Jargonagraphia in a left-handed aphasia due to a left hemisphere lesion]

We report a case who developed jargonagraphia, severe aphasia and unilateral spatial neglect due to cerebral infarction in the left hemisphere. The patient was a 57 year-old left-handed woman. She suddenly developed hemiplegia on the right side and aphasia, and was admitted to our hospital. Neuropsychological examination showed non-fluent spontaneous speech. Repetition, reading and auditory comprehension were impaired. Writing was severely impaired and she showed paragraphia without meaning (jargonagraphia). Right unilateral spatial neglect and buccofacial apraxia were noted, but neither ideomotor nor ideational apraxia was observed. The mechanisms of jargonagraphia remain unknown. The localization of language function in this patient is not a mirror image of same function in dextral aphasia. Her condition was considered that free-running on motor engrams of characters stored in the right hemisphere caused jargonagraphia.     

A study of right unilateral spatial neglect in left hemispheric lesions: the difference between right-handed and non-right-handed post-stroke patients

We report 20 cases of right unilateral spatial neglect caused by lesions in the left cerebral hemisphere. Differences in neuropsychological symptoms and lesions sites are discussed in connection with handedness. Of the right-handed patients, 6 had severe aphasia, 4 had Gerstmann's syndrome, and 1 had pure agraphia, but unilateral spatial neglect in these cases disappeared after a number of months. Six of the non-right-handed patients had moderate-to-severe aphasia, while the other 3 cases had no aphasia at all. Eight of the 9 cases in this group continued to have right unilateral spatial neglect for more than 6 months. Lesion site as determined by CT differed as to hemisphere, but all fell into the common area previously mentioned in connection with such disorders: i.e., the temporal, parietal and occipital lobes.     

Anterior choroidal artery syndrome. Neuropsychological study of 4 cases

A neuropsychological study was carried out in 4 cases of infarction in the territory of the anterior choro?dal artery. In 3 cases the lesions were on the right side. A syndrome of the minor hemisphere was present with severe visual neglect, constructional apraxia, alexia due to disorders of visuo-spatial strategy, anosognosia and motor impersistence. In the case with a left-sided lesion there was no neglect but a mild aphasia with impaired fluency, semantic paraphasias, perseveration and a decreased psycho-linguistic ability. The mechanisms of neglect in right-sided lesions are considered.     

Ideatory Apraxia in a Left-Handed Patient with Right-Sided Brain Lesion

A case is described of a left-handed patient with a circumscribed right-sided posterior brain lesion, who presented with a neuro-psychological syndrome of Wernicke's aphasia, ideomotor and ideatory apraxia. The aphasia and ideomotor apraxia cleared within 10 days, while ideatory apraxia persisted. Ideatory apraxia therefore was not dependent on the language disorder, nor was it related to ideomotor apraxia. On the basis of various neuropsychological examinations, the nature of the apraxic movement disorder in this case is discussed. To our knowledge, this is the first case of ideatory apraxia with right-sided brain damage described in the literature. A particular feature of this patient is that obviously language and the motor functions underlying performance in tests for ideomotor apraxia had a bilateral hemispheric representation whereas a unilateral lesion was sufficient to bring about persistent ideatory apraxia.     

Right unilateral jargonagraphia as a symptom of callosal disconnection

We report the case of a right-handed patient who exhibited right unilateral jargonagraphia after a traumatic callosal hemorrhage. The lesions involved the entire corpus callosum, except for the lower part of the genu and the splenium. The patient's right unilateral jargonagraphia was characterized by neologisms and perseveration in kanji and kana, and was more prominent in kana than kanji. The jargonagraphia was similar to that observed in crossed aphasia, except that agraphia occurred only with the right hand. The patient also showed right unilateral tactile anomia and right tactile alexia, along with right-ear extinction on a dichotic listening test for verbal stimuli, which suggested that language function was lateralized to the right hemisphere. Since this patient had learned to write with his right hand, kinesthetic images of characters were thought to be formed and stored dominantly in the left hemisphere. We suggest that the callosal lesions disturbed the interhemispheric transfer of information for the dual-route procedures for writing in the right hemisphere, allowing the kinesthetic images of characters stored in the left hemisphere to be processed freely, resulting in the right unilateral jargonagraphia. At least two factors seem to explain that kana was more defective than kanji. First, writing in kana, which is assumed to be processed mainly via a sub-word phoneme to grapheme conversion route, might depend more strongly on lateralized linguistic processing than writing in kanji. Second, kanji, which represent meaning as well as phonology, with much more complicated graphic patterns than kana, are assumed to be processed in both hemispheres.     

Is the intact side really intact? Perseverative responses in patients with unilateral neglect: a productive manifestation.

The main defective manifestations of extra-personal unilateral spatial neglect concern the side of space contralateral to the hemispheric lesion (contralesional). Since the disorder is more frequent and severe after damage to the right hemisphere, patients typically fail to explore the left side and ignore stimuli located in that sector of space. The patients' behaviour in the side of space ipsilateral to the side of the lesion (ipsilesional) is not intact, however. In cancellation tasks, it can be observed that patients with unilateral neglect, in addition to failing to respond to contralesional stimuli, may show perseverative behaviour, crossing out many times the same stimulus in the ipsilesional side of the sheet. We analyzed the occurrence of this phenomenon during the execution of a cancellation task in a large series of brain-damaged patients with left- and right-sided hemispheric lesions, with and without evidence of unilateral spatial neglect, and in a group of patients suffering from senile dementia of the Alzheimer-type. Perseverative responses were found to be much more frequent in patients with spatial neglect and when the frontal lobe or subcortical structures were damaged. The results are interpreted in the context of a multi-componential view of the neglect syndrome, with reference to a distinction originally put forward by Derek Denny-Brown (1958) between 'frontal or magnetic' and 'parietal or repellent' apraxia. In patients with spatial neglect, frontal damage releases drawing perseverative behaviour in the ipsilesional sector of space. Perseveration in exploratory tasks constitutes a main instance of the productive manifestations of spatial neglect.     

Music therapy for dementia and higher cognitive dysfunction: a review

Music is known to affect the human mind and body. Music therapy utilizes the effects of music for medical purposes. The history of music therapy is quite long, but only limited evidence supports its usefulness in the treatment of higher cognitive dysfunction. As for dementia, some studies conclude that music therapy is effective for preventing cognitive deterioration and the occurrence of behavioral and psychological symptoms of dementia (BPSD). In patients receiving music therapy for the treatment of higher cognitive dysfunction, aphasia was reported as the most common symptom. Many studies have been conducted to determine whether singing can improve aphasic symptoms: singing familiar and/or unfamiliar songs did not show any positive effect on aphasia. Melodic intonation therapy (MIT) is a method that utilizes melody and rhythm to improve speech output. MIT is a method that is known to have positive effects on aphasic patients. Some studies of music therapy for patients with unilateral spatial neglect; apraxia; hemiparesis; and walking disturbances, including parkinsonian gait, are available in the literature. Studies showed that the symptoms of unilateral spatial neglect and hemiparesis significantly improved when musical instruments were played for several months as a part of the music therapy. Here, I describe my study in which mental singing showed a positive effect on parkinsonian gait. Music is interesting, and every patient can go through training without any pain. Future studies need to be conducted to establish evidence of the positive effects of music therapy on neurological and neuropsychological symptoms.     

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     

Focal brain lesions and intelligence: a study with a new version of Raven's Colored Matrices

Contrasting results have been obtained in previous investigations, which have used the standard version of Raven's Colored Progressive Matrices for studying the effects of localized brain lesion on visual-spatial intelligence. Some of these discrepancies might be due to the fact that specific factors, such as unilateral spatial neglect, could contribute to decreased performance obtained on Raven's test by patients with focal brain lesions. A new set of Colored Matrices, devised to minimize the influence of unilateral spatial neglect without changing the essential features of the original task, was therefore constructed. The test was administered to 76 normal controls, 74 right brain-damaged patients, 87 aphasics, and 61 nonaphasic left brain-damaged patients, in order to study the effect of laterality of lesions and of language impairment on Raven's scores. The results show that, if the influence of unilateral spatial neglect is minimized and Raven's scores are corrected in reference to age, educational level, and lesion size, then: no significant differences are observed between right and left brain-damaged patients; aphasics score worse than nonaphasic left brain-damaged patients; impairment is greater in patients with Wernicke's and Global aphasia (i.e., in patients with severe language comprehension disorders) than in patients classified as Broca's, Anomic, or Conduction aphasia; impairment is greater in patients with semantic-lexical discrimination errors than in patients free from semantic-lexical comprehension disorders.     

Non-verbal disturbances in crossed aphasia

Abstract

Aphasia is generally accompanied by signs of non-verbal dysfunction. The study of crossed aphasia can help to clarify the relationship between the two orders of phenomena. Four personal cases are reported and the relevant literature is reviewed concerning disorders of non-verbal function which accompany crossed aphasia. Left-sided neglect and constructional apraxia are common findings. Limb apraxia is a rarity among the cases reported, but bucco-facial apraxia is as frequent as in left hemisphere lesioned aphasics. In the light of these observations, the role of each hemisphere for verbal and non-verbal behaviour is reconsidered.     

Spared musical abilities in a conductor with global aphasia and ideomotor apraxia.

A conductor suddenly developed global aphasia and severe ideomotor apraxia as a result of an infarct in the territory of the left middle cerebral artery. Although aphasia and apraxia remained unchanged during the following six years, his musical capacities were largely spared and he was still able to conduct. This case provides some evidence in favour of right hemisphere dominance for music.     

Focal brain lesions and intelligence: A study with a new version of Raven's colored matrices

Abstract

Contrasting results have been obtained in previous investigations, which have used the standard version of Raven's Colored Progressive Matrices for studying the effects of localized brain lesion on visual-spatial intelligence. Some of these discrepancies might be due to the fact that specific factors, such as unilateral spatial neglect, could contribute to decreased performance obtained on Raven's test by patients with focal brain lesions. A new set of Colored Matrices, devised to minimize the influence of unilateral spatial neglect without changing the essential features of the original task, was therefore constructed. The test was administered to 76 normal controls, 74 right brain-damaged patients, 87 aphasics, and 61 nonaphasic left brain-damaged patients, in order to study the effect of laterality of lesions and of language impairment on Raven's scores. The results show that, if the influence of unilateral spatial neglect is minimized and Raven's scores are corrected in reference to age, educational level, and lesion size, then: (a) no significant differences are observed between right and left brain-damaged patients; (b) aphasics score worse than nonaphasic left brain-damaged patients; (c) impairment is greater in patients with Wernicke's and Global aphasia (i.e., in patients with severe language comprehension disorders) than in patients classified as Broca's, Anomic, or Conduction aphasia; (d) impairment is greater in patients with semantic-lexical discrimination errors than in patients free from semantic-lexical comprehension disorders.     

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.     

Constructive disabilities in focal brain-damaged patients. Influence of hemispheric side, locus of lesion and coexistent mental deterioration

The performance of 185 focal brain-damaged patients on two non-verbal constructive tasks ('Copying Drawings' and 'Copying Drawings with Landmarks') was evaluated with regard to three variables: laterality of cerebral lesion, intrahemispheric locus of lesion, and coexistence of mental deterioration. The aim of the study was to assess the relationships between each of these variables and both the incidence and severity of constructional apraxia. Different evaluations were carried out in order to partial-out the possible interference of unilateral spatial neglect. Results showed that, regardless of whether faults attributable to unilateral spatial neglect were penalized or not: right brain-damaged patients performed slightly worse and showed a higher percentage of pathologic performances than left brain-damaged patients; subjects with parietal--and particularly with right parietal--damage obtained the poorest mean scores and exhibited the highest incidence of apraxic performances; and coexistence of mental deterioration was the most relevant variable associated with global decay of constructive scores and incidence of constructional apraxia.     

Crossed aphasia: a PET follow up study of two cases.

Two cases of aphasia after right hemispheric stroke in right handed patients are described. The first patient had a severe mixed transcortical aphasia, apraxia and neglect after a lesion involving the right lenticular nucleus and periventricular white matter; aphasia was still present after three months. The second patient had a mild, transient fluent aphasia after a small right hemispheric periventricular lesion. Studies with [18F]FDG and positron emission tomography (PET) showed functional depression extending to the structurally unaffected left hemisphere in both patients in the acute stage. After three months, in the patient with persistent aphasia, metabolism was still reduced in the right hemisphere, with some recovery of hypometabolism on the left, while metabolic values had returned to normal in the patient with full language recovery. A close parallelism between glucose metabolism and clinical course in crossed aphasia is shown, as well as the presence of a functional involvement of the structurally unaffected left hemisphere in the acute stage.     

Mixed aphasia with jargonographia in a right-handed patient

We report a case of crossed aphasia with jargonagraphia in a forty-eight year old right handed monolingual man without family history of handedness or prior neurological illness. He developed a right temporo-insulo-parietal hamatomae documented by CT scan and accompanied by aphasia, left hemineglect, left hemiplegia, left lateral homonymous hemianopsia. The oral language was reduced and writing language was characterised by jargon. The writing and oral comprehension were preserved. This aphasia suggested a relationship between cerebral lateralization of language function and manual preference and the similarity between childhood aphasia and crossed aphasia in right-handed patients.     

Transcortical motor aphasia due to a right hemisphere lesion in a right-handed man

Abstract

A 67-year-old, right-handed male became aphasic following a right hemispheric infarction involving the frontal and parietal regions. The patient was evaluated by means of neurological, behavioural, and neuroradiological examinations. Behavioural investigations included Ianguage and nonverbal visuospatial and constructive evaluations. Language evaluation demonstrated transcortical motor aphasia and nonverbal tests showed left-sided visual neglect, left hemiakinesia, and constructional apraxia. Besides the information concerning crossed aphasia in a right-handed person, this case also supports the hypothesis that right-sided language representation does not affect right hemisphere dominance for visuospatial abilities.     

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.     

Crossed Aphasia: One Or More Syndromes?

Seven strongly right-handed patients developed aphasia following a right hemisphere vascular lesion documented by computerized tomography. One patient had a severe unilateral neglect, indication of its presence were evident in three and absent in three patients. The Token Test scores were significantly higher than in matched controls. Two patients had Broca aphasia, four had Wernicke aphasia and one had agraphia. The correlation between type of aphasia and locus of lesion was not much different from that normally found in standard left hemisphere brain damaged aphasics.     

Right hemiplegia and spatial neglect with apraxia and agraphia without aphasia in a right-handed patient

A 65 year-old right-handed woman was admitted after the sudden onset of a right dense hemiplegia. C.T. showed a large left infarction in the middle cerebral artery territory. There was a slight anosognosia and neglect of the right space without confusion. She had aprosodia but no aphasia. On the other hand, there was a severe apraxia and all the components of Gerstmann's syndrome were present. This suggests an unusual sattering of hemispheric functional dominances.