This chapter defends the 2-agents claim, according to which the two hemispheres of a split-brain subject are associated with distinct intentional agents. The empirical basis of this claim is that, while both hemispheres are the source or site of intentions, the capacity to integrate them in practical reasoning no longer operates interhemispherically after split-brain surgery. As a result, the right hemisphere-associated agent, R, and the left hemisphere-associated agent, L, enjoy intentional autonomy from each other. Although the positive case for the 2-agents claim is grounded mainly in experimental findings, the claim is not contradicted by what we know of split-brain subjects’ ordinary behavior, that is, the way they act outside of experimental conditions.
OBJECTIVE: The accuracy of stroke volume variation (SVV) obtained by the FloTrac™/Vigileo™ system in otherwise healthy patients undergoing brain surgery was assessed. METHODS: Anaesthesia was induced in 48 patients with minimal fluid infusion. Before surgery, fluid volume loading was performed by infusion with Ringer's lactate solution in 200 ml steps over 3 min, repeated successively if the patient responded with an increase in stroke volume of ≥ 10%, until the increase was < 10% (nonresponsive). RESULTS: A total of 157 volume loading steps were performed in the 48 patients. Responsive and nonresponsive steps differed significantly in baseline values of blood pressure, heart rate and SVV. Significant correlations were found between the change in stroke volume after fluid loading and values of blood pressure, heart rate and SVV before fluid loading, with SVV the most sensitive variable. CONCLUSION: Stroke volume variation obtained using the FloTrac™/Vigileo™ system is a sensitive predictor of fluid responsiveness in healthy patients before brain surgery.
Abstract
Brodmann’s areas 44/45 of the inferior frontal gyrus (IFG), are the seat of Broca’s area. The Western Aphasia Battery is a commonly used language battery that diagnoses aphasias based on fluency, comprehension, naming and repetition. Broca’s aphasia is defined as low fluency (0-4/10), retained comprehension (4-10/10), and variable deficits in repetition (0-7.9/10) and naming (0-8/10). The purpose of this study was to find anatomic areas associated with Broca’s aphasia. Patients who underwent resective brain surgery in the dominant hemisphere were evaluated with standardized language batteries pre-op, POD 2, and 1-month post-op. The resection cavities were outlined to construct 3D-volumes of interest. These were aligned using an affine transformation to MNI brain space. A voxel-based lesion-symptom mapping (VLSM) algorithm determined areas associated with Broca’s aphasia when incorporated into a resection. Post-op MRIs were reviewed blindly and percent involvement of pars orbitalis, triangularis and opercularis was recorded. 287 patients had pre-op and POD 2 language evaluations and 178 had 1 month post-op language evaluation. 82/287 patients had IFG involvement in resections. Only 5/82 IFG resections led to Broca’s aphasia. 11/16 patients with Broca’s aphasia at POD 2 had no involvement of IFG in resection. 35% of IFG resections were associated with non-specific dysnomia and 36% were normal. By one-month, 76% of patients had normal speech. 80% of patients with Broca’s aphasia at POD 2 improved to normal speech at 1-month, with 20% improved to non-specific dysnomia. The most highly correlated (P< 0.005) anatomic areas with Broca’s aphasia were juxta-sylvian pre- and post-central gyrus extending to supramarginal gyrus. While Broca’s area resections were rarely associated with Broca’s aphasia, juxta-sylvian pre- and post-central gyri extending to the supramarginal gyrus were statistically associated with Broca’s type aphasia when resected. These results have implications for planning resective brain surgery in these presumed eloquent brain areas.
Evaluation of Stroke Volume Variation Obtained by the FloTrac™/Vigileo™ System to Guide Preoperative Fluid Therapy in Patients Undergoing Brain Surgery