The evaluation of elusive neuropsychological sequelae of frontal lobe lesions: suggestion from a case report

A.M. is a 43 year old man with a history of head trauma occurred about five years before in a skiing accident. His brain MR imaging shows bilateral and extensive areas of malacia at the frontal and temporal poles, also including the orbito-frontal region (mainly on the right) and white matter distrophy at the left cerebellar hemisphere. He has average verbal IQ (113), performs at a good, or even very good level on most measures of memory, language and visuo-constructional abilities and he also obtains high scores at traditional tests of executive functions (Trail Making Test, Wisconsin Card Sorting Test, Stroop Test, cognitive estimation tasks, logical reasoning). From an affective point of view, he presents with depression, anxiety and apathy. Although he performs so well at testing sessions, following the trauma he experienced dramatic occupational and social disruptions: he lost his job as a financial planner and divorced; he now lives with his parents and is unable to manage his social and professional life normally. He underwent further assessment of the executive domain through a decision making test (the Iowa Gambling Task) and two social cognition tests (the Social Context and Moral/Conventional Distinction tasks) which evidenced gross impairment of these aspects, with the patients performing significantly worse than a pool of age-, gender- and education-matched controls. This finding suggests that these relatively new tools for the assessment of complex, everyday life-relevant executive abilities may be particularly helpful for the detection and quantification of elusive neuropsychological sequelae of frontal lobe lesions