高次脳機能障害
大脳半球の働きには左右差があり、右半球と左半球で司る役割が異なる。言語機能を司る方を優位半球と呼び、空間認知機能を司る方を劣位半球と呼ぶ。
一般的に左半球が優位半球(右半球が劣位半球)であることが多く、医師国家試験問題においては左半球を優位半球だと考えて問題を解いて差し支えないと思われる。
高次脳機能障害とは脳梗塞や脳出血や脳外傷などによって脳が部分的な損傷を受けた結果として生じる失語・失行・失認といった認知障害全般を指す。
失語症
言語機能を司る優位半球(左半球)の障害によって、言語を聞いたり読んだりして理解するというinput能力と言語を話したり書いたりして表出するというoutput能力が部分的または完全に失われた状態を指す。
優位半球(左半球)のうち側頭葉には言語理解機能を司るWernicke野、前頭葉には言語表出機能を司るBroca野、頭頂葉にはWernicke野とBroca野をつないで音の選択の働きを担っている弓状束が存在する。
Wernicke野が損傷するとWernicke失語、Broca野が損傷するとBroca失語、弓状束が損傷すると伝導性失語、Wernicke野とBroca野を同時に損傷すると全失語となる。これらは急性期(病初期)の失語症であり全て復唱障害を認める。
回復期の失語症としては超皮質性感覚失語・超皮質性運動失語・健忘性失語がある。回復期の失語症は復唱障害を認めない。
復唱能力はそれぞれの失語症の特徴を示す目安のようなものであり、失語症を分類するために確認される。
Wernicke失語(感覚性失語)
言語理解機能を司るWernicke野が損傷した結果として起こる失語である。
言語output能力(発話・書字)は保たれているものの、言語input能力(聴覚的理解・読解)と復唱能力が失われる。
発話は流暢であり自発的に喋るが言語を理解して話していないため、単語の意味を間違える語性錯語がみられ支離滅裂語となることが多い。
具体的には、眼鏡を指差して「えんぴつ」と言い間違えたりする。
超皮質性感覚失語
Wernicke失語(感覚性失語)の回復期に復唱が可能となったものを指す。
つまり、「復唱可能なWernicke失語」というように考えてよい。
Broca失語(運動性失語)
言語表出機能を司るBroca野が損傷した結果として起こる失語である。
Broca野はごく単純に説明すると、喉・舌・唇などを動かして言葉を発する役割を担っている。
言語input能力(聴覚的理解・読解)は保たれているものの、言語output能力(発話・書字)と復唱能力が失われる。
聴覚的理解障害はないので相手が話すことを聞いて理解することはできるのだが、言語をoutput(表出)する過程で障害が生じるため発話が非流暢となり文法的に複雑な文章を作り出すことは不可能となる。
超皮質性運動失語
Broca失語(運動性失語)の回復期に復唱が可能となったものを指す。
つまり、「復唱可能なBroca失語」というように考えてよい。
伝導性失語
Wernicke野とBroca野をつなぎ音の選択機能を司る弓状束が損傷した結果として起こる失語である。
言語input能力(聴覚的理解・読解)と言語output能力(発話・書字)は保たれているのにも関わらず、復唱能力が失われる。
伝導性失語は復唱障害が最大の特徴であり、復唱を指示されても途中で考え込んでしまったり省略したりして元の文章通りに復唱することができない。
また、弓状束は音の選択機能を司っているため損傷によって単語の音の間違いをする音韻性錯語を認める。
具体的には、えんぴつを「えんぺつ」と言ったりして単語の中の一音を間違えたりする。
健忘性失語
どの部分を損傷すると健忘性失語になるといった話ではなく、健忘性失語は他の失語症の回復期にみられることが多いものであり他の失語症のように一つの失語症としては独立してはいないと主張する専門家もいる。
言語input能力と言語output能力はあるものの「しばしば言いたい単語が思い浮かばずに遠回しな表現をする」様子を指す。
頭頂葉機能障害
頭頂葉機能障害は優位半球(左半球)と劣位半球(右半球)でそれぞれ異なる症状が生じる。
優位半球(左半球)の頭頂葉は計算機能や書字機能を主に司るのに対して、劣位半球(右半球)の頭頂葉は空間認知機能を司るためである。
中大脳動脈領域の脳梗塞が原因として多く、医師国家試験問題においてもこの設定で出題されることが多い。
医師国家試験問題では放線冠レベルのMRI拡散強調画像が記載されていることが多いのだが、放線冠レベルのスライスでは後頭葉の占める割合が小さいため、頭頂葉梗塞と後頭葉梗塞を間違えないように注意する必要がある。
ちなみにMRI拡散強調画像とは脳梗塞が高信号域(白い領域)としてみえる撮像方法であり脳梗塞評価に用いられる。
左頭頂葉梗塞
左中大脳動脈領域の脳梗塞が原因となる。
Gerstmann症候群
失算(計算障害)・失書(書字障害)・左右失認(左右が分からなくなる)・手指失認(親指と小指の区別がつかなくなる)といった症状を特徴とする症候群である。
観念運動失行
手の形を真似するように指示されても模倣することができなくなる。
大脳皮質基底核変性症の症状としても医師国家試験問題では出題されたことがある。
構成失行
図形の模写ができなくなる。
右頭頂葉梗塞
右中大脳動脈領域の脳梗塞が原因となる。
半側空間失認
視力などに影響はないのにも関わらず左側の空間に存在するものを認知できなくなり無視するようになる。
患者は正面を向いていても右に視線が偏っており、左側の食事だけ食べなかったりする。左側に注意が向かないようになる。
半側身体失認
右中大脳動脈領域の脳梗塞が原因となるので左半身麻痺を伴っていることが多いのだが、患者は左半身を認知できなくなるので左半身麻痺を否定する。
また、左半身麻痺がなくても患者は左半身を認知できないので右半身ばかりを動かすようになり左半身を動かさなくなる。
着衣失行
半側空間失認や半側身体失認の影響によって衣服を正しく着ることができなくなり、これを着衣失行と呼ぶ。
前頭葉機能障害
前頭葉は感情や行動をコントロールする役割を果たす。
前頭葉機能が障害されると怒りやすくなる情動障害や衝動的な行動をする脱抑制や発動性の低下(自発的な活動が乏しい)などが起こる。
後頭葉機能障害
視覚を通じて物事を認知できなくなる。
視覚失認が起こると「鏡に映った自分に挨拶する」といったようなことが起こる。
つまり、自分の顔さえも視覚を通じては認知できなくなるということである。
ただし、視覚以外の感覚を通じたら認知できるため自分の声を聞いたりした場合は即座に自分だと認知することができる。
何か物を見ても視覚からは認知できないため、例えばりんごを見せられても見ているものがりんごだとは認知できない。
しかし、この場合にもりんごを触ると触覚からりんごだとすぐに認知することができる。
参考文献
失語症の病巣:https://www.jstage.jst.go.jp/article/ninchishinkeikagaku1999/10/3-4/10_3-4_278/_pdf
復唱障害の構造について:http://www.neuropsychology.gr.jp/journal/archive/1990_06_02_05.pdf
今日の視点からみた伝導失語:http://www.neuropsychology.gr.jp/journal/archive/1993_09_02_05.pdf
高次脳機能障害:https://www.tokyo.med.or.jp/docs/handbook/358-375.pdf
失行のみかた:https://www.jstage.jst.go.jp/article/hbfr/40/2/40_199/_pdf/-char/ja
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