1655 Case Reports Irish Brogue After Stroke Glenn M. Seliger, MD; Gary M. Abrams, MD; and Amy Horton, MS.CCC-SLP Background: We describe a patient who presented a unique variation of the previously described acquired foreign accent syndrome. Case Description: A 65-year-old woman developed an Irish brogue immediately after a deep left hemisphere stroke. The newly accented speech possibly represented a previously learned speech pattern. Conclusions: Suppressed prosodic speech patterns may reemerge in the setting of brain injury. (Stroke 1992;23:1655-1656) KEY WORDS • aphasia • cerebral infarction • speech T he appearance of unlearned, accented speech after brain injury has been rarely reported.1-7 To our knowledge, the emergence of a previously learned accent as a consequence of a cerebral infarction has not been observed. We recently encountered a patient whose speech was characterized by an Irish brogue immediately after a subcortical infarction of the left hemisphere. Our case suggests that accented language is a learned motor behavior and that injury to motor systems may unmask suppressed or inhibited areas of the brain involved in accented speech. Downloaded from http://ahajournals.org by on April 11, 2024 Case Report A 65-year-old left-handed woman developed sudden onset of slurred speech and right-side weakness. She was admitted to a hospital for diagnostic evaluation and treatment. Initial neurological examination was notable for dysarthria accompanied by a dense right hemiplegia. Computed tomography of the brain was negative, and within 48 hours her dysarthria improved markedly. Close acquaintances who visited the patient commented on the clearly discernible and newly acquired Irish brogue that characterized her speech. Natives of Ireland who were unaware of the patient's background identified her accent as characteristic of Northern Ireland, from which her mother had originated. She was transferred to our neurorehabilitation unit 2 weeks after onset of the stroke. Significant findings on neurological examination included very mild dysarthria with a moderate Irish brogue, normal language function, and a right hemiplegia. Detailed speech and language evaluation revealed the following salient features suggestive of an Irish brogue.8 There was mild dysarthria characterized by compensatory alveolar and lingual palatal articulatory movements. Suprasegmental speech pattern was obFrom the Department of Neurology, College of Physicians and Surgeons, Columbia University (G.M.S., G.M.A.), New York; and the Departments of Neurology and Speech and Audiology, Helen Hayes Hospital (G.M.S., G.M.A., A.H.), West Haverstraw, N.Y. Address for correspondence: Glenn M. Seliger, MD, Helen Hayes Hospital, Route 9W, West Haverstraw, NY 10993. Received May 22, 1992; final revision received June 30, 1992; accepted July 15, 1992. served as indicated by a gliding (four-six semitones) melodic intonation pattern, dialect-related phonemic vowel substitutions (e.g., /tudai/ /t dao/), vowel elongations (e.g., /deiz/ /daiz/), and diphthongal alternations (e.g., /how li/ /hav li/). In addition, all vowels preceding a final consonantal /r/ were changed to /a/ and were temporally elongated and stressed. Magnetic resonance imaging of the brain showed an area of increased signal intensity on T2-weighted sequences and decreased intensity on Tl-weighted sequences in the centrum semiovale extending just posterior to the waist of the left lateral ventricle (Figure 1). Three weeks after the infarction, the new accent had noticeably faded, although the patient noted that her speech pattern had not returned to baseline. At 4 months after the stroke, the Irish brogue had almost completely disappeared. Discussion The patient appeared to present a new variation of the previously reported foreign accent syndrome.1-7 The syndrome has been described as the development of a foreign accent, without evident exposure to the new accent, in an individual recovering from aphasia. Blumstein et al7 reported the case of a patient with a stroke who retained near-normal language function but developed a "generic" foreign accent during the recovery of dysarthric speech. Careful review of the rare reports in the literature1-7 would seem to confirm the nonspecificity of the newly exhibited accents and the lack of clear consensus on the prosodic origin of this phenomenon. In contrast, while the premorbid accent of our patient was alternatively described as "Bronx" or "New York," multiple independent observers easily identified the newly manifested accent as an Irish brogue. Our patient gave a history of extensive childhood exposure to individuals with Irish accents, although she did not explicitly recall having Irish-accented speech. However, a review of the speech and language literature suggests that very young preschool children adopt the prosodic pattern of their primary care givers.9'10 We have clear documentation that the patient's mother spoke with an Irish brogue. 1656 Stroke Vol 23, No 11 November 1992 FIGURE 1. Magnetic resonance image of brain of 65-year-old woman whose speech was characterized by an Irish brogue after subcortical infarction of left hemisphere. Area of increased signal intensity in centrum semiovale extends just posterior to waist of left lateral ventricle. Downloaded from http://ahajournals.org by on April 11, 2024 It is interesting to speculate that this "new" accent may have represented the return of a previously suppressed prosody pattern rather than an accent acquired during the recovery process. There have been multiple theories postulated to account for neurological recovery from brain injury, e.g., sprouting, diaschisis, pairing, redundancy, functional substitution, cortical reorganization, and inefficient synapses.11 Although there are multiple neurophysiological hypotheses for the observed phenomenon in our patient, we would like to speculate on two possible options. Jenkins et al12 have shown that cortical reorganization of neurosystems beginning within a few hours of injury may play a role in neurological recovery of function. The proposed mechanism for this early reorganization is unmasking of previously suppressed neural circuitry. The question arises as to whether the emergence of an accent is analogous to the unmasking phenomenon suggested by Jenkins et al. We propose that the childhood accent of our patient may have become suppressed by subsequent language development. The reappearance of her accent during the injury and recovery process associated with cerebral infarction may represent a unique expression of hierarchical neural organization. This case is consistent with the hypothesis that suppressed neural systems that reappear with brain injury may have been functional at an earlier time in neurodevelopment. The work of Ojemann and Whitaker,13 however, suggests an alternative explanation. They have theorized that when languages are learned at different ages, their anatomic localizations in the brain may differ. If accents are acquired in a similar manner, their anatomic localizations in the brain may also be distinct and separated from other motor areas associated with language. Following this line of reasoning, it could be hypothesized that this patient's "New York accent" center was damaged by the stroke, and her "Irish accent" center was left relatively undamaged. The Irish accent thus reappeared in her everyday speech. With recovery, the New York accent center subsequently reestablished dominance over the Irish accent center. Acknowledgment The authors would like to thank William M. Jenkins, PhD, for his thoughtful comments on this report. References 1. SchiffHB, Alexander MP, Naeser MA, Galaburda AM: Aphemia: Clinical-anatomical correlations. Arch Neurol 1983;40:720-727 2. Monrad-Krohn GH: The third element of speech prosody and its disorders, in Problems of Dynamic Neurology. Jerusalem, Hebrew University Press, 1963, pp 101-118 3. Monrad-Krohn GH: The prosodic quality of speech and its disorders. Acta Psychiatr Neurol Scand 1947;22:255-269 4. Monrad-Krohn GH: Dysprosody or altered "melody of language." Brain 1947;70:405-415 5. Monrad-Krohn GH: Altered melody of language ("dysprosody") as an element of aphasia. Acta Psychiatr Neurol Scand Suppl 1947; 46:204-212 6. Whitty CWM: Cortical dysarthria and dysprosody of speech. J Neurol Neurosurg Psychiatry 1964;27:507-510 7. 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