Lasting mutism associated with buccofacial apraxia

Abstract

A right-handed 56-year-old male patient suddenly presented with mutism, and right hemiparesis. Hemiparesis quickly evolved and disappeared, and language slightly improved. However, 7 months later a total mutism and a very severe buccofacial apraxia associated with a mild aphasia were observed. A CT scan disclosed two almost homologous infarction areas: a left frontal opercular and a right orbitofrontal gyms infarction area. Several months later the patient passed away without any further change in his speech disorder. It is asserted that transient mutism can be associated with unilateral left damage, but lasting mutism associated with buccofacial apraxia requires bilateral lesions.     

Dichotic listening in crossed aphasia: "paradoxical" ipsilateral suppression

In a 35-year-old right-handed man who had no personal or family history of left-handedness, left hemiparesis and predominantly motor aphasia suddenly developed following cerebrovascular accident. Clinical and laboratory data, including computerized tomographic scan, showed a clearly defined right hemisphere lesion. On dichotic listening test, a clear-cut right ear extinction was present.     

Aphasia in left-handers: lesion site, lesion side, and hemispheric asymmetries on CT

Language in left-handed aphasics with left (n = 27) or right (n = 4) hemisphere lesion was examined. Left occipital CT asymmetry was the most common asymmetry and could not be used to predict handedness or which hemisphere, if damaged, would produce aphasia. When left hemisphere lesion sites were matched between eight left-handed and eight right-handed aphasics, there were no significant group differences on language measures. Two nonfluent cases with good comprehension and large right frontal, parietal, and temporal lesions appeared to have "Broca's area" in the right hemisphere, but "Wernicke's area" in the left. Results suggest separate hemispheric loci for handedness, speech output, and/or comprehension dominance in some left-handers.     

Two cases of cerebral embolism showing global aphasia without hemiparesis]

We report two cases of typical global aphasia without hemiparesis due to cerebral embolism. Case 1 was a 65-year-old right-handed man with a history of old myocardial infarction. No spontaneous speech was noted by his family. Neurological examination upon admission revealed confusional state, global aphasia, conjugate deviation to the left and slight drift of the outstretched right limbs. The right hemiparesis rapidly recovered after admission. CT scan performed on the second hospital day showed discrete low density areas in the left posterior frontal lobe and left temporo-parietal regions. The extent and severity of his global aphasia were unchanged. The second case was an 82-year-old right-handed man with a history of atrial fibrillation. He was admitted to our hospital one hour after he was found unable to speak. Neurological examination upon admission revealed global aphasia, conjugate deviation to the left and suspected right homonymous hemianopia by confrontation. There was no sign of hemiparesis. CT scan showed extensive low density area in the left temporo-parietal regions. In both cases, cerebral angiography failed to demonstrate any occlusion of intra- and extra-cranial blood vessels. IMP-SPECT showed a depression of cerebral blood flow in the left anterior and posterior watershed areas in case 1 and 2. In the literature, there have been 20 cases of global aphasia without hemiparesis including our two cases. In many cases, the initial symptom was inability or difficulty in speaking.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sequential changes of brain CT and MRI after febrile status epilepticus in a 6-year-old girl

Brain CT or MRI occasionally shows transient or permanent changes in the brain after status epilepticus (SE). The mechanism for these changes has not been well elucidated. We performed repeated imaging studies on a patient with febrile SE characterized by right hemiconvulsion. CT showed transient mild edema on both hemispheres immediately after the cessation of SE. The edema improved the next day. But aphasia and right hemiparesis were observed. On day 17, CT revealed edema on left hemisphere and MRI showed a high signal intensity in cortex and subcortical white matter of the left hemisphere on T2-weighted images. Although right hemiparesis and aphasia were improved, severe atrophy of the left hemisphere was noted on CT and MRI. The results suggest that brain edema observed in several days after SE but not edema observed immediately after the cessation of SE is more pathological for the permanent brain damage. Possible mechanisms of the initial brain edema and the second edema preceded severe atrophy in left hemisphere were discussed.     

Cerebral embolism following trivial trauma in children--report of three cases]

Three cases of cerebral embolism secondary to trivial trauma are reported. Case 1: A 12-year-old male suffered a severe headache followed by a generalized convulsion after he turned his head when he was flying a kite. A neurological examination on admission demonstrated right hemiparesis and aphasia. A CT revealed a low density in the left putamen, temporal lobe and frontal lobe. Left carotid angiography (CAG) showed irregular narrowing of the internal carotid with an embolic occlusion and narrowing of the middle cerebral artery with the intraluminal presence of emboli both in the anterior and middle cerebral arteries. He is now doing well but has right hemiparesis. Case 2: This 6-year-old female could not grasp chopsticks and had neck pain 10 minutes after being pulled up by the right arm by her father. Neurological examination demonstrated a right hemiparesis and aphasia. A CT scan and magnetic resonance imaging (MRI) of the head showed an infarcted area in the left caudate head, anterior limb of the internal capsule and putamen. Left CAG revealed an obstruction of the trunk of the middle cerebral artery. She has slight weakness in her right extremities. Case 3: This 11-year-old female noted a weakness in her left lower limb soon after her hair was pulled backward. On admission, a neurological examination failed to demonstrate any abnormality. CT showed an ill defined low density lesion in the right putamen. MRI revealed a high intensity lesion in a T2 weighted image. Right CAG showed an irregularity of the arterial wall in the cavernous portion of the right internal carotid artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dissociated crossed aphasia: a challenging language representation disorder

A monolingual strongly right-handed woman developed a left hemiparesis and severe motor aphasia following a right middle cerebral artery infraction, whereas comprehension was entirely intact. She had a history of a transient cerebrovascular event characterized by right hemiparesis and fluent sensory aphasia. This case suggests a transhemispheric pattern of language organization in which the Broca area resides in the right hemisphere, whereas the Wernicke area is in the left.     

A case of crossed aphasia in a dextral patient with polycythemia]

We report a 72-year-old right-handed man who was diagnosed as having crossed aphasia. He had polycythemia, hypertension and an old cerebral infarction in the right occipital lobe. He was admitted to our hospital because of muscle weakness in the left extremities at the age of 71. In the laboratory data, red blood cells(689 x 10(4)/microliter) and platelets(87.6 x 10(4)/microliter) were increased in number. Brain CT detected a right putaminal hematoma and an old infarct in the occipital lobe on the right. After admission, he developed non-fluent speech, and impairments of auditory comprehension, writing and naming due to the infarction in his right cerebral hemisphere including the middle cerebral artery distribution. The standard language test of aphasia(SLTA) revealed marked impairments in the language function, except for reading kana and kanji words. This writing was severely impaired compared with other language dysfunctions. Auditory comprehension, repetition and reading were impaired at the sentence level rather than at the kana word level. Furthermore, he suffered from left hemiparesis and left unilateral spatial neglect. We diagnosed his impairments of language function as crossed aphasia based on his right-handedness, CT findings and the results of SLTA. His language center was considered to be located in both cerebral hemispheres. Compared with typical findings in reported cases of crossed aphasia, the presence of both non-fluent speech and mutism were consistent with previous observations. However, the marked impairments of auditory comprehension, repetition and naming were different. Polycythemia and hypertension were considered to be the risk factors of cerebral infarction in our patient.     

Cerebral lateralization in two cases of crossed dextral aphasia with right-hemisphere arteriovenous malformation

This paper reports two cases of crossed dextral aphasia. The first patient was a 60-year-old right-handed male with no family history of sinistrality. He experienced sudden onset of left hemiplegia and loss of consciousness. A CT scan showed high-density area in the right fronto-parietal region. An angiography revealed an arteriovenous malformation (AVM) in the right parietal lobe. It was fed by a branch of the middle cerebral artery and drained through a cortical vein. Neuropsychological examination one week after the surgery showed severe defects of all language moderalities. He was alert and cooperative, but completely mute. He recognized common words by auditory and visual stimuli, but could not perform simple command. He wrote some meaningless letters when asked to write his own name. Auditory and reading comprehension gradually improved thereafter, but Broca's type of aphasia with non-fluent hesitant and effortful output was still present four months after the surgery. The second patient was a 38-year-old right-handed male. All members of this family are right-handed except for one sister who is left-handed. He suddenly suffered left hemiparesis and loss of consciousness. A CT scan disclosed a right parietal intracerebral hematoma. And an AVM which was fed by the angular artery and drained through a cortical vein was angiographically demonstrated in the same area. Postoperatively the left hemiparesis rapidly disappeared, but left homonymous hemianopsia and anomic type of aphasia still persisted. His speech was fluent and daily communication was possible in spite of circumlocutory paraphasic output.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of cerebral thrombosis presenting global aphasia without hemiparesis]

We reported a 62-year-old male with cerebral thrombosis presenting global aphasia without hemiparesis. The patient had an episode of aphasia 15 years ago, but recovered within 6 months. This time he had transient right sided mild hemiparesis, then he became aphasia next morning. When we examined at day 10 and day 15, his consciousness was clear, nothing he could speech, he could not understand or repeat. We diagnosed him global aphasia, but he had no hemiparesis except for right facial mild paresis and was able to walk. CT scan showed low density area in left and right posterior, left anterior watershed and left terminal zone. Cerebral angiography disclosed thrombotic occlusion of main trunk of left middle cerebral artery, and ambient segment of right posterior cerebral artery. Global aphasia without hemiparesis has been said a sign of embolic encephalopathy. This case was considered a very rare case, because he revealed global aphasia without hemiparesis by thrombotic occlusion.     

Crossed aphasia with left spatial neglect and visual imperception: a case report

A 64-year-old right-handed woman with no left-handers in the family developed aphasia associated with moderate left hemiparesis and dense left homonymous hemianopia following rupture of a right middle cerebral artery aneurysm and subsequent selective surgery confined to the right hemisphere. Severe left spatial neglect and constructional apraxia were also present. The patient was an achondroplasic dwarf whose previous medical and neurological history was otherwise unremarkable. Computed tomography of the brain showed a large right temporo-insulofrontoparietal lesion. Language and nonverbal cognitive functions were assessed after 2 and 6 months, and then four years later. A reportedly overall language disruption in the acute period evolved into Wernicke's aphasia and then into a mild form of conduction aphasia. The associated left spatial neglect eventually shrank to a minimum. The patient never had clinically detectable visual agnosia, but on specific tests of visual recognition and perception some impairment was found four years after onset. The left hemiparesis disappeared in time while the left hemianopia persisted. This case is a convincing example of an entirely righthanded person in whom both linguistic and visuospatial functions are represented in the right hemisphere. Received: 12 May 2002 / Accepted in revised form: 18 November 2002 Correspondence to L.A. Vignolo     

Left unilateral apraxia

A 32-year-old right-handed man suffered a traffic accident with head injury, resulting in loss of spontaneity, right hemiparesis, severe aphasia, and unilateral apraxia, which was noticed on his non-paralyzed left hand. An MRI scan conducted 11 months after onset revealed a large lesion in the left frontal lobe, a small lesion in the right frontal lobe and a striking thinning of the trunk of the corpus callosum with remarkable dilatation of the lateral ventricles. An IMP-SPECT scan, performed 1 year after onset, showed a diffuse hypoperfusion extending to the left temporo-parietal area further than the MRI verified abnormal density areas. The patient's praxic abilities were precisely evaluated 1 year after onset. The performance on the object use task was characterized by content errors. For example, when using a match with his left hand, he always treated with it like a cigarette. The right hand performance of this task was clumsy due to his right hemiparesis but successful. The performance on his left hand did not improved even when the patient was given visual examples. The term "ideational apraxia" proposed by Liepmann, which was characterized by content errors, implies a conceptual deficit. Morlaas defined ideational apraxia as a agnosia of usage. Ideational apraxia has been so far investigated mainly on patients with these difficulties in both hands. On the other hand, left unilateral apraxia has been explained by callosal disconnection. Liepmann and Maas thought that a lesion of the corpus callosum would prevent the space-time engrams in the left hemisphere from reaching the right sensorimotor area necessary to carry out the skilled act with the left hand, thereby inducing apraxia.(ABSTRACT TRUNCATED AT 250 WORDS)     

"Left unilateral agraphia with right hemiparesis" after occlusion of the left middle cerebral artery]

This paper presented a case of a right-handed male who showed a right hemiplegia without aphasia and apraxia. He lost the ability to write with the left hand. A 56-year-old right-handed man, who had a daughter of left-handedness, was sent to our hospital with a homonymous hemianopsia, facial weakness, spastic hemiparesis and sensory disturbance in the right side. CT scan revealed an infarction in the territory of the left middle cerebral artery. On a month after the onset, he was alert and oriented. His speech was normal and verbal comprehension was intact. Although he neglected the right side of the page, he could read and comprehend it correctly. In contrast with his normal abilities to speak, comprehend, and read, difficulties in writing were prominent. Spontaneous writing with the left hand was extremely poor, and he even had difficulty writing his own name. His dictation was also poor, but his writing improved with copying letters. Agraphia had seen even after USN was recovered. Analysis of this case suggested the presence of the dominance for speech, comprehension, and praxis in the intact right hemisphere, and writing center in the damaged left hemisphere.     

Middle cerebral artery dolichoectasia in a young woman with a previous stroke

We observed a 32-year-old female who had suffered from a left hemisphere ischemic stroke with right hemiparesis at the age of seven. At that time, a CT scan demonstrated a left ischemic lesion in nucleo-capsular region and a cerebral angiogram documented a complete occlusion of the supraclinoid segment of the internal carotid artery. When we observed the patient neurological examination demonstrated a moderate right brachio-crural hemiparesis. A brain MRI showed an old ischemic lesion involving the left nucleo-capsular and 'flow voids' suggestive for a vascular malformation in the left sylvian region. A cerebral rotational angiogram with 3-D reconstructions demonstrated a dolichoectatic left middle cerebral artery with an unusual 'corkscrew' aspect. Middle cerebral artery dolichoectasia is a rare pathological condition that may manifest with a stroke. The patients with intracranial arterial dolichoectasia (IADE) are most often hypertensive elderly men, and, to the best of our knowledge, an ischemic stroke associated with IADE has never been reported in children.     

Giant parenchymal cysticercosis with unusual imaging features

Giant neurocysticercosis is a relatively rare condition. A 40-year-old woman presented with left focal seizures and progressive left hemiparesis. A CT scan of the brain showed multiple hypodense lesions in the right cerebral hemisphere with no contrast enhancement or perilesional edema. MRI showed multiple hypointense lesions in the right perisylvian area. At surgery, the lesion was found to be a single large parasitic cyst measuring approximately 5.0 x 4.5 x 5.0 cm and the same was excised. Histopathology showed a solitary cysticercus cyst with scolex. The patient made an uneventful recovery. This imaging appearance of giant neurocysticercosis is very unusual and only two similar instances have been reported thus far.     

A case of jargon aphasia--a clinicopathological study

An autopsied case of jargon aphasia by multiple cerebral infarction was reported. A 75-year-old right-handed woman developed a Wernicke's aphasia with the first attack of cerebral infarction in the left hemisphere in July 1980. With the second attack of infarction in October 1980, she developed a neologistic and semantic jargon aphasia, in which her speech consisted of neologisms, literal paraphasias, empty phrases and so-called "misused words". CT-findings showed two low density areas; one was in the left hemisphere and the other in the posterior region of the right hemisphere. Her jargon aphasia persisted for about one year. In November 1981, she suffered a third attack of infarction and developed an apallic syndrome. Neuropathological examination confirmed that the lesion of the right hemisphere played a decisive role in the outbreak of jargon aphasia in this case.     

Transcortical sensory aphasia due to extensive infarction of left cerebral hemisphere]

We report a case of transcortical sensory aphasia occurred after extensive infarction of left cerebral hemisphere. A 68-year-old, right-handed man with atrial fibrillation suddenly developed cerebral embolism of left middle cerebral artery. He was treated conservatively, and the right hemiplegia, aphasia, apraxia in a slight degree and right hemispatial neglect in a slight degree consequently existed. MRI showed a large cortical and subcortical infarct lesion including the left Broca's area, central region, perisylvian area with Wernicke's area and temporal lobe. In contrast, neuropsychological evaluation using the Western Aphasia Battery (WAB) demonstrated transcortical sensory aphasia, e.g., fluency 8, auditory comprehension 1. repetition 10 and object naming 2.4. In addition to preserved repetition, both linguistic prosody and affective prosody were well preserved. Most cases with transcortical sensory aphasia are known to occur with the lesion including temporo-parieto-occipital junction of dominant hemisphere. Our patient and a few other reported cases of transcortical sensory aphasia had a lesion in perisylvian area including Wernicke's area. Therefore, it is possible that their minor hemisphere worked selectively for repetition. Furthermore, we suggest that this patient presented dissociative aphasia that all the process of repetition and the function of linguistic and emotional prosody were represented in the right hemisphere and the other functions including comprehension of word meanings were existed in the left hemisphere. We believe that our case of transcortical sensory aphasia with dissociative aphasia gives a suggestion about the mechanism and localization of repetition and prosody in the whole system of language.     

Reversed laterality of cerebral functions in a non-right-hander: neuropsychological and spect findings in a case of 'atypical' dominance.

A 54-year-old non-right-handed man with positive familial sinistrality showed a pure right hemisphere syndrome following a left hemisphere stroke. Severe right side hemineglect, transcortical motor dysprosodia, spatial dysgraphia and visuo-constructive impairments were observed. At no time were the expected left hemisphere abnormalities such as aphasia, alexia, right-left disorientation or finger agnosia noted. A left fronto-temporal subcortical lesion was documented on CT scan. A Tc-99m HM-PAO SPECT study revealed no cerebral blood flow changes in the right hemisphere while in the left hemisphere a fronto-temporo-parietal cerebral blood flow reduction was evident. This case of a complete reversed laterality of cognitive functions argues for a distinction to be made between 'anomalous' cerebral dominance and 'atypical' cerebral dominance.     

Japanese crossed Wernicke's aphasia.

A right-handed Japanese man with no personal or family history of left-handedness developed severe Wernicke's aphasia, a mild constructional disorder, and slight left hemiparesis. MRI revealed infarction in the territory of the righ middle cerebral artery, including areas homologous to Broca's and Wernicke's areas. The cerebral blood flow in these areas remained diminished even after language activation. The most likely explanation is that language production occurred in the left Broca's area, while language comprehension occurred in the right Wernicke's area (a dissociated aphasia).     

Acute mixed transcortical aphasia with bihemispheric neurological deficits following diffuse cerebral dysfunction

A 78 year old man presented with acute mixed transcortical aphasia with intact naming and bilateral involvement of the motor systems following a left internal carotid artery stenosis. The CT scan showed hypodense areas in the border zones of the left hemisphere together with diffuse areas of ischaemia. Intact repetition the hallmark of transcortical aphasias and the exceptional preserved naming in this patient support the earlier findings that the contralateral hemisphere could mediate some aspects of language function. The patient also had bilateral motor abnormalities which could be explained on the occipito-parietal lesion. It is suggested that widespread hypofunction of the left hemisphere following cerebral ischaemia could give rise to bihemispheric neurological deficits which could be short lived and could possibly be attributed to bilateral cerebral blood flow changes that may occur with the hemispheric lesion.