Crossed Transcortical Motor Aphasia, Left Spatial Neglect, and Limb and Magnetic Apraxia Due to Right Anterior Cerebral Artery Infarction

[A case of crossed aphasia following infarction in the right anterior cerebral artery territory]

We report a patient presenting with crossed aphasia following infarction in the territory of the right anterior cerebral artery (ACA). A right-handed 68-year-old woman without a history of correction had acute disturbance of consciousness, left hemiparesis predominant in the lower extremity, speech disorder and left unilateral spatial neglect during the admission due to hypertensive emergency. No other family member was left-handed. MRI of the head revealed acute phase infarction in the territory of the right ACA: mesial frontal lobe including the supplementary motor area, anterior cingulate gyrus, and the corpus callosum. Language symptoms in the subacute phase included difficulty in initiation, slow speech rate, loss of intonation and phonetic paraphasia, and accompanying errors in comprehension, repetition, reading, and writing letters. These symptoms suggested "anomalous" type crossed aphasia. No limb apraxia, construction disorder or left unilateral spatial neglect was observed in this period. Only a few cases of crossed aphasia due to infarction in the territory of the ACA have been reported so far. However, language and concomitant symptoms differs, depending on each case, suggesting a difference in individual cerebral lateralization.

[Crossed aphasia in neurosurgical practice: case report and literature review]

BACKGROUND

Crossed aphasia in dexstral (CAD) is an extremely rare disorder. To date, about 200 cases have been described in the literature.

MATERIAL AND METHODS

The authors report 4 cases of CAD. Luria's neuropsychological examination was carried out. Functional asymmetry in the arm was analyzed using the Annett questionnaire. MRI and intraoperative findings confirmed localization of lesion in the right hemisphere in all patients.

RESULTS

A 59-year-old right-handed man developed frontotemporal aphasia after previous resection of right-sided glioblastoma of fronto-insular-temporal region. In a 31-year-old right-handed man, crossed aphasia occurred after extensive hemorrhage from arteriovenous malformation into the right frontotemporoparietal region. A 39-year-old right-handed man developed severe combined aphasia after resection of diffuse glioma of the right insular-temporal region. A 10-year-old right-handed boy developed aphasia with word forgetting after resection of a large tumor of the right temporal lobe. All patients had impaired dynamic praxis. Other cognitive functions were intact.

CONCLUSION

The authors discuss possible combinations of functions in one hemisphere for both right-handers and left-handers and emphasize diverse types of functional asymmetries described in the literature. Different localizations of functions in right-handers and left-handers indicate that local zones with different methods of information processing (successive or simultaneous) can coexist in one hemisphere. Therefore, the functions requiring different processing of information (for example, speech with praxis or spatial functions) can develop in one hemisphere. Cognitive impairment depends not only on the type of functional asymmetry, but also on localization of lesion. Crossed aphasia in right-handers indicates the rarest normal type of functional brain asymmetry with localization of speech functions in the right hemisphere. Possible aphasia in right-handers following damage to homologues of speech zones in the right hemisphere can require additional examination of these patients.

A case report on crossed aphasia in dextrals: Consideration about clinical features and neural network

RATIONALE

The term crossed aphasia in dextrals (CAD) describes aphasia following a right hemisphere lesion in right-handed subjects. The diagnostic criteria for CAD, defined on the basis of clinical cases observed over the years, are aphasia; lesion in right hemisphere; strong preference for right hand use without familial history of left handedness; structural integrity of left hemisphere; and absence of brain damage in childhood. The studies of CAD have mainly been focused on the neurobiological mechanisms underlying the functional neurocognitive lateralization and organization of the brain, such as a dissociation between language and handedness, language and praxis, or other cognitive functions.Patient concerns: We described a case of a patient affected by an aphasic syndrome following cerebral hemorrhage located in right hemisphere.

DIAGNOSIS

Considering the correlation between clinical data and instrumental investigations such as magnetic resonance imaging, we diagnose the patient with non-fluent aphasia. Specifically, the patient came to our attention showing a trans-cortical mixed aphasia that, later, developed in a trans-cortical motor aphasia. Contrary to most cases of CAD, our patient does not show apraxia and visuo-spatial neglect. Interventions language and visual attention when latter functions are related to right hemisphere.

INTERVENTIONS

The rehabilitation program consisted in exercises stimulating verbal fluency, comprehension, reading, and writing.

OUTCOMES

After 5 months of rehabilitation patient showed significant improvement in comprehension and absence of echolalia.

LESSONS

At present there is no agreement about pathogenesis of CAD and neural mechanism is still unclear. Considering the clinical symptomatology, we can argue that we observed a non-fluent aphasia. However, a more large sample should be studied to asses the role of brain circuits.