Brain Injury, October 2005; 19(11): 955–958 CASE STUDY Foreign accent syndrome following traumatic brain injury M. LIPPERT-GRUENER1, U. WEINERT2, T. GREISBACH3, & C. WEDEKIND1 Department of Neurosurgery, University of Cologne, Cologne, Gemany, 2Department of Neurology, University of Cologne, Cologne, Germany, and 3Institute of Phonetics, University of Cologne, Cologne, Germany Brain Inj Downloaded from informahealthcare.com by University of Connecticut on 06/17/13 For personal use only. 1 (Received 17 November 2003; accepted 14 February 2005) Abstract Foreign accent syndrome (FAS) is a very rare disorder, caused by lesions of the dominant brain hemisphere and defined as a loss of normal phonetic contrast when using the mother language. The pronounciation is perceived by native speakers as compromised by a foreign accent. This study reports about a 35-years old women, with a FAS following a brain injury with a traumatic left temporal haemorrhage, who experienced excellent remission after 2 years. Keywords: FAS, traumatic temporal haemorrhage, rehabilitation, speech disorder Introduction Foreign accent syndrome (FAS) represents a rare disorder caused by lesions of the dominant brain hemisphere [1, 2]. It is defined as a loss of normal phonetic contrast when using the mother language. The pronounciation is perceived by native speakers as if compromised by a foreign accent. By now, 15 cases of FAS have been described in the literature; the majority of these patients suffered from brain ischemia [3–5]. Only four cases after traumatic brain injury (TBI) have been communicated so far [6–9]. This report presents a further case of FAS consequent to TBI. Case report A native German woman of 35 years was the victim of a traffic accident. Without losing consciousness, she was admitted to the hospital. Two hours later, she presented with amnestic aphasia and became obtunded. She was then transferred to the Neurosurgical Department of the Cologne University and underwent CT scanning there. CT scans revealed traumatic haemorrhage in the left temporal lobe (Figure 1). The speech disorder increased and finally ended up with severe global aphasia without any capacity to obey commands, to utter words or to write. Surprisingly, she had retained the capacity to obey commands expressed in English and to speak a few short English words. Figure 1 displays the MRI findings in terms of a traumatic left temporal haemorrhage. After discharge from the Neurosurgical Department, she was admitted to a rehabilitation centre. At that time, neurologic examination revealed no deficits besides amnestic aphasia (with respect to German) and dysprosodia. Three months after trauma, the patient presented with minor aphasic symptoms in terms of amnestic aphasia. However, her German pronounciation was compromised by an English accent. The use of foreign languages (she was experienced in English and Spanish) was merely impossible. A neuropsychological examination at that time did not reveal further neuropsychological deficits. Six and also 12 months after injury, the condition had only slightly improved despite intensive training. Two years after the accident, however, the patient had recovered completely; FAS had remitted spontaneously without further therapeutic intervention. Correspondence: PD Dr C. Wedekind, Department of Neurosurgery, University of Cologne, D-50924 Cologne, Germany. Tel: þ49 221 478 4550. Fax: þ49 221 478 5921. E-mail: drchrwedekind@web.de ISSN 0269–9052 print/ISSN 1362–301X online # 2005 Taylor & Francis DOI: 10.1080/02699050500109506 Brain Inj Downloaded from informahealthcare.com by University of Connecticut on 06/17/13 For personal use only. 956 M. Lippert-Gruener et al. Figure 1. MRI (T2-weighted sequence) of the patient described showing the left sided post-traumatic haemorrhagic lesion of the temporal lobe. Table I. Definition of technical language used. High vowels Back vowels Strong lowering and centralization Unpredictable advancement or retraction Diphthong Diphthongization TCMA (transcortical motor aphasia) Amnestic aphasia Closure in dental plosives Palato-alveolar fricative Palatal voiceless fricative ‘Schleifton’ Strong lowering Vowels produced with the tongue in a high position within the mouth, in German ‘i’, ‘ü’, ‘u’. Vowels produced with the tongue in a retracted position within the mouth, in German ‘u’, ‘o’—in this case only ‘u’. Tongue is not elevated so high as necessary and tends to remain in a central, undifferentiated position. The tongue root can be shifted forward or backward in the mouth. This will alter the sound quality—unpredictable: This seems to be not systematic Double vowel, in German ‘au’, ‘ei’, ‘eu’. Vowel tends to change its quality at the end to a stronger constriction. Typical for the high vowels of English or Swedish, can be denoted as ‘ij’, ‘uw’. Special kind of motor aphasia with well preserved reproduction of speech. Type of aphasia with predominant impairment of retrieval of words, whereas understanding and communication facilities are well preserved. Dental plosivs are ‘t’ and ‘d’. Every plosive consist of a closure (in this case tongue tip is in contact with the palate) and a release (or plosion not to say explosion). Phonetic term for ‘sch’. Phonetic term for the ‘ich’ sound. This term is so specific that there is no appropriate term in English. The high vowels ‘i’, ‘y’ and ‘u’ tend to be pronounced ‘e’, ‘ö’ and ‘o’. Phonetic findings An auditory phonetic analysis was performed on speech samples recorded 2 months after the accident. These recordings consisted of an interview of the patient by her speech therapist. A second recording was done 1 year after injury. It consisted of an interview and of reading a short text. The technical language used in the following is explained in Table I. The auditory phonetic analysis of the first speech samples revealed some characteristic articulatory differences as opposed to native German speakers. The following phenomena were observed: (1) Vowels: . Strong lowering and centralization of the high vowels, especially of the back vowels in unaccented function words. Long vowels as well as short ones were affected. Brain Inj Downloaded from informahealthcare.com by University of Connecticut on 06/17/13 For personal use only. Foreign accent syndrome after trauma . Instability in tongue position concerning the vowel ‘a’, i.e. an unpredictable advancement or retraction of the tongue. . Nasalization of diphthongs and long vowels. . Slight diphthongization of long vowels. . Unusual lengthening of short vowels. (2) Consonants: . Delayed release of the closure in dental plosives ‘t’ and ‘d’ leading to a slight affrication. . The palato-alveolar fricative sound ‘sch’ which is rounded in German appeared to be disrounded. . The realization of the palatal voiceless fricative (‘ich’ sound in German) seemed to be more advanced as is typical for the German pronounciation in the Cologne area. The word accent exhibited an additional lengthening of long vowels with an additional ‘Schleifton’. The patients articulatory jaw movements were strongly reduced with the jaw almost immobile during speech production. The phonetic analysis of the speech samples showed specific variations from standard German pronounciation. The combination of these— especially strong lowering of high vowels, the sound quality of ‘a’ and diphthongization of long vowels—have evoked the impression of an English accent. Discussion Among the total of 15 cases of FAS described in the literature, there were only four suffering from TBI [6–9]. Moonis et al. [8] analysed a female case of 59 years who exhibited a French accent in her English mother tongue. This developed after minor head injury without any structural brain damage as assessed by magnetic resonance imaging. Carbary et al. [6] have communicated a case of FAS suffering from head injury after a physical assault with a pre-existent lesion of the left frontal cortex. Gonzalez-Alvarez et al. [7] have published a case who developed FAS after TBI located in the right basal ganglia. Most of the FAS cases reported so far, however, were caused by cerebral ischemia. Neuroimaging studies revealed lesions located in the dominant hemisphere mainly in the frontal pre-central cortex and white matter and also in associated sub-cortical structures (caudate nucleus, internal capsule) (reviewed in [6]). A PET study on the cerebral representation of a second language has put forward the role of left putaminal activation when speaking a second language [10]. 957 In a patient presenting with FAS, Gurd et al. [11] failed to detect any neurological causes. They hypothesized that a functional disorder could also account for the development of FAS since voice disorders are ‘a prototype of disorders which reflect the intricate interplay of emotional, cognitive and physiological functions’ [12]. In a detailed report on a case of FAS due to lefthemispheric stroke with lesions in the sub-cortical white matter of the pre- and post-rolandic gyri, Blumstein et al. [2] suggested that the acoustic anomaly in the speech of their patient was based on an impairment of speech prosody. They hypothesized that the listener’s perception of a ‘normal’ speaker with a foreign accent instead of an impaired speaker of the native language can be attributed to two factors. On one hand, language is near normal on lexical and grammatical levels. On the other hand, FAS patients’ speech only contains features which also occur in natural languages. The latter is in contrast to what is observed in Broca’s aphasia or in most dysarthrias. About 50% of FAS patients, however, additonally suffer from aphasia classified as transcortical motor type aphasia or as Broca type aphasia [4]. Most patients experienced near complete remission of aphasia but FAS persisted. This finding is in contrast to the observations. It is of interest that the patient described here felt FAS helpful in struggling against her aphasia: During situations of increased strain where there was increase of aphasia symptoms, the patient was—due to her foreign accent—supposed to come from abroad and, therefore, was supported whithout embarrassment in order to enable her to overcome her ‘vocabulatory restriction’. 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