This article describes transitions in the progress and neuropsychological test results of four patients with traumatic brain injuries undergoing rehabilitation therapy for over 25 years and what the author has learned from the patients (a) until ten years ago and (b) during the last ten years. ［Case 1］The patient was under ten years of age when injured and suffered from a diffused axonal injury with noticeable memory impairment and disorientation. The author learned from the case about “confusion in the recovery period” and “a prolonged course of intelligence recovery.” ［Case 2］The patient was in his 20s when injured and suffered from damage to the bilateral temporal lobe (diffused) with noticeable memory impairments. The author learned from the case “conflicts in accepting the disorder” and “about social participation.” ［Case 3］The patient was in his 20s when injured and suffered from a frontal lobe (orbital area) contusion with a noticeable emotional disorder. The author learned from the case about “the base of irritability” and “family power.” ［Case 4］The patient was in his 40s when injured and suffered a frontal lobe (diffused) contusion with noticeable executive function disorders. The author learned from the case about “tenacious employment support” and “maintenance.” These cases are discussed from the perspective of medical staff and supporters.

  I have discussed about aging and cognitive function from two points of view : 1. The effect of aging on cognitive function per se, 2. The effect of aging on cognitive disorders including recovery. It is well known that aging causes cognitive decline, however it has become clear that it is not so simple. Many findings have suggested that we have to distinguish longitudinal study and cross-sectional study, correct test-retest effect, correct educational background to come to the right findings. Many studies have indicated that some cognitive functions decline according to aging, but not all, and even some people with pathologic changes of Alzhemerʼs disease in their brain develop no dementia. And some studies show adult hippocampal neurogenesis. Regarding patients with aphasia or other cognitive disorders, aging causes negative effect of symptoms and recovery, however not all the aspects. Thus, we need new point of view to understand what aging causes without prejudice negative effect of aging.

  Multilingual speakers are those who speak more than one language in daily life.
  The recovery of aphasia in multilingual speakers is multidimensional and involves several interrelated factors, resulting in different recovery patterns.
  The main factors involved in the recovery of aphasia in multilingual speakers are the pre-onset language status : differences in language modalities used before disease onset : differences in size of the lesion site and severity of aphasia after disease onset : linguistic similarity between languages : influence of the language environment, including language therapy, after disease onset: impairment of language switch mechanisms : and differences in the lateralization of language functions.
  Especially, the role of language status before disease onset is significant. The greater the linguistic similarity between the two languages, the more likely they are to have overlapping localization of language functions and to recover in parallel.
  Hemispheric lateralization of language function has been suggested to involve the right hemisphere in reported cases of crossed aphasia. However, a subsequent meta-analysis showed that early bilingual speakers had bilateral organization of both languages. In late bilingual and monolingual speakers, left hemisphere dominance has been shown in both languages.

  As the globalization of Japanese society proceeds, the number of the brain-damaged polyglots with aphasia is increasing. Researchers in this field should be interested in aphasic status of such polyglots and their recovery. This might be the main background of the symposium of the 45th Annual Academic Meeting of Higher Brain Function Research.
  The author (hereafter, I) , the right-brain-damaged polyglot of three languages (English, Spanish, and Japanese) and a neuropsychologist as well, happened to be nominated as a speaker at the Symposium. My self-estimation in my acute stage indicated that I had almost no problem in Spanish but I had difficulty in making long and complicated sentences in both Japanese and English. I think my ability in speaking these two languages have almost improved.
  I felt uncomfortable with the offer, since I noticed that my ability to speak each language was too poor to express me as a polyglot. The other problems I noticed were that I was not the left but the right-hemisphere-damaged and, also constitutional left-handed. Eventually, I accepted the nomination to confirm 1) whether or not my speech disturbance was due to aphasia, and 2) the effective factor for the recovery in polyglots.
  The results revealed that my speech disturbance could be treated as aphasia, and that the right-hemisphere-lesion and the left-handedness are the possible factors for recovery.

  I discuss the following three questions in regard to Autism Spectrum Disorder (ASD) and multilingualism.
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  1) Do multilingual environments adversely affect the language development of children with ASD ?
  2) Can children with ASD acquire multiple languages ?
  3) How can we assess whether a childʼs language problems are caused by the multilingual environment or a disorder ?

  Regarding 1) and 2) , I refer a research paper published in 2012. The authors assessed the language development of 75 children with ASD (mean age : 4.5 years) , dividing them into three groups : monolinguals, simultaneous bilinguals, and sequential bilinguals. The results showed no significant differences between these groups. There now seems to be a consensus that multiple language environments do not affect the language development of children with ASD adversely, and that children with ASD can acquire multiple languages.
  Regarding 3) , I present a case of a Japanese girl with ASD to demonstrate the significance of thorough understanding of multilingualsʼ psycholinguistic characteristics in accurate language development assessment of multilingual children. The girl spent her early years in a foreign country where English was the official language. At the age of seven, a psychiatric evaluation of her communication problems concluded her language delay was attributed to ASD, and not to the multilingual environment.

  Electrical stimulation mapping (ESM) is a method to evaluate the brainʼs functional organization in brain tumors and epilepsy patients by directly stimulating it and observing the responses. Many publications have described the cortical organization of language in multilingual subjects : however, the localization patterns among the first, second, and even later languages seem to be diverse and complex. One of the reasons for this complexity is that language organization in multilingualism can be influenced by many factors, such as the age of languages acquisition, languages proficiency level, degree of exposure to each language, degree of language hemispheric lateralization, and localization and duration of the pathology. According to a recent systematic review, it is necessary to evaluate each language separately when performing resection of brain lesions since languages can demonstrate distinctive organization patterns depending on the factors mentioned above. Here, we present two multilingual patients who had awake surgery in which EMS has demonstrated common and specific areas for their languages. Also, some areas elicited language switching after stimulation. Interestingly, in one patient, a significant change in cortical language organization was observed at the time of reoperation, reflecting the process of brain plasticity in slowly growing glial tumor.

  The right hemisphere damaged patients who are considered for the driving evaluation are mainly have mild symptoms, their symptoms have improved after rehabilitation, they are at the stage of independent ADL by using compensation strategy, or they are in the active phase before returning home or working. In contrast to moderate and severe cases, these mild cases are often difficult to detect problems in BIT, unless there is a time limit. In particular, dynamic assessments, such as lane following and reaction tasks on driving simulators, may provide useful information for predicting the risk in car driving for RHD patients. In this paper, we present the results of a driving simulator task that we developed for RHD patients, whose symptoms of USN may be undetected by only a paper-and-pencil test.

  In our stroke center, we have developed a driving evaluation and support system for individuals with stroke. This system is connected to the on-line clinical pathway and covers acute and recovery stage and the outpatient clinic. Linked to the clinical pathway, the evaluation of fitness to drive is easy to conduct during routine care. Evaluation in the acute stage allows early-discharged patients who passed the test to resume driving soon after, and encourages patients who failed to receive more active rehabilitation for fitness to drive during the recovery stage. The outpatient-clinic evaluation is essential for patients classified as borderline regarding fitness for recommendation for the on-road driving test. For the first time, our on-line system has made it easy to indicate the result of driving support for stroke patients : 18% of all stroke patients, and 43% of supported patients, and 56% of early-discharge patients were assessed as “fit to drive”.

  Patients with acquired brain injury (ABI) may present physical, cognitive, and/or behavioral problems that may impact driving ability. In Western countries, on-road training conducted in real traffic conditions has been identified as an important aspect of driver rehabilitation for the ABI patients who showed some problems on on-road driving assessment. In Japan, however, the intervention of on-road training has not been conducted. The authors have developed the system of on-road driving training in Koriyama district. So far 31 patients with ABI received the training lessons. Thirty patients passed the on-road reassessment after 2 to 10 lessons and successfully returned to drive. Preliminary follow-up survey revealed that their driving performance was comparable with that of those who passed the initial on-road assessment. Little evidence, however, as to the efficacy of on-road driving training has been established. Further investigation of the full randomized controlled trial should be necessary.

  The Society of Rehabilitation and Resumption of Driving, centered on the Department of Rehabilitation Medicine at the University of Occupational and Environmental Health in Fukuoka, developed the Guidance for Driving Resumption for Patients with Higher Brain Dysfunction following three years of activities. However, due to many problems, such as the lack of cooperation between driving schools and medical facilities, it became necessary to standardize the Fukuoka-specific assessment of driving resumption, including the on-road evaluation. Therefore, since being established in 2016, the Fukuoka Liaison Council of Safe Driving and Medical Conditions has held a biannual meeting consisting of educational lectures, information, and discussions. One consequence has been to unify the basic test elements to be and judgment criteria by which higher brain function should be evaluated as a minimum in Fukuoka. Also, in cooperation with driving schools, those conducting on-road evaluations have been registered and the names and contact details of instructors posted on our website. Furthermore, the On-road Evaluation Request Form and On-road Evaluation Report have been unified in Fukuoka and to ensure consistency among instructors, a Judgment Guide produced. It is hoped that a similar system will expand to other prefectures in the future.

  This article described for the novice therapists on how to support patients with aphasia and their family members be based on analytical perspective on aphasic symptoms and on long-term perspective of recovery from aphasia. In the first part, we suggested the importance of collecting both quantitative (number of correct answers) and qualitative data (characteristics of errors) from patients with aphasia to estimate the mechanisms of their aphasic symptoms and to obtain clues for effective therapeutic intervention. In the second part, we suggested how to answer to questions from patients with aphasia and their families as a language specialist, leading them to a deeper understanding of the symptoms.

  Awake surgery, or awake craniotomy, is performed in brain tumors called gliomas, which grow and infi ltrate into brain tissue, as well as drug resistance epilepsy, aiming to protect higher brain functions, including speech and language. In other words, awake surgery is a surgery that ensures the patientsʼ true quality of lives, returning them to their normal social lives. In Japan, the guidelines for awake surgery were established ahead of the rest of the world. It has been incorporated into the health insurance system, as well, and becoming more and more popular. To have a maximum success, it is crucial to have a good surgical team, consisting of multidisciplinary professionals, such as neurosurgeons, neurologists, speech therapists, occupational therapists and so on, and to achieve a fi ne balance of the two goals, the excision of brain lesions and preservation of the cognitive and behavioral functions, depending on patientsʼ social backgrounds and lifestyles. Awake surgery also provides a precious opportunity to directly evaluate indigenous functions to humans, contributing to a progress in neuroscience. I hope this article will inspire many of our colleagues from these specialties to become interested in this exciting scientifi c fi eld.

  Differential diagnosis between depression and apathy is critical because both of them can cause substantial deterioration in prognosis in patients after acquired brain injury and degenerative disorders and the treatment methods for these two conditions are quite different. The key feature to differentiate between depression and apathy is the presence of depressive mood and/or negative thinking patterns, both of which are the hallmarks for depression. Recent brain imaging studies reveal that while there is a hyperactive region in patients with depression, particularly, the ventromedial prefrontal cortex, patients with apathy have no hyperactive region in their brain. Treatment strategies for patients with depression after acquired brain injury include pharmacotherapy, psychological therapy, and social intervention. In addition, a tailor-made rehabilitation approach with an achievable goal for individual patients after acquired brain injury might improve their depression, which is also the case with patients with apathy.

  The idea that the symptoms of neurological disease are dual in nature, negative and positive, is scientifically valuable and practically useful. Hughlings Jackson claimed that the nervous system is an evolutionary hierarchy of three levels, from simple, organized, and most automatic state to complex, least organized and least automatic state. The higher level controlled and inhibited the function of lower levels so that neurological disease led to two sets of symptoms, negative and positive, which is called “duality of symptomatology”. Negative symptoms are related to loss of the controlling cortex while positive symptoms are associated with excitation or the release of lower levels from higher inhibitory control. Positive and negative symptoms are closely intertwined such that they both occur contemporaneously. The brain damage that gives the negative symptoms at the same time allows expression of the positive symptoms. For example, aphasic patients may show difficulties in recalling words (negative symptom) and echolalia (positive symptom) simultaneously. To comprehend complex neurological symptoms, it is important to consider duality of symptoms in relationship to the underlying neural mechanisms.

  This report describes six cases of dementia that presented with atypical symptoms or brain imaging findings. Among two patients with Alzheimerʼs-type dementia, one exhibited face recognition disorder and another exhibited jargon aphasia : in these cases single-photon emission computed tomography revealed decreased blood flow to the anterior tip of the right temporal lobe and the posterior portion of the left temporal lobe, respectively. Another patient exhibited acute to subacute progressive cognitive disorder during hypothyroidism treatment : considering Hashimotoʼs encephalopathy, steroid therapy was administered, which partially improved cognitive disorder. In the fourth case, brain magnetic resonance imaging (MRI) revealed progressive atrophy of the frontal and temporal lobes in a patient with progressive dementia: after further pathological examination, the diagnosis of dementia with Lewy bodies was established. The fifth case involves amyotrophic lateral sclerosis and dementia in a patient who exhibited Alzheimerʼs disease pathology although there was no TAR DNA-binding protein 43 pathology in the limbic system and cerebral cortex. Brain MRI revealed prominent cerebral white matter lesions in another patient with juvenile dementia that began with cognitive impairment and personality change : the pathological diagnosis was diffuse leukodystrophy with axonal spheroids. These observations emphasize the importance of considering atypical symptoms or imaging findings during the clinical diagnosis of dementia.

  We report a case of fluent aphasia after an infarction of the left frontal lobe.We discussed the dissociation between modalities, variated symptoms during the course, neologism, and the peculiar naming reaction from the viewpoint of perseveration, word formation and overextention.

  Topographical disorientation, which causes loss of orientation within oneʼs environment, comprises several types. Clinical conditions of the various types are complicated and their mechanisms remain unclear. We investigated the clinical condition of a patient with topographical disorientation. The patient was a 71-year-old, right-handed female who had surgery to remove a meningioma in the medial surface of the right parieto-occipital lobe. Although she was able to identify townscapes, she continued to become lost in unfamiliar places. Her abilities of mental rotation and spatial orientation were inhibited, which indicated that her allocentric spatial representation and ability to recognize objects in relation to herself were impaired. We concluded that this condition of losing her way was caused by heading disorientation with egocentric disorientation.

  We report a patient with anomic aphasia with mild surface dyslexia due to a cerebral hemorrhage in the left putamen. To investigate the mechanism of her reading impairment, we conducted a set of language tasks that included a reading aloud task using Kanji word and Kanji non-word, lexical decision task using Kanji pseudohomophone stimuli, Kanji word reading comprehension task, and a picture naming task were conducted. The patient had a low score on the reading aloud task with low frequency and atypical reading words, and her error responses in this task were all LARC (legitimate alternative reading of components) errors. These findings are consistent with the characteristics of surface dyslexia. Because the patient showed a normal score on the reading aloud task with non-pseudohomophone non-words, we concluded that her ability of Kanji-to-phoneme conversion was preserved. In addition, she had a low score on the lexical decision task including pseudohomophone non-words, and therefore we concluded that a problem existed in her word identification process. Based on analysis using a dual route cascaded model, we believe that the emergence of her mild surface dyslexia in this case might be related to impairment of the orthographic lexicon and phonological lexicon, not to impairment of the semantic system.

  In this study, we report a case of aberrant social behavior after bilateral temporal lobe injury. The patient was a right-handed male aged 70 years. He had developed a cerebral infarction about 10 years previously and was diagnosed with Wernickeʼs aphasia. Problems in communication increased with the recurrence of cerebral infarction in the right temporal lobe cortex, and his behavior became aggressive and disinhibited. As a result of the auditory comprehension test, no obvious deterioration of speech discrimination ability or auditory agnosia was observed. However, following the prosody comprehension test, prosody comprehension disorder was suspected. Furthermore, the characteristics of the aberrant social behavior in this case were similar to those of frontotemporal dementia. Therefore, it was clarified that aberrant social behavior appeared even in association with localized lesions of the bilateral temporal lobe. On the other hand, the characteristics of the patientʼs aberrant social behavior case were qualitatively different from those caused by localized damage to the frontal lobe and were specific to bilateral temporal lobe injury.

  Carers of patients with acquired brain injury (ABI) have a greater burden than carers of patients with dementia, but no Japanese studies have directly compared these two groups of carers. The present study examined the burden and need for psychological support of carers of patients with ABI or dementia in the home. Carers of ABI and dementia patients (n＝46 in both groups) completed the Zarit Caregiver Burden Interview (ZBI) , WHO-5 Well-Being Index (WHO-5) , and questions regarding the need for psychological support in the home and the patientsʼ physical condition and cognitive function. No significant differences were observed in psychological burden between carers of ABI and dementia patients, and half of the carers in both groups had a high burden. A comparison of patient activities of daily living (ADL) and cognitive function showed that the functioning of ABI patients was better than that of dementia patients, although carers of ABI patients had a greater need for psychological support in the home compared to carers of dementia patients, In conclusion, carers of ABI and dementia patients have high care burdens, but the specific characteristics thereof differ between these two types of carers.

  One month after onset of a recent stroke, a woman in her late 60s was admitted to the convalescent rehabilitation ward of our rehabilitation center presenting with obvious topographical disorientation. Brain magnetic resonance imaging demonstrated right-sided cerebral infarctions involving the parahippocampal gyrus, fusiform gyrus, basal ganglia, superior parietal lobule, and retrosplenial region. Even after one week in hospital, the patient showed difficulty in moving from her room to the dining room or training room, despite their being connected by a straight corridor. The conventional neuropsychological evaluation revealed heading disorientation and landmark agnosia, and the Card Placing Test (CPT) devised by Hashimoto et al. (2016) additionally disclosed coexistence of egocentric disorientation. Accordingly, to compensate her topographical problems, we introduced a strategy using memos describing in words the spatial orientation of environmental items based on the patientʼs egocentric reference frame (e.g. “the AED is behind to the right” and “the counter is behind to the left”) . After 5 weeks of training using the spatial orientation memos, she was able to move independently throughout the hospital ward. Adding a test of egocentric disorientation, such as CPT, may contribute to elucidating the problems underlying topographical disorientation and gaining clues for rehabilitation methods.

  In this study, we report a 64-year-old female without a history of psychotic illness, who developed delusional supernumerary phantom limb after right putaminal hemorrhage. She had been undergoing artificial dialysis for 8 years due to chronic kidney disease and had a shunt on her left arm. On admission, she presented with severe left hemiplegia, sensory disturbance, and left unilateral spatial neglect. From day 7 after onset, she began to complain that she had another left arm in addition to her paralyzed left arm, which had been removed from her body. She also expressed the belief that she could undergo dialysis using the phantom limb, without having to go herself. On day 27, she reported that a third arm, which could be moved, was protruding from her left shoulder, and she stated that this third arm was “genuine” and that the paralyzed left arm was “not mine.” On day 34, with improvement in the motor function of her left extremities, her delusional phantom limb disappeared. We hypothesized that the phantom limb sensation might have derived from a severe sensory disturbance. We further speculated that the preserved left hemisphere induced various incorrect interpretations of the phantom limb in a situation where the right frontal lobe function to monitor the validity of beliefs was impaired. It is also possible that the content of the delusions was influenced by several psychological factors, including resistance to dialysis and denial of hemiplegia.

  We report two cases with Kanji writing disorder after right hemisphere damage.We examined their errors. Case 1 was a right-handed man in his 70ʼs who had had a right thalamic hemorrhage. Case 2 was a right-handed man in his 60ʼs who had a right putaminal hemorrhage and a left-handed family member. These two cases presented Kanji writing disorder, but they did not show aphasic symptoms or Kana writing disorder. We performed a dictation task of Kanji words. The correct answer rates were 37.1% in case 1 and 61.5% in case 2. Error features differed between the two cases, with case 1 showing partial omission or substitution of Kanji letters and case 2 unable to recall letters. Based on these error features, case 1 was thought to be spatial dysgraphia and case 2 pure dysgraphia caused by atypical lateralization.