Prominent mental symptoms and obscure physical signs; report of six cases with temporal lobe lesions

Six cases of temporal lobe lesions with prominent mental symptoms and without clear physical signs are reported. Case one, a right handed 53 year old female, suffered from speech disturbances and impaired mentation. The initial diagnosis had been presenile dementia. But closer examination confirmed the presence of transcortical aphasia. With the help of CT scans the final diagnosis of metastatic brain tumor was established with a principal lesion in the left temporal lobe. Case two, a 61 year old right handed male, developed headache, speech disturbances and mild left hemiparesis. Neuropsychological examination revealed amnestic aphasia. The patient was operated for an astrocytoma which was situated in the right temporal lobe. In subsequent course of radiation therapy violent behavior was often observed. Case three, a right handed 59 year old female, experienced aphasic seizures which were characterized by a loss of auditory language comprehension and the spontaneous production of incoherent words and would last about 10 seconds. A left-sided sphenoidal ridge meningioma was removed. Case four, a right handed 67 year old female, had a sudden fall followed by nausea, vomiting, headache and confusion. In a hospital she would shriek, become angry and did not cooperate. An autopsy revealed putamenal hemorrhage rupturing into the left temporal lobe. Case five, a right handed 63 year old man, began to behave abnormally. Agitation and violent behavior were also present. A glioblastoma of the right temporal lobe was found and eventually removed. Case six, a right handed 39 year old male, had been recovering from an initial infarction of the right temporo-occipital area due to Moyamoya disease when the second infarction destroyed the left temporo occipital area. Cortical blindness, and oral tendency, as well as violent behavior developed. Thus, aphasias such as the transcortical sensory type or amnesic type which was crossed, were major symptoms in the first two cases. These atypical aphasias have to be kept in mind when apparently demented patients are encountered. Aphasic seizure in case 3 was unusual but the proper diagnosis pointed to the temporal lobe lesion also. Violent behavior was characteristic in the last three patients. Although a responsible structure for violent behavior is still disputed, our present experience suggests the importance of temporal lobe lesions. When patients with prominent mental symptoms but with obscure physical signs are encountered, a possibility of temporal lobe lesion has to be considered.