BRIEF COMMUNICATIONS

Aphemia after Infarction of the Left Precentral
Gyrus and Premotor Area
Abdullah M. Al-Ajmi, Paul E. Cooper, Rossen T. Rousseff
Can J Neurol Sci. 2012; 39: 658-659

The term “aphemia” is now used to describe a motor disorder
that affects speech production but leaves the comprehension of
spoken and written language intact. Aphemia is a specific form
of mutism. Aphemia was formerly referred to as phonetic
disintegration, pure anarthria, apraxic dysarthria, cortical
dysarthria, verbal apraxia, subcortical motor aphasia, pure motor
aphasia, small or mini Broca’s aphasia, pure word mutism and
kinetic speech production disorder, reflecting the differing views
on the nature of the underlying disorder (e.g., aphasia,
dysarthria, apraxia). This condition may lie between pure speech
disorders (i.e., dysarthrias) and language disorders (i.e.,
aphasias) and it usually reflects damage in the left frontal
operculum1. Aphemia may emerge during recovery from more
extensive deficits. Occasional cases of progressive aphemia
resulting from selective left temporal lobe degeneration have
been reported2. In addition, cases of epileptic aphemia have been
described3.
CASE
A 60-year-old right-handed man presented to the neurology
clinic with several complaints. He awoke with an inability to
speak, right hand weakness and facial asymmetry. His past
history was notable for hypertension. He was taking blood
pressure medication.
His general physical examination was unremarkable. During
the neurological examination, the patient appeared alert. He had
no verbal output and was unable to articulate any sounds,
comprehensible or incomprehensible. He could not repeat
sounds, hum or sing, but could produce low-pitched guttural
moaning. To communicate, he used gestures. The patient had
normal comprehension of verbal commands in his native
language (Urdu, through an interpreter), Arabic and English.
Furthermore he had normal comprehension of the three written
languages. His writing was tested in his native language and in
English. His penmanship was adversely affected by impaired
dexterity; however, his spontaneous writing and writing in
response to dictation were accurate. Formal neuropsychological
testing was not performed. The patient also had right upper
motor neuron-type facial weakness. A slight pronator drift was
present on the right side. He had slow and irregular fine finger

movements of the right hand and moderately weak finger
extension was present in the right hand. Manual strength testing
was otherwise normal throughout. Deep tendon reflexes were
normal and flexor plantar responses were present. The sensory
exam, including responsiveness to light touch, temperature,
pinprick and vibration, was normal. The cerebellar examination
was normal as were stance and gait.
The patient’s presentation was consistent with an ischemic
stroke involving the left middle cerebral artery (MCA)
distribution. He was admitted to the hospital for a diagnostic
work-up and management.
An unenhanced computed tomography scan of the head
confirmed an infarction involving the left precentral gyrus and
premotor area (Figure).
The blood work showed an elevated low density lipoprotein
level of 2.6 mmol/L, but other blood tests were normal. An
electrocardiogram showed a normal sinus rhythm and
echocardiogram revealed global hypokinesia, a dilated left
ventricle and an ejection fraction of 15-20%. The carotid
Doppler ultrasound was normal.
The stroke was thought to be cardioembolic in origin and was
treated with warfarin (the patient had history of gastric
intolerance to aspirin).
After two weeks, the patient regained hand function. He
communicated by writing and reported his hand function “back
to normal”. His facial weakness had also improved, and he was
capable of producing incomprehensible sounds when he
attempted to say words. Six months later, an interpreter was able
to understand the patient’s language which sounded
“strange/foreign” although both the patient and the interpreter
were from the same area. The patient did not show for a further
follow up.
DISCUSSION
The patient was diagnosed as having aphemia. On admission
he was mute but had normal comprehension, reading and writing
ability. Furthermore, his comprehension of three languages was
normal and his written replies to questions were appropriate
irrespective of his aphemia when two languages were tested. He
had no facial, oral or lingual apraxia.

From the Division of Neurology (AMAA), Department of Medicine, Health Sciences Centre and Mubarak Hospital; Department of Neurology (RTR), Ibn Sina Hospital, Kuwait City,
Kuwait; Department of Clinical Neurological Sciences (PEC), University of Western Ontario, London, Ontario, Canada.
RECEIVED JANUARY 17, 2012. FINAL REVISIONS SUBMITTED MAY 1, 2012.
Correspondence to: Rossen T Rousseff, Department of Neurology, Ibn-Sina Hospital, pob 24527, Safat, 13115, Kuwait City, Kuwait. Email: rossentrousseff@yahoo.co.uk.

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https://doi.org/10.1017/S0317167100015432 Published online by Cambridge University Press

LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES

Figure: CT image of infarction involving the left precentral gyrus, extending into the premotor area.

Mutism is the absence of speech output1. Several diseases and
pathologies at different sites can produce mutism1. For example,
peripheral disorders, such as laryngitis and vocal cord paralysis,
can occasionally cause a mute state. In addition, aphemia , global
aphasia, transcortical motor aphasia, and aphasia with
subcortical lesions frequently present with mutism. Persistent
mutism can be seen with bihemispheric involvement,
particularly of the frontal lobes. Furthermore, tissue destruction
or dysfunction affecting the upper brain stem or bilaterally
affecting the frontal cingulate/supplementary motor area can
interfere with the initiation of both behavior and verbal output.
When it is severe, this state is called akinetic mutism. Finally,
mutism can also be of psychogenic origin.
Broca’s aphasia is a nonfluent aphasia with agrammatism,
repetition failure, and relatively normal comprehension, usually
accompanied by right hemiparesis and oral apraxia. Broca first
used the term aphemia (aphemie in French) to designate the
syndrome later called “Broca's aphasia”. In recent years,
however, the term aphemia has been reserved for a syndrome of
near-muteness with normal comprehension, reading, and
writing. Aphemia is clearly a motor speech disorder rather than
an aphasia, because written language and comprehension remain
intact. Patients are often anarthric, with no speech whatsoever
initially and then effortful, non-fluent speech after sometime.
Some patients have persistent dysarthria with dysphonia and
sometimes distortions of articulation that sound similar to
foreign accents - the “foreign accent syndrome”1 which likely
happened to our patient. In aphemia, the communication
disturbance involves verbal output and is a speech problem
rather than an impairment of language. Aphemia differs from
Boca’s aphasia because of the absence of agrammatism in
spoken and written output; however, controversy remains as to
whether aphemia is equivalent to apraxia of speech1,4.
Aphemia is associated with anterior lesions of the dominant
hemisphere including the pars opercularis, the inferior preRolandic gyrus, or the subjacent white matter4. Terao et al5
described three cases in which the patients developed severe
dysarthria that temporarily mimicked speech arrest or aphemia.

Volume 39, No. 5 – September 2012
https://doi.org/10.1017/S0317167100015432 Published online by Cambridge University Press

These cases were due to a localized brain lesion near the left
face representation of the human primary motor cortex (faceM1)5. Aphemia can also result from an infarction in the territory
of the left MCA, similar to the infarction in our patient, and it
often emerges during recovery from more extensive deficits;
however, occasional cases of progressive aphemia resulting from
selective left temporal lobe degeneration have been reported2.
CONCLUSION
Multiple disease states and sites of pathology can cause
various types of mutism, including aphemia. Aphemia is a rare
condition in which patients have impaired speech but intact
comprehension and writing. In our patient, aphemia was caused
by an infarction in the dominant hemisphere involving the
precentral gyrus, extending anteriorly with subjacent white
matter involvement.
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Panayiotopoulos CP. Early-onset benign childhood occipital seizure
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Schiff HB, Alexander MP, Naeser MA, et al. Aphemia: Clinicalanatomic correlations. Arch Neurol. 1983;40:720-7.
Terao Y, Ugawa Y, Yamamoto Y et al. Primary face motor area as
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