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.
WESTBOROUGH, MA 4-8-2016 “What is up with the clock of the week?” For those of you who have been following these pages you may already know. As you can see it is quite small – 23 mm in size – about 1 inch. It is almost a clean circle but you can see that the 77-year old male had trouble placing the hands. He is in the hospital for rehabilitation following an episode of altered mental status. He is a 1996 heart transplant recipient previously in good health. Send your clocks to me at email@example.com
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
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.
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.