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Long-term Effects of Bilateral Frontal Brain Lesion
60 Years After Injury With an Iron Bar
Maria Mataró, PhD;
M. Ángeles Jurado, PhD;
Carmen García-Sánchez, PhD;
Lluis Barraquer, MD;
Frederic R. Costa-Jussà, MD;
Carme Junqué, PhD
Arch Neurol. 2001;58:1139-1142.
ABSTRACT
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Background Harlow's report of the case of Phineas P. Gage in 1848 was one of the
earliest description of the personality and behavioral changes following frontal
lobe damage. Since Harlow's articles, a few more case reports of frontal lobe
damage have been published. As standard neuropsychological and neurologic
evaluations may reveal subtle defects, case reports have been particularly
useful in characterizing the behavioral changes that follow frontal lobe damage.
Objective To describe the long-term outcome of an 81-year-old patient who sustained
a severe frontal brain lesion 60 years ago caused by the passage of an iron
spike through his head.
Results The patient has bilateral damage affecting the orbital and dorsolateral
frontal regions. He displays many of the typical frontal behavioral disturbances
described in the literature. His conduct is characterized by dependence on
others, cheerfulness, planning difficulties, problems establishing realistic
goals, lack of drive, and difficulties in initiating, continuing, and finishing
activities. Although gross cognitive functioning is intact, neuropsychological
deficits are present in the executive functioning, memory, and visuoconstructive
domains.
Conclusions In contrast with the antisocial conduct pattern usually associated with
frontal damage in the literature, this case suggests that large frontal lesions
can produce behavioral and personality changes that are compatible with stable
functioning in family, professional, and social settings. In addition to the
localization of the lesion, many other factors should be considered in the
long-term prognosis of frontal brain injured patients.
INTRODUCTION
HARLOW'S report of the case of Phineas P. Gage1, 2
was one of the earliest and most striking descriptions of personality and
behavior changes after frontal lobe damage. In 1848, Gage, a 25-year-old construction
foreman, suffered and survived the passage of an iron bar through his head.
Although subsequently his physical and intellectual capacities seemed to recover
totally, he was unable to obtain a similar job again and spent the rest of
his life wandering. He was described as irreverent, impatient, capricious,
and vacillating, with no control over his instincts. His ex-employers considered
the changes so prominent that they refused to rehire him, and for his friends
he was "no longer Gage." Since Harlow's articles, a few more case reports
of frontal lobe damage have been published.3, 4, 5, 6
The best studied case is patient EVR.7, 8
At age 35 years, a large orbitofrontal meningioma compressing both frontal
lobes was removed. Although the subject's scores on basic neuropsychological
test performances remained normal, his social, professional, and personal
conduct was profoundly affected after the injury and was characterized by
divorces, bankruptcy, and the inability to sustain normal work behavior. This
article describes the long-term outcome of an 81-year-old patient who sustained
a severe frontal brain lesion 60 years ago, caused, as in the case of Phineas
Gage, by the passage of an iron bar through his head.
REPORT OF A CASE
Our patient was raised in a wealthy family in Barcelona, Spain. The
outbreak of the Spanish Civil War (1936-1939) interrupted his university studies
when he was 20 years old. At the age of 21 years, in 1937, he was forced to
escape through a window and slid down a pipe that gave way. He fell and he
was impaled, through the head, on the spike of an iron gate. He remained there
until the bar was cut; he was conscious, and even helped in the rescue. He
was taken to Hospital de la Santa Creu i Sant Pau, Barcelona, where he received
neurologic treatment from the father of one of us (L.B.) and coworkers. The
fragment of the spike protruding from both frontal bones was removed (Figure 1). The spike (Figure 2) penetrated the left frontal region, passed through both
frontal lobes injuring the left eyeball, and emerged from the right side.
The patient survived the brain injury. After the war, he married at the age
of 24 years and fathered 2 children. He had met his fiancée during
his childhood and they had been engaged since he was 18 years old. He worked
in the small family firm until his retirement.
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Figure 1. The patient at hospital after
the bar was removed in 1937.9
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Figure 2. Fragment of the spike that injured
the patient. Ruler measurement expressed in centimeters.
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The patient experienced "pseudoabsence" epileptic seizures and has received
treatment from the age of 43 years onward. In 1991 a fall caused a right parietal
hemorrhagic contusion with a right-sided sylvian subarachnoidal hematoma and
left-sided occipital intraventricular hemorrhage. The initial Glasgow Coma
Scale score was 13. Since this injury, his attentional and memory problems
seemed to be aggravated. The patient was 81 years old when the neuropsychological,
neurologic, and neuroimaging assessments were made. The neuropsychological
and neurologic evaluations were performed within the same week; the magnetic
resonance image was obtained 6 months later.
BEHAVIORAL OBSERVATIONS
Family descriptions of the subject's behavior highlighted his dependence
on others. Although he had started university, he had been unable to work
without close supervision since the spike injury. His occupations consisted
mainly of simple manual tasks that were always organized and checked by others.
He required supervision even in everyday activities. He was incapable of planning
or remembering his agenda or of fulfilling his responsibilities and he had
difficulties managing money. His daughter described her father as follows:
"As a child, I realized that my father was a ‘protected' person.
When I was young I soon saw what the ‘problem' was, although I had always
suspected it. At 17, I became part of this protection, and I still am."
Also noteworthy were his apathy, lack of drive, and problems with initiating,
continuing, and finishing tasks. Restlessness and impatience were also occasionally
reported. Another noticeable characteristic was his cheerfulness; he would
spend a long time telling the same jokes. No outbursts of range, emotional
lability, difficulties controlling his emotions, irritability, and hostility
were reported (Table 1). There
is no known history of drug or alcohol abuse, antisocial behavior, or illegal
activities.
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Table 1. Scores on the Neurobehavioral Rating Scale
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NEUROPSYCHOLOGICAL EVALUATION
The patient was orientated in place but not in time. Remote memory including
personal and current information was impaired for both names and dates. Basic
attention skills seemed to be intact: the patient's forward digit span was
5 and backward digit span was 4. The most striking deficits were in executive
functioning, memory, and visuoconstructive domains and in motor speed (Table 2). Gross cognitive functioning was
intact. Within the verbal domain, he performed in the average range on tasks
measuring his knowledge of the world (Information and Vocabulary) and judgment
and understanding of social conventions (Comprehension). He showed no evidence
of language difficulties.
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Table 2. Neuropsychological Results*
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NEUROLOGIC FINDINGS AND MAGNETIC RESONANCE IMAGING
Findings from the current neurologic examination were normal apart from
postinjury left pulsatil exophthalmos with ipsilateral ophthalmoparesis and
severe loss of visual acuity in the left eye. Magnetic resonance imaging showed
an extensive bifrontal lobe lesion affecting orbital, dorsolateral, and mesial
regions of the prefrontal cortex. The lesion was analyzed following the templates
proposed by Damasio and Damasio.10 Figure 3 shows the affected areas, including
Brodmann cytoarchitectonic fields 10, 11, 47, 46, 45, 25, 24, 32 on both sides,
and part of 44 and 6 on the right side.
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Figure 3. T1-weighted magnetic resonance
images showing the bilateral frontal lobe lesion caused by the passage on
the bar, ie, horizontal cuts (A), coronal cuts (B), and sagittal cuts (C).
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COMMENT
The study of the behavioral consequences of frontal lobe lesions is
a challenging task because the standard neuropsychological and neurologic
evaluations may reveal only subtle defects. In this context, case reports
have been particularly useful in characterizing the personality and behavioral
changes that follow frontal lobe damage. Our patient displays many of the
typical frontal behavioral disturbances described in the literature. His conduct
is characterized by dependence on others, cheerfulness, planning difficulties,
problems establishing realistic goals, lack of drive, and difficulties in
initiating, continuing, and finishing activities.
Changes in personality, emotion, mood, and social behavior control have
frequently been associated with frontal lobe damage. Benson and Blumer11 suggested 2 types of personality change. The first,
characterized by apathy, poor planning, and lack of drive and concern, is
associated with dorsolateral frontal lesions or massive frontal lesions. The
second, known as pseudopsychopathic change, is related to orbital damage and
consists of disinhibition, puerilism, and euphoria. The patient shows bilateral
damage affecting both orbital (Brodmann areas 10 and 11) and dorsolateral
(areas 10, 11, 44, 45, and 46) regions, which could be consistent with some
of the characteristics exhibited. Although he is predominantly dependent,
with decreased initiative and poor planning capacities, according to the Neurobehavioral
Rating Scale,12 he also displays impatience,
restlessness, and cheerfulness. During the 60 years following injury, his
behavior has to some extent been unchanged, characterized by stable functioning
in family, professional, and social settings. The best known frontal cases,
such as Gage and EVR, are of the psychopathic type; the main lesion difference
between those cases and ours is that the others present preserved dorsolateral
regions.7, 13
Executive functions, including planning, mental flexibility, and temporal
organization, are ascribed to the dorsolateral aspect of the frontal lobes.
Our patient exhibited major impairments on executive functioning tests such
as the Wisconsin Card Sorting Test, Verbal Fluency Test, and the Luria (motor
tasks) Test. However, as frontal lobe tests are not independent, the poor
performance on the Wisconsin Card Sorting Test could be also related to visuospatial
and memory difficulties. The presence of such deficits can be highly disruptive
of everyday functioning, despite apparently normal intelligence and preserved
cognitive abilities. The substantial memory and visuoconstructive deficits
found in the current neuropsychological evaluation may be related to the 1991
brain injury.
To our knowledge, there are no descriptions in the literature of evolution
of so long a period. This case illustrates that large frontal lesions can
produce behavioral and personality changes other than a striking antisocial
pattern, changes that are compatible with long-term, stable functioning in
family, professional, and social settings. In addition to the localization
of the lesion, many other factors should be considered in the long-term prognosis.
In the current case, the protected and structured family and work environment
has probably made it easier for him to lead a relatively normal life.
AUTHOR INFORMATION
Accepted for publication February 20, 2001.
From the Departament de Psiquiatria i Psicobiologia Clínica,
Universitat de Barcelona (Drs Mataró, Jurado, and Junqué), Neurotraumatology
Research Unit, Vall d'Hebron University Hospital (Dr Matáro), Servei
de Neurologia, Hospital de la Santa Creu i Sant Pau (Drs García-Sánchez
and Barraquer), and Servei de Neurologia, Hospital de Barcelona (Dr Costa-Jussà),
Barcelona, Spain.
Corresponding author: Maria Mataró, PhD, Departament de Psiquiatria
i Psicobiologia Clínica, Universitat de Barcelona, Passeig de la Vall
d'Hebron 171, 08035 Barcelona, Spain (e-mail: mmataro{at}teleline.es).
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