Acquired dysfluencies following infarction of the left mesiofrontal cortex

Abstract

The present study describes the acquired dysfluencies observed in a patient with transcortical motor aphasia (TCMA) following ischaemic infarction of the mesiofrontal cortex due to occlusion of the anterior cerebral artery. Prolongation of labial plosives and labiodental fricatives as well as hesitations concomitant with a few repetitions of syllables and sounds, respectively, were noted. The dorsolateral aspects of the frontal lobe of the dominant hemisphere have been considered the relevant site of lesion in instances of acquired stuttering concomitant with TCMA. The present case demonstrates that dysfluencies May-June be present with mesiofrontal lesions as well. The patient's stuttering was confined to production of complex sentences. Since transcortical motor aphasia is characterized by paucity of speech, consisting mostly in one- to two-word utterances, the dysfluencies of patients with this kind of disorder often might be masked. The observed stuttering-like behaviour differed in two respects from other reports on this disorder: the dysfluencies, first, were restricted to word-initial sounds and, secondly, did not occur during repetition tasks and reading aloud. Thus, acquired stuttering due to mesiofrontal lesions might represent a specific constellation of dysfluencies.     

卒中后失语症类型及其影响因素分析

目的 通过探讨性别、年龄、病变部位及卒中病因等与失语症类型之间的关系,探索影响卒中后失 语类型的因素。 方法 回顾性分析2004年1月-2018年12月于首都医科大学附属北京天坛医院就诊、因语言障碍进行 西部失语成套测验（western aphasia battery,WAB）的卒中后失语症患者临床资料。分析失语症类型与 性别、年龄、卒中类型、卒中病因及发病机制之间的关系。 结果 共纳入失语症患者681例,按照失语症类型分为完全性失语（global aphasia,GA）（n =185）、 运动性失语（broca’s aphasia,BA）（n =148）、经皮质混合性失语（mixed transcortical aphasia,MTCA） （n =30）、经皮质运动性失语（transcortical motor aphasia,TCMA）（n =67）、感觉性失语（werni cke’s aphasia,WA）（n =69）、经皮质感觉性失语（transcortical sensor aphasia,TCSA）（n =21）、传导性失 语（conduction aphasia,CA）（n =32）和命名性失语（anomic aphasia,NA）（n =129）。将患者分为青年组 （18～44岁）、中年组（45～59岁）、老年组（≥60岁）,校正其他因素影响后,三组人群间失语症类型 无统计学差异。男性和女性患者的失语症类型也无统计学差异。各类型失语症患者的病变部位具有 异质性,除合并经典语言区损伤外,还可合并左侧基底节及丘脑损伤。在脑出血所致的各类型失语 症患者中,最常见的病因均为高血压（77.8%～100.0%）。脑梗死后GA患者中,最常见的卒中发病机制 是混合型（42.4%）和动脉-动脉栓塞（27.3%）,而BA、WA及CA患者以动脉-动脉栓塞（分别占51.5%, 71.4%和40.0%）最常见,TCMA、TCSA及NA以低灌注/栓子清除能力下降（分别占65.9%,58.3%和 38.4%）最常见。 结论 年龄及性别对失语症类型均无明显影响。男性和女性患者均以GA、BA和NA最为常见。病变 部位对失语症类型具有重要影响,卒中病因及发病机制对失语症类型的影响可能与特定血管及血管 供血区损伤有关。     

Crossed aphasia in right handed patients

The very rare aphasia following damage to the right cerebral hemisphere in right-handed subjects is described, with a survey of the views on this problem and presentation of two cases of this so-called crossed aphasia in right-handed subjects. On one of these cases the lesion was cortico-subcortical in a part of the frontal lobe, temporal lobe and a part of the occipital lobe, with sparing of the deep structures of the right hemisphere and with clinical pattern resembling that of Broca aphasia. In the second case the lesion involved the subcortical and deep structures with destruction of the lentiform nucleus, anterior part of the internal capsule and part of the head of the caudate nucleus, and the clinical pattern resembled that of Wernicke aphasia.     

卒中后失语症类型及其影响因素分析

目的 通过探讨性别、年龄、病变部位及卒中病因等与失语症类型之间的关系，探索影响卒中后失
语类型的因素。
方法 回顾性分析2004年1月-2018年12月于首都医科大学附属北京天坛医院就诊、因语言障碍进行
西部失语成套测验（western aphasia battery，WAB）的卒中后失语症患者临床资料。分析失语症类型与
性别、年龄、卒中类型、卒中病因及发病机制之间的关系。
结果 共纳入失语症患者681例，按照失语症类型分为完全性失语（global aphasia，GA）（n =185）、
运动性失语（broca’s aphasia，BA）（n =148）、经皮质混合性失语（mixed transcortical aphasia，MTCA）
（n =30）、经皮质运动性失语（transcortical motor aphasia，TCMA）（n =67）、感觉性失语（werni cke’s
aphasia，WA）（n =69）、经皮质感觉性失语（transcortical sensor aphasia，TCSA）（n =21）、传导性失
语（conduction aphasia，CA）（n =32）和命名性失语（anomic aphasia，NA）（n =129）。将患者分为青年组
（18～44岁）、中年组（45～59岁）、老年组（≥60岁），校正其他因素影响后，三组人群间失语症类型
无统计学差异。男性和女性患者的失语症类型也无统计学差异。各类型失语症患者的病变部位具有
异质性，除合并经典语言区损伤外，还可合并左侧基底节及丘脑损伤。在脑出血所致的各类型失语
症患者中，最常见的病因均为高血压（77.8%～100.0%）。脑梗死后GA患者中，最常见的卒中发病机制
是混合型（42.4%）和动脉-动脉栓塞（27.3%），而BA、WA及CA患者以动脉-动脉栓塞（分别占51.5%，
71.4%和40.0%）最常见，TCMA、TCSA及NA以低灌注/栓子清除能力下降（分别占65.9%，58.3%和
38.4%）最常见。
结论 年龄及性别对失语症类型均无明显影响。男性和女性患者均以GA、BA和NA最为常见。病变
部位对失语症类型具有重要影响，卒中病因及发病机制对失语症类型的影响可能与特定血管及血管
供血区损伤有关。     

Clinical-anatomical correlation in a selective phonemic speech production impairment

Although phonemic paraphasias are common in aphasic disorders, including Broca's aphasia, conduction aphasia and transcortical motor aphasia, selective phonemic speech production impairment, or phonemic disintegration, is unusual. A patient with a selective phonemic speech production disorder underwent clinical, neuropsychological and structural neuroradiological assessment over a period of 6 years. The disorder was characterised by phonemic paraphasias (phonemic disintegration) with preserved comprehension and naming. Imaging showed a focal lesion in the white matter of the left precentral gyrus and, to a lesser extent, the posterior part of the left middle frontal gyrus, with overlying cortical atrophy. Biopsy of the lesion, after several years of observation, showed a calcified haemangioma. Clinical-anatomical correlation in this case suggests the importance of primary motor cortex of the inferior precentral (pre-Rolandic) gyrus and subjacent white matter in phoneme production, with sparing of the posterior inferior frontal gyrus (Broca's area).     

Aphasia induced by gliomas growing in the ventrolateral frontal region: assessment with diffusion MR tractography, functional MR imaging and neuropsychology

IntroductionLesions in the ventrolateral region of the dominant frontal lobe have been historically associated with aphasia. Recent imaging results suggest that frontal language regions extend beyond classically defined Broca’s area to include the ventral precentral gyrus (VPCG) and the arcuate fasciculus (AF). Frontal gliomas offer a unique opportunity to identify structures that are essential for speech production. The aim of this prospective study was to investigate the correlation between language deficits and lesion location in patients with gliomas.MethodsNineteen patients with glioma and 10 healthy subjects were evaluated with diffusion tensor imaging magnetic resonance (MR) tractography, functional MR (verb generation task) and the Aachener Aphasie Test. Patients were divided into two groups according to lesion location with respect to the ventral precentral sulcus: (i) anterior (n = 8) with glioma growing in the inferior frontal gyrus (IFG) and underlying white matter; (ii) posterior (n = 11) with glioma growing in the VPCG and underlying white matter. Virtual dissection of the AF, frontal intralobar tract, uncinate fasciculus (UF) and inferior frontal occipital fasciculus (IFOF) was performed with a deterministic approach.ResultsSeven posterior patients showed aphasia classified as conduction (4), Broca (1), transcortical motor (1) and an isolated deficit of semantic fluency; one anterior patient had transcortical mixed aphasia. All posterior patients had invasion of the VPCG, however only patients with aphasia had also lesion extension to the AF as demonstrated by tractography dissections. All patients with language deficits had high grade glioma. Groups did not differ regarding tumour volume. A functional pars opercularis was identified with functional MR imaging (fMRI) in 17 patients.ConclusionsGliomas growing in the left VPCG are much more likely to cause speech deficits than gliomas infiltrating the IFG, including Broca’s area. Lesion extension to the AF connecting frontal to parietal and temporal regions is an important mechanism for the appearance of aphasia.     

Crossed optic ataxia: possible role of the dorsal splenium.

An unusual combination of disconnective syndromes is reported: transcortical motor aphasia, left arm apraxia and optic ataxia. Neuropathological examination showed a left parieto-occipital and a subcortical frontal infarct and a lesion of the dorsal part of the posterior two-fifths of the callosum. The frontal lesion caused the transcortical motor aphasia and produced the left arm apraxia. Visuomotor incoordination in the right hemispace was due to the left parieto-occipital infarct, while the crossed optic ataxia in the left hemispace was attributed to the callosal lesion. It is proposed that the pathway that serves crossed visual reaching passes through the dorsal part of the posterior callosum. This case reinforces the growing evidence that fibres in the corpus callosum are arranged in ventro-dorsal functional lamination.     

Damage to temporo-parietal cortex decreases incidental activation of thematic relations during spoken word comprehension

Both taxonomic and thematic semantic relations have been studied extensively in behavioral studies and there is an emerging consensus that the anterior temporal lobe plays a particularly important role in the representation and processing of taxonomic relations, but the neural basis of thematic semantics is less clear. We used eye tracking to examine incidental activation of taxonomic and thematic relations during spoken word comprehension in participants with aphasia. Three groups of participants were tested: neurologically intact control participants (N=14), individuals with aphasia resulting from lesions in left hemisphere BA 39 and surrounding temporo-parietal cortex regions (N=7), and individuals with the same degree of aphasia severity and semantic impairment and anterior left hemisphere lesions (primarily inferior frontal gyrus and anterior temporal lobe) that spared BA 39 (N=6). The posterior lesion group showed reduced and delayed activation of thematic relations, but not taxonomic relations. In contrast, the anterior lesion group exhibited longer-lasting activation of taxonomic relations and did not differ from control participants in terms of activation of thematic relations. These results suggest that taxonomic and thematic semantic knowledge are functionally and neuroanatomically distinct, with the temporo-parietal cortex playing a particularly important role in thematic semantics.     

Ataxic hemiparesis associated with transcortical motor aphasia

Two patients, ages 51 and 76 years, suddenly developed transcortical motor aphasia combined with pyramidal signs and ataxia of the right extremities that affected the leg more severely than the arm. Computed tomography revealed nonenhancing lucencies in the distribution territory of the left anterior cerebral artery involving the genu of the corpus callosum, white matter ventral to the left frontal horn, medial primary motor area, supplementary motor area, and superior part of the premotor area. It is postulated that aphasia, ataxia, and weakness resulted from involvement of the supplementary motor area and deep white matter, premotor, and primary motor areas, respectively. Anterior cerebral artery infarctions of the dominant hemisphere may result in transcortical motor aphasia associated with contralateral ataxic hemiparesis.     

Broca's area aphasias: aphasia after lesions including the frontal operculum

We report 9 cases of aphasia following lesions in the region of the left frontal operculum. It is not possible to capture their variety of clinical manifestations with the simple labels of "Broca's area aphasia." or "Broca's area aphasia." Analysis of the breakdown of various components of speech and language in these cases suggests that the operculum, lower motor cortex, and subjacent subcortical and periventricular white matter contain critical parts of different language systems. These systems can be independently impaired. There are several common language syndromes that follow damage that includes the left frontal operculum. These syndromes reflect the effects of the direction and extent of the lesion in the various language systems.     

The anatomy of aphasia revisited

OBJECTIVE: To determine lesion locations associated with the various types of aphasic disorders in patients with stroke. BACKGROUND: The anatomy of aphasia has been challenged by several recent studies. Discrepancies are likely to be due to methodologic issues. METHODS: We examined 107 patients with a standardized aphasia battery and MRI. Three examiners blinded to the clinical data rated signal abnormalities in 69 predetermined regions of interest. The statistical procedure used classification tree testing, which selected regions associated with each aphasic disorder. RESULTS: 1) Nonfluent aphasia depended on the presence of frontal or putaminal lesions; 2) repetition disorder on insula-external capsule lesions; 3) comprehension disorder on posterior lesions of the temporal gyri; 4) phonemic paraphasia on external capsule lesions extending either to the posterior part of the temporal lobe or to the internal capsule; 5) verbal paraphasia on temporal or caudate lesions; and 6) perseveration on caudate lesions. These analyses correctly classified 67% to 94% of patients. CONCLUSIONS: Lesion location is the main determinant of aphasic disorders at the acute stage. Most clinical-radiologic correlations supported the classic anatomy of aphasia.     

Lesion localization of global aphasia without hemiparesis by overlapping of the brain magnetic resonance images

Global aphasia without hemiparesis is a striking stroke syndrome involving language impairment without the typically manifested contralateral hemiparesis, which is usually seen in patients with global aphasia following large left perisylvian lesions. The objective of this study is to elucidate the specific areas for lesion localization of global aphasia without hemiparesis by retrospectively studying the brain magnetic resonance images of six patients with global aphasia without hemiparesis to define global aphasia without hemiparesis-related stroke lesions before overlapping the images to visualize the most overlapped area. Talairach coordinates for the most overlapped areas were converted to corresponding anatomical regions. Lesions where the images of more than three patients overlapped were considered significant. The overlapped global aphasia without hemiparesis related stroke lesions of six patients revealed that the significantly involved anatomi- cal lesions were as follows： frontal lobe, sub-gyral, sub-lobar, extra-nuclear, corpus callosum, and inferior frontal gyrus, while caudate, claustrum, middle frontal gyrus, limbic lobe, temporal lobe, superior temporal gyrus, uncus, anterior cingulate, parahippocampal, amygdala, and subcallosal gyrus were seen less significantly involved. This study is the first to demonstrate the heterogeneous anatomical involvement in global aphasia without hemiparesis by overlapping of the brain magnetic resonance images.     

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.     

Global aphasia without hemiparesis: lesion analysis and its mechanism in 11 Korean patients

BACKGROUND: Global aphasia without hemiparesis (GAWH) is a rare stroke syndrome. This study localized the lesion and examined the pathogenic mechanism in Korean patients with GAWH, and investigated whether areas of extensive hypoperfusion existed outside the diffusion-weighted imaging (DWI) lesions seen in these patients. MATERIAL AND METHODS: Eleven patients were diagnosed with aphasia using the Western Aphasia Battery. To identify decreased perfusion, which might be functionally relevant to aphasia but not detected by DWI, single photon emission tomography (SPECT) was performed in five patients. To uncover the possible pathogenic mechanisms of ischemic stroke, vascular and cardiologic work-ups were performed in all of the patients. RESULTS: The lesions seen on DWI varied, and included both inferior frontal and superior temporal (three), isolated inferior frontal (four) or superior temporal (one), subcortical (two), and even parieto-occipital (one) lesions. Brain SPECT did not reveal an extensive lesion of the peri-sylvian area outside the DWI lesion in any of the patients, except one with the subcortical lesions. CONCLUSION: Our results indicate that a single lesion in different locations may be sufficient to produce GAWH, and the lesion profile and stroke mechanism in GAWH are heterogeneous, suggesting that lesions to an area of complex functional anatomy result in aphasia.     

Global aphasia without hemiparesis: language profiles and lesion distribution

OBJECTIVES: Global aphasia without hemiparesis (GAWH) is an uncommon stroke syndrome involving receptive and expressive language impairment, without the hemiparesis typically manifested by patients with global aphasia after large left perisylvian lesions. A few cases of GAWH have been reported with conflicting conclusions regarding pathogenesis, lesion localisation, and recovery. The current study was conducted to attempt to clarify these issues. METHODS: Ten cases of GAWH were prospectively studied with language profiles and lesion analysis; five patients had multiple lesions, four patients had a single lesion, and one had a subarachnoid haemorrhage. Eight patients met criteria for cardioembolic ischaemic stroke. RESULTS: Cluster analysis based on acute language profiles disclosed three subtypes of patients with GAWH; these clusters persisted on follow up language assessment. Each cluster evolved into a different aphasia subtype: persistent GAWH, Wernicke's aphasia, or transcortical motor aphasia (TCM). Composite lesion analysis showed that persistent GAWH was related to lesioning of the left superior temporal gyrus. Patients with acute GAWH who evolved into TCM type aphasia had common lesioning of the left inferior frontal gyrus and adjacent subcortical white matter. Patients with acute GAWH who evolved into Wernicke's type aphasia were characterised by lesioning of the left precentral and postcentral gyri. Recovery of language was poor in all but one patient. CONCLUSIONS: Although patients with acute GAWH are similar on neurological examination, they are heterogeneous with respect to early aphasia profile, language recovery, and lesion profile.     

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)     

Atypical conduction aphasia. A disconnection syndrome

Conduction aphasia was originally proposed to result from separation of the posterior language comprehension area and the anterior motor speech area of the left hemisphere. The arcuate fasciculus has been the most frequently suggested site of such a disconnection, but the syndrome has been reported in cases in which the abnormality involved the dominant Wernicke's area. This challenges the arcuate fasciculus theory, and it has been suggested that a cortical lesion, not a disconnection, is the crucial factor. Three new cases in which the lesion does not lie in the arcuate fasciculus are reported, two in left-handed patients with left temporoparietal lesions and one in a right-handed patient with a right temporoparietal infarct, a "crossed" aphasia. While atypical, these cases offer evidence that disconnection of the circuit linking language comprehension to motor speech output, not damage to a specific cortical region, underlies the syndrome of conduction aphasia.     

Infarction in the territory of the anterior choroidal artery: A cause of transcortical motor aphasia

Abstract

We report a case of transcortical motor aphasia associated with an infarction in the territory of the left anterior choroidal artery. The same clinical picture has been described in a small number of patients with a similar lesion site. The implications of this finding for theories of subcortical aphasia are discussed.     

Transcortical aphasia and echolalia; problems of speech initiative]

Transcortical aphasia accompanied by echolalia occurs with malacias involving the postero-median part of the frontal lobe which includes the supplementary motor field of Penfield and is nourished by the anterior cerebral artery. The syndrome manifests itself in such cases even in fine detials in the same form as does in Pick's atrophy. The same also holds true for cases in which a tumour involves the region mentioned. Sentences or fragments of sentences are echolalised; tendency to perseveration is very marked. It is hardly, if at all, possible to evaluate the verbal understanding of these patients. Analysis of their behaviour supports the assumption that they have not lost the adaptation to some situations. Echolalia is often associated with forced grasping and other compulsory phenomena. Therefore, it may be interpreted as a sign of disinhibition of the acusticomotor reflex present during the development of the speech. Competition between the intentionality and the appearance of compulsory phenomena greatly depends on the general condition of the patient, particularly on the clarity of consciousness. The integrity of the postero-median part of the frontal lobe is indespensable for a normal reaction by speech to stimuli received from the sensory areas. The influence of the supplementary motor field on speech intention seems to be linked to the dominant hemisphere. In case lesions of the territory of the anterior cerebral artery and the cortico-bulbar neuron system are coexisting in the dominant hemisphere, the speech disturbance shifts to complete motor aphasia. In such cases the pathomechanism is analogous to that of the syndrome of Liepmann, i.e., right-sided hemiparesis with left-sided apraxia. So-called transcortical motor aphasia without echolalia can be caused by loss of stimuli from the sensory fields.     

Spatio-temporal cortical dynamics of phonemic and semantic fluency

Hemodynamic brain imaging and lesion studies have suggested differential involvement of expressive language-related cortical regions based on the phonemic versus semantic characteristics of verbal cues. The aims of this study were: 1) to elucidate the relative timing of the activity of inferior frontal and anterior insular versus motor and supplementary motor cortex during a fluency task and 2) to assess potential differences in the location or timing of activity in anterior and posterior language areas based on letter versus category cues. Using magnetic source imaging (MSI), we found significantly earlier onset latencies and a greater number of activity sources in motor and supplementary motor compared with inferior frontal and anterior insular regions. We also observed greater left versus right hemispheric asymmetry of activation for letter compared with category cues. This study provides new insights into cortico-cortical interactions during expressive language tasks.