Global aphasia in a case of bilateral frontal lobe
infarcts involving both caudate nuclei
Davala Krishna Karthik,1 Vikram Khardenavis,2 Sharvari Kulkarni,3
Anirudda Deshpande4
1

Department of Radiology,
Surya Diagnostics, Warangal,
Telangana, India
2
Department of Medicine,
Miraj Medical College, Miraj,
Maharashtra, India
3
Department of Medicine,
Maharashtra Institute of Medical
Education and Research, Pune,
Maharashtra, India
4
Department of Neurology,
Vinayaka Neuro Multispecialty
Clinic, Warangal, Telangana,
India

Description

We report a 50-year-old man with history of
systemic hypertension, nicotine addiction and a folk
singer by profession was brought to the hospital
with history of abrupt onset of speech arrest at the
peak of a high note during his stage performance.
His co-performer friend noticed that he was unable
to restart his song performance despite back stage
prompting. He appeared clueless and unresponsive with expressionless face all of a sudden. His

Correspondence to
Anirudda Deshpande,
​dr.​anirudda.d​ eshpande@​gmail.​
com

Figure 3 Magnetic resonance angiography (MRA)
shows bilateral anterior cerebral arteries (A1) thrombosis.

Accepted 17 October 2017

Figure 1 The diffusion-weighted imaging and apparent
diffusion coefficient sequences of MRI brain axial view
shows bilateral caudate, bihemispherical (left→right)
cortical frontal, genu of corpus callosum diffusion
restriction. MRI, magnetic resonance imaging.

To cite: Krishna Karthik D,
Khardenavis V, Kulkarni S,
et al. BMJ Case Rep
Published Online First:
[please include Day Month
Year]. doi:10.1136/bcr-2017221642

Figure 2 The diffusion-weighted imaging (DWI)
and apparent diffusion coefficient (ADC) sequences
of MRI brain axial view shows bilateral caudate,
bihemispherical (left→right) cortical frontal, genu
of corpus callosum diffusion restriction. ADC,
apparent diffusion coefficient; DWI, diffusion weighted
imaging; MRI, magnetic resonance imaging.

relatives were certain that there was a dramatic
change in patient’s personality (from an extrovert
to an introvert). The patient seemed disinterested
in his surroundings. He seemed to have a ‘vacant
stare’. On examination, his blood pressure was
170/100 mm Hg. He was conscious, alert, but unresponsive to simple verbal commands. There was
no speech output. Fundus examination showed
grade 1 hypertensive retinopathy, no papilloedema.
Motor functions were preserved. MRI of brain with
magnetic resonance angiography (MRA) was done
in view of strong possibility of cerebrovascular accident. The diffusion-weighted imaging and apparent
diffusion coefficient sequences of MRI brain showed
bilateral caudate, bihemispherical (left→right)
cortical frontal, genu of corpus callosum diffusion
restriction (figures 1 and 2). The MRA showed
bilateral anterior cerebral arteries (ACA) thrombosis (figure 3). MRA indicates bilateral A1 occlusion, and infarction areas are corresponding to the
territory of A1 perforating arteries. Other ACA
territories are spared possibly because of collateral
blood supply.
At 6-month follow-up, the patient seemed to have
had very minimal improvement in his cognitive

Learning points
►► Affection of bilateral caudate nuclei can

manifest in different ways involving multiple
cognitive domains.
►► Global aphasia is a rare manifestation of
bilateral caudate infarcts.

Krishna Karthik D, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221642

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symptoms despite good compliance to antiplatelet and antihypertensive medications.
Global aphasia is a non-fluent aphasia, which impairs both
expressive and receptive language skills. It leads to severe impairment of production, comprehension and repetition of language.1
Caudate lesions (unilateral or bilateral) can rarely manifest as
global aphasia.2 3
Contributors DKK and VK made substantial contributions to the conception and
design of the work, acquisition, analysis and interpretation of the data. SK and AD
were involved in drafting the work and revising it critically for important intellectual
content. AD approved the final version to be published.
Competing interests None declared.

Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article)
2017. All rights reserved. No commercial use is permitted unless otherwise expressly
granted.

References

1 Kemmerer D. Cognitive neuroscience of language. New York: Psychology Press,
2015:86.
2 Kumral E, Evyapan D, Balkir K. Acute caudate vascular lesions. Stroke
1999;30:100–8.
3 Paciaroni M, Agnelli G, Caso V, et al. Manifestations of stroke. Frontiers Neurology
Neuroscience. Basel: Karger, 2012;vol 30:137–40.

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Krishna Karthik D, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221642

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