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Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere Thomas Jefferson University Jefferson Digital Commons Student Papers & Posters Student Works 9-2017 Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere Stephanie Prater Morristown Medical Center Neil Anand Morristown Medical Center Lawrence Wei Thomas Jefferson University Neil Horner Overlook Medical Center Follow this and additional works at: https://jdc.jefferson.edu/student_papers Part of the Radiology Commons Let us know how access to this document benefits ouy Recommended Citation Prater, Stephanie; Anand, Neil; Wei, Lawrence; and Horner, Neil, "Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere" (2017). Student Papers & Posters. Paper 10. https://jdc.jefferson.edu/student_papers/10 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarly publications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers and interested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion in Student Papers & Posters by an authorized administrator of the Jefferson Digital Commons. For more information, please contact: [email protected]. Neuror adiology: Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere Prater et al. Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere Stephanie Prater1*, Neil Anand1, Lawrence Wei2, Neil Horner3 1. Department of Radiology, Morristown Medical Center, Morristown, NJ, USA 2. Sidney Kimmel Medical College, Jefferson University, Philadelphia, PA, USA 3. Department of Radiology, Overlook Medical Center, Summit, NJ, USA * Correspondence: Stephanie Prater, Morristown Medical Center. 100 Madison Ave, Morristown, NJ 07960, USA ( [email protected]) Radiology Case. 2017 Sep; 11(9):1-9 :: DOI: 10.3941/jrcr.v11i9.3154 ABSTRACT Aphasia describes a spectrum of speech impairments due to damage in the language centers of the brain. Insult to the inferior frontal gyrus of the dominant cerebral hemisphere results in Broca's aphasia - the inability to produce fluent speech. The left cerebral hemisphere has historically been considered the dominant side, a characteristic long presumed to be related to www.RadiologyCases.com a person's "handedness". However, recent studies utilizing fMRI have shown that right hemispheric dominance occurs more frequently than previously proposed and despite a person's handedness. Here we present a case of a right-handed patient with Broca's aphasia caused by a right-sided brain tumor. This is significant not only because the occurrence of aphasia in right- handed-individuals with right hemispheric brain damage (so-called "crossed aphasia") is unusual but also because such findings support dissociation between hemispheric linguistic dominance and handedness. CASE REPORT JournalRadiology of Case Reports the MRI diagnosis, the patient was placed on high-dose CASE REPORT steroids to reduce the edema surrounding the tumor. We present the case of a 54-year-old right-handed woman with no significant past medical history who presented with The combination of the patient’s aphasic symptoms, right expressive aphasia following a seizure. She had never sidedness of the lesion, and the proximity of the lesion to the experienced a seizure before this occurrence nor was there any anatomical homologue of the expressive language center family history of epilepsy or seizure disorders. Furthermore, known as Broca’s area raised concern for right-hemispheric she had no familial history of left-handedness. expressive speech dysfunction, such that evaluation with fMRI was recommended by the neurosurgery service. A non-contrast CT of the head was performed as part of the initial evaluation. A vague focus of hypoattenuation was To localize Broca’s speech area, the patient was asked to noted along the right perisylvian ribbon (Figure 1). Further speak to generate a semantically related word to complete a investigation with gadolinium enhanced MRI revealed simple blanked sentence that was presented on a screen. The increased T2WI/FLAIR signal in the right perisylvian response was covert (thought) rather than overt (spoken), to operculum with adjacent gyral expansion but no appreciable identify the expressive speech centers while avoiding contrast enhancement (Figure 2 and Figure 3). This finding activation of the facial motor regions. During completion of was suggestive of an infiltrative neoplastic process. Based on this task, the fMRI of the brain was performed utilizing a 3 Radiology Case . 2017 Sep; 11(9):1-9 1 Neuror adiology: Crossed Aphasia in a Patient with Anaplastic Astrocytoma of the Non-Dominant Hemisphere Prater et al. Tesla GE-brand MRI scanner then fusing the acquired BOLD white matter must also occur [2]. However, lesions to the area functional sequences with the fast spin echo T2-weight images alone may cause “minor Broca’s aphasia,” the symptoms of and post-contrast 3-D gradient echo images. The study which are similar but lesser in severity than classical Broca’s revealed speech function activation in the pars opercularis of aphasia [2]. Furthermore, damage to Broca’s area does not the posterior portion of the right inferior frontal gyrus (Figure always result in permanent Broca’s aphasia, as many patients 4). This region of activation is analogous to Broca’s area, the with damage to the area can regain lost language functions language center responsible for speech production located in overtime. This recovery may be due to reorganization, in the left (typically dominant) cerebral hemisphere. which language tasks that previously depended on Broca’s Additionally, because the patient was asked to look at the area now accomplished using different brain regions, including screen to view the blanked sentence, the visual cortices in the those in the opposite hemisphere [3]. bilateral calcarine fissures of the occipital lobe also demonstrated activation. Interestingly, functional activity was All types of aphasia, including Broca’s, are caused by also noted within pars opercularis of the left cerebral lesions of various language areas throughout the dominant hemisphere, suggesting bilaterality of the patient’s speech cerebral hemisphere. Insults include infarction, neoplastic functionality. process, seizure disorders, traumatic brain injury, and neurodegenerative diseases [1]. There was a 3 day interval between the initial MRI and the fMRI; the aphasia resolved completely within this time It is estimated that there are 80,000 new cases of aphasia frame. Indeed, the fMRI images (Figure 4) do not show direct due to stroke per year in the United States [4]. 15% of stroke contact between the tumor and the speech area such that the patients under the age of 65 experience aphasia; this authors believe the aphasia was induced by peritumoral edema percentage increases to 43% for stroke patients age 85 and and subsequent mass effect on the adjacent speech area rather older [4]. With regard to neoplastic processes as the cause of than direct contact by the tumor itself. The authors believe the aphasia, about 30%–50% of patients with primary brain 3 days of treatment with high dose steroids reduced the amount tumors experience aphasia. These numbers, as well additional of edema, thus reversing the aphasia. studies suggest the prevalence of stroke-induced aphasia seems www.RadiologyCases.com to be lower than it is from tumor-induced aphasia [5]. Given the assumption of right hemispheric linguistic dominance and the close proximity of the tumor to the region Furthermore, various studies conclude that gender may of speech function activation, the neurosurgeon recommended play a role in the type and severity of stroke-induced aphasia awake craniotomy with intraoperative speech mapping in order experienced. For example, Wernicke's and global aphasia to safely resect the mass. Total resection was achieved without occur more commonly in women while Broca's aphasia occurs any language disturbance during the intraoperative continuous more commonly in men [6]. speech testing or postoperatively. Histological analysis revealed the mass to be a high grade anaplastic astrocytoma (Figure 5). The patient was scheduled for outpatient follow up Clinical: with Oncology to begin a radiotherapy regimen and adjuvant temozolomide. It is widely accepted that language production and processing is predominantly a left-hemispheric function. Several studies have reported that linguistic hemispheric dominance in healthy JournalRadiology of Case Reports subjects depends primarily on personal handedness such that DISCUSSION left cerebral hemisphere language dominance is the most Etiology & Demographics: common, as is dextrality [7-9]. Furthermore, several non- invasive neuroimaging studies in healthy adults demonstrated Broca’s area, Brodmann’s area 44 and 45 in the inferior that approximately 95% of patients have left hemispheric frontal gyrus, plays a key role in complex speech, receiving the language dominance no matter their handedness [8-10]. In flow of sensory input from the temporal cortex, creating a plan healthy right-handed subjects 'atypical', i.e. right hemisphere for speaking and
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