Acta Neurol Belg
DOI 10.1007/s13760-016-0618-1

LETTER TO THE EDITOR

Wernicke’s aphasia and attempted suicide
Antonio Carota1,2 • Francesca Rimoldi2 • Pasquale Calabrese2

Received: 26 December 2015 / Accepted: 9 February 2016
Ó Belgian Neurological Society 2016

Poststroke depression (PSD) is the most frequent mood
disorder in early and late phases after stroke onset. Recent
studies indicate that 30–40 % of stroke patients suffer from
this disorder [1] and prevalence is supposed to be even
higher in patients with aphasia [2]. Suicidal ideation might
occur in 15 % of stroke patients, doubling the prevalence in
the normal population [3]. PSD is one of the most important risk factors for suicide in stroke patients [4]. Thus,
early diagnosis and treatment are crucial. However, the
assessment of PSD and suicide ideation in patients with
severe aphasia poses serious challenges.
We report the case of a 66-year-old right-handed man
with persisting Wernicke’s aphasia (WA), 16 years after a
left perisylvian stroke due to atrial fibrillation. The patient
was not known for prestroke mood disorders.
Residual deficits were severe WA, right homonymous
hemianopia, right faciobrachial paresis and hypoesthesia.
Spontaneous language was fluent, but uncommunicative
due to continuous phonological and verbal paraphasias
(jargonophasia). Comprehension of auditory, written and

& Antonio Carota
acarota@genolier.net; a.carota@bluewin.ch
Francesca Rimoldi
Francesca.Rimoldi@unibas.ch
Pasquale Calabrese
Pasquale.Calabrese@unibas.ch
1

GSMN Neurocenter, Genolier Clinic, Genolier Swiss
Medical Network, Route du Muids 3, CP 100, 1272 Genolier,
Switzerland

2

Division of Molecular and Cognitive Neuroscience,
Neuropsychology and Behavioral Neurology Unit, Faculty of
Psychology and Interdisciplinary Platform Psychiatry and
Psychology, University of Basel, 4055 Basel, Switzerland

visually presented material, naming, repetition, reading and
writing were severely reduced. Finally, the patient was
unable to process any kind of communication, even by
gesticulation or pantomime.
In spite of aphasia, the patient’s autonomy was preserved for daily living activities. He was able to walk with
a cane and to participate together with his wife in few
scheduled activities and social events. Aphasia therapy was
withdrawn several years before because of the recurrence
of irritability and anger in coping with linguistic tasks.
Few days before Christmas, 16 years after stroke, the
patient shot himself in the head with a pellet gun, which he
had moved secretly from the storage basement into his
bureau. Brain CT-scan showed the lead bullets, which
pierced the temples throughout the orbits, sectioning the
optic nerves outside the cranial cavity (Fig. 1). The patient
became blind, but the brain remained grossly uninjured. No
surgery was performed. Citalopram was introduced and the
dose increased progressively to 60 mg/day. The patient
spent 2 months in a psychiatric hospital, 1 month in a
rehabilitation hospital and 2 months in a nursing home
before being discharged home.
After the suicidal attempt, there were no possibilities of
assessing mood with standardized questionnaires or scales.
To our knowledge, this is the first report of a premeditated suicide attempt of a patient with WA. The peculiar
clinical feature of this case is that the attempted suicide
occurred 16 years after the stroke without warnings.
Aphasia is a frequent consequence of stroke (about
30 % of patients in the acute phase) [5]. Although
improvement of linguistic faculties generally occurs with
variable degree over the first year, about 50 % of patients
are left with long-term residual deficits [5]. Stroke patients
experience high frustration when verbal communication is
impaired.

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Acta Neurol Belg

Fig. 1 Brain CT-scan sections showing bullet remnants in the orbits
along the optic nerves with evidence of orbital hematoma on the left.
Note the holes on the left (entrance) and right (outlet) temples,

delineating the bullet trajectory. Note the ancient malacic ischemic
lesion located within the left MCA territory and including the
perisylvian language areas

WA is a severe form of fluent aphasia as verbal
expression (consistent with fluent paraphasic speech) and
comprehension are severely affected. Lesions are located in
or near Wernicke’s area. Except some context-based
management, there are only limited treatment approaches
and the prognosis for rehabilitation, compared to non-fluent
aphasias is poor.
Although residual non-linguistic thought processes are
probably spared, individuals with WA show limited awareness
of linguistic difficulties and reduced monitoring of verbal
outputs. It is extremely difficult to access from outside the
patient’s inner world and to perform systematic studies of their
affective experiences. Standardized questionnaire screening or
assessing poststroke depression (PSD) or other affective disorders (such as mania and psychosis) and visual mood scales
cannot be employed in patients with WA or other severe
aphasias [6]. Neuropsychiatric diagnosis for WA would rely
only on behavioral observations.
The peculiar behavioral profile of patients with WA,
probably due to the damage of associative temporal areas,
includes paranoid agitation, frustration, anger, aggressiveness,
psychosis, euphoric indifference, anxiety and restlessness.
For the patient we reported, it is not possible to conclude
whether depression, anger, episodic dyscontrol or the
feeling of loneliness and being detached from others drove
the suicide attempt.
In conclusion, we propose that the potential for
depression, anxiety, alienation, behavioral dyscontrol and

finally suicide should be seriously considered for every
patient with severe WA, assessed by all health-care providers and explained carefully to the family.
Neurologists, neuropsychiatrists, neuropsychologists and
speech-language therapists have an important role in identifying affective symptoms, making differential diagnosis
and planning behavioral or pharmacological interventions.
The access to harmful situations or to weapons should
be carefully prevented for all the patients with WA, especially when they overtly display anger or frustration.

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Compliance with ethical standards
Conflict of interest
interest.

I declare that the authors do not have conflict of

Ethical standard The authors declare that they act in accordance
with ethical standard laid down in the 1964 Declaration of Helsinki.
Funding All the authors declare that there is no financial disclosure
(sponsorship or funding) to report.
Informed consent
from the patient.

Informed consent for publication was obtained

References
1. Robinson RG, Spalletta G (2010) Poststroke depression: a review.
Can J Psychiatry 55:341–349

Acta Neurol Belg
2. Kauhanen ML, Korpelainen JT, Hiltunen P et al (2000) Aphasia,
depression, and non-verbal cognitive impairment in ischaemic
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suicide? An overview of the current literature. CNS Neurosci Ther
18:711–721

5. Pedersen PM, Jorgensen HS, Nakayama H, Raaschou HO, Olsen
TS (1995) Aphasia in acute stroke: incidence, determinants, and
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depression after stroke: a comparison of different screening
instruments. Stroke 40:523–529

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