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BMJ Case Reports 2017; doi:10.1136/bcr-2017-221642
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Global aphasia in a case of bilateral frontal lobe infarcts involving both caudate nuclei

  1. Anirudda Deshpande4
  1. 1Department of Radiology, Surya Diagnostics, Warangal, Telangana, India
  2. 2Department of Medicine, Miraj Medical College, Miraj, Maharashtra, India
  3. 3Department of Medicine, Maharashtra Institute of Medical Education and Research, Pune, Maharashtra, India
  4. 4Department of Neurology, Vinayaka Neuro Multispecialty Clinic, Warangal, Telangana, India
  1. Correspondence to Anirudda Deshpande, dr.anirudda.deshpande{at}gmail.com
  • Accepted 17 October 2017
  • Published 12 November 2017

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 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.

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.

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.

Figure 3

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

At 6-month follow-up, the patient seemed to have had very minimal improvement in his cognitive 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

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.

Footnotes

  • 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.

References

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