[Transcortical sensory aphasia following a left frontal lesion--case report]

We report a patient with transcortical sensory aphasia (TCSA) following a left frontal lesion. The patient was a 63-year-old right handed Buddhist priest admitted to our hospital with a complaint of word-finding difficulty. Neurological examination failed to reveal any abnormal findings except aphasia. The patients spontaneous speech was fluent, not agrammatic, and free of phonemic paraphasia but he sometimes exhibited semantic paraphasia. His ability to repeat sentences was excellent, but he had severe difficulty in word-finding, auditory comprehension and writing. He read aloud correctly, but his reading comprehension of kana (phonograms) was poor in contrast to excellent reading comprehension of kanji (morphonograms). His clinical picture was characterized by poor comprehension but excellent repetition, and a diagnosis of TCSA was made. CT and MRI revealed an infarction involving the pars opercularis and pars triangularis in the inferior frontal gyrus and the anterior portion of the lower prefrontal gyrus and the middle frontal gyrus. Regional cerebral blood flow was measured by single photon emission CT and was found to be decreased in the same region as indicated on CT and MRI. The clinical picture in this patient was comparable to that of TCSA due to a posterior parieto-occipital lesion, but the rapid improvement (within 1 to 2 months) of this patient was characteristic. Auditory comprehension, kana (phonograms) reading comprehension, and word recall, which were severely impaired in this patient, all demand interaction between phonological processes and semantic processes. Thus we conclude that this patient had impairment of the phonological-semantic interaction process.

Jargonagraphia in Kanji and Kana in a Japanese crossed Wernicke's aphasic

A right-handed Japanese crossed Wernicke's aphasic showed complete neologistic jargonagraphia in kanji and kana with anosognosia of his writing deficits. Prominent jargonagraphia in kanji is quite rare and has not been previously described in the literature. Marked dissociation between speaking and writing during the course suggested that his jargonagraphia might be unique to crossed aphasia. His condition was interpreted for the main part by Yokoyama, Okubo, Doseki, and Yamadori's hypothesis (1981) that free-running on of motor engrams of characters stored in the left hemisphere caused jargonagraphia in crossed aphasia. This case of jargonagraphia in kanji suggests that this hypothesis should be supplemented by the following points: (1) in kanji, not necessarily a character as a whole, but radicals or parts of radicals, function as motor units, which may be released to produce jargonagraphia in kanji; (2) free-running on of visual images as well as of kinesthetic images should be considered especially in written jargon in kanji.

Stroke-related aphasias mistaken for psychotic speech: two case reports

A large portion of the human central nervous system is dedicated to and specialized for language function. Aphasias, disorders of language, can be seen in many psychiatric and neurologic conditions. On occasion, it is difficult to differentiate between language abnormalities secondary to a patient's psychiatric illness and those secondary to a superimposed neurologic condition. In particular, in the evaluation of a patient with a history of a psychotic illness, it is easy to misinterpret the presentation of "abnormal" speech as an exacerbation of the patient's pre-existing psychiatric illness. To show this psychoneurologic comorbidity, two case reports are presented.

Patterns of recovery and change in verbal and nonverbal functions in a case of crossed aphasia: implications for models of functional brain lateralization and localization

We present a 2-year verbal and nonverbal follow-up of a crossed aphasic patient. The patient had suffered from widespread ischemic damage in the area of right middle cerebral artery, with a parieto-temporal lesion. Three months postonset he showed classical Wernicke's aphasia associated with oral, limb and constructional apraxia and left hemineglect. However, follow-up findings showed a complex, dynamic pattern entirely consistent with cognitive models of language and nonlanguage abilities. Current models of functional brain lateralizations could not satisfactorily account for such longitudinal, fine-grain observations.

An on-line analysis of syntactic processing in Broca's and Wernicke's aphasia

This paper is about syntactic processing in aphasia. Specifically, we present data concerning the ability of Broca's and Wernicke's aphasic patients to link moved constituents and empty elements in real time. We show that Wernicke's aphasic patients carry out this syntactic analysis in a normal fashion, but that Broca's aphasic patients do not. We discuss these data in the context of some current grammar-based theories of comprehension limitations in aphasia and in terms of the different functional commitments of the brain regions implicated in Broca's and Wernicke's aphasia, respectively.

Impairments of lexical-semantic processing in aphasia: evidence from the processing of lexical ambiguities

Broca's and Wernicke's aphasics performed speeded lexical decisions on the third member of auditorily presented triplets consisting of two word primes followed by either a word or a nonword. In three of the four priming conditions, the second prime was a homonym with two unrelated meanings. The relation of the first prime and the target with the two meanings of the homonym was manipulated in the different priming conditions. The two readings of the ambiguous words either shared their grammatical form class (noun-noun ambiguities) or not (noun-verb ambiguities). The silent intervals between the members of the triplets were varied between 100, 500, and 1250 msec. Priming at the shortest interval is mainly attributed to automatic lexical processing, and priming at the longest interval is mainly due to forms of controlled lexical processing. For both Broca's and Wernicke's aphasics overall priming effects were obtained at ISIs of 100 and 500 msec, but not at an ISI of 1250 msec. This pattern of results is consistent with the view that both types of aphasics can automatically access the semantic lexicon, but might be impaired in integrating lexical-semantic information into the context. Broca's aphasics showed a specific impairment in selecting the contextually appropriate reading of noun-verb ambiguities, which is suggested to result from a failure either in the on-line morphological parsing of complex word forms into a stem and an inflection or in the on-line exploitation of the syntactic implications of the inflectional suffix. In a final experiment patients were asked to explicitly judge the semantic relations between a subset of the primes that were used in the lexical decision study. Wernicke's aphasics performed worse than both Broca's aphasics and normal controls, indicating a specific impairment for these patients in consciously operating on automatically accessed lexical-semantic information.

Intraword timing relations in Thai after unilateral brain damage

The present study examined temporal characteristics of monosyllabic, bisyallabic, and trisyllabic words in Thai to evaluate timing control at the word level in brain-damaged patients. Subjects included young and old normal adults, right hemisphere patients, and left hemisphere nonfluent and fluent aphasic patients. Utterances were produced at a conversational speaking rate. Results indicated that, on an absolute or relative measurement scale, magnitude of the shortening effect on nonfinal syllables in polysyllabic words was significantly smaller in left nonfluent aphasics than in other groups. In trisyllabic words, duration of the penultimate syllable for left fluent aphasics was also significantly longer than that of normals. Left nonfluent and fluent aphasics were significantly more variable than other speakers in their production of bisyllabic and trisyllabic words. Findings are discussed in relation to issues pertaining to the nature of timing deficits in nonfluent and fluent aphasic patients.

Rate of speech effects in aphasia: voice onset time

This study investigated the ability to produce appropriate voice onset time (VOT) contrasts under conditions of rate modulation in groups of nonfluent aphasic subjects, fluent aphasic subjects, and nonneurological controls. Acoustic analyses of the consonants [b d g p t k] produced in the context of the vowels [i e a o u] at two different rates of speech revealed that normal subjects' VOTs were significantly shorter at the fast rate of speech relative to the slow/normal rate, as expected. In addition, the rate change had a significantly greater effect on voiceless stops as compared to voiced and on velar consonants as compared to labials and alveolars. The nonfluent aphasic patients exhibited a similar pattern except that no differences in magnitude of rate-related changes were found across place of articulation. Further, similar to previous studies, the nonfluent aphasic patients produced voice and voiceless consonants with somewhat overlapping VOT distributions, indicating an impairment in temporal integration in these subjects. Finally, the fluent aphasic patients demonstrated a surprisingly aberrant pattern of results, with VOTs under th fast condition shorter than under the slow, but no differences in magnitude of change across place of articulation or voicing categories. The results are discussed in relation to the nature of speech production deficits in both nonfluent and fluent aphasic patients. Implications for remediation are considered.

An acoustic analysis of rate of speech effects on vowel production in aphasia

The present investigation examined the production of tense and lax vowel duration differences at two speaking rates in the speech of 10 nonfluent aphasics, 8 fluent aphasics, and 10 normal control subjects. Subjects produced four repetitions of each of the vowels [i e ae o u I epsilon upsilon --] at each speaking rate. Acoustic analyses revealed that subjects in all three groups were able to manipulate overall rate of speech. In addition, normal controls and fluent aphasic subjects produced vowels under the fast rate condition which were significantly shorter than those under the slow rate condition. Despite a change in overall speaking rate, the nonfluent aphasics did not exhibit a significant difference in vowel duration at the two rates of speech, suggesting a deficit in the implementation of this temporal parameter. Both normal controls and fluent aphasic patients produced nonoverlapping distributions of tense and lax vowels at both speaking rates. In contrast, the nonfluent aphasics demonstrated a great deal of overlap in the distribution of tense and lax vowel durations at the fast rate. Results are discussed in relation to the nature of the speech production deficits in nonfluent and fluent aphasic patients.

Slowly progressive aphasia associated with surface dyslexia

We report an Italian patient affected by slowly progressive aphasia (SPA) lasting since four years when he first came to our observation. During the successive four years, we documented a progressive language decline resembling transcortical sensory aphasia, associated with a reading disorder corresponding to surface dyslexia, a form extremely rare in patients with native transparent language. His performance at standard intelligence tasks remained in the normal range, without any variation. CT scan showed left temporal atrophy. We emphasize the heterogeneity of the syndrome of SPA and suggest that it can represent one of the pictures of focal cortical degenerative disease, with variable onset, progression, and evolution.

Lexical-phonological processing of functors: evidence from fluent aphasia

The purpose of this study was to investigate how functors are processed at the lexical-phonological level. Four fluent aphasics with impaired ability to fully activate entries in the phonological lexicon, as revealed by their noun production, were asked to repeat and read aloud individual functors. Similarities between their functor and noun production (e.g., level of performance, production of phonological errors) indicated that functors are stored along with content words in the phonological lexicon, and are stored with a similar abstract structure. We also considered whether the sentence-planning system can facilitate the phonological encoding of functors presented in isolation.

The structural determinants of recovery in Wernicke's aphasia

Recovery of comprehension and total language in 22 Wernicke's aphasics was correlated with lesion size and extent of involvement of certain structures on CT. Recovery rates and outcomes were separately examined using 0-3 months and 0-12 months poststroke language data. Quantitative measures of structural damage were regressed on total aphasia and comprehension outcome measures. Supramarginal and angular gyri appeared to be the most significant structures in recovery in addition to initial severity and lesion size. This was confirmed by using ANOVA to compare the extent of involvement in each postcentral structure among the poor, moderate, and good recovery groups. The superior temporal and middle temporal gyri are less involved in the good recovery group. Structures posteriorly adjacent to Wernicke's area are important for compensation in Wernicke's aphasia and in the accompanying comprehension deficit. Persisting Wernicke's aphasia usually involves the supramarginal and angular gyri in addition to the superior temporal area.

Clinical forms of aphasia

A survey is given on the history of knowledge of aphasia and on the necessity and possibilities of classification of aphasic disability. Also the association of clinical syndromes of aphasia with particular damage to the brain is outlined. For Wernicke's aphasia (fluent aphasia with comprehension deficit) a superior posterior temporal lesion is obligatory. The persistent jargon aphasia is associated with a lesion of the supramarginal gyrus. Broca's aphasia is seen with posterior inferior frontal lesions, but additional central and subcortical components are involved in persisting deficit. The lesions producing transcortical motor aphasia involve the supplementary speech area of Penfield. Transcortical sensory aphasia is related to lesions that overlap the watershed area between the middle cerebral and the posterior cerebral arteries.

On the nature of naming difficulties in aphasia

An extensive naming battery was administered to ten patients representing classical aphasia syndromes. The battery included traditional performance measures and error scoring, phonological cuing, multiple-choice tasks tapping semantic and phonological knowledge, and word repetition tests. Differences in the patients' performance profiles were interpreted as reflecting lexical-phonological, phoneme assembly or multiple deficits. The results suggest that the hypothesized naming deficits have complex relationships to classical aphasia syndromes.

Fluency versus conscious recollection in the word completion performance of amnesic patients

To examine the relative contribution of fluency and recollection to the word completion performance of amnesics, we administered a task in which patients were told specifically not to utilize previously presented words during stem completion (an Exclusion condition). This condition was contrasted with a standard word completion task in which patients were encouraged simply to complete the stem with the first word that came to mind (an Inclusion condition). Since the exclusion condition necessitated controlled respecification of the initial presentation, it was hypothesized that amnesics would be less able than controls to exclude study list items. Consistent with this hypothesis, the results indicated that the amnesics' performance, unlike that of the alcoholic controls, did not significantly differ as a function of task condition. To examine whether amnesics' conscious recollection could be enhanced, Experiment 2 presented the study list five times. The amnesics now were able to exclude a significant number of items from the study list; however, they still did so considerably less frequently than alcoholic controls. For the alcoholic controls, increasing the number of study trials had little additional effect on their exclusion performance, but it significantly enhanced their inclusion performance. Taken together, these findings suggest that for control subjects, word completion performance is likely mediated by a combination of fluency and recollection, while for amnesic patients, performance is almost exclusively based on the fluency with which an item comes to mind.

Auditory and visual verbal short-term memory in aphasia

Phonological short-term memory was investigated in 24 aphasic left brain-damaged patients and in 12 matched controls. Aphasic patients have a reduced auditory and visual immediate memory span and show the standard detrimental effect of phonological similarity on immediate retention only when the stimuli are auditorily presented, while in the control group the effect is present with both auditory and visual input. Most patients have phonological processing deficits, but two patients have an impaired immediate verbal memory in the absence of analysis disorders. These results, in line with most individual case studies of patients with selective deficits of verbal short-term memory, are interpreted with reference to a model distinguishing a phonological short-term store component of memory, to which auditory input has direct and automatic access, and a rehearsal component, that, after phonological recoding, conveys visually presented stimuli to the phonological store. This latter system, that appears to become fully operational later in development, is less resistive to brain damage.

[The Aachen Aphasia Bedside Test--criteria for validity of psychologic tests]

The Aachen Aphasia Bedside Test (AABT) has been developed in order to examine aphasic patients within the first 4 to 6 weeks after onset of illness. The psychometric properties of the AABT were established by repeated examination of 82 acute stroke patients, ratings by 20 raters on the basis of 10 videotapes, repeated examination of 28 chronic aphasics three times with an interval of 2 days, and parallel examination of 47 chronic aphasic patients with the AABT and the Aachen Aphasia Test (AAT), administered on the same day. Objectivity, reliability and validity of the AABT were highly rated, indicating its usefulness in acute stroke cases. Data on the 82 acute stroke patients showed that an initial prognosis can be made as early as the fourth day after the stroke.

Search patterns and neglect: a case study

An irregular and unsystematic search pattern may contribute to unilateral neglect. We examined the sequence of cancellations performed by a patient with unilateral neglect and found that she followed a systematic and stereotypic vertical search pattern. To overcome this vertical search pattern, foils were placed in rows. These foils induced slightly more horizontal movements, but did not alter her neglect. In another attempt to overcome her vertical search and tendency to cancel on the right, she was explicitly instructed to cancel targets alternating to and from the right and left sides of the array. This strategy overcame her vertical search, but, instead of modifying the severity of her neglect, this task only changed its spatial distribution. The altered spatial distribution of neglect is difficult to reconcile with current theories of neglect. We suggest that this patient demonstrates a limited capacity to sequentially be aware of or act upon stimuli.

The production of grammatical morphology in Broca's and Wernicke's aphasics: speed and accuracy factors

A group of Broca's aphasics (BA), Wernicke's aphasics (WA) and normal controls participated in a CLOZE experiment which required the oral production of various types of free and bound morphemes. Results provided support for the hypothesis that BA and WA share the same underlying impairment in the production of grammatical morphology. The relative difficulty of the various free and bound morpheme types was the same for BA and WA. This appeared to be the case not only in an analysis of the number of errors but also in an analysis of response times. The same analyses furthermore revealed no significant differences in the absolute levels of performance of BA and WA. Finally, it was found that BA and WA show the same relative contribution of within- and across-category substitutions of free morphemes. For bound morphemes, there was a slight difference between BA and WA, in that BA exclusively produced within-category substitutions while WA also produced some across-category substitutions.

Reading aloud in jargonaphasia: an unusual dissociation in speech output

A patient is described who showed several dissociations between oral and written language processing after bilateral retrorolandic vascular lesion. Dissociation was firstly between abolished auditory comprehension and preserved written comprehension and then involved confrontation naming, clearly superior in the written modality. The third striking dissociation involved oral output; spontaneous speech, although fluent and well articulated, consisted of neologistic jargon, while reading aloud was clearly superior though not perfect. Data are discussed with reference to a cognitive model of word processing. The pattern of dissociation in word production may be due to a failure in retrieving the phonological word form from the semantic system.

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).

Vocabulary grammatical structure in aphasic patients

In 10 aphasics (7 Broca's and 3 Wernicke's) of vascular etiology and 10 normal controls, a corpus of 2,500 words was selected in each subject by means of a standard interview. The 10 grammatical classes of the Romanian language were studied. The vocabulary reduction observed in aphasics was produced by the loss of nouns, adjectives and verbs. In exchange, proportionally to their vocabulary, they used more adverbs, pronouns and numerals than the normals. Articles, prepositions and conjunctions showed a similar use with that of the normals. The aphasic patients preserved basic words for each part of speech, the loss of vocabulary operated among the non-basic words. It was revealed by the Token-Type ratio that the verbal creativity was lower in aphasics than in controls. However, in normals as in aphasics verbal creativity was higher in the non-basic words than in the basic ones. The results are discussed by the action of different factors as: the semantic and syntactical constraints, semantic characteristics and syntactical functions proper to each class as well as the influence of the different amounts of words comprised in each grammatical class on the selection of the necessary word.

Fluent aphasia in children: definition and natural history

We compared the course of a preschool child we followed for 4 years with published reports of 24 children with fluent aphasia. Our patient spoke fluently within 3 weeks of the injury. She was severely anomic and made many semantic paraphasic errors. Unlike other children with fluent aphasia, her prosody of speech was impaired initially, and her spontaneous language was dominated by stock phrases. Residual deficits include chronic impairment of auditory comprehension, repetition, and word retrieval. She has more disfluencies in spontaneous speech 4 years after her head injury than acutely. School achievement in reading and mathematics remains below age level. Attention to the timing of recovery of fluent speech and to the characteristics of receptive and expressive language over time will permit more accurate description of fluent aphasia in childhood.

Type and frequency of phonetic errors in aphasics: therapeutic aspects

Fifty aphasics were studied in three separate groups: nonfluent Broca, fluent Wernicke and fluent anomics in order to form a therapeutic guide of their phonetic errors (omission substitution, addition, repeated phonemes, perseveration of phonemes belonging to the preceding word, reversed order, phonematic targetting and misplacing. Frequency of phonetic error was also assessed.

[Lipomatous hypertrophy of the interauricular septum as a cause of cerebral embolism in a patient with isolated Wernicke's aphasia]

The clinical observation of a 74 year old male presenting isolated Wernicke's aphasia due to a temporal left infarction of cardiac embolic origin secondary to paroxysmal auricular flutter is described. Transthoracic and transesophageal echocardiography, computerized tomography and magnetic resonance provided characteristic images which permitted the establishment of the diagnosis of lipomatous hypertrophy of the interauricular septum without requiring the use of invasive techniques. Lipomatous hypertrophy of the interauricular septum is a cardiac tumor of unusual presentation constituted of an abnormal accumulation of non-encapsulated fatty tissue which occupies a thickness greater than 15 mm of the interauricular septum. Wernicke's aphasia as a form of presentation of the lipomatous hypertrophy of the interauricular septum has not previously been described in the literature.