Chuang et al. BMC Neurology
(2021) 21:111
https://doi.org/10.1186/s12883-021-02131-w

CASE REPORT

Open Access

Shifting of global aphasia to Wernicke’s
aphasia in a patient with intact motor
function: a case report
Ya-Chi Chuang1†, Chuan-Ching Liu2†, I-Ching Yu2, Yu-Lin Tsai2 and Shin-Tsu Chang2,3,5,4*

Abstract
Background: Global aphasia without hemiparesis (GAWH) is a rare stroke syndrome characterized by the
dissociation of motor and language functions. Here, we present a case of GAWH with the patient later regaining
speech fluency.
Case presentation: A 73-year-old man was admitted to our emergency department immediately after an episode
of syncope. On arrival, we noted his global aphasia but without any focal neurologic signs. Computed tomography
(CT) perfusion scans showed a large hypodense region over his left perisylvian area. Under the impression of acute
ischaemic stroke, he received recombinant tissue plasminogen activator (rtPA) injection and was treated as an
inpatient. The patient was later discharged with GAWH status and received regular speech rehabilitation. After 14
months of rehabilitation, the patient gradually recovered his language expression ability. The degree of aphasia was
evaluated with the Concise Chinese Aphasia Test (CCAT), and we obtained brain single photon emission computed
tomography (SPECT) scans to assess cerebral blood flow.
Conclusion: A patient with severe impairments of Broca’s and Wernicke’s areas was able to talk fluently despite
being unintelligible. SPECT revealed relative high level of radioactivity uptake in the right frontal lobe, suggesting
the deficits in speech fluency could have been compensated by the right hemisphere. Although this is a single
case demonstration, the results may strengthen the role of the right hemisphere in GAWH patients and suggests
additional study that examines the possible benefits of stimulating activity at right homologous regions for
recovering language function after global aphasia.
Keywords: Global aphasia without hemiparesis, Single photon emission computed tomography, Concise Chinese
Aphasia Test

* Correspondence: ccdivlaser1959@gmail.com
†
Ya-Chi Chuang and Chuan-Ching Liu contributed equally to this work.
2
Department of Physical Medicine and Rehabilitation, Taichung Veterans
General Hospital, Taichung, Taiwan
3
Department of Physical Medicine and Rehabilitation, Tri-Service General
Hospital, Taipei, Taiwan
Full list of author information is available at the end of the article
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Chuang et al. BMC Neurology

(2021) 21:111

Background
Global aphasia without hemiparesis (GAWH) is a rare
stroke syndrome. The incidence of GAWH was once
mentioned as 0.32 % in ischaemic stroke patients by Pai
et al. in 2011 [1]. It is manifested by global aphasia after
large left perisylvian lesions [2]. The disorder is typically
characterized by language impairment without contralateral hemiparesis. Earlier studies on GAWH investigated
only the lesion site via brain MRI or CT in the acute
phase [1, 3], and few studies discussed plastic changes in
the brain during the chronic recovery phase. For adult
Chinese individuals, the Concise Chinese Aphasia Test
(CCAT) is a standardized and comprehensive test of language functions. In Taiwanese hospitals, this test is the
most common and reliable test for assessing aphasia, including varying types of aphasia, and has benefits for
quantifying communication disorders [4]. Here, we report a 73-year-old male Taiwanese patient with initial
acute global aphasia without hemiparesis, and later recovery into Wernicke’s aphasia, with supporting evidence from the CCAT. Additionally, brain SPECT scans
were obtained to assess cerebral perfusion during the
chronic recovery phase.
Case presentation
A 73-year-old right-handed Taiwanese man was admitted to our hospital after suffering syncope. On the day of
admission, he had been well until 7:00 in the morning,

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when he was playing tennis. Specifically, he suddenly lost
consciousness and fell to the ground. The patient
promptly regained consciousness, but his verbal output
was limited to saying the word “hao” (meaning “yes” in
English). His friends took him to our emergency department at 8:39 am.
On arrival, the patient was E2VaM4. On examination,
he was alert. He had impairments in speech fluency, comprehension and repetition. His only verbal output was the
sound “hao” or “hum”. Gait, extraocular motion, motor,
and sensory functions were all normal. He showed no eye
ptosis nor facial palsy. Blood parameters, including homocysteine levels, lipid profile, diabetes, oncology and endocrine measures, were unremarkable. Brain CT with
contrast revealed no apparent intracranial haemorrhage or
mass. However, CT perfusion indicated poor perfusion
over the left middle cerebral territory (Fig. 1).
Tracing back his medical history, the patient was normostenic (body mass index was 18). He had hypertension for more than twenty years. He also suffered from
hyperlipidaemia and coronary artery disease, and 7
months previously, he had received one drug-eluting
stent. His daily medications included amlodipine 5 mg,
aspirin 100 mg and rosuvastatin 5 mg. He played tennis
twice a day and never smoked or drank alcohol. His
highest education was senior high school and was fluent
in Chinese, Taiwanese and Japanese. He used to work at

Fig. 1 Brain CT and perfusion imaging-derived maps obtained in the emergency department. a: Pre contrast image showed no haemorrhage or
obvious hypodense region. b: Cerebral blood flow (CBF). c: Mean transit time (MTT). d: Cerebral blood volume (CBV). e: CT perfusion (CTP). Corepenumbra colour map with estimated core and penumbra areas, highlighted in red and green, respectively. CTP shows a large deep core and
penumbra regions over the left middle cerebral artery territory. f: CT angiography (CTA) showed no obvious vascular lesion on the main trunk of
the intracranial arteries

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an international trading company but had been retired
for two years.
Under the impression of acute cerebral infarction with
global aphasia, he then received a recombinant tissue
plasminogen activator (rtPA) injection at 9:26 am and
was switched to our intensive care unit for further management. Brain non-contrast magnetic resonance imaging (MRI; Fig. 2) was conducted on day 5, disclosing
an acute infarction in the territory of the left middle
cerebral artery (MCA), just in the perisylvian gyri, the
classic areas of Wernicke and Broca. After 12 days of inpatient treatment, the patient was later discharged under
stable conditions with global aphasia status and no focal
neurologic signs. He was able to resume playing tennis
on a daily basis soon after discharge.
The patient then received speech rehabilitation, including verbal production, auditory comprehension training,
augmentative communication training, phonetic placement and high-level cognitive function training at our
hospital and another hospital. His language expression
gradually recovered. The CCAT was then performed 14
months after the initial stroke. His average CCAT score
was 5.6, indicating moderate to severe aphasia (Fig. 3). Detailed analyses of his spoken language characteristics
showed subnormal performances for both sentence intonation and sentence length (Fig. 4), indicating he had fluent
aphasia.
We subsequently checked is cerebral blood flow using
regional brain single photon emission computed tomography (SPECT; Fig. 5). No radioactivity was found in the
left frontal and left parietotemporal regions, and instead,
a relatively high level of radioactivity uptake was noted
over the right thalamus, frontal and occipital lobes.

Discussion and conclusion
Here, we presented a case of Wernicke’s aphasia recovered from acute global aphasia without hemiparesis
(GAWH), with supporting evidence from the CCAT.
Both imaging tools, MRI in the acute phase and brain

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SPECT in the chronic recovery phase, showed a large infarction present over the left perisylvian regions involving both anterior and posterior language areas (Figs. 2
and 5). However, unlike the classic consensus that damage to both Broca’s and Wernicke’s areas results in global aphasia, our patient later showed only Wernicke’s
aphasia. Although a previous study demonstrated that
some patients present with an unexpected lesion-todeficit correspondence, such as lesions in Broca’s area
causing global aphasia [5] or lesions in the inferior and
middle gyri causing Wernicke’s aphasia [6]. Our present
case is the first to show severe impairments in the classic
language network regions while preserving speech
function.
It has been reported that there are better improvements in spoken language comprehension than speech
production [7, 8]. However, in our case, we found the opposite results. One explanation is that GAWH is a unique
stroke syndrome in which speech functions likely improve
faster than sensory function, including language comprehension, through preserved motor structures in the brain.
Mechanisms underlying recovery from aphasia could be
coalesced into two principles by Stefaniak et al. (2020): (a)
degeneracy and (b) variable neuro-displacement. In the
theory of degeneracy, brain regions have the capacity to
perform particular functions but will do so only when the
original region underlying that function is damaged. With
regard to variable neuro-displacement, a neural network
utilizes its spare capacity and increases its performance in
situations of increased difficulty [9]. Regarding the various
mechanisms of recovery in different types of aphasia,
Thomas et al. [10] suggested that during recovery in Broca’s aphasia, the initial right-hemispheric preponderance
changed to left frontal lateralization, while in Wernicke’s
aphasia, a presumably permanent shift towards the right
hemisphere occurred.
Our case showed relatively high level of activity over
the right hemisphere, especially in the thalamus and
frontal and occipital lobes, and no left frontal
lateralization was seen (Fig. 5). The results observed in

Fig. 2 Brain magnetic resonance imaging on the fifth day after admission. a: Diffusion-weighted imaging (DWI) showed hyperintensity over the
left frontal and temporoparietal regions. b: The apparent diffusion coefficient (ADC) image showed decreased ADC values in the same area. c:
The T2-weighted fluid-attenuated inversion recovery (T2-FLAIR) image showed hyperintense regions in the same area. d: Magnetic resonance
angiography (MRA) showed no obvious stenosis on the main trunk of the intracranial vessels. These findings combined with the clinical picture
were consistent with acute ischaemic infarction

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Fig. 3 Profile of the Concise Chinese Aphasia Test (CCAT) 14 months after stroke onset. Blue bar: the average raw score obtained from 70 healthy
control subjects based on Chung et al. [4]. Additionally, the error bar represents two standard deviations. Orange bar: our patient’s score on
the CCAT

our patient could be explained by the variable neurodisplacement theory, which differs from how language
expression was previously thought to recover [10].
In 1999, Hanlon et al. investigated recovery from
GAWH and proposed three types of GAWH: (a) persistent GAWH—global aphasia without any improvements
in language functions, (b) GAWH-TCM—recovery from
global aphasia to transcortical motor aphasia, and (c)
GAWH-Wernicke’s—recovery from global aphasia with
a shift to Wernicke’s aphasia [2]. Our case fell into the
GAWH-Wernicke’s category. Based on the recovery
mechanisms mentioned above and in line with the

proposal of Hanlon et al., we speculated that the pattern
of recovery in our patient was due to relatively higher
activity in the right hemisphere that preserved motor
function during a large stroke involving the MCA territory. Thus, during the 14-month recovery period, there
was a faster recovery of speech function.
Previous studies, in particular, Jodzio et al. [11] and
Mariën et al. [12], have provided discussions of the relationships between the recovery phase of aphasia and
SPECT findings. The former studied 50 stroke patients
with global aphasia and found extensive damage
throughout the perisylvian region of the left hemisphere

Fig. 4 Profile of the analysis of expository speech on the Concise Chinese Aphasia Test. The average score in healthy people was 7. In this figure,
we found that speech expression in our patient nearly reached healthy control levels in terms of sentence intonation and sentence length,
suggesting that he had Wernicke’s aphasia

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Fig. 5 Brain single photon emission computed tomography (SPECT) image at 14 months after stroke onset. No radioactivity was seen in the left
frontal and left parietotemporal regions. However, a relatively high level of radioactivity uptake was noted in the right thalamus, frontal and
occipital regions

on SPECT. The latter reported a bilingual boy with acquired aphasia confirmed by SPECT, whose original lesion was in the left frontal lobe and left caudate nucleus,
and remission of the deficit was associated with changes
in the same areas.
In this case report, we presented a patient with recovery from global aphasia to fluent aphasia that was
assessed by CCAT in support of the theory that the right
hemisphere engages in language functions when the left
perisylvian regions are severely impaired. Our findings
provide insights into the role of the right hemisphere in
GAWH patients. Further studies are needed to explore
such patients and the plastic changes that occur in the
right hemisphere that are homologous to the language
regions following global aphasia. In the future, perhaps
some interventions, such as repetitive transcranial magnetic stimulation, could be applied to these regions in
the right (or left) hemisphere in this group of patients,
thereby providing some benefits. Additionally, we should
keep in mind that whenever we encounter GAWH patients, we should focus more on comprehension speech
therapy for patients due to their delayed or poor recovery. Furthermore, brain SPECT is a good tool to evaluate
the effectiveness of the treatment and is recommended
for use by clinical doctors.
Abbreviations
GAWH: Global aphasia without hemiparesis; CT: Computed tomography;
CCAT: Concise Chinese Aphasia Test; SPECT: Single photon emission

computed tomography; MRI: Magnetic resonance imaging; MCA: Middle
cerebral artery; MTT: Mean transit time; CTP: CT perfusion
Acknowledgements
Not applicable.
Authors’ contributions
YCC and CCL drafted the main manuscript and reviewed the paper. ICY
acquired the clinical data and conducted the analysis. YLT participated in the
care of the patient and edited the manuscript. STC conceptualized and
executed the case report. All authors read and approved the final
manuscript.
Funding
This study was not funded.
Availability of data and materials
The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
The study was approved by the Institutional Review Board of Taichung
Veterans General Hospital and the patient gave written informed consent
prior to obtain the data.
Consent for publication
Written informed consent was obtained from the patient after treatment for
publication of this case report and any accompanying images. A copy of the
written consent is available for review by the Editor of this journal.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Taichung Veterans General Hospital, Taichung, Taiwan. 2Department of
Physical Medicine and Rehabilitation, Taichung Veterans General Hospital,

Chuang et al. BMC Neurology

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Taichung, Taiwan. 3Department of Physical Medicine and Rehabilitation,
Tri-Service General Hospital, Taipei, Taiwan. 4School of Medicine, National
Defense Medical Center, Taipei, Taiwan. 5Department of Medicine, Chung
Shan Medical University, Taichung, Taiwan.
Received: 13 November 2020 Accepted: 1 March 2021

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