphia, Acalculia, and Anomia: A Single Case Report Applied Neuropsychology, 10, 205-214 Grossman, M. Prevalence estimates for primary brain tumors in the United States by age, gender, behavior, and histology, NeuroOncology, 12. Heart disease and stroke statistics -2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 115, e69-e171 Aphasia Handbook 46 Chapter 3 Linguistic analysis of aphasia Introduction Aphasia is the loss or impairment of language function caused by brain damage (Benson & Ardila, 1996). In the previous chapter, the brain damage (neurological dimension) potentially associated with aphasia was reviewed. In this chapter, the specific language disturbances (linguistic dimension) observed in aphasia will be reviewed. There are different communication systems and consequently, different types of language: sign language, animal languages, computers languages, etc. Human language is a specific example of a communication system characterized by the use of a limited amount of articulated sounds (phonemes), which can be combined in different ways to create meaningful units (morphemes and words) (so called double articulation; that is, speech output can be divided into meaningful elements words-, which can be further subdivided into sound elements phonemes-). Tongue is the specific verbal communication system characteristic of a human community (for instance, English, Spanish, Chinese, etc). Speech refers to the phonoarticulatory act that produces the acoustic signal in which phonemes and words are coded.

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