Ictal aphasia: an unusual presentation of temporal lobe seizures

Language disturbances during epileptic seizures are not uncommon, but isolated speech impairment is rare. We report a 67-year-old male with sudden onset of aphasia initially thought to be the result of an infarction of left middle cerebral artery territory. He had recurrent episodes of non-fluent, severely aphasic speech with intact comprehension as the primary manifestation, without other clinical seizure activity. After the administration of antiepileptic medication, his language returned to the baseline level. This case suggests that paroxysmal non-fluent aphasia can result from a seizure focus in the dominant temporal lobe. This is an important differential to be considered in patients with aphasia, which will assist in early diagnosis and treatment.     

A case of crossed aphasia with echolalia after the resection of tumor in the right medial frontal lobe]

We report a right-handed woman, who developed a non-fluent aphasia after resection of astrocytoma (grade III) in the right medial frontal lobe. On admission to the rehabilitation department, neurological examination revealed mild left hemiparesis, hyperreflexia on the left side and grasp reflex on the left hand. Neuropsychologically she showed general inattention, non-fluent aphasia, acalculia, constructional disability, and mild buccofacial apraxia. No other apraxia, unilateral spatial neglect or extinction phenomena were observed. An MRI demonstrated resected areas in the right superior frontal gyrus, subcortical region in the right middle frontal gyrus, anterior part of the cingulate gyrus, a part of supplementary motor area. Surrounding area in the right frontal lobe showed diffuse signal change. She demonstrated non-fluent aprosodic speech with word finding difficulty. No phonemic paraphasia, or anarthria was observed. Auditory comprehension was fair with some difficulty in comprehending complex commands. Naming was good, but verbal fluency tests for a category or phonemic cuing was severely impaired. She could repeat words but not sentences. Reading comprehension was disturbed by semantic paralexia and writing words was poor for both Kana (syllabogram) and Kanji(logogram) characters. A significant feature of her speech was mitigated echolalia. In both free conversation and examination setting, she often repeated phrases spoken to her which she used to start her speech. In addition, she repeated words spoken to others which were totally irrelevant to her conversation. She was aware of her echoing, which always embarrassed her. She described her echolalic tendency as a great nuisance. However, once echoing being forbidden, she could not initiate her speech and made incorrect responses after long delay. Thus, her compulsive echolalia helped to start her speech. Only four patients with crossed aphasia demonstrated echolalia in the literature. They showed severe aphasia with markedly decreased speech and severe comprehension deficit. A patient with a similar lesion in the right medial frontal lobe had aspontaneity in general and language function per se could not be examined properly. Echolalia related to the medial frontal lesion in the language dominant hemisphere was described as a compulsive speech response, because some other 'echoing' phenomena or compulsive behavior were also observed in these patients. On the other hand, some patients with a large lesion in the right hemisphere tended to respond to stimuli directed to other patients, so called 'response-to-next-patient-stimulation'. This behavior was explained by disinhibited shift of attention or perseveration of the set. Both compulsive speech responses and 'response-to-next-patient-stimulation' like phenomena may have contributed to the echolalia phenomena of the present case.     

Ipsilateral auditory extinction following frontal and basal ganglia lesions of the left hemisphere

When tested on a dichotic digits listening task, patients with unilateral lesions of the left frontal lobe and left anterior basal ganglia exhibited ipsilateral auditory extinction. This phenomenon has been documented before, but only in patients with lesions involving the region posterior and lateral to the posterior aspect of the left lateral ventricle. As patients with lesions in the equivalent region of the right hemisphere also exhibit extinction of verbal material arriving in their left ears it has been hypothesized that these posterior lesions disrupt an interhemispheric pathway connecting the two temporal lobes. As it appears that the ipsilateral auditory pathways are suppressed under conditions of dichotic stimulation, such an interhemispheric pathway would be the means whereby left-ear verbal stimuli reached the left (speech) hemisphere. Therefore a disruption of this pathway could result in left-ear extinction for verbal material. The finding that left anterior lesions also result in left-ear extinction poses problems for this hypothesis and in particular for the suggested posterior route of the interhimispheric pathway.     

PET in generalized anxiety disorder

Positron emission tomography (PET) measurements of cerebral glucose use were made in 18 patients with generalized anxiety disorder (GAD) during a passive viewing task off medication, and an active vigilance viewing task before and after medication or placebo treatment. In the passive viewing task, patients with GAD were compared with 15 normal controls. A significant difference in pattern of absolute brain metabolism was found. Patients showed lower absolute metabolic rates in basal ganglia and white matter. Relative metabolism was increased in the left inferior area 17 in the occipital lobe, right posterior temporal lobe, and the right precentral frontal gyrus. Significant left-right asymmetry of the parahippocampal gyri was not found in patients with GAD. An active vigilance task resulted in activation of relative basal ganglia metabolism in patients. Benzodiazepine therapy resulted in decreases in absolute metabolic rates for cortical surface, limbic system, and basal ganglia and was not associated with normalization of patterns of glucose metabolism. Change in anxiety scores was significantly correlated with change in limbic system and basal ganglia for the placebo group. The normal-anxious difference in the basal ganglia and the change seen in this region after benzodiazepine treatment are suggestive of a role in anxiety for this structure.     

Tactile agnosia and tactile aphasia: symptomatological and anatomical differences.

Two patients with tactile naming disorders are reported. Case 1 (right hand tactile agnosia due to bilateral cerebral infarction) differentiated tactile qualities of objects normally, but could neither name nor categorize the objects. Case 2 (bilateral tactile aphasia after operation of an epidural left parietal haematoma) had as severe a tactile naming disturbance as Case 1, but could categorize objects normally, demonstrating that tactile recognition was preserved. Case 1 may be the first case of tactile agnosia clearly differentiated from tactile aphasia. CT scans of Case 1 revealed lesions in the left angular gyrus, and in the right parietal, temporal, and occipital lobes. Case 2 had lesions in the left angular gyrus and of posterior callosal radiations. Our findings suggest that tactile agnosia appears when the somatosensory association cortex is disconnected by a subcortical lesion of the angular gyrus from the semantic memory store located in the inferior temporal lobe, while tactile aphasia represents a tactual-verbal disconnection.     

Possible involvement of the tip of temporal lobe in Landau-Kleffner syndrome

Landau-Kleffner syndrome (LKS) is a childhood disorder of unknown etiology characterized by an acquired aphasia and epilepsy. We have performed comprehensive neurofunctional studies on an 8-year-old girl with typical LKS, with the aim of identifying lesions that may be responsible for her condition. 18F-fluoro-D-glucose (FDG) positron emission computed tomography (PET), 11C-Flumazenil (FMZ) PET, 99mTc-hexamethylpropyleneamine oxime single photon emission computed tomography (SPECT) and magnetoencephalography were performed before and after changes to the patient's medication led to a clinical improvement. Interictal SPECT showed hypoperfusion in the left frontal, left temporal, and left occipital lobes. 18F-FDG PET demonstrated a decrease in glucose metabolism medially in both temporal lobes and superiorly in the left temporal lobe. 11C-FMZ PET revealed a deficit in benzodiazepine receptor binding at the tip of the left temporal lobe. Magnetoencephalography demonstrated equivalent current dipoles located superiorly in the left temporal lobe. Our results suggest that the tip of the left temporal lobe plays an important role in the pathogenesis of LKS in our patient.     

Disturbance of rhythm sense following right hemisphere damage

In a patient with right temporal lobe and additional right basal ganglia damage following a stroke, recognition and reproduction of simple rhythmical Gestalten were examined and found grossly undisturbed. In contrast to this undisturbed perception and production of rhythm, the patient could not tap or move rhythmically in beat with an auditory pacer such as a metronome or marching band music, yet he could do so to rhythmically presented light or touch stimuli. Thus, the impairment seems to be a previously undescribed, modality specific disturbance of auditorily paced predictive motor behavior affecting, for example, walking, dancing, singing and speech.     

老年抑郁症患者的脑正电子发射体层摄影术显像分析

目的 探讨老年抑郁症患者脑^18氟-脱氧葡萄糖（18^F-FDG）正电子发射体层摄影术（PET）显像的特点。方法 分别对6例老年抑郁症患者（GD组）及10名健康体检者（对照组）进行脑^18 F-FDGPET显像，按年龄、简易智力状态检查量表总分和性别构成配对，用统计参数图第2版软件比较两组间脑局部葡萄糖代谢的差别。结果 GD组较对照组在双侧尾状核、额下回、颞上回、额中回，右侧核外、额上回、舌回和左侧扣带回、中央前回等脑区局部葡萄糖代谢减低（均P〈0．005）。GD组无局部脑葡萄糖代谢增加的脑区。结论 老年抑郁症患者存在基底节区、前额叶、颞叶和边缘系统的局部葡萄糖代谢下降。     

Dissociation Between Semantic and Autobiographic Memory: A Case Report

We report a patient who showed a dissociation between impaired semantic memory and preserved autobiographic memory. M.N., a 56-year-old right-handed woman, developed a supra sellar meningioma and underwent multiple operations. Following Lineac radiation, necrosis occurred in the left temporal lobe. Magnetic Resonance Imaging revealed bilateral lesions in the temporal lobes and in the right basal frontal lobe.

The patient's intellectual deterioration and anterograde amnesia were mild. Language was preserved, but for a subtle anomia. Autobiographic memory remained intact, while semantic memory for public events, historical figures, cultural items, knowledge of low frequency words and technical terms related to her profession was severely impaired. We hypothesize that bilateral lesions of the anterior half of the middle region of the temporal lobe plays a crucial role in causing deficits in semantic memory.     

强迫症患者局部脑血流灌注研究

目的　探讨强迫症(OCD)患者局部脑血流灌注(rCBF)特点及临床症状与rCBF的关系。方法　对2 8例符合国际疾病分类第1 0版(ICD 1 0 )强迫障碍诊断标准患者和1 5名正常人进行单光子发射计算机断层扫描(SPECT)脑显像分析。用耶鲁 布朗强迫评定量表(YBOCS)、Hamilton焦虑量表(HAMA)和Hamilton抑郁量表(HAMD)对患者临床症状进行评定。结果　OCD患者两侧丘脑、顶叶和基底神经节的平均放射性计数百分数(PMRC)显著高于正常组;右颞PMRC明显低于正常组;且正常组两侧颞叶和顶叶PMRC值差异非常显著。在强迫恐惧/洗涤、回避组,YBOCS强迫行为分量表评分与右基底PMRC显著正相关(r =0 .70 1 )。结论　OCD患者两侧丘脑、顶叶和基底神经节的血流灌注增加和功能亢进;右颞血流灌注减少和功能低下,两侧颞叶和顶叶血流灌注的不对称性与正常人显著不同,后者的不对称性非常显著;在强迫恐惧/洗涤、回避组,强迫行为与右基底节功能增强有关。     

局灶性难治性颞叶癫痫全脑葡萄糖代谢特点

目的 探讨局灶性难治性颞叶癫痫全脑葡萄糖代谢特点。方法 回顾性分析2017年1~12月行发作间期18FDG-PET/CT检查的23例局灶性难治性颞叶癫痫的影像学资料。将PET图像导入MIM neuro软件,软件自动分析癫痫病人葡萄糖代谢水平与正常人群葡萄糖代谢的差异,各脑区差异结果以Z-Score值显示,分析颞叶癫痫病人全脑葡萄糖代谢特点。结果 术后病理为脑皮质发育不良22例,节细胞胶质瘤1例;病灶位于左侧颞叶16例,右侧颞叶7例。除颞叶呈葡萄糖低代谢改变外,还存在同侧海马、海马旁回、岛叶、杏仁核、颞叶岛盖以及双侧小脑半球葡萄糖代谢不同程度减低;对侧颞叶、额叶、顶叶、顶上小叶以及角回葡萄糖代谢不同程度增高。结论 颞叶癫痫具有一定葡萄糖代谢特点,其特定的葡萄糖代谢特点有助于更加精准的癫痫术前定位及其病理特征的分析。     

Cortical mapping of naming errors in aphasia

Persons with aphasia vary greatly with regard to clinical profile; yet, they all share one common feature—anomia—an impairment in naming common objects. Previous research has demonstrated that particular naming errors are associated with specific left hemisphere lesions. However, we know very little about the cortical activity in the preserved brain areas that is associated with aphasic speech errors. Utilizing functional magnetic resonance imaging (fMRI), we show for the first time that specific speech errors are associated with common cortical activity in different types and severities of aphasia. Specifically, productions of phonemic errors recruited the left posterior perilesional occipital and temporal lobe areas. A similar pattern of activity was associated with semantic errors, albeit in the right hemisphere. This study does not discount variability in cortical activity following left hemisphere stroke; rather, it highlights commonalities in brain modulation in a population of patients with a common diagnosis but vastly different clinical profiles. Hum Brain Mapp 2009. © 2009 Wiley‐Liss, Inc.     

阿尔茨海默病的脑血流灌注研究

目的探讨AD患者脑血流灌注的特征性变化。方法选择20例确诊AD患者和10例认知正常者,对所有入组对象行SPECT脑血流灌注显像检查,对所得图像进行视觉分析和半定量分析,比较两组对象各脑区血流灌注情况的差异,并比较AD患者左、右脑叶脑血流灌注的差异。结果 (1)视觉分析结果显示,AD组以颞叶或顶叶脑血流灌注减低为主,各占55%,其中双侧颞顶叶血流灌注减低者占15%,单侧颞顶叶血流灌注减低占20%。正常认知组SPECT影像学表现各异,额叶、颞叶、顶叶、枕叶、丘脑、基底节血流灌注减少情况均存在,各占10%。但无双侧颞顶叶血流灌注减少者,40%表现完全正常。(2)半定量分析结果显示,AD组在右额叶、双侧颞顶叶、右枕叶血流灌注显著低于正常认知组(P<0.05),以右侧颞叶血流灌注降低最明显,左右颞顶叶血流低灌注程度对比无显著性差异。结论 AD患者的SPECT特征性表现为双侧对称性颞顶叶血流低灌注,其中右侧颞叶血流灌注下降最严重。     

Corticobasal degeneration presenting with progressive conduction aphasia

We report the case of a woman with primary progressive aphasia (PPA) presenting with conduction aphasia. Neurological findings showed bilateral finger tremor and signe de poignet figé in her right hand. Memory, orientation, and activities of daily living were well preserved. Linguistic examination showed severe impairment in repetition, fluent spontaneous speech with phonemic paraphasia, and relatively well preserved comprehension. Limb-kinetic apraxia and parkinsonism were not observed during the course of her illness. T1-weighted magnetic resonance imaging revealed severe atrophy of the left temporal lobe and dilatation of the left Sylvian fissure. Neuropathological findings demonstrated the most severe atrophy in the left superior temporal gyrus and Gallyas–Braak-positive or phosphorylated tau-immunoreactive cytoskeletal structures, which were consistent with corticobasal degeneration (CBD). We speculate that the progressive conduction aphasia of our patient might have been caused by left temporal lobe impairment. We suggest that progressive conduction aphasia may be a feature of CBD presenting with PPA.     

Dynamic-intentional thalamic aphasia: a failure of lexical-semantic self-activation

Background: Previous research has described patients with aphasia from thalamic lesions, some of whom were non-fluent with intact comprehension, others who were fluent with impaired comprehension, and some of whom are non-fluent with impaired comprehension. Whereas these three subtypes usually have normal repetition, they had impaired naming, suggesting a deficit in lexical (phonological word forms)-semantic processing. We report a patient with a left thalamic hemorrhage in which lexical-semantic representations appear to be intact but the patient demonstrates an inability to spontaneously activate his lexical-semantic system Methods: A 82-year-old, right-handed man presented with decreased verbal fluency and memory loss following a thalamic hemorrhage. Neuropsychological assessment revealed significant decrements in verbal fluency with intact naming, comprehension, repetition and vocabulary. Conclusions: To the best of our knowledge this pattern of language disturbance, which mirrors dynamic aphasia induced by frontal lesions, has not previously been described with thalamic injury. The thalamus has strong connections with the frontal lobe and rather than degradation of lexical-semantic representations, this patient's thalamic lesion probably induced frontal lobe dysfunction with a failure to spontaneously active lexical semantic representations.     

Focal CT abnormality and epileptogenic focus

In 31 patients with temporal lobe epilepsy, the precise site of epileptogenic focus was determined by means of a depth EEG recording as one of the presurgical evaluations. In 13 patients, a CT scan revealed focal lesions; 7 in the left temporal lobe and 6 in the right temporal lobe. In 5 of the 7 patients and in 5 of the 6 patients the epileptogenic foci were determined in the temporal lobe on the side of a CT lesion. However, in 2 of the patients with a CT lesion in the left temporal lobe, independent epileptogenic foci were found in both the temporal lobes, and in the other patient with a CT lesion in the right temporal lobe, they were found in the right frontal and left temporal lobes. Thus, the CT lesions agreed in lateralization and focality with the epileptogenic foci in 10 of the 13 patients (77%), but they disagreed in 3 (23%). A CT lesion disclosed in the temporal lobe does not necessarily indicate the side and/or site where the epileptogenic focus may be localized. Although exceptions may be made, spatial disagreement was exemplified between the CT lesion and epileptogenic focus. Therefore, extreme caution has to be taken on the side and/or site of the epileptogenic focus when functional surgical indication is to be made.     

Focal CT Abnormality and Epileptogenic Focus

Abstract: In 31 patients with temporal lobe epilepsy, the precise site of epileptogenic focus was determined by means of a depth EEG recording as one of the presurgical evaluations. In 13 patients, a CT scan revealed focal lesions; 7 in the left temporal lobe and 6 in the right temporal lobe. In 5 of the 7 patients and in 5 of the 6 patients the epileptogenic foci were determined in the temporal lobe on the side of a CT lesion. However, in 2 of the patients with a CT lesion in the left temporal lobe, independent epileptogenic foci were found in both the temporal lobes, and in the other patient with a CT lesion in the right temporal lobe, they were found in the right frontal and left temporal lobes. Thus, the CT lesions agreed in lateralikeation and focality with the epileptogenic foci in 10 of the 13 patients (77%), but they disagreed in 3 (23%). A CT lesion disclosed in the temporal lobe does not necessarily indicate the side and/or site where the epileptogenic focus may be localized. Although exceptions may be made, spatial disagreement was exemplified between the CT lesion and epileptogenic focus. Therefore, extreme caution has to be taken on the side and/or site of the epileptogenic focus when functional surgical indication is to be made.     

Improvement of language functions in a chronic non-fluent post-stroke aphasic patient following bilateral sequential theta burst magnetic stimulation

In chronic non-fluent aphasia patients, inhibition of the intact right hemisphere (RH), by transcranial magnetic stimulation (TMS) or similar methods, can induce improvement in language functions. The supposed mechanism behind this improvement is a release of preserved left hemisphere (LH) language networks from RH transcallosal inhibition. Direct stimulation of the damaged LH can sometimes bring similar results too. Therefore, we developed a novel treatment approach that combined direct LH (Broca’s area (BA)) stimulation, by intermittent theta burst stimulation (TBS), with homologue RH area’s inhibition, by continuous TBS. We present the results of application of 15 daily sessions of the described treatment approach in a right-handed patient with chronic post-stroke non-fluent aphasia. The intervention appeared to improve several language functions, but most notably propositional speech, semantic fluency, short-term verbal memory, and verbal learning. Bilateral TBS modulation of activation of the language-related areas of both hemispheres seems to be a feasible and promising way to induce recovery in chronic aphasic patients. Due to potentially cumulative physiological effects of bilateral stimulation, the improvements may be even greater than following unilateral interventions.     

Hemisphere memory of concrete and abstract information determined with the intracarotid Sodium Amytal test

An extended version of the bilateral intracarotid Sodium Amytal test was administered pre-operatively to 13 patients with intractable complex partial epileptic seizures, to determine cerebral hemisphere speech and memory. There were 6 patients with left temporal lobe lesions and 7 patients with right temporal lobe lesions. Amobarbital (175 mg, 10%), injected on 2 occasions, determined the left hemisphere to be speech dominant in all cases. Memory assessed with recall, cued recall, and recognition of concrete/abstract words and pictures, was studied on 3 occasions: in a baseline test considered to indicate the degree of patient cooperation and the bilateral hemisphere memory; in a right hemisphere Amytal test; and in a left hemisphere Amytal test. The specific data pattern obtained, that abstract pictorial information is most efficiently processed by an intact right hemisphere and that verbal information is processed best by an intact left hemisphere, demonstrates the reliability of the approach taken here to present abstract and concrete to be remembered information.