Clock of the Week June 6

Westborough, MA June 6, 2017 The clock of the week is depicted below.  It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital.  I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine.  I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient.  It was drawn by a 93-year old male with congestive heart

SLP_93 YOScan
Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s.  This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient.  The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well.  I once had a patient draw and elaborate grandfather clock fit for a castle.  The clock face became secondary and insignificant – for him.  The clock is a regular feature here at Concussion Assessment and Management.  
Anyone can submit a clock for consideration of the clock of the week.  Upload to my email address: – No identifying HIPPA protected information please but a brief overview is always helpful. 

Mayo Clinic. Taken June 6, 2017

Delirium: sudden onset often lingering emotional impact

Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.  STAT Boston Globe taken 10-17-2016
Try as he might a patient with delirium cannot complete simple tasks according to Sefton.

Perseveration, severation, eration, ation

WESTBOROUGH, MA October 14, 2016 What does the term ‘to perseverate’ refer to in clinical terms.  The media attached below will illustrate the concept of perseveration in its clinical presentation. The patient was asked to copy her name.  A model was presented for her by the examiner. Most people have control over behavior through a series of feedback loops that become active in the brain that allow for anticipatory awareness and behavioral prospective as a person reaches full cognitive maturity.  Patients who are recovering from right hemisphere lesions often exhibit the pattern

Patient asked to copy her name – Frances

of repetition without regard for how appropriate the pattern may be in respect to the task demand. You can see that the patient draws what appear to be tee pee shaped figures and two horizontal lines – perhaps a modified upper case A.  Meanwhile, she repeated the figure until she ran out of paper at the bottom margin.  In blogs already published I have mentioned the term perseveration and made an effort to illustrate its unusual presentation. One can see in the feature image a circular pattern of zeros as a patient attempted the clock drawing.  The patient got stuck making the number 0.  In the recent blog on this topic, I posted a video for the readers use that shows one case of perseveration in an older patient drawing circles over and over.


The term refers to the pattern of repeated motor movement in spite of the indication (or feedback) that the response is no longer needed or is inappropriate.  As you can see by this drawing the individual continued to make the same pattern over and over without regard for the task I had assigned – copy your name.

Treatment from serious stroke require months of cognitive rehabilitation in addition to physical and occupational therapy.  patients must be taught to recognize their cognitive vulnerability to errors like this.  As recovery is made most patients establish improved self-monitoring to compensate for their weaknesses. But some fail to re-establish the feedback loops and awareness that allow them to live in the world with the immediate awareness that once is enough and it is okay to stop.

Perseveration: Often seen in concussion – in short duration before recovery

WESTBOROUGH, MA July 23, 2016 Perseveration results from a change in cognitive status often seen in athletes with concussion. It is most often manifest when an athlete says or does the same thing over and over without realizing it. In some cases the athlete will make an effort to cover for themselves expecting that no one will notice that anything is amiss. Not so fast.  The last one to notice that anything is wrong is the athlete with a concussed brain.  Everyone else notices but not him.  Recently the NFL has made it mandatory for a teammate who suspects that a teammate has sustained a concussion must say something to the coaches or trainer.

In patients with concussion the confusion evaporates quickly generally within minutes to hours.  The video shown here depicts a case of perseveration that is more severe.  It is an older patient who sustained a fall and is quite altered. The video illustrates a case of altered mental status resulting in perseverative drawing in circles.  In general, patients who are older have a slower recovery than younger ones. This video shows the stark lack of self-monitoring as the patient attempts to construct a simple clock.

This video was put together by the Neuropsychology Service at Whittier Rehabilitation Hospital in Westborough, MA USA


Bike of the week – acquired brain injury

Draw a bike – How does it work?

WESTBOROUGH, MA June 6, 2016 The Bike of the week is drawn by a 86-year old man who is undergoing inpatient rehabilitation for an acquired brain injury and stroke. Actually I rarely publish the drawings made by patients I see unless I am going through a dry spell of interesting clocks.  The man who drew this bicycle was independent prior to a fall and driving.  In this case, there was a a fall 2 months ago – in April 2016 from which he largely recovered.  He underwent lab studies and a C-T scan of his brain being diagnosed with subdural hematoma (SDH).  The C-T scan revealed a collection of blood in the frontal part of his brain known as a subdural hematoma (SDH) often associated with brain trauma from a fall or motor vehicle crash.  The patient in this case had fallen in his bathroom. He had been prescribed a blood thinner and his atrial fibrillation which was stopped.  These levels were supratherapeutic – too high making him at high risk for bleeding – in this case in his brain. He was taken off the blood thinner in the weeks following the traumatic injury to allow the bleeding in his brain to be controlled. In late May, 2016, he was found at home to be slurring his words and demonstrating right hand weakness. He was rushed to Cape Cod Hospital and diagnosed with a left MCA ischemic stroke and he was treated conservatively.

Bleeding on the brain is a life threatening condition that will eventually result in herniation of brain tissue and death unless it is controlled.  Trauma can lead to edema or swelling of brain tissue.  In many cases, neurosurgery is required to remove subdural blood allowing space in the skull for the brain to swell as much as needed to recover.  In some rare cases, the part of the skull is actually removed to allow for brain swelling.  By removing a portion of the skull the brain tissue does not efface ipsilateral tissue or cause herniation by crowding out other viable brain tissue.



Clock of the week 3-23-16

Clock drawing 23 mm or 0.9 inch


WESTBOROUGH, MA  March 23, 2016  Here is a new clock drawn by a 85-year old male who is undergoing acute rehabilitation here is Westborough.  As you can see from the measuring tape it is about 23 mm in size.  It is just a bit over 1 inch in size.  Although somewhat subjective, I would call this an example of micrographia. In general micrographic drawing refers to constructions and writing that are well below the expected size – especially when the patient is copying a design and produces a tiny drawing – micrographic in size.  It is associated with lesions of the basal ganglia or neurodegeneration in the midbrain and is often seen in patients with Parkinson’s Disease.  Some might argue that micrographia results from diminished frontal-executive functioning.  This explanation is plausible to me but must include the system of attention as well. The patient who drew this clock needed two hands to craft some of his work by using his non-dominant left hand to steady the right as he wrote or drew.  He had sustained a cardiac arrest and was successfully resuscitated.  This man is not diagnosed with Parkinson’s. 

I have added a second clock of the week  also an example of micrographia. This clock was drawn by a 54-year old woman undergoing rehabilitation for a liver transplant.  She

Micrographia 2Scan
Micrographic clock only 19 mm in size drawn by 54 year old female

had had a long history of alcohol dependence resulting in damage to her liver.  A transplant was undertaken in February 2016.  Her drawing of 19 mm is only 3/4 inch in size.  I use a mechanical pencil to be sure and get as much detail in the drawings as possible.  Patients undergoing liver transplantation require weeks of rehabilitation due to the stress on the body this procedure instills. Below I have added another example drawn by the woman who is receiving treatment following a liver transplant.

Luria patterns

The Luria patterns is a test of set switching – thought to be a frontal lobe function.  This requires both attention to detail and the capacity to change the shape and angle of each character.  Some people fail to appreciate that the pattern is only 2 shapes – flat & pointed – repeated over and over.  I hope these drawings are of interest to those in training and or those with years of training in neuropsychology.  I enjoy receiving the occasional clock drawing or some other construction of interest.  Please do not hesitate to send your interesting clocks along with patient information and your interpretation.