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Description
An 80-year-old Japanese woman presented with sudden onset of speech disturbance and confusion. She was riding a bicycle when she suddenly felt unwell and subsequently noticed she could not find words to express her thoughts. A pedestrian found her sitting on the ground, at a loss for words and looking confused. She was brought to the emergency department for evaluation. On examination, she was alert, but looked very anxious, frustrated and confused. She was not oriented to time, place and person. She spoke hesitantly and non-fluently, she seemed not to be able to find words to respond (speaking and writing) to the physician's questions. She also showed impairment in repetition and comprehension to questions with complex syntax. The rest of the neurological examination was normal. Laboratory studies showed high cholesterol and elevated glycated haemoglobin of 8.2.
Diffusion-weighted MRI revealed acute infarction involving the Broca area (figure 1). MR angiography showed severe stenosis of the distal left middle cerebral artery (figure 2). The patient was diagnosed as pure motor aphasia (Broca aphasia). After conservative treatment with a speech therapist, she made an uneventful recovery.
Broca aphasia is characterised by severe impairment in expressing speech and writing.1 Comprehension is sometimes affected. Broca aphasia stems from neurological damage to the Broca area. The differential diagnosis is broad, encompassing vascular, infectious, inflammatory or degenerative conditions (box 1). Also, some cases with limited symptoms, as seen in this case, can mislead clinicians to other diagnoses such as herpes encephalitis, Alzheimer's disease and conversion disorder.2
Differential diagnosis of Broca aphasia
Ischaemic disease
Cerebral infarction
Transient ischaemic attack
Haemorrhage
Intracerebral haemorrhage
Traumatic injury
Subdural haematoma
Subarachnoid haemorrhage
Infection
Herpes encephalitis
West Nile encephalitis
Bacterial infection/abscess
Fungal abscess
Prion disease
Toxoplasmosis
Lyme disease
Degeneration
Alzheimer’s disease
Primary progressive aphasia
Amyotrophic lateral sclerosis
Demyelination
Multiple sclerosis
Acute disseminated encephalomyelitis
Tumour
Primary brain tumour
Brain metastases
Others
Sarcoidosis
Migraine
Seizure
Conversion disorder
Wernicke’s encephalopathy
Learning points
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Broca aphasia should be suspected when a patient has difficulty in repetition and naming, and if dysfluency or inaccuracy of expression of speech and writing are detected.
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The diagnosis is sometimes difficult because of the limited manifestation of symptoms.
References
Footnotes
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Contributors TW wrote the manuscript. TS and YT revised the manuscript.
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Competing interests None.
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Patient consent Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.