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Retrograde Amnesia After Traumatic Injuryof the Fronto-Temporal Cortex

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98898ournal ofNeurology, Neurosurgery, and Psychiatry 1993;56:988-992 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.9.988 on 1 September 1993. Downloaded from Retrograde amnesia after traumatic injury of the fronto-temporal cortex H J Markowitsch, P Calabrese, J Liess, M Haupts, H F Durwen, W Gehlen Abstract cortex,'011 25 in the temporo-polar cortex,7 8 An industrial manager had severe retro- and Kopelman26 27 favoured the prefrontal grade and variable but usually mild cortex as the principal target region impli- anterograde amnesia four years after a cated in the retrieval of remote memories. In head injury. MRI showed damage ofboth his 1991 article, Kopelman27 specifically sug- temporal poles and the lateral portion of gested that "dorsolateral frontal lesions the right prefrontal cortex. The pre- (occurring in combination with limbic-dien- frontal and temporal cortical damage on cephalic pathology) may account for an im- the right side extended deeply into the poverished retrieval of retrograde memories." white matter while the temporal cortical damage on the left side was much smaller. There was an additional left Case report temporo-parietal lesion. The patient was A 45 year old male patient had had a severe of average intelligence. His attention, traumatic brain injury four years earlier, short term memory and learning ability caused by falling off a horse. He had been were average or somewhat below aver- comatose for about six weeks. Before his acci- age. His old memories were severely dent the patient had been employed as a affected for the personal-episodic manager in a big company. He had been domain and less so for semantic remote referred to us because of his persistent retro- memory abilities. Therefore an anatomi- grade memory deficits. His present neuro- cal dissociation between anterograde and logical status was examined with MRI and his retrograde amnesia is possible at the neuropsychological status was tested during anterior temporal regions, possibly several sessions, over three days. interacting with the prefrontal cortex; Most of the behavioural findings of the these regions seem necessary for the patient are compared with those of a normal retrieval of old episodic memories. subject of an age of 52 years, comparable intelligence, and a similar occupational posi- (3 Neurol Neurosurg Psychiatry 1993:56:988-992) tion as the patient. For the retrograde mem- ory tests additional comparisons were used. For the Autobiographical Memory Interview28 There are now descriptions of several cases of reference is made to the cut-off scores pro- http://jnnp.bmj.com/ dissociation of anterograde and retrograde vided in that test. Results in the Famous amnesia.'-" In most of these cases the dam- Faces Test29 are compared with those of a age to the brain was the result of traumatic sample of control subjects tested by U Schuri injury and can therefore be seen as resem- (City Hospital Munich-Bogenhausen), and bling that described in several earlier reports for the Famous names test we collected our in which concussions of the brain were fol- own data by testing five normal subjects of lowed by severe old memory disturbances.'2-2' comparable or lower educational background on September 28, 2021 by guest. Protected copyright. Physiological Last century a number of reports already and age. Psychology, dealt with the phenomenon of retrograde University of 22-24 Bielefeld, Germany amnesia. - NEURORADIOLOGICAL EXAMINATION H J Markowitsch Characteristic for most of the recent cases MRI of his brain was performed using serial P Calabrese with dominant retrograde amnesia is the vari- Ti and T2-weighted coronal and axial J Liess ability of their brain damage and the relatively images (6 and 7 mm slices). Both temporal Neurological University Hospital, better preserved semantic or priming-related poles, with preference to the right hemi- Bochum- remote memory compared with the severely sphere, were severely affected. Furthermore, Langendreer, affected episodic old memories. (Semantic the basal and lateral part of the right temporal Germany P Calabrese memory refers to general knowledge about the lobe was damaged, sparing, however, the M Haupts world, for example, grammar, mathematical medial temporal lobe structures, including H F Durwen relations, chemical formulas; priming to "sub- the hippocampal formation, on both sides W Gehlen conscious" knowledge or facilitated identifi- (fig). Major brain damage was found in the Correspondence to: HJ Markowitsch, cation of information previously exposed to, fronto-basal cortex with preference to the Physiological Psychology, and episodic memory to personal, temporally right side. Additionally, an extensive cortico- University of Bielefeld, PO Box 100131, D-33501 dated events.) In some case descriptions the subcortical lesion was situated in the left tem- Bielefeld retrograde amnesia related brain damage was poro-parietal transition zone. Received 13 July 1992 identified in the junction zone of pons and and in revised form 19 October 1992. mesencephalon,2' in the temporal, including NEUROPSYCHOLOGICAL EXAMINATION Accepted 20 November 1992 the entorhinal cortex,6 in the temporo-parietal The neuropsychological tests and a summary Retrograde amnesia after traumatic injury ofthefronto-temporal cortex 989 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.9.988 on 1 September 1993. Downloaded from Figure The principal brain damage in coronal and axial views. a-d: Coronal T2-weighted MRI scans showing the main portions ofthe damage in the prefrontal and temporal lobesfrom anterior to posterior. 'R' and 'L' denote the left and right halves ofthe brain. e: Magnification ofthe medial temporal area ofthe section shown in d to demonstrate preservation of the hippocampal formation. f, g: Horizontal T,-weighted MRI scans showing the main portions ofthe damage in the anterior and lateral temporal lobes. http://jnnp.bmj.com/ on September 28, 2021 by guest. Protected copyright. of the results are listed in table 1. They well-adjusted, and was able to interact in vari- included tests of intelligence, attention, con- ous ways with his environment. When centration, sensory and language functions, instructed, he could remember to do some- and various forms of memory tests. A number thing or to go to a certain place. In formal of these tests had been used and described in testing, he gained an IQ of 100 points, his detail in a previous publication of a case with attention, measured by three tests, was bilateral thalamic damage.30 slightly below average. In the Wechsler- The patient appeared to be alert, and inter- Memory-Scale-R he received 85 points for ested. He made suggestions, was socially the General-Memory-Index. The other values 990 Markowitsch, Calabrese, Liess, Haupts, Gehlen Durven, J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.9.988 on 1 September 1993. Downloaded from Table 1 Neuropsychological tests used Table 2 Performance (points) ofthe patient and the control subject in the Autobiographical Memory Test Control Patient subject(s)* Control Cut-off INTELLIGENCE 100 110 Personal semantic events Patient subject scores [31]* ATTENTION (3 tests) average average MEMORY IN GENERAL Childhood 6 18 <11 Wechsler-Memory-Scale-R (General-Memory-Index) 85 110 Early adulthood 12 19-5 <14 Rivermead Behavioural Memory Test (German form) 76/150 112/150 Actual life 13-5 21 <17 SHORT TERM MEMORY (Corsi-block-tapping; Digit span) 5; 4 5; 4 Sum (max.: 63 points) 31-5 58-5 <47 CONCEPT FORMATION, COGNITIVE FLEXIBIITY, Autobiographical incidents ABILITY TO CALCULATE Childhood 0 9 <3 WCST (categories achieved; perseverative errors) 2; >18 7; 0 Early adulthood 0 9 <3 Tower ofHanoi (4 disc version) (trials needed; perseverative errors) 39; 4 15; 0 Actual life 6 9 <5 Conceptformation task 18/20 19/20 Sum (max.: 27 points) 6 27 <12 Fibonacci series average average Simple calculations average average *The cut-off scores refer to "definitely abnormal" values; this Test requiring to transcode numbers average average means that the only not definitely abnormal (but "border- PRIMING TASKS line") value was seen for the patient's recent autobiographical Gollin Incomplete Figures Test (3 sessions) incidents, that is, for the current (post-injury) time period. average level of identification: (1st presentation) 7-3 6-6 (2nd presentation) 6-2 4-3 (3rd presentation) 4 9 2-9 of people (actors, politicians, sportsmen, etc) Word stem completion (2 lists) 60% 65% Mirror image reading (1st, 2nd presentation in s) 5-7, 3-2 from different time periods, and he or she has RETROGRADE MEMORY to produce the name of the respective subject. Famous Faces Test (see text for a comparison with control subjects' performance): 1946-55 (from 20 faces correctly recognised) 13/20 19/20 In scoring his (and the control subject's) per- 1956-65 10/20 19/20 formance, we also gave points when a correct 1966-75 9/20 1976-85 6/20 19/20 answer was given after helping the subject by 1986-92 13/20 15/20 presenting initials or first names. The patient Famous names 33/60 Semantic Knowledge Test 70/100 98/100 was rated poor for the intermediate time peri- Autobiographical Memory Interview: but showed a for personal semantic events 31-5/63 58-5/63 ods, gradient remembering autobiographical incidents 6/27 27/27 of famous faces from different decades (table Personal Objects Test (individual episodic remembrance of owned objects) 1). Compared with a sample of control sub- 1956-65 4/5 1966-75 3/5 5/5 jects that were tested, the only values in a 1976-85 1/5 5/5 normal range were found for the first LONG TERM MEMORY and the Verbal Recognition Test (similar to RBMT) 5/10 10/10 last time period tested. We attributed the Rey-Osterrieth-Figure (complete value: 36) normal remembrance for the last time period copy; immediate reproduction; delayed reproduction 24; 14; 7 21; 20; 10 to his less affected anterograde memory abili- Verbal Learning ofNew Facts (contents of 13 sentences after 2 days delay) 7/13 10/13 ties, as his injury occurred in 1987.
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