Long-term Effects of Bilateral Frontal Brain Lesion60 Years After Injury With an Iron Bar

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.

HARLOW'S report of the case of Phineas P. Gage^1,2 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- 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.

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.

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.

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.

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.

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.¹⁰Figure 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.

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.

Accepted for publication February 20, 2001.

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@teleline.es).