Transient Aphasia With Persistent Apraxia
Uncommon Sequela of Massive Left-Hemisphere Stroke
Ola A. Selnes, PhD; Alan B. Rubens, MD; Gail L. Risse, PhD; Ronald S. Levy, PhD

58-year-old, right-handed man beaphasic following a left-hemisphere
stroke. Despite the massive size of the
lesion, the aphasia was transient. An
apraxia and agraphia did, however, persist three years after onset. The pattern of
language impairment and subsequent
recovery is believed to represent the rarely documented condition of mixed cerebral dominance for language.
(Arch Neurol 1982;39:122-126)
\s=b\ A

came

Although certain areas of the left
hemisphere are general¬
ly accepted as crucial to normal lan¬
guage functioning, a number of
reports documenting exceptions to
"^ cerebral

this standard have been published.
They include examples of crossed
aphasia in dextrals,1 lack of correla¬
tion between type of aphasia and loca¬
tion of lesion,- and absence of aphasia
despite an appropriate lesion.' Such
cases are of importance for clinicopathologic correlations and also con¬
tribute to the development of a more
detailed account of the ways in which
language may be organized in the
human brain. The purpose of this com¬
munication is to report an exceptional
case of aphasia in a right-handed man,
in whom massive damage to the ante¬
rior and posterior supra-Sylvian lan¬
guage zones produced only a moderate
aphasia that cleared completely over a
short time. Ideomotor apraxia and
agraphia were the only language-

Accepted for publication April 21, 1981.
From the Neurology/Aphasia Service, Hennepin County Medical Center, Minneapolis (Drs
Seines, Rubens, and Risse), and the Department
of Psychology, University of Houston (Dr
Levy).
Read in part at the 17th annual meeting of the
Academy of Aphasia, San Diego, Oct 15, 1979.
Reprint requests to Neurology/Aphasia AB
280, Hennepin County Medical Center, 701 Park
Ave S, Minneapolis, MN 55415 (Dr Seines).

Fig 1.—Approximate lateral projection of lesion, which involves most of frontal operculum, including "Broca's area," and extends posteriorly to involve central and parietal
opercula. Dotted line indicates involvement deep to temporal lobe in insula and
underlying white matter.
related behavioral deficits that per¬
sisted. The case is important in that it
documents the rarely seen condition
of mixed, as contrasted with bilateral,
cerebral language dominance in a

right-handed aphasie patient.
REPORT OF A CASE

A 58-year-old, right-handed man was
hospitalized on June 26, 1976, with the
sudden development of a right hemiparesis
and aphasia. Neurologic examination re¬
vealed a dense right hemiparesis and corti¬

cal hemisensory loss, severe ideomotor
apraxia, and Gerstmann's syndrome. The
aphasia, which was moderately severe, was
characterized during the first several days
by a deficit in auditory comprehension,
repetition, and writing. The patient's

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In
was dysarthric but fluent.
response to the question "Why are you
here?" he said, "I had an accident." The
hemiparesis cleared in several days so that
the patient was able to walk around the
ward. He was left, however, with a rightsided lower facial weakness that persisted
for several months and a corticosensory
deficit involving the right hand that has
persisted up to the present. The ideomotor
apraxia and some elements of Gerstmann's
syndrome have also persisted. The details
of his language recovery will be discussed
in a separate section. A radioisotopic brain
scan obtained during the second week after
onset revealed a large area of abnormal
uptake in the left frontoparietal region
over the superior division of the left middle
cerebral artery. A diagnosis of occlusion of
branches of the left middle cerebral artery
with infarction of the frontocentral and

speech

Fig 2.—Representative computed tomographic scans. Scanning angle is extremely flat,
approximately 0° relative to canthomeatal line. At lowest level (top left), temporal pole is
unaffected. At next levels (top center and right), low density involves inferotemporal
region anterior and deep to temporal lobe but seems to spare temporal lobe structures
almost entirely. Higher cuts (center left, center, and right) show involvement of large
portions of insula and frontoparietal operculum. Highest cut (bottom) shows lesion
extending into parietal region.

parietal regions on the left side was made.
This diagnosis was confirmed, during
another hospitalization 2'/2 years later, by
cerebral arteriography and computed to¬
mographic (CT) scanning. The arteriogram
revealed an occlusion of a major branch of
the left middle cerebral artery with a scar¬

city of vessels in the frontal and parietal
opercula and sparing of the temporal
branches.

The CT scans demonstrated a large area
of low attenuation involving the left fron¬
tal, central, and parietal opercula and
extending into the angular gyrus and
superior parietal lobule (Fig 1 through 3).
The lesion also involved the insula and
extended almost to the ventricular surface.
A portion of the anterior temporal lobe
may have been affected. The supra-Sylvian
language zones and the facial sensory and
motor cortical region were almost totally
destroyed. The lesion seemed to spare
Heschl's gyrus and the posterior superior
temporal lobe (Wernicke's area).
The findings on CT scan were particular¬
ly surprising in that despite total destruc¬
tion of the frontal, central, and parietal
opercula and much of the angular gyrus,
the aphasia had cleared completely, and all
that remained were a writing disturbance
and a moderately severe ideomotor aprax¬
ia. There was also a residual corticosensory

loss involving the right hand that was
manifested by astereognosis, loss of posi¬
tion sense, and two-point discrimination.

Language Assessment in the
Acute Period

Administration of the Boston Diagnostic
Aphasia Examination (BDAE) eight days
after onset demonstrated that expressive
language functions were essentially intact;

overall results were as follows:

Severity rating, 4/5
Articulatory rating, 7/7
Phrase length, 5/7
Verbal agility, 11/14
Word discrimination, 29/72
Body-part identification, 15/20

Commands, 11/15
Complex material, 7/12

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Fig 3.—Scan with contrast enhancement
of middle cerebral artery indicating posi¬
tion of posterior Sylvian fissure and show¬
ing intact temporal lobe at this level (ar¬
rows). Anterior to enhancing vessel, tem¬
poral lobe is less dense because of partial
volume effect, associated with absence of
central and parietal opercula.

Responsive naming, 17/30
Confrontation naming, 91/105
Animal naming, 9/23
Body-part naming, 18/30
Oral reading, 30/30
Oral sentences, 10/10

Repetition (words), 10/10
High probability, 8/8
Low probability, 8/8
Neologisms, 0
Literal paraphasias, 0
Verbal paraphasias, 0
Word recognition, 8/8
Oral spelling/comprehension, 1/8
Word-picture matching, 8/10

Primer dictation, 10/15
Written confrontation naming, 2/10

Spelling to dictation, 1/10
Sentences to dictation, 6/12
Narrative writing, 2/4

Sentence melody, phrase length, and artic¬
ulatory agility were within normal limits,
and there were no paraphasic errors or any
evidence of agrammatism. There were,
however, some minor word-finding prob¬
lems. The patient was noted, for example,
to be vague and nonspecific when asked to
explain his duties as an engineer; he had
difficulty finding the appropriate words.
His speaking rate was also increased, and
his sentences often had a peculiar, burst¬
like onset. Repetition of both high- and
low-probability sentences was intact at
this time.

Comprehension was more severely im¬
paired than expression. On body-part iden¬
tification, he could point to major body
parts but had difficulty with finer discrim¬
inations, such as shoulder, wrist, and

thumb. Left-right discrimination was ap¬
propriate but slow. He could follow axial
commands, but was unable to do multi¬
stage commands requiring manipulation of
objects, such as "Put the pencil on top of
the card, then put it back." On a test of
word discrimination (pointing to pictures
of named objects), he also evidenced diffi¬
culty, scoring 16 of 36 points, and showed
particular difficulty with letters, numbers,
colors, and forms. His score on comprehen¬
sion of complex ¡deational material was
seven of 12 possible points, and on part 5 of
the Token Test, he scored eight of a possi¬
ble 21 (38% correct), suggesting a substan¬
tial impairment. Comprehension of written
language was relatively intact. He scored
eight of a possible ten on a word-picture
matching task and nine of a possible ten on
a task requiring comprehension of printed
sentences and paragraphs. He was, howev¬
er, unable to comprehend words spelled
aloud by the examiner.
The patient's writing was considerably
more impaired than his speech. He could
write to dictation (with his right hand) four
of five letters and two of five numbers. He
could also write a few simple words to
dictation, for example "boy," "run," and
"come," but was unable to write more
difficult ones, for example "belong,"
"soap," and "fight." His oral spelling was
similarly impaired. On written confronta¬
tion naming, he was able to write the
names of two of ten pictures, and his
responses contained both paragraphias (eg,
"zee" for "thee," "sofa," for "chair," and
"schair" for "square"). His written descrip¬
tion of the Cookie Theft Card was incom¬
plete but otherwise appropriate: "The boy
in the cookie jar giving candy to the

girl."

His ability to name was mildly to moder¬
ately impaired. He scored 60% correct on a
test of responsive naming, 94% correct on a
test of visual confrontation naming, and
60% correct on the body-part naming test.
His fluency score was reduced in that he
was able to name only nine animals in a
one-minute period. On the test of word

definition, he tended to perseverate with

the response, "It's an instrument of suc¬
cess." He defined a chair as "a table," a
hand as "an instrument of success," and his
definition of a calendar was as follows: "A
person uses a calendar to improve his
image, among other things."
One of the most striking components of
this patient's deficit was severe buccofacial
and limb apraxia. On DeRenzi's Oral
Apraxia Battery (approximately three
weeks after onset), he performed only two
of ten commands completely correctly.
Demonstration by the examiner only mar¬
ginally improved his performance. To
explore his apraxic difficulties further, he

given a specially designed apraxia
battery, the results of which fit the classic
picture of ideomotor apraxia4: adequate
comprehension, poor performance to verbal
command, not much improvement with
demonstration by the examiner, but suc¬
cess when using the real objects. There was
was

no substantial difference between his left
and right hands, which makes it unlikely
that his apraxia was due to a callosal

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separation from the language-processing

hemisphere.

Language Assessment 34 Months
After Onset

On retesting almost three years after the

patient's stroke, word-finding difficulties
were no longer evident in his spontaneous
speech, but a moderately increased rate of
speech was still present.
Auditory language comprehension had
dramatically improved to the point that all
test results were within the normal range,
including normal performance on part 5 of
the Token Test. In addition, he made no

errors on an Experimental Test of Syntax,
comprising 84 sentences that require pri¬
marily syntactic knowledge for their prop¬
er decoding. His reading comprehension
was also entirely within normal limits,
although the patient maintained that his
reading now required more effort and pro¬
ceeded somewhat more slowly than before

his stroke.
The only persisting deficit was a spelling
problem, which manifested itself both in
oral and written spelling. Although his
writing had improved, he still found it
difficult to write and limited his writing to
that of writing checks. His narrative writ¬
ing had improved, but he still had difficul¬
ties with spelling certain words. When
describing the Cookie Theft Card of the
BDAE, he was, for example, unable to spell
"tilted"; he then tried to write "slanted,"
but failing that, finally had to settle for
"off balance." His word fluency was still
impaired; he was able to produce only five
words beginning with specified letters of
the alphabet in a three-minute period.
An incidental finding was the patient's
difficulty in providing nonconcrete inter¬
pretations of proverbs. When asked to
explain a proverb like "Rome was not built
in a day," he responded, "It took a long
time for that city to be built." This deficit
was also present when he was tested on a
multiple-choice version of Gorham's Prov¬
erbs Test (57.5% correct).
A complete battery of nonlanguage and
memory tests was also administered, the
results of which are summarized in Table 1.
As can be seen, both the Performance
portion of the Wechsler Adult Intelligence
Scale and Porteus Maze Test scores are
above normal. No impairment was de¬
tected in the area of memory, with the
possible exception of some mildly increased
susceptibility to interference effects, ver¬
bal being greater than nonverbal. His
visual, perceptual, and spatial functions all
seemed to be intact. Tests of manual prax¬
is, dexterity, and sensory functions still
showed moderate to severe impairment
with the right hand and less severe but still
notable difficulty with the left. Words,
numbers, and drawings tachistoscopically
presented to a single visual field were
correctly named on 70% of left-field trials
and 80% of right-field trials, thus arguing
against a visual disconnection syndrome.
However, extinction of items in the right
field was noted on double simultaneous
stimulation. His performance on tests for
apraxia was improved relative to his ear-

Table 1.—General Intelligence, Memory, Somatosensory Function,
and Dichotic Listening*
Score
1979

Test
Wechsler Adult Intelligence Scale
Verbal
Performance
Full-scale
Porteus test quotient
Word fluency (Thurstone)

1976

General Intelligence
113

106

104

97

110

102

132

Memory

Wechsler Memory
Quotient

124
30/36

Rey Figure
Buschke's Verbal

Learning

10/12

Somatosensory Function

2-Point discrimination

Right hand (total errors)
Left hand (total errors)
Digits
Right ear, %

23/90(moderate impairment)
15/90(mild impairment)
Dichotic Listening
73
100

Left ear, %
Consonant-vowel syllables
Right ear, %
Left ear, %
*
Results in 1979
available.

are

30
96

approximately three years after onset; 1976 scores are presented as

Table 2.—Performance on Experimental Apraxia Battery Immediately and
Three Years After Onset*

August 1976
Stimulus and Task
1. Name—pointing

2. Sound—pointing
3. Name—gesture
4. Picture—gesture
5. Sound—gesture
6. Imitation—gesture
7. Real object-

gesture

May 1979,
Right

Right Hand

Left Hand

3/10
4/10

9/10

10/10

6/10
2/10
2/10

9/10
5/10

0/10
1/10
0/10

1/10

0/10
1/10

8/10

7/10

Hand

7/10
6/10
9/10
10/10

"'In conditions 1 and 2, the patient points to a picture of an object in response to either its name or

sound. In the remaining conditions, the patient demonstrates the appropriate use of the object in
response to (3) the spoken name of the object, (4) a picture of the object, (5) the sound associated
with the object, (6) demonstration of the use of the object by the examiner, and (7) using the real

object.

lier evaluation, but was still moderately
impaired, regardless of the mode in which
the commands were presented. These
results are given in Table 2. The most
notable improvement was his ability to
imitate gestures, which was almost com¬
pletely intact on retesting.
In summary, in the acute period there
was severe impairment of auditory com¬
prehension and somewhat less but still
notable impairment of reading and writ¬
ing, particularly of spelling. Three years
later, a complete recovery of both reading
and auditory comprehension was evident.
The only remaining deficits formally doc¬
umented were an impairment in word
fluency and in oral and written spelling,

difficulty with providing interpretations
of proverbs, and a moderately severe
apraxia.
COMMENT

The most important feature of this
degree of apha¬
sia was far less severe than one would
have predicted based on the size of
this massive ischemie lesion of the
frontoparietal language zone in a
right-handed man. Recent studies by
Mohr and his colleagues5·6 suggested
that patients with large lesions of the
frontoparietal operculum that destroy
case is that the initial

Broca's area and much of the sur¬
rounding cortex typically are seen ini¬
tially with a severe, global type of
aphasia that gradually evolves into a
chronic Broca-type aphasia. Our pa¬
tient, despite the fact that the lesion
destroyed the entire frontoparietal
operculum, had only a mild aphasia,
which subsequently cleared within a
short time. Another important fea¬
ture is the persistence in the nonacute
period of ideomotor apraxia and dysgraphia (associated with an underly¬
ing receptive and expressive spelling
deficit) in the absence of aphasia.
The key to understanding the unu¬
sual features of this case is probably
found in the patient's premorbid ana¬
tomic organization of language. Basi¬
cally, there are only three possibilities:
either language was represented uni¬
laterally in the left or in the right
hemisphere or it was represented in
both hemispheres.
Compatible with the possibility of
left-hemisphere language dominance
are the observations that the patient
has always and still prefers to write
with his right hand despite a persis¬
tent right sensory deficit. This feature
is even more surprising given that one
of his younger brothers is left-handed.
In addition, left-hemisphere domi¬
nance for language is suggested by
the presence of Gerstmann's syn¬
drome initially. Finally, the patient
was not left-hemisphere dominant for
visuospatial perceptual functions, be¬
cause at no time did he show any
evidence of visual neglect, visuospa¬
tial deficit, or other nondominant
hemisphere involvement. The major
problem with this hypothesis, howev¬
er, is that if language functions were
mediated by the classical peri-Sylvian
areas of the left hemisphere, this
patient should have had a nonfluent
aphasia of greater severity, most like¬
ly a severe global aphasia. Since he
manifestly did not have a global apha¬
sia, one may conclude that either his
language functions were not mediated
by the left hemisphere, or if they were
they must have been subserved by
areas other than those traditionally
believed to be involved in language
functions. Although the literature
documents considerable individual va¬
riation in the neuroanatomic organi¬
zation of cortical functions,7 it is
unlikely that the brain of this patient
could have deviated so much from the
that it almost completely
norm
escaped the effects of this massive
left hemisphere lesion. Even if one
does assume that Broca's area in this
patient was in a region of the frontal
lobes not affected by the lesion, it

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would still be functionally discon¬
nected from the temporal lobe, which
on CT scan appears isolated from
anterior regions of the left hemi¬
sphere, as well as from homologous
right-hemisphere areas. It is unlikely,
therefore, given the virtual absence of
any expressive or articulatory diffi¬
culties, that the patient was left-hem¬
isphere dominant for expressive lan¬
guage functions.
It is, however, equally unlikely that
the patient could have been entirely
right-hemisphere dominant for lan¬
guage. Were this the case, he should
not have become aphasie at all follow¬
ing his left-hemisphere stroke.
The possibility of some degree of
premorbid bilaterality of language
representation therefore must be con¬
sidered. The major argument against
the assumption of bilateral language
in a right-hander is a statistical one.
The amobarbital (Amytal) sodium
studies of the Montreal group" indi¬
cate that right-handers who become
aphasie with injection of barbiturate
on one side do not become aphasie
when the other carotid is injected,
thus suggesting that bilateral lan¬
guage function in right-handers is

exceedingly rare. Assuming, however,
that some degree of bilaterality or

mixed dominance is present, the
details of the organization of lan¬
guage functions in this patient's brain
must still be determined. In light of
the patient's minimal impairment in
expressive speech even in the acute
stage, it is most likely that the motor
components of his language were rep¬
resented largely in the right hemi¬

sphere premorbidly, although one may
not completely rule out some left hem¬
ispheric influence to account for the
minor changes in his prosody.

It is, however, somewhat more diffi¬
cult to account for his early compre¬
hension problems, particularly since
this function showed near complete
recovery. Unquestionably, the left
hemisphere played an important role
in auditory decoding of language pre¬
morbidly, given the severity of his
initial comprehension deficit. Al¬
though the left temporal lobe ap¬
peared on CT scan to be relatively
spared by the lesion, the comprehen¬
sion deficit might be explained in
terms of a disconnection between lan¬
guage areas within the left hemi¬
sphere or transcallosally. The lesion
was located so as to compromise temporotemporal transcallosal connec¬
tions, as well as intrahemispheric left
temporal lobe connections with anteri¬
or motor

regions.91"

Recovery of auditory comprehen-

sion, which is now complete, could
have taken place in either hemisphere,

but results of dichotic listening tests
(Table 1), which showed a pronounced
left-ear advantage for both digits and
consonant-vowel syllables, are most
compatible with current right-hemi¬

sphere auditory processing.
The patient's writing and spelling
functions must have been mediated by
the left hemisphere. The fact that he
used and still uses his right hand

would lead one to suspect this associa¬
tion. However, prior to his stroke, the
patient used an inverted or hooked
writing posture, which would be inter¬
preted by some as a sign of righthemisphere dominance. His spelling
errors are much like those seen in the
syndrome of alexia with agraphia of
left parietal-lobe origin, although our
patient is not alexic in the true sense.
He does show evidence of impaired
phonologic processing when asked to
spell words orally and to decide which
words rhyme. Whether his relatively
intact reading ability means that he is
using the right hemisphere and thus
possibly bypassing the phonologic
stage remains an open question. The
possibility that aphasies may use such
a route has been suggested by some

investigators.
The persistent ideomotor apraxia
strongly suggests that premorbidly
the left hemisphere was dominant for
higher-level motor control. To our
knowledge, the only previous descrip¬
tion of ideomotor apraxia and agra¬
phia in a nonaphasic right-hander is
that of Heilman et al." The patient
was a 56-year-old, right-handed man

who was not examined until three
months following his left-hemisphere
stroke; therefore, it is possible that
mild aphasia was present initially.
The patient had a right hemiplegia
and hemianopsia, and he neglected
the left side of the page when reading.
Beyond reporting that he correctly
spelled the word "cat" aloud, no
account of oral spelling or comprehen¬
sion of orally spelled words was pre¬
sented. Information about the site of
the lesion as determined by CT scan
was not available. The authors con¬
cluded that in their patient the right
hemisphere was dominant for lan¬
guage and the left was dominant for
complex manual skills. The finding of
buccof acial apraxia without a disorder
of speech production demonstrated
the independence of the two motor
mechanisms. In our patient the
absence of hemiplegia permitted the
demonstration of bilateral ideomotor
apraxia and agraphia and therefore
ruled out the possibility (that existed

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in the hémiplégie patient of Heilman
and associates) that the left-hand
writing and praxis errors were of callosal origin. Also in our patient there

neglect or other visuospatial
deficit.
In summary, the language func¬
tions in our patient seem to have been
represented in both hemispheres pre¬
morbidly and, with the possible excep¬
tion of auditory comprehension, were
without duplication. We interpret our
data as being most compatible with
right-hemisphere dominance for ex¬
pressive language and visuospatial
function and with left-hemisphere
dominance for praxis, writing, and
spelling. In the patient's current stage
of recovery, comprehension is sub¬
served by the right hemisphere; how¬
ever, this point remains conjectural.
His premorbid reading functions can¬
not be as easily localized.
Rather than calling this case bilat¬
eral language representation, one
might more appropriately refer to it
as a case of mixed dominance, repre¬
senting an interesting example of the
variety of ways in which language and
high-level motor functions may be dis¬
tributed in the human brain.
was no

This study was supported in part by contract
N01-NS-2378 from the National Institute of Neu¬
rological and Communicative Disorders and
Stroke.

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