Hemispherectomy: Living with no right hemisphere

Hemispherectomy: Living with no
right hemisphere
Hunter Manasco PhD SLP
Christina Santhouse MS SLP
Today:
1. Discussion of
hemispherectomy and
implications to neuroplasticity
and laterality of cognition and
language.
2. Introduce main details of Ms.
Santhouse’s case.
3. Life and language after
hemispherectomy.
4. Q & A
Hemispherectomy
• Anatomical/functional
• Goal: Save or improve life
• Seizure free outcome 73-94%
Lettori, et al. (2008);Chandra, et al. (2008).
• Medical Complications 11-35%
Cook, et al. (2004)
• Physical/perceptual/cognitive-linguistic
outcomes
Hemiparesis, hemi neglect, contralateral field cuts
Prognostic indicators
• Primary etiology
Tumor, cortical dysplasia, Sturge-Weber, Rasmussens
• Age of hemispherectomy
• Length of time between seizure
onset and surgery
• Right vs. left hemisphere
(Curtiss & Schaeffler, 2005; Liegeois, et al. 2008)
• Post surgery rehabilitation
• Family support
Speech/Language/Cognition
Outcomes
•
Speech
– UUMN dysarthria
•
Language and Cognition
– Highly variable
– May rise or fall, usually rise
– Very early surgery
• Approximates normal levels language and cognition
– Later childhood & adult hemispherectomy
• Right hemispherectomy
– Deficits in identification of emotional expression
– Difficulties with lie/sarcasm detection
• Left hemispherectomy
– Short-term verbal memory deficits
– Aphasic symptoms
– Verbal intelligence decreases
So why the discrepancy?
No brain is better than bad brain
• Disordered hemisphere
– inhibiting processes other hemisphere
would otherwise be able to accomplish
independently
– disordered signals to intact hemisphere
or disordering shared thought processes
– actively destroying abilities of other
hemisphere
Neuroplasticity
• Samargia & Kimberly (2009)
• In early development there is no
hardwired laterality of function
• Removal of one hemisphere
releases inhibited abilities of other
• Villablanca & Hovda (2000)
• Rearrangement of remaining
sensorimotor cortex
• Neuronal sprouting/reinnervation in
descending pathways
• Novel reinnervation and decussation
to reduce visual field cuts
Case at hand
• R handed, Age 7-4: Aug 20 1995,
Presenting symptom- Irregular
twitching of left foot and ankle.
• Age 7-5: Sept 1995 Progression
to leg and thigh.
• Dx of Rasmussen’s made (a quickly
made Dx)
• Eval: Above average
cognitive/language scores but
showing some R hemi frontotemporal disfunction (visual memory,
visuo spatial skills, L motor skills)
• Age 7-8: Progression to left body
intractable seizures. Child
decides she wants the surgery.
http://sixtyminutes.ninemsn.com.au/stories/7936979/the-deepest-cut
Hemispherectomy performed
• Age 7-9: Feb 1996 Right cerebral
hemispherectomy performed
• Time between symptom onset
and surgery: approx. 5 months
• Seizure free post surgery
• Completed 3rd grade fully included
Case at hand: Immediate outcome
following surgery
• Directly after surgery (R hemispherectomy)
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L hemiplegia/ L visual field cuts
Decreased visual organization and visual memory skills
Left neglect
Decreased non-verbal problem solving
Impulsivity
Difficulties with math
Age appropriate language skills
Intelligible speech
Case at hand: Immediate outcome
following surgery
• Standardized scores dipped then recovered:
– Attributed to hemiplegia and visual field cuts.
• Self-report measures:
– No indication of depression or negative mood
– Above average confidence in herself intellectually,
socially, physically.
• “p.s. I’m going to get A’s all my life.”
• Noted in chart by one professional as being
“possibly in denial” and as another as having
“difficulty accepting her limitations”.
Difficulty accepting limitations.
Life and Language
After Hemispherectomy
Presented by:
Hunter Manasco, PhD. SLP
Christina Santhouse, MA, SLP
Bucks County Intermediate Unit 22
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Surgery
“We cannot change the cards we
are dealt, just how we play the
hand.” – Randy Pausch
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LUCK
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•
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Right hemisphere
Insightful/observant parents
Therapeutic support system
Competitive nature
Severe Headaches
• 1000 times a migraine
– Affects daily life and work
• Debilitating; routines are broken; limited focus
• Can not concentrate, bothered by light and smells
– Remedy
• Quick meds
• Dark room
• Quiet
Therapies
• Occupational Therapy
– Daily life skills, stretching, learn one handed
techniques
• Ex: Botox, car modifications, tying shoes,
buttoning shirts, cutting, opening cans and bottles
• Physical Therapy
– Gait training, stretching, mofos,
– Bioness
• Ex: walking, climbing stairs
Therapies
• Vision
– Scanning environment, mobility training, low vision eye doctor,
visual neglect
• Ex: prism glasses, navigating within the community, driving
• IEP & 504 Accommodations & ADA
–
Extended time, tutoring, extra set of books, different test
environment, note takers, Alternative Learners Program, office
hours, academic counselors
Speech Therapy
• Impaired Attention
• Pragmatic
Impairments
• Perseveration
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Attention Impairment Strategies
•Awareness
•Mental/sticky note reminders
•Consistency and schedules
•Asking questions
•Early bird gets the worm
•Time to organize
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Pragmatics Strategies
•Maturing into my own person
•Rote conversations
•Learned acceptance
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Overcoming Perseveration
Strategies
•Verbal and non verbal cues
•Treatments:
•Verbal cues
•Reassurance from self and others
•Thinking outside the box
•Trial and error
•Encouragement and support from family and
friends
•Non verbal cues
•Person friendly smile
•Body language
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INDEPENDENCE
• Driving
• Bioness
• Finding my voice
to help others
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Advocacy
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•
•
•
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Believing in myself
Standing up for what I need
Asserting against adversity
Helping others in need
(phone, in-person, conferences,
classrooms)
• Raising awareness & funds for
medical/community organizations
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Must Haves and Can’t Live Without
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Positive Attitude
Faith
Surrounded by family, friends,
colleagues, and my dog
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“If your mind can conceive
it, and my heart can
believe it, I know I can
achieve it”
-Jessie Jackson
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