Mapping Connectivity Damage in the Case of Phineas Gage

This case study explores the mapping of connectivity damage in the case of Phineas Gage, providing insights into brain damage and its effects on behavior and functioning.

Running Head: PHINEAS GAGE CASE STUDY
Case study: Mapping Connectivity Damage in the Case of Phineas Gage
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Introduction
Due to advancement in technology various neuroimaging techniques have been
developed for mapping human brain connectivity. Various researchers and doctors seek to
understand the role that white matter (WM) and other regions of brain play in normal brain
function, brain damage, and how they influence human behavior. The most commonly used
methods are magnetic resonance imaging (MRI) and diffusion weighted imaging (DWI) (Van
Horn et al., 2012). Gage case whereby a “tamping iron” was accidentally lodged into the skull
and brain, offers a clear example of understanding how brain damage can affect the behavior and
normal functioning of the brain. The authors used Gage’s data obtained from computed
tomography (CT) to access the effect of the iron on the brain and damaged that occurred to the
white matter and gray matter (GM).
Neo-physiological/ biological components of the case
The iron rod penetrated Gage’s brain when he was working at a construction site causing
significant damage to the brain tissue. It pierced through the left check under the zygomatic arch
slightly behind the left eyeball. It also passed through the cranial vault below the left forebrain
hence penetrating the brain (Van Horn et al., 2012). Medical imaging technology revealed that
the grey matter on the left frontal cortical was severed injured and also it extended to the
secondary tissues. This could be explained by the fact that he experienced memory deficiencies
and failures to plan well. Through atlas mapping studies of human white matter connectome,
nerve damage was reported and was linked to Gage’s loss of sight as well as left eyelid ptosis.
Methodology

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The authors obtained the original CT data of Gages’ skull and through computational
studies they were able to estimate the best-fit rod trajectory across the skull. They then used the
MRI and DWI techniques and multimodal analysis to determine the magnitude of acute regional
cortical loss and probable extent of damage to other WM pathways (Van Horn et al., 2012).
They took measurements of the skull and tamping iron and determined the trajectory paths and
network connectivity. They used 110 normal right-handed males between the age of 25 to 36.
Results
They realized that 3.9760.29% of the GM was intersected with the most affected regions
being the cortical region (0.25%). The left middle superior and frontal sulcus, left orbital sulcus
and gyrus, lateral orbital sulcus, inferior frontal gyrus (orbital), and frontal part of both globular
and lateral sulcus of insula. The results showed that the iron rod didn’t pass through the midline
contrary to the results of other researchers (Van Horn et al., 2012). The most damage was on the
insular cortex and left temporal and left frontal polar. Also, 10.7265.46% of WM was destroyed
as well as fiber bundles of the connectivity matrices. Integration studies and segregation studies
deficiency revealed a higher path length compared to intact network and lower mean local
efficiency. This proved that the Gage’s lesion was severe and it affected white mater
connectivity of the left cerebral hemisphere.
Discussion
Various contradictory information regarding damage of the Gage’s brain has been
reported since the incidence occurred. Some claim that only the left side was affected while
others claim it was both the left and right sides. Van Horn et al. 2012, however, supported the
fact that only the left hemisphere was damaged since the midline was not bypassed. Results from

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this article supports the evidence that the damage was specifically directed to the left frontal lobe
with 10% of WM destroyed. In addition, there was alteration of the network connectivity
indicating damage to the global network topology such as the basal ganglia, limbic area, and
insula of the left hemisphere. The neural system of the brain was hugely destroyed that explains
the loss of memory observed with Gage.
An interesting finding was that the small worldness of the tamping iron showed that
lesion did not have any effect on network clustering (Van Horn et al., 2012). As such, the
unaffected network of the brain maintains its functionality integrity and nodal clustering. Other
studies as well have proved that networks are insensitive to lesions and damage occurring to the
nodes. Therefore, damage of Gage’s brain network connectivity could be unlikely. However, due
to the deleterious effect of lesion on network segregation and integration, sensory-specific
changes in connectivity such as blindness is possible. Therefore, these results indicate that iron
tamping into Gage’s brain destroyed the limbic, temporal, and central hub structures on the left
hemisphere and the effect was spread to network hubs leading to cognitive and symptomatology
seen in Gage.
Symptoms of the disorder and treatments
Traumatic brain injury is usually connected with behavioral and social alterations,
planning deficits, alteration of social functioning, memory loss, and changes in moods as
observed with Phineas Gage. Damage to the network connectivity particularly the uncinated
fasciculi affect processing of emotion stimuli. This could be the reason why Gage’s personality
was altered. Although this case study did not look at the treatments offered to Gage, a treatment
plan for patients undergoing traumatic brain injury has been developed. Empirically-based
treatments for this disorder involves specific targeted therapy (Sugden, Kile, Farrimond, Hilty, &

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Bourgeois, 2006) such as use of amantadine, risperidone, and psychostimulants such as
methylene. They improve the symptoms leading to visual attention, less agitation, mood swings
as well as attention and increased arousal due to dopaminergic effect. Cholinergic augmentation
also has been accepted as a treatment method for cognitive impairment.
The most commonly treatments for traumatic brain injury(TBI) include diuretics, anti-
seizure drugs, and coma inducing drugs. Diuretics reduces pressure built-up in the brain. Putting
the patient in a coma is crucial since the compressed blood vessels are not able to supply enough
oxygen and nutrients to the brain. Treatment for TBI takes several weeks and, therefore, the
patients should be monitored often since they take time to stabilize (Sugden, Kile, Farrimond,
Hilty, & Bourgeois, 2006). Sometimes symptoms may resolve and within few days they shoot up
again. In such cases, the dosage of the drug should be considered carefully. If symptoms worsen
the treatment should be changed. For instance, administration of 10 mg of donepezil accelerated
the aggressiveness and agitation of the patient. As such, it had to be stopped and administration
of 500 mg of Valproic acid (VPA) lowered the intensity of the symptoms.
In severe cases surgery can revert the damage (Sugden, Kile, Farrimond, Hilty, &
Bourgeois, 2006). This may involve removal of the clotted blood, repairing skull fractures, and
opening a window in the skull. Lastly, rehabilitation of the patient is crucial so that they can
relearn the basic skills such as talking, writing, and walking. All these treatments are aimed at
controlling the psychiatric symptoms and helping the patients recover. For instance, after
treatment Gage recovered from the brain trauma and his mental status stabilized. He was able to
take other forms of employment, travel to various countries such as New England, South
America, and Western US. Nevertheless, 12 years later he succumbed to epilepsy linked to the
white matter connectivity injuries (Van Horn et al., 2012). Although the available treatments

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alleviate the symptoms of TBI, there is scarcity of information regarding natural recovery. Also,
if the brain cells are destroyed completely, there is no repair.
Conclusion
MRI and DWI techniques have played a crucial role neurological disorders studies. The
case study of Phineas Gage has contributed hugely to brain studies by offering great insights on
what happens when brain is damaged and the pharmacological intervention of diseases causing
traumatic brain injury. The iron tamping on Gage’s brain caused direct damage on the left
cerebral hemisphere leading to destruction of the white and grey matter. Also, it altered the
network hubs and connectivity leading to brain lesions that affected other areas of the brain. As a
consequence, the neural system was affected leading to psychological and behavioral changes
observed in Gage. This article offers detailed information that eliminates controversies
surrounding the Gage case.

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References
Sugden, S. G., Kile, S. J., Farrimond, D. D., Hilty, D. M., & Bourgeois, J. A. (2006).
Pharmacological intervention for cognitive deficits and aggression in frontal lobe injury.
NeuroRehabilitation, 21(1), 3-7.
Van Horn, J. D., Irimia, A., Torgerson, C. M., Chambers, M. C., Kikinis, R., & Toga, A. W.
(2012). Mapping connectivity damage in the case of Phineas Gage. PloS one, 7(5),
e37454.