Sometimes so very hard.... This last June started a huge change in how I see the world of neuroscience. Not just because of the craniofacial world of 11 years and chiari world of four years either. The month of June we had to learn about epilepsy, possible hydrocephalus, encephalomalacia and acute disseminated encephalomyelitis. All within weeks apart. The encephalomalacia was due to the pressure being too high in my son's head prior to his last craniofacial surgery. I don't blame anyone, it is what it is..... We didn't know the pressure was so bad till the day of surgery.... Now, I was a neuro mom even before my son was born due to my daughter's medical but nothing like I am now. I know way more than I wish I ever had to.... I never thought I would learn so much in the neuro world..... Let alone be on stuff like Medscape or the NIH to learn even more!
Till recently, I had wanted to blame my son's epilepsy on the ADEM, and hope that the encephalomalacia had no involvement with anything. I was dead wrong.....
Oh yeah, the ADEM added to it but it wasn't the culprit for the seizures like we hoped.
As to what else the encephalomalacia will do in time, it's honestly hard to say. I've been doing some more digging into TBI stuff. This video was amazing!
Now particularly I have been doing research on the left middle frontal lobe gyrus and the right temporal pole region. Now the encephalomalacia affects the white matter. What is the white brain matter? White matter refers to areas of the central nervous system (CNS) that are mainly made up of myelinated axons, also called tracts. Long thought to be passive tissue, white matter affects learning and brain functions, modulating the distribution of action potentials, acting as a relay and coordinating communication between different brain regions. In other words, it's like power lines. Without those lines working properly, you don't get electricity like you should. Or like a cell phone, without good service your calls break up, if they work at all and your data is really slow if working at all. The main thing it affects is cognitive function, executive function, learning and memory. Now how exactly depends on the areas of damage/loss. My son is likely, if not already to have at least some issues with all of this. With issues mainly at school, sometimes home, only time will tell us if encephalomalasia or something else is triggering it all. How long or to what extent is unknown at this point. Now, he's been off of steroids totally now since Thanksgiving day so steroids now should not be affecting much if anything.
As to the seizures:
Seizures is one way that literal electrical signals in the brain don't work properly. It's like a power surge to a single area and or to multiple areas of the brain. Depends on the seizure, where, how it starts and if it spreads out during it. Sometimes you can see a cause on an MRI and sometimes not. If your first seizure occurred at the time of an injury or infection in the brain, then you are more likely to develop epilepsy. Often, more seizures don’t occur until weeks or months after the initial injury or infection. My son's are most often complex partial (focal) seizures. We've had two EEG's catch seizures already. One caught one from the left side encephalomalacia area and the other from the right side encephalomalacia. Most I've seen have been from the left side due to how he stares right with most when he has them. His first one was the left side, we know because he was staring right. Looking back at the first one, I saw his left arm stiffen up and a little nystagmus going with the seizure. I remember riding up with him in the EMS for the first one. It was surreal..... Anytime now I hear our county ambulance sirens, I feel anxiety and sometimes get choked up... Almost feels sorta like PTSD or something....
For details, here's his last three EEG's. Two were inpatient and the most recent outpatient one before we saw neurology.
6-1-18 Focal seizure localized to the left frontal region with associated jerking of the right arm with head turned to right.
6-14-18 A focal seizure was captured at the onset of this recording from the right temporal region. Post-ictal right hemispheric slowing was noted after this, most prominent in the right temporocentral region. In addition, occasional left frontotemporal sharp waves were noted throughout the recording. (This was during the stay with ADEM)
9-26-18 Intermittent focal slowing was noted in the right temporal region suggestive of white matter injury in this region. (No seizure during this BUT it does confirm the encephalomalacia is a cause...)
So.... With that in mind, I did some digging.
The closest I had gotten in my research so far is this: The two pictures posted show on MRI but also in online sketches where the encephalomalacia is. The only things I have found on what could all be affected is this: Memory loss, if the frontal lobe is affected, mood swings, working memory and executive function problems also in the event of the frontal lobe’s involvement. So could his behavior issues at school all be related to this? If it is then it's for the long haul, like it or not.
Now in particular I did find this on the left middle frontal gyrus. "findings confirmed that the LMFG takes active parts in word production, and suggested that it may serve as a temporal perceptual information storage space, supporting the hierarchical state feedback control model of word production." Hence it could also add to his speech language issues.
The right temporal pole involvement, I found this but also I did read here that with the temporal lobes of themselves that "When damage occurs to these areas of the brain, patients may experience disturbance of auditory sensation and perception, an inability to pay attention to what they see or hear, impaired ability to comprehend language, impaired factual and long term memory, emotional disturbance, and altered sexual behaviors. They may also have seizures, lose their sense of humor, and become obsessive." As to the temporal pole, several studies have shown that the temporal pole is an association cortex involved with multimodal analysis, especially in social and emotional processing.
I wanted more information. I want to know more. I want to know exactly how this all will affect my son. So, more research yesterday and today I did.
Here is where I'll probably lose many of you. Sorry, come into research with me.
Come see how my brain works when I learn.
Come see how my brain works when I learn.
The Kindle book I've been reading about the frontal lobe, in particular with where my son's is affected says this "The left frontal area mediates the synactical, lexical, semantic, and temporal sequental aspects of speech." "The left frontal lobe is clearly dominant in this regard (expressive speech) as is also demonstrated in functional imaging." and "If the left frontal lobe is injured, cognitive and expressive functions tend to become suppressed and inhibited - a function not only of the injury but right frontal suppressive influences." I have also read elsewhere how it is affected through executive function and other behavioral aspects, similar to those affected by ADHD and similar.
The other Kindle book I have about the temporal lobes said this "Right temporal injuries can disrupt the ability to remember musical tunes or to create musical imagery." Yet my son can imaginary play a trumpet and can keep the beat to music. It does not appear that his damage has affected that area of the temporal lobe but moreso the area around where the frontal and temporal meet. Of the research I've seen it's more likely that his ability to auditory process words could be affected, not so much seeing or pronouncing.
While researching in particular, the Brodmann areas and seeing them on a map vs my son's MRI, I was able to better see where exactly the right temporal pole was on his brain but also the left middle front gyrus.
You might want to use that image for a little reference for the next little bit. 10 is the front, 17 is the back.
Left middle frontal gyrus
Through my researching however, it looks more like it's area 46 of the Brodmann brain map that's affected on the left side. Still the left middle frontal gyrus but less of area 8 & 9. Area 46 is the dorsolateral prefrontal cortex plays a central role in sustaining attention and managing working memory, and has recently been shown to regulate self-control. It is one of the few cortical areas whose activity diminishes during REM sleep.
The high connectivity of this area within the frontal lobe as well as other parts of the brain means that damage can have a wide variety of effects. Lesions or damage impair short-term memory, cause difficulty inhibiting responses, impair the ability to judge the relevance of stimuli, and cause problems in organization.
In particular this site said the following about Brodmann area 46:
"Departing from the neuroimaging studies it is evident that BA46, as well as BA9/10, is involved in memory, particularly working memory and memory control and organization. Because of the association of working memory with prefrontal activity, some clarification about working memory is important. It has been assumed that working memory is involved in a diversity of cognitive processes, including language comprehension, planning, reasoning, problem solving and even consciousness. It is important to emphasize that span tests (e.g., digit span) (working memory storage process) exhibit greater dependence on the posterior cortex, whereas delayed recognition performance (working memory rehearsal process) exhibits greater dependence on the prefrontal cortex. When information has to be manipulated, increased prefrontal activity is found. The manipulation-related processes ascribed to the dorsolateral prefrontal cortex are fundamentally extramnemonic in nature (that means, metamemory). Whereas they play a fundamental role in the exercise of executive control of working memory, they do not govern the storage per se of the information held in working memory. The participation of the left anterior middle frontal gyrus in language is also shared by other left prefrontal convexital areas; according to current knowledge of languages disturbances associated with brain pathology, other linguistic functions potentially related with BA46, such as verbal initiative and language pragmatics, have not been fully approached in fMRI studies. Two fMRI studies attract special attention: (1) “Willed acts” in the two response modalities studied (speaking a word, or lifting a finger) were associated with increased blood flow in BA46; (2) mirror neurons: a basic circuit underlying imitation learning including the inferior parietal lobule and the posterior part of the inferior frontal gyrus plus the adjacent premotor cortex (mirror neuron circuit) has been proposed. During pause, the middle frontal gyrus (area 46) plus those structures involved in motor preparation (dorsal premotor cortex, superior parietal lobule, rostral mesial areas) also become active."
Now, due to how close 46 is to a couple of others, I looked them up too. Here's what it said about areas 8 & 9:
"Without question, BA9/10 has a significant participation in memory, particularly memory encoding, memory retrieval, and working memory. Those studies relating BA10 with “event- and time-based prospective memory” and “intentional forgetting”, suggest the involvement of BA10 in controlling, and manipulating memory (metamemory). Hence, it could be argued that the middle frontal gyrus participates in an extensive memory circuit, and it has some fundamental role in organizing memory strategies and controlling memory. BA9/10 have also other evident executive functions, such as “executive control of behavior”, “inferential reasoning”, and “decision making”. Its participation in complex language processes may suggest the use of verbal strategies in executive processing; in these cases (e.g., syntactic processing, metaphor comprehension, generating sentences, etc), an extensive network is activated, involving diverse language related areas. Interestingly, BA10 seems to be involved in attending to sensory stimulation (e.g., response to baroreceptor stimulation, response to painful thermal stimuli, and joint attention). Two studies related the middle frontal gyrus with processing emotions. This involvement may be related to making decisions about emotional stimuli." Left side was highly remarked on the list for speech problems, as confirmed earlier.
Since area 44 is close to 46 along with 9/10, here's what it said about that.
"From the traditional point of view, Broca's area corresponds to BA 44, but several contemporary authors also include BA 45. It can be conjectured that in the future, the most anterior part of the insula could also be included in the Broca’s area, given its participation in the praxis of speech (motor speech programming). Different proposals have been presented to explain language disturbances in so-called Broca’s aphasia; different hypotheses have attempted to postulate a core BA44 function, including: binding the elements of the language, selecting information among competing sources, generating/extracting action meanings; sequencing motor/expressive elements; cognitive control mechanism for the syntactic processing of sentences; construction of higher parts of the syntactic tree in speech production; and verbal working memory. Functional studies have further improved our understanding of BA44. Although the core BA44 function remain elusive, fluency and sequencing may potentially account for many of the functions in which BA44 participates. The suggestion that BA44 includes mirror neurons for expressive movements is particularly provocative and may enlighten the question of inner speech (e.g., internally generated language). Functional studies have also contributed to further understand right BA44, which seemingly participates in perception and expression of prosodic and emotional information. From the perspective of the lesional model, unfortunately just few studies have analyzed the clinical disturbances associated with right BA44. Functional studies have also disclosed the participation of BA44 in a diversity of tasks that are difficult to interpret with our current understanding of the brain, such as pain anticipation, perception of tactile stimulation, motion after-effect, object manipulation, smelling familiar odors, and music enjoyment; in those cases, BA44 activation is just an additional element in a complex brain network; it may be suggested that some internal verbalization can account for BA44 involvement in these unexpected activities. Its participation in working memory may also reflect the internal rehearsal of the information."
The final area I looked up was the BA45.
"Without question, the functions of BA45 are significantly coincidental with the functions of BA44, supporting the proposal that they both, at least partially, correspond to a single system. Nonetheless, BA45 seems to be involved in relatively more complex verbal functions, for instance, processing of metaphors and reasoning processes. As observed with BA44, BA45 participate in a diversity of functions difficult to interpret with our current understanding of the brain (e.g., smelling of familiar odors) and probably reflecting some inner speech during the performance of those tasks. BA45 participation in working memory may also reflect the internal rehearsal of the information."
I believe though 45 is not affected, at least directly by the encephalomalacia. It's more likely to be 9,46 and or 44.
Right temporal pole
As to the right side, I have looked up more into that. Brodmann area 38 in particular. One part that it can affect is irony processing which is the way the mind can block some things out. Also identifying familiar voices. That site also said this. "Functional studies have disclosed the unexpected complexity of BA38 functions. Because of its location in the brain, it is understandable that BA38 participates in language processes, emotion, executive functions, and memory. Left BA38 is involved in diverse “high level” verbal functions (e.g., semantic processing, naming of items learned in early life, lexico-semantic ambiguity processing, etc.). Departing from the reported functional studies BA38 involvement in emotion seems evident (e.g., visual processing of emotional images, emotional attachment, response to threat/fearful stimulus, etc.). In some executive functions (e.g., moral judgment, inferential reasoning, etc) BA38 is also active. Diverse studies support BA38 contribution to multimodal memory retrieval. Additionally, it seems to contribute to some complex auditory processing; for instance, recognition of familiar voices (phonognosis), and response to averse auditory stimulation. Interestingly, traumatic head injury usually impacts the temporal pole, and it has been suggested that the difficulties to separate auditory “figure” (e.g., language) from background “noise” found in patients with head injury, is a result of BA38 damage."
Overall that site was quite helpful beyond what digging I had already been doing. However comparing my son's imaging to the maps I have been seeing along with what the radiology reports and docs noted where the encephalomalacia is, this all makes sense. This one has helped too along with Google Translate.
So if you kept up with all of that earlier or not, either way, research is what I've been doing, neuropsych with a QEEG is coming up next month for my son and hopefully answers. What he needs is neuropsychological testing and a special type of EEG called a Quantitative Electroencephalography. It will help us better know what is all going on inside his brain and how he is processing the world around him. It should also tell us how all the encephalomalacia has affected hum along with the epilepsy. We already know the epilepsy was caused from the encephalomalacia. This testing will also strongly help with his IEP meeting for public schools come spring.
What is a QEEG?
The QEEG is a special type of EEG that will help us better know exactly how his brain is functioning. A standard EEG is very good, but sometimes not detailed enough. The QEEG will be like having a Rand McNally map of his brain vs a sketch map of his brain.
What is Brain Mapping?
"Quantitative electroencephalography or qEEG is the process of measuring, recording and analyzing electrical activity in the brain and comparing it to normative or average values. This process is also called brain mapping, because brainwave data reveals a detailed picture of how your brain is functioning relative to these normative databases. LoRETA imaging is a newer, more advanced application of qEEG we employ to get help uncover the root causes of your symptoms. Brain mapping is just one of the many brain training tools we utilize at APEX Brain Centers.
How is qEEG Brain Mapping Used?
A qEEG brain map can show how each part of a brain functions under a variety of conditions. This precise measurement of brain waves reveals which areas of the brain are functioning optimally, and which areas can be improved. We use qEEG as a guide to determine the most efficient and effective way to train your brain to achieve your goals: better memory, increased focus and attention, decreased anxiety, and peak performance; among others." source
What is Brain Mapping?
"Quantitative electroencephalography or qEEG is the process of measuring, recording and analyzing electrical activity in the brain and comparing it to normative or average values. This process is also called brain mapping, because brainwave data reveals a detailed picture of how your brain is functioning relative to these normative databases. LoRETA imaging is a newer, more advanced application of qEEG we employ to get help uncover the root causes of your symptoms. Brain mapping is just one of the many brain training tools we utilize at APEX Brain Centers.
How is qEEG Brain Mapping Used?
A qEEG brain map can show how each part of a brain functions under a variety of conditions. This precise measurement of brain waves reveals which areas of the brain are functioning optimally, and which areas can be improved. We use qEEG as a guide to determine the most efficient and effective way to train your brain to achieve your goals: better memory, increased focus and attention, decreased anxiety, and peak performance; among others." source
What is neuropsych testing?
"Neuropsychological evaluation is an assessment of how one’s brain functions, which indirectly yields information about the structural and functional integrity of your brain. The neuropsychological evaluation involves an interview and the administration of tests. The tests are typically pencil and paper type tests. Some tasks might be self-reports meaning that they are completed by the patient with assistance from a technician, but the majority of the tests require administration by a neuropsychologist or trained, skilled psychometrist.
Neuropsychological tests (unlike bedside cognitive and behavioral neurologic screens) are standardized, meaning that they are given in the same manner to all patients and scored in a similar manner time after time. An individual’s scores on tests are interpreted by comparing their score to that of healthy individuals of a similar demographic background (i.e., of similar age, education, gender, and/or ethnic background) and to expected levels of functioning. In this way, a neuropsychologist can determine whether one’s performance on any given task represents a strength or weakness. Although individual scores are important, the neuropsychologist looks at all of the data from the evaluation to determine a pattern of cognitive strengths and weaknesses and, in turn, to understand more about how the brain is functioning.
Neuropsychological tests evaluate functioning in a number of areas including: intelligence, executive functions (such as planning, abstraction, conceptualization), attention, memory, language, perception, sensorimotor functions, motivation, mood state and emotion, quality of life, and personality styles. The areas addressed in an individual’s evaluation are determined by the referral question (what the referring doctor and patient wants to know), patient’s complaints and symptoms, and observations made during interview and test administration." source
Let's see if my research has any backing. Some of it already has given how the first neuropsych appointment went recently. Much of what I had been digging up before today was confirmed by the neuropsychologist I met. Behavior, speech, processing mainly being affected by those two areas of encephalomalacia.
I need a shirt that says "Neuro mom? NAILED IT!" with a huge brain on the front of the shirt.
So, right now that is where we are. The lesson in neuroscience you just read is just the tip of the iceberg.... I know so little but know so much more than your average Joe for sure.
The questions now is, what's next? Where do we go from here? What else is affected as a result of all of this? Did the lesions do long term issues? What of the encephalomalacia? What of the three long seizures he's had before? Longest timed one was 12 minutes. The first one ever I'd wager was easily 15 minutes, if not longer from the time it started to the time the paramedic finally stopped it. It took them a bit to get it under control. It gets dangerous after 5 minutes, which is why we have to go Diastat after 5 minutes... And watch his O2 levels. His lowest O2 I remember seeing after a seizure with meds was 66%.....
What results will show with his fine motor, gross motor and speech? His recent testing showed good progress in speech, some progress and regression with PT and stayed stagnant with OT.
Hopefully neuropsych testing and his QEEG can help with that. I almost fear the results though. We need those results to better help him, yet how much heartbreak will it carry? I'm sure there'll be some good in there too but I fear the "official" stoff sometimes. The stuff you do see some of, but overlook most days. The stuff that just says "He's behind a little" but is it really "little" or is it much more than that?
This journey brings triumph. This journey brings tears. This journey brings joy. This journey brings sorrow. This journey shows many blessings. This journey also shows some curses.
It is the journey in the world of neuroscience. It is also a journey in endocrinology, urology, and other specialties outside the realm of the brain.
I may talk about many topics on this blog but I'm a child of God first, a wife second and a mother third. Beyond that, lies the rest, including being a musician.
So let's see where this journey goes....
It is mine!
It is the journey in the world of neuroscience. It is also a journey in endocrinology, urology, and other specialties outside the realm of the brain.
I may talk about many topics on this blog but I'm a child of God first, a wife second and a mother third. Beyond that, lies the rest, including being a musician.
So let's see where this journey goes....
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