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Biomedical subjects

H S Kirshner

Publications and source records attributed to H S Kirshner.

At least 19 recordsLinked to original sources

The neurology clerkship core curriculum.

Neurologic symptoms are common in all practice settings, and neurologic diseases comprise a large and increasing proportion of health care expenditures and global disease burden. Consequently, the training of all physicians should prepare them to recognize patients who may have neurologic disease, and to take the initial steps in evaluating and managing those patients. We present a core curriculum outlining the clinical neurology skills and knowledge necessary to achieve that degree of preparation. The curriculum emphasizes general principles and a systematic approach to patients with neurologic symptoms and signs. The ability to perform and interpret the neurologic examination is fundamental to that approach, so the curriculum delineates the essential components of the examination in three different clinical settings. The focus of the curriculum is on symptom-based rather than disease-based learning. The only specific diseases selected for inclusion are conditions that are common or require urgent management. This curriculum has been approved by the national organization of neurology clerkship directors and endorsed by the major national professional organizations of neurologists. It is intended as a template for planning a neurology clerkship and as a benchmark for evaluating existing clerkships. It should be especially helpful to clerkship directors, neurology chairs, deans of medical education, and members of external accreditation groups.

Clinical Clerkship↗

Occipital pole area and language dominance.

A previous report demonstrated a relationship between asymmetries of occipital lobe length measured on magnetic resonance images (MRIs) and the hemisphere verified as dominant for language. This study sought to discern whether asymmetry in occipital pole area is more predictive of the hemisphere dominant for language. Language dominance was identified by the Wada test in 55 patients evaluated for surgical treatment of epilepsy. In a blinded fashion, an examiner measured bilateral occipital pole area on MRIs for each patient. Asymmetry of the occipital pole area on the MRI made at 10 mm above the tentorium was significantly related to language dominance. This two-dimensional analysis was better than previously described linear measurements in discriminating patients with left-hemisphere dominance for language.

Adult↗

Crossed aphasia. Functional brain imaging with PET or SPECT.

OBJECTIVES: To study patients with crossed aphasia (aphasia secondary to lesions in the right hemisphere in right-handed patients) with functional brain imaging using positron emission tomography (PET) or single photon emission computed tomography (SPECT); to see whether left hemisphere structures were metabolically depressed during the acute phase and, in 1 patient, during recovery; and to review the modern literature on crossed aphasia, with special reference to left hemisphere involvement. DESIGN: Case studies of 3 patients with crossed aphasia, including language testing, computed tomographic scanning, and functional imaging with PET or SPECT. SETTING: Hospital case studies. PATIENTS: Three right-handed patients with crossed aphasia secondary to acute infarctions in the right hemisphere and left hemiparesis. METHODS: All 3 patients were studied by means of bedside language testing, computed tomographic scanning, and functional brain imaging with PET or SPECT. Patient 1 also underwent serial testing with the Boston Diagnostic Aphasia Examination and follow-up PET scanning after 2 months of recovery. OUTCOME MEASURES: Clinical examination in all 3 patients and follow-up Boston Diagnostic Aphasia Examination and PET scanning in patient 1. RESULTS: Two patients had severe global aphasia and 1 had Broca aphasia. In all cases, computed tomographic scans failed to reveal any left hemispheric lesions. Functional imaging with PET or SPECT showed extensive hypometabolism or hypoperfusion in the right hemisphere, with initial reductions in the left hemisphere as well. In patient I, a follow-up PET image showed only persistent hypometabolism in the right hemisphere. CONCLUSIONS: These findings suggest that abnormal dominance for at least some language functions in the right hemisphere underlies the syndrome of crossed aphasia. Diaschisis, or functional depression of the anatomically normal left hemisphere, was seen in all 3 patients during the acute phase, but not in patient 1 after recovery had begun.

Aged↗

Aphasia secondary to partial status epilepticus of the basal temporal language area.

We present a patient with aphasia of several days' duration that was secondary to spontaneous partial status epilepticus arising from the left basal temporal region. Evidence from MRI, EEG, and PET confirmed the origin of the seizures in the basal temporal area. Both the seizure discharges and the aphasia resolved after antiepileptic therapy. This case, to our knowledge, is the first documented example of epileptic aphasia secondary to spontaneous partial status epilepticus originating from the basal temporal area.

Aphasia↗

Syndromes of language dissolution in aging and dementia.

This article has reviewed the language deterioration of aging, dementia, and the syndrome of primary progressive aphasia. Language deterioration is generally mild in normal aging but is a universal accompaniment of dementing diseases. Isolated, progressive language disturbance, especially nonfluent aphasia, is the hallmark of the syndrome called ¿Primary Progressive Aphasia¿ or PPA. The language findings in these patients illustrate that distinctions between focal and generalized brain disease are difficult. Much remains to be learned about the spectrum of diseases that can produce progressive aphasia. The discovery of biological or genetic markers for these diseases is likely to lead to a better understanding of their behavioral characteristics.

Aging↗

MRI asymmetries and language dominance.

OBJECTIVE: To examine the relationship between language dominance, as measured by Wada testing, and hemispheric asymmetries on MR brain images. BACKGROUND: A previous report that did not include verification of language dominance compared the length of the planum temporale with hemispheric asymmetries seen on CT and inferred that occipital lobe asymmetry is related to language dominance. METHODS: Language dominance was identified by the Wada test in 57 patients evaluated for surgical treatment of epilepsy. Fifty-five had an MRI scan that allowed accurate measurement. In a blinded fashion, two examiners independently measured bilateral frontal, parietal, and occipital lobe lengths on MR scan for each patient. Measurements of asymmetries were compared with language dominance established by the Wada test. RESULTS: Reliability of measurement between the examiners was 97%. Asymmetry of the occipital lobe length on MR scan 10 mm above the tentorium was the only measurement significantly related to language dominance (p < 0.01). Occipital lobe length was longer on the left in 19 (40%) and on the right in 10 (21%) patients with left dominance. The right lobe was longer in six of seven (86%) patients with bilateral dominance. One patient with right hemisphere dominance had a longer left lobe. None of the measurements significantly related to handedness. CONCLUSION: Asymmetries of occipital lobe length relate to language dominance, but such dominance cannot be reliably identified by MR in an individual patient.

Adolescent↗

Subdural hematoma after normal CT.

Two patients suffered minor head injuries diagnosed as cerebral concussions. Both had normal CTs in the emergency room but developed progressive neurologic symptoms weeks later. Both had large subdural hematomas requiring surgical drainage. Physicians should be alert for neurologic deterioration in patients with minor head injuries, even after normal CTs.

Craniocerebral Trauma↗