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CASE 63: RIGHT HEMIPARESIS AND NONFLUENT AGRAMMATIC APHASIA

A 55-year-old right-handed man suddenly develops difficulty speaking and weakness of his right side. Admitted to a hospital a few hours later, he is described as having right hemiparesis, with speech limited to inarticulate grunts but intact speech comprehension as evidenced by ability to follow simple commands.

Three days later, he has regained some speech, and a more comprehensive neurological examination is performed. He is alert, attentive, cooperative, and appropriately anxious. His speech is nonfluent, with delayed effortful initiation and an output of less than a dozen words per minute. One- or two-word phrases are often perseveratively repeated. His speech lacks melody and rhythm and is poorly articulated. His words consist largely of nouns and verbs, often incorrectly constructed (eg, a noun lacking a plural ending or a verb with a wrong tense); strikingly absent are function words (conjunctions, prepositions, articles, pronouns, and relational adjectives), giving his speech a telegrammatic style.

Speech comprehension is normal when tested with simple commands and yes/no questions, but he makes errors when asked to point to several objects in sequence or when a command depends on grammatical structure. Shown a variety of objects, body parts, and colors, he names most of them correctly but laboriously. With some objects, he offers the wrong word (eg, clock for watch), and with others, he perseveratively repeats the name of the previous object. He is able to repeat single words but not phrases of two or more words.

Using his nonparalyzed left hand, he is able to write single letters to dictation, but they are poorly formed to a degree not explained by the use of his nondominant hand, and he cannot write whole words. Reading aloud is effortful but largely correct; he has greater difficulty reading individual letters and grammatical words aloud than imageable nouns. Reading comprehension is mildly impaired, particularly with grammatically complex phrases.

Right-sided facial weakness spares the forehead. His right arm is paralyzed and flaccid; his right leg is moderately weak proximally and mildly weak distally. Pinprick, temperature, and touch sensation are mildly impaired over his right face and arm, and proprioception is reduced in his right hand. Visual fields are normal to gross bedside testing. Tendon reflexes are increased in his right arm, and a right plantar response is absent.

Computed tomography (CT) reveals abnormal lucency in the territory of the superior division of the left middle cerebral artery, including pre- and postrolandic motor and sensory cortices and frontal and parietal opercular areas. An electrocardiogram reveals atrial fibrillation.

Comment

Aphasia is an acquired disorder of previously intact language function. It is not explained by impaired speech (dysarthria or dysphonia) or impaired thinking (dementia or psychosis), although, as this patient demonstrates, some aphasics also have abnormal articulation. Aphasia, however, refers to a disturbance of ...

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