Eur Neurol 1997:37:193-194

Crossed Mixed Transcortical Aphasia with
Hypernomia
Toskikatsu Fujiia , Atsushi Yamadoria . Reiko Fukatsuh,
Tatsuji Ogawac, Kyoko Suzuki3
“Section ofNeuropsychology. Division of Disability Science.
Tohoku University Graduate School of Medicine, Sendai,
bDepartment of Neurology, Miyagi National Hospital. Miyagi.
‘ Department of Neurology. Sendai City Hospital. Sendai, Japan

corpus callosum. A Tl-weighled MRI in the sagittal plane demonstrating
hypointensity of the middle portion of the corpus callosum, the genu and splenium (D).
Fig. 2. A-D Cranial MRI on May 9. 1994. Slight hypcrintcnsity on T2W1
in the sagittal image was observed at the middle portion of the corpus callosum
(B)

.

3 Truffcrt A, Dumas J-J, Dandclot J-B: Dvsconncxion interhcmisphcrique
syndrome de Balint et troubles arthritiques persistants: maladie de Marchiafava-Bignami avec hémorragie de la substance blanche. Rev Neurol
(Paris) 1996;152:174-180.
4 Bottomley P. Hart IIR Jr. Edelstcin WA.Schenck JF. Smith LS, Leuc WM.
Mueller OM. Redington RW: Anatomy and metabolism of the normal
human brain studied by magnetic resonance at 1.5 tesla. Radiology 1984;
150:441-446.
Kazuya Yamashita. Third Department of Internal Medicine.
Shimane Medical University. 89-1. Enya-cho, l/.umo. Shimanc (Japan)

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Fig. 1. Cranial MRI on March 3, 1994. A T2-wcighted MRI in the axial
(A) , the sagittal (B). and the coronal image (C) revealing hypcrintcnsity of the

Mixed transcortical aphasia is a syndrome characterized by
reduced speech, severe comprehension deficits, preserved ability of
repetition and naming difficulty [1]. We report here a patient with
crossed mixed transcortical aphasia who showed preserved naming
and unique naming behavior.
The patient was a 75-year-old, strongly right-handed [2] house­
wife with an eighth-grade education. She had no left-handed rela­
tives. She suddenly developed left hemiplegia and aphasia. Neurolog­
ical examination on day 27 revealed left homonymous hemianopsia
with intact remaining cranial-nerve functions. She had a hemiplegia,
hyperreflexia and pathological reflexes on the left side. We could not
obtain reliable data of sensory function because of the patients' poor
comprehension. CT scan on day 60 revealed a large infarct in the
territory of the right middle cerebral artery' (fig. 1). EEG on day 67
showed generalized slowing throughout the right hemisphere.
On neuropsychological examination, she was alert, but disori­
ented to tim e and place. She showed mild left unilateral neglect and
constructional impairment. On testing of apraxia, she could not
understand the examiner's commands. She seldom spoke sponta­
neously and tended to speak only when she was spoken to. Further­
more, when she spoke, she utilized the speech which had been spoken
to her. She showed completion phenomenon. Her speech was fluent
with normal rhythm but lacked affective elements. She repeated
words perfectly and sentences fairly well with normal intonation. She
showed occasional omitting of postpositional particles and verbal
paraphasia. She showed little evidence of comprehending conversa­
tional speech and simple commands. Contrary to poor comprehen­
sion, her naming ability was quite good. Whenever objects, pictures
or color tokens were presented, she started naming these stimuli one
after another without waiting for the examiner’s instructions. She
named most of these stimuli correctly. Some errors were mainly
semantic paraphasic without category specificity. Naming on defini­
tion and generating words (verbal fluency) was not feasible because
of the patient’s extremely poor comprehension. Reading aloud was
excellent but reading comprehension was poor. She correctly wrote 3
names out of 8 visually presented stimuli in kanji on first examina­
tion. and 5 out of 5 on second examination. On both occasions, she
never wrote in kana despite our commands. On writing to dictation,
she could write words in kanji but never in kana. However, on anoth­
er occasion, she wrote down sentences correctly mixing kanji and
kana scripts. The Standard Language Test of Aphasia [3] was admin­
istered twice. Table 1 summarizes the results.
The most interesting feature of this crossed mixed transcortical
aphasia was a preserved naming ability and its compulsive nature.
There have been a few reports regarding spared naming without com­
prehension [4, 5]. These cases including ours have a theoretical
importance. The fact that both auditory and reading comprehension
were impaired, with preserved repetition, writing to dictation and

Fig. 1. CT scan obtained on day 60 showing a large infarct in the territory
of the right middle cerebral artery.

Table 1. Results on subtestsofSLTA

Day 27 - 34

Day 49 - 56

Auditory
comprehension

Words
Sentences

O'
NE

O'
NE

Repetition

Words
Sentences

10/10(100)
6/10(60)

10/10(100)
7/10(70)

18/20(90)

16/20(80)

Naming of visually
presented stimuli
Reading aloud

Kana words
Kanji words
Sentences

10/10(100)
10/10(100)
4/5 (80)

10/10(100)
10/10(100)
5/5(100)

Reading
comprehension

Kana words
Kanji words
Sentences

O'
O'
NE

O'
O'
NE

Writing the name of
visually presented
stimuli

Kana words
Kanji words

02
3/8(37.5)

02
5/5(100)

Writing to dictation

Kana words
Kanji words
Sentences

02
2/5 (40)
2/5 (40)

O2
5/5(100)
3/5 (60)

reading aloud, indicate that the phonological and orthographic word
form systems were intact, but could only activate the phonological
and orthographic output systems and not gain access to the seman­
tics. On the contrary, she could name and write the names of visually
presented stimuli in kanji, suggesting that the visual form system
remained accessible to the phonological and orthographic output sys­
tems. This patient’s profile provides evidence supporting the multi­
ple semantic systems hypothesis or the direct visual-lexicon route
hypothesis [6].
She started naming without any command whenever objects, pic­
tures or color tokens were presented to her. We propose using the
term ‘hypemomia’ for this compulsive and indiscriminate naming
behavior. Like our patient, Heilman et al. [4] reported a case of
mixed transcortical aphasia with intact naming who spontaneously
named objects. Jacome [7] reported a mixed transcortical aphasic
who showed repetitive, spontaneous whistling, and whistling in
response to questions. He speculated that the symptom resulted from
the release of the nondominant musical function by damage to the
dominant hemisphere. Yamadori ct al. [8, 9] described two symp­
toms they termed ‘hypergraphia’ and ‘hypcrlalia’ as a right hemi­
sphere syndrome. They hypothesized that the exaggerated writing
and talking activity might result from disinhibition of the left hemi­
sphere speech area from the right hemisphere. Hypemomia seen in
the present case may be explained by a similar disinhibition hypothe­
sis because she had a large right hemisphere infarct which might have
released the left hemisphere activity.
References
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Toshikatsu Fujii. MD, Section of Neuropsychology,
Division of Disability Science. Tohoku University Graduate School
of Medicine. 1-1. Seiryo-machi, Aoba-ku. Sendai 980-77 (Japan)
Phone: +81-22-717-7357, Fax: +81-22-717-7360
e-mail: fujii@mail.cc.tohoku.ac.jp

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SLTA: Standard Language Test of Aphasia: NH: not examined: Kana: Japa­
nese characters for syllabic writing; Kanji: Chinese characters used in Japanese
writing. Percentages in parentheses.
1 The patient could not understand the task and named all the pictures.
2 We asked the patient to write with Kana character, but the patient contin­
ued writing with Kanji.