Case Report Stroke-Associated Acquired Stuttering By Robert G. Fawcett, MD CASE REPORT An 84-year-old, left-handed widow, whom I had treated for 20 years for recurrent major depression and generalized anxiety disorder, reported a sudden onset of speech difficulty. She had a history of hypertension, gastroesophageal reflux disease, goiter, and hypercholesterolemia. Years before, she had undergone surgery for cervical spinal stenosis and had placement of a ventricular shunt for normal pressure hydrocephalus 2 years previously. Her speech was aprosodic and showed stammering with repetition of initial phonemes but she was able to say several words correctly in the middle of a stateABSTRACT ment. Speech recognition was good. She could not In this case report, the syndrome of acquired stutterrepeat "No ifs, ands, or buts" because of her staming is described including its etiology, common presenting mering, but could say "Ta ta ta." She could sing features, and differences from developmental stuttering. "Jingle Bells" without stuttering. She displayed dysA case is described in an elderly female patient with suddiadochokinesis, worse in the right hand and had den acquired stuttering associated with ischemic infarct mild right facial weakness. Neuromuscular signs near the left basal ganglia. which had not changed in recent months, included CNS Spectr. 2005; 10(2) -.94-95 increased muscle tone, decreased strength of lower extremities, slight bradykinesia, and tremor with INTRODUCTION an intention and postural component. She used a Acquired stuttering is an uncommon phenomwheeled walker with a slow, wide-based gait. She enon that has been associated most frequently with was mildly disoriented in time, and recalled one of stroke, but also with head injury and medications, three objects in 3 minutes. However, she was able including phenothiazines, tricyclics antidepressants, 14 to perform simple calculations and recall several and selective serotonin reuptake inhibitors. ' It is recent United States presidents. This cognitive usually sudden in onset and may be associated with performance was consistent with her 27 out of 30 aphasia, dysarthria, or other neurologic signs. Lesions score in a Mini-Mental State Exam9 achieved 6 in all lobes of the cortex as well as subcortical, thamonths before the speech difficulty began. She lamic, and mid-brain regions have been associated 57 was seen by her neurologist, whose initial recomwith acquired stuttering. ' Acquired stuttering, in mendation was to target her symptoms of anxiety. contrast to developmental stuttering, often is not Successive individual additions of bupropion susrestricted to initial phonemes, occurs in monosyltained-release 100 mg/day, clonazepam 0.25 BID, labic and polysyllabic words, does not adapt, does and primidone 25 mg/day to her regimen of fluoxoccur during singing, and is not associated with etine 20 mg/day did not improve her speech. collateral motor phenomena, such as grimacing or 8 clenching of the fist. Stroke-related cases have been Increasing depression related to her difficulties associated with left-sided or bilateral lesions and with in conversing led to a psychiatric hospitalization difficulties in tests of nonlinguistic motor control.3 3 months after the onset of her speech difficulties. Described below is a case of the sudden onset of stutA computed tomography scan performed during tering remarkable for the paucity of other associated that hospitalization (Figure) showed an area of low symptoms of acute stroke. attenuation lateral to the left basal ganglia conFOCUS POINTS • Sudden onset of stuttering in an adult may have an organic origin, most often a stroke. • Acquired stuttering can be associated w i t h brain infarcts in various cortical and subcortical areas. • Acquired stuttering frequently differs f r o m developmental stuttering in speech patterns and associated motor phenomena. Dr. Fawcett is psychiatrist at Little Traverse Psychiatric Associates, PC, in Petoskey, Michigan. Disclosure: Dr. Fawcett has received honoraria from Abbott, Janssen, Pfizer, and Wyeth. This article was submitted on April 16, 2004, and accepted on August 31, 2004Please direct all correspondnece to: Robert G. Fawcett, MD, Little Traverse Psychiatric Associates PC, 2206 Mitchell Park Drive, Suite 10, Petosky, Ml 49770; Tel: 231-487-2415, Fax: 231-487-6569; E-mail: 4dripgs@chartermi.net. Volume 10-Number 2 CNS Spectrums - February 2005 94subject to the Cambridge Core terms of use, available at Downloaded from https://www.cambridge.org/core. INSEAD, on 07 Mar 2018 at 15:29:47, https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852900019416 Case Report sistent with an old lacunar infarct, which had not been present on previous computed tomography scans. The ventriculostomy and mild prominence of her ventricles were unchanged from previous exams. Speech therapy was begun along with psychotherapy and an increase in her fluoxetine from 20 mg/day to 40 mg/day. Her mood improved. After hospital discharge, speech therapy was continued and she became more confident talking with others and no longer avoided social encounters. Two years later, her speech was still abnormal with some initial stammering and dysprosody but improved from her original presentation. This patient's acquired stuttering occurred suddenly, not in the context of any medication changes, was associated in time with some impairment of her right-sided motor performance and with a lacunar infarct in her left basal ganglia, an area which has previously been associated with acquired stuttering.3 She had a history of normal pressure hydrocephalus that caused some bilateral cortical changes. Some features of her acquired stuttering, namely restriction to initial phonemes and ability to sing without stuttering, while not typical of acquired stutterers, have been reported previously. Her speech impairment exacerbated her depression. Speech therapy led to sustained improvement of her speech but not an abolition of the acquired stuttering. CONCLUSION Acquired stuttering is a syndrome associated with an insult to the brain, physical, or chemical, but most vascular. Lesions in various cortical and subcortical regions have been associated with it. Speech patterns that may distinguish acquired stuttering from developmental stuttering are not always reliable. Acquired stuttering may improve as the underlying pathophysiology improves or with the aid of speech therapy. ISDiltl REFERENCES 1. Meghji C. Acquired stuttering. J Fam Pract. 1994;39:325-326. 2. Grant A, Biousse V, Cook A, Newman N. Stroke-associated stuttering. Arch Neurol. 1999;56:624-627. 3. Ciabarra AM, Elkind MS, Roberts JK, Marshall RS. Subcortical infarction resulting in acquired stuttering. J Neurol Neurosurg Psychiatry. 2000;69:546-549. 4. Numberg H, Greenwald, B. Stuttering: an unusual side effect of phenothiazines. Am] Psychiatry. 1981;138:356-357. 5. Ardila A, Lopez M. Severe stuttering associated with right hemisphere lesion. Brain Lang. 1986;27:239-246. 6. Balasubramanian V, Max L, Van Borsel J, Rayca KO, Richardson D, Acquired stuttering following right frontal and bilateral pontine lesion: a case study. Brain Cogn. 2003;53:185-189. 7. Doi M, Nakayasu H, Soda T, Shimoda K, Ito A, Nakashima K. Brainstem infarction presenting with neurogenic stuttering. Intern Med. 2003;42:884-887. 8. Helm N, Butler R, Benson D. Acquired stuttering. Neurology. 1978;28:1159-1165. 9. Folstein MF, Fostein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinican. J Psychiatry Res. 1975;12:189-198. FIGURE. CT scan showing infarct in area of the left basal ganglia L=left; A=anterior; P=posterior; R-right; Ex=exam; Se=series; lm=image; Ax=axial; NOC=no contrast; MRG=initals of technician; Acc=accession number; Acq Tm=acquisition time; DFOV=defined field of view; CT=computed tomography. Fawcett RG. CNS Spectr. Vol 10, No 2. 2005. Volume 10 - Number 2 Spectrums - February 2005 Downloaded from https://www.cambridge.org/core. INSEAD, on 07 Mar 2018 at 15:29:47, subject to the Cambridge Core terms of use,CNS available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1092852900019416 95