Neuroscience · Year 2 · from Neuroscience
Case 3: Wernicke's Aphasia - Receptive Language Deficit
Patient Presentation
Demographics: 72-year-old female
Chief Complaint: "She's talking nonsense" - husband's report
History of Present Illness: A 72-year-old right-handed woman with a history of atrial fibrillation (not on anticoagulation due to prior fall risk) was found by her husband speaking fluently but making no sense. She strings together words into grammatically correct sentences, but the content is meaningless and includes made-up words. She does not seem to understand what her husband says to her. She appears unaware that anything is wrong with her speech. Onset was approximately 90 minutes ago.
Physical Examination:
- Vital signs: BP 155/88, HR 95 (irregular), RR 14
- General: Awake, speaking fluently but with word salad and neologisms
- Neurological:
- Mental status: Alert; speech is fluent with normal prosody but filled with paraphasias (word substitutions) and neologisms (made-up words); does not follow commands; naming severely impaired; repetition impaired; comprehension severely impaired; unaware of deficits
- Cranial nerves: Right superior quadrantanopia
- Motor: No weakness
- Sensory: Likely intact (limited by comprehension deficit)
- NIHSS: 7 (primarily language)
Workup:
- CT head without contrast: No hemorrhage; subtle hypodensity left temporal lobe
- CT angiography: Occlusion of left inferior division of MCA
- MRI brain: Acute infarct in left posterior superior temporal gyrus (Wernicke's area) extending into inferior parietal lobule
Diagnosis: Left MCA inferior division stroke affecting Wernicke's area
Treatment:
- IV alteplase administered (within window)
- No mechanical thrombectomy (distal occlusion)
- Aspirin after 24 hours
- Started on anticoagulation (DOAC) for atrial fibrillation with cardiology guidance on fall risk
- Intensive speech-language therapy
- Family education on communication strategies
- Some improvement at 3 months; able to follow simple commands but significant persistent comprehension and expression deficits
Clinical Pearl: Wernicke's area, in the posterior superior temporal gyrus of the dominant hemisphere, is critical for language comprehension. Wernicke's aphasia presents with fluent, well-articulated speech that lacks meaningful content - patients produce plentiful words (often paraphasic substitutions or neologisms) but fail to convey or understand meaning. Unlike Broca's aphasia, patients are often unaware of their deficit. The fluent nature of the speech can initially mislead observers into thinking the patient is confused or psychiatrically disturbed rather than aphasic. The preserved fluency but impaired content localizes to the posterior language areas.
Clinical Image
Image Description: Lateral view of the left hemisphere showing the location of Broca's area (posterior inferior frontal gyrus) and Wernicke's area (posterior superior temporal gyrus), connected by the arcuate fasciculus, forming the core language network.
Attribution: Image from Wikimedia Commons (https://commons.wikimedia.org/), Creative Commons Attribution-ShareAlike license.