The Resolving Stroke and Aphasia A Case Study With Computerized Tomography Margaret A. Naeser, PhD, Robert W. Hayward, MD \s=b\ A 39-year-old man suffered an intracerebral hemorrhage in the region of the left internal capsule deep to Wernicke's area. The location of the lesion was confirmed by computerized tomography (CT) performed two days postictally. Two weeks after admission, the Boston Diagnostic Aphasia Examination (BDAE) disclosed Wernicke's aphasia. We hypothe- size that the hematoma exerted pressure on Wernicke's cortical area, thus causing the resulting Wernicke's aphasia at that time. A CT scan three months later showed absorption of the hematoma, with a residual low-density lesion deep to Wernicke's area, in the region of the arcuate fasciculus. At that time, BDAE testing disclosed a mild conduction aphasia. Serial CT scanning combined with discriminating clinical evaluation of aphasia provides a valuable opportunity for study of the processes underlying stroke resolution and aphasia. (Arch Neurol 36:233-235, 1979) patient whose aphasia syndrome findings changed concomitantly, with improvement, over a three-month period. a and CT REPORT OF A CASE A 39-year-old right-handed man was admitted to Stanford University Medical Center, Palo Alto, Calif, after the sudden onset of headache, right hemiplegia, and aphasia. The history was negative for hypertension, diabetes, or previous neuro¬ logical symptoms. The patient was alert. All pulses were normal; there were no bruits. Blood pressure was 160/106 mm Hg; a sinus rhythm was present. Neurological examination demonstrated a right homonymous hemianopsia, right central facial weakness, and inability to protrude the tongue. A right hemiplegia and hypore¬ flexia were present, with decreased sensa¬ tion to pain and touch on the.same side. A weak right extensor plantar response was elicited. Computerized tomography performed two days after admission (Fig 1) demon¬ strated a small intracerebral hematoma in the region of the left caudate nucleus, with compression of the adjacent frontal horn of the lateral ventricle. A second, larger hematoma was present in the region of the posterior limb of the left internal capsule, with compression of the atrium and body of the left lateral ventricle. Cerebral angi¬ ography disclosed a mass effect in the left internal capsule. No aneurysm, arteriove¬ nous malformation, or extracranial vascu¬ lar disease was demonstrated. The patient was transferred to the Palo Alto Veterans Administration Hospital for convalescence and rehabilitation nine days after onset. Initial Aphasia Testing The BDAE utilizes a test profile (Fig 2) to aid in classification of aphasia.3 Initial testing carried out two weeks after admis¬ sion disclosed a moderate to severe fluent Wernicke's aphasia. Spontaneous speech was fluent (items 1 through 6, Fig 2) and marked with multiple verbal paraphasias. ß have been investigating the relationship between types of v" aphasia, as demonstrated with the Boston Diagnostic Aphasia Examina¬ tion (BDAE), and site of anatomic lesion inferred from computerized tomography (CT) in stable stroke patients.1·2 Recently, we have studied Accepted for publication March 3, 1978. From the Departments of Audiology and Speech Pathology, and Radiology, Veterans Administration Hospital and Stanford University Medical Center, Palo Alto, Calif. Dr Naeser is now with the Veterans Administration Hospital, Boston. Reprint requests to Aphasia Research Unit (116B), Veterans Administration Hospital, 150 S Huntington Ave, Boston, MA 02130 (Dr Naeser). Fig 1.—Computerized tomographic scan two days after stroke. Small hematoma near head of left caudate nucleus. Larger hematoma in region of posterior limb of internal capsule, anterior to atrium of left lateral ventricle (left) and lateral to body of left lateral ventricle (right). Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/30/2015 co en g ÈS «I cu o m c 0) E.£ (D !9. ai O — CO 5. >. *~ co >. . - S J3 ~ J5a c co co o o °? m ?> «¬ . .; m .11 ¿ V m " D- 0) CO 2>: i S" M- >-.B «s 11 s co ™ o "*· o *- ° — Si » S o o o a> •a o E li s Ä si _ F g I I£ g « o E co .^ ¡2 O es .. µ ^ — . c «-* > LU hco-— £ ro o u. E u Ä Eoo. «rt £2 1 .2 ¡8 5 <" •a Si <= o = LL. o O •| g £ 'i3§ .Ï E t o c o o U3 Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/30/2015 2 ce S o o co o o ginal gyrus and Wernicke's areas to Broca's area.5 The four patients with conduction aphasia studied with BDAE and CT in our previously reported studies12 showed this type of aphasia to be primarily associated with subcortical lesions in the posteri¬ or portions of the arcuate fasciculus (anterior to the atrium, and lateral to the body of the left lateral ventricle). In this patient, CT disclosed a small Fig 3.—Computerized tomographic scan three months after onset. Both hematomas have resorbed. Slight enlargement of frontal horn of left lateral ventricle (left). Small low-density lesion deep in posterior portions of arcuate fasciculus anterior to atrium (left scan arrow) and lateral to body of left lateral ventricle (right scan arrow). Language comprehension was moderately to severely impaired at -.6 on the BDAE auditory comprehension z-score (item 7, Fig 2) and less than 50% on the Token Test.4 These test results are graphically displayed as the solid line in Fig 2. They are compatible with a fluent Wernicke's aphasia.3 Word and phrase repetition were severely impaired, reading was moderately impaired (seven of ten sentences were comprehended correctly in silent reading), and writing was severely impaired. After six weeks, the patient was able to walk with a cane, and was discharged with residual weakness of the right extremi¬ ties. Subsequent Examination Computerized tomography and BDAE testing were done again three months after onset of aphasia. The CT scan demon¬ strated résorption of the hematomas (Fig 3). Slight enlargement of the frontal horn of the left lateral ventricle was noted, with a small low-density area, anterior to the atrium and lateral to the body of the left lateral ventricle, that did not extend to the cortical surface. The BDAE testing disclosed a mild conduction aphasia (Fig 2). Spontaneous speech was substantially improved and near normal (items 1 through 6, Fig 2) with occasional literal paraphasias. Language comprehension was normal, at +1 on the BDAE auditory comprehension z-score (item 7, Fig 2) and 98% on the Token Test. Due to major improvement in auditory comprehension, the BDAE aphasia profile was now compatible with a fluent conduc¬ tion aphasia (broken line, Fig 2).3 Although word and phrase repetition had also improved, there remained a persistent problem with number and low frequency of occurrence phrase repetition. For the stan¬ dard conduction aphasia test phrase, "No ifs, ands, or buts," he responded, "Nos ifs...." When asked to repeat "1776" he answered "776." Reading ability had improved (nine of ten sentences were comprehended correctly in silent reading) and writing had also improved. COMMENT In recent CT studies of stable stroke patients with aphasia,12 the patients with Wernicke's aphasia had temporal lobe lesions located anterior to the atrium of the left lateral ventricle that involved cortical as well as deep structures. In our patient, in whom initial BDAE testing demonstrated a typical fluent Wernicke's aphasia, CT done two days after the stroke (Fig 1) showed a large intracerebral hemato¬ ma in the posterior limb of the inter¬ nal capsule (anterior to the atrium of the left lateral ventricle). The mass effect of this intracerebral hematoma might well have exerted pressure laterally onto Wernicke's area, thus causing the characteristic deficits of the usually cortically located lesion. At the time of BDAE testing three months later, the patient had mild conduction aphasia (graphic profile in Fig 2, broken line). Conduction apha¬ sia is commonly observed with lesions in the arcuate fasciculus, a deep path¬ way that extends from the supramar- Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 05/30/2015 subcortical lesion anterior to the atrium and lateral to the body of the left lateral ventricle (the residua from the previous hematoma), consistent with involvement of the posterior portions of the arcuate fasciculus (Fig 3). Also present was a slight enlarge¬ ment of the left frontal horn (the residua from the previous caudate hematoma). The relative contribution of the caudate lesion to the aphasia is not known. As serial CT scans confirmed the resolution of the hemorrhage and mass effect, concomitant BDAE test¬ ing demonstrated a change in aphasia type from severe Wernicke's to mild conduction. Computerized tomogra¬ phy, when correlated with discrimi¬ nating clinical evaluation, can provide a challenging opportunity to correlate function with anatomic changes. Properly used, such studies may be found to have predictive value in recovery from aphasia. The Syntex Corporation provided the Palo Alto Veterans Administration Hospital with the Syntex System 60 CT Scanner that was used in this study. This investigation was supported in part by the Medical Research Service, Veterans Administra¬ tion. References 1. Hayward RW, Naeser MA, Zatz LM: Cranial computed tomography in aphasia: Correlation of anatomical lesions with functional deficits. Radiology 123:653-660, 1977. 2. Naeser MA, Hayward RW: Lesion localization in aphasia with cranial computed tomography and the Boston Diagnostic Aphasia Exam. Neurology 28:545-551, 1978. 3. Goodglass H, Kaplan E: The Assessment of Aphasia and Related Disorders. Philadelphia, Lea & Febiger Publishers, 1972. 4. Spreen C, Benton AL: Neurosensory Center Comprehensive Examination for Aphasia. Victoria, Canada, University of Victoria, 1969. 5. Benson DF, Geschwind N: The aphasias and related disturbances, in Baker AB, Baker LH (eds): Clinical Neurology. Hagerstown, Md, Harper & Row Publishers, 1971, vol 1.