A case of crossed aphasia with apraxia of speech
A 48-year-old right-handed man presented with sudden-onset difficulty in speaking and left-sided weakness. He was able to understand what was spoken to him and was communicating using gestures. There was no difficulty in chewing or swallowing. He was a chronic smoker and was diagnosed with chronic obstructive pulmonary disease 6 months back. There was no history of any other medical comorbidity. His general physical examination revealed absent right carotid, brachial and radial pulses; with feeble other peripheral pulses. Blood pressure was not recordable in right upper limb, 100/60 mmHg in left upper limb, 130/100 mmHg in left lower limb, and 134/110 mmHg in right lower limb. He was conscious, alert, and attentive. Neurological examination revealed differential left hemiparesis (upper limb Medical Research Council (MRC) 0/5 and lower limb MRC 2/5) with ipsilateral facial palsy. He was producing only few incomprehensible sounds, with intact verbal and reading comprehension; and was able to communicate using gestures. Despite being right-handed with no motor weakness in the right hand, he could not write. [] He was able to copy simple figures but not able to draw a clock. He was also having ideational (buccofacial and limb) and ideomotor apraxia, but no dressing apraxia, right-left confusion, or finger anomia. Rest of the cranial nerves including bulbar examination and tongue movements were normal. There was no family history of left handedness or ambidexterity. After establishing strong right-hand dominance by Edinburgh Handedness Inventory, we made a provisional diagnosis of the left hemiparesis with Crossed Broca's aphasia with AOS, with ideational and ideomotor apraxia.\nHis routine investigations including complete blood count, blood sugar, lipid profile, liver, and renal functions were normal. His abdominal ultrasound was normal; 2d-Echo showed concentric left ventricular hypertrophy with type-I diastolic dysfunction and High Resolution Computed Tomography (HRCT) thorax which showed bilateral emphysematous changes.\nHis magnetic resonance imaging (MRI) brain showed acute ischemic infarct in right peri-insular, fronto-temporal, and periventricular white matter including centrum semiovale [Figure ,]. Positron emission tomography (PET) scan revealed hypometabolism in the right cerebral hemisphere and opposite cerebellum []. In the magnetic resonance MR arteriogram, the right brachicephalic trunk, vertebral arteries, common and internal carotid arteries could not be visualized; there was focal stenosis in the left proximal subclavian artery; however, the celiac, superior mesenteric and renal arteries were normal in their course and caliber [Figure ,]. The patient was further investigated for the cause of aortic vasculopathy. (Anti nuclear antibody, Anti-neutrophil cytoplasmic antibody, Rheumatoid factor ANA, ANCA, RA factor, Venereal Disease Research Laboratory, Human immunodeficiency virus, Hepatitis B surface antigen VDRL, HIV, HBs Ag, and anti Hepatitis C virus HCV were all negative.\nA final diagnosis of left hemiparesis with crossed Broca's aphasia with AOS, with ideational and ideomotor apraxia due to acute ischemic stroke in right hemisphere with Takayasu's arteritis (TA) was made. The patient was discharged on antiplatelet (Aspirin 150 mg/day) and statin (Atorvastatin 20 mg/day) along with physiotherapy and speech therapy. At 2-months follow-up, he was able to walk independently with minimal improvement in upper limb power. His speech was significantly improved and was characterized by start hesitation, reduced fluency, word finding difficulty, and dysprosody. He was able to speak short sentences (3-4 words/sentence) which were meaningful, but with some grammatical errors and phonemic paraphasia [Video]. The articulatory errors in speech, while reading aloud and writing were irregular with attempts of self-correction. [] He was able to name objects, could repeat simple sentences with intact comprehension. Now, he could do calculations, draw a clock with improved ideational and ideomotor apraxia. On further follow-up at 4 and 8 months, his speech showed further improvement in the aspects of start hesitation and fluency; but irregular articulatory errors, attempts of self-correction, grammatical errors, and phonemic paraphasia were still persistent [Figure and ].