Neuroscience · Year 2 · from Neuroscience
Case 1: Broca's Aphasia - Expressive Language Deficit
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Difficulty speaking after sudden onset this morning
History of Present Illness: A 68-year-old right-handed man with a history of atrial fibrillation and hypertension was eating breakfast when he suddenly had difficulty speaking. He appears to understand what is said to him and follows commands appropriately. However, his speech output is markedly reduced and effortful. He becomes frustrated when unable to express himself. His wife called 911 immediately. He takes warfarin for atrial fibrillation but missed his INR check last month.
Physical Examination:
- Vital signs: BP 168/95, HR 88 (irregular), RR 14
- General: Awake, frustrated, non-fluent speech
- Neurological:
- Mental status: Alert; follows complex commands; speech is non-fluent with effortful, telegraphic output ("want...water...no...help"); naming impaired; repetition impaired; comprehension intact
- Cranial nerves: Right lower facial droop; no visual field deficit; tongue deviates right
- Motor: Right arm 3/5; right leg 4/5; left side 5/5
- Sensory: Intact
- Reflexes: Right-sided hyperreflexia with upgoing Babinski
- NIHSS: 8
Workup:
- CT head without contrast (acute): Hyperdense MCA sign on left; no hemorrhage
- CT angiography: Occlusion of left M2 branch
- INR: 1.4 (subtherapeutic)
- MRI brain (24 hours later): Acute infarct involving left inferior frontal gyrus (Broca's area) and adjacent motor cortex
Diagnosis: Left MCA territory ischemic stroke affecting Broca's area, cardioembolic etiology
Treatment:
- IV alteplase administered (within 4.5-hour window)
- Aspirin 325 mg after 24-hour imaging
- Anticoagulation restarted after appropriate interval
- Speech-language therapy initiated
- INR monitoring improved
- Moderate improvement in speech at 3 months; able to communicate basic needs but persistent non-fluent aphasia
Clinical Pearl: Broca's area, located in the posterior inferior frontal gyrus of the dominant hemisphere (usually left), is critical for speech production. Broca's aphasia is characterized by non-fluent, effortful, telegraphic speech with relatively preserved comprehension. Patients understand what is said but struggle to express themselves, often causing significant frustration. Repetition is impaired because the arcuate fasciculus connecting Wernicke's and Broca's areas is often involved. The pattern of "non-fluent aphasia with good comprehension" localizes to the anterior dominant hemisphere, while "fluent aphasia with poor comprehension" localizes posteriorly (Wernicke's).