# Clinical Cases: Cerebral Cortex ## 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). --- ## Case 2: Hemispatial Neglect - Right Parietal Stroke ### Patient Presentation **Demographics:** 75-year-old female **Chief Complaint:** Daughter noticed patient not responding to things on her left side **History of Present Illness:** A 75-year-old right-handed woman with hypertension and hyperlipidemia was found by her daughter sitting in her chair, apparently unaware of her left arm which was hanging off the armrest. When approached from the left side, she did not respond until the daughter moved to her right. The patient denies any problem and insists she is "perfectly fine" despite obvious deficits. Symptoms began approximately 2 hours ago. **Physical Examination:** - Vital signs: BP 175/95, HR 82, RR 16 - General: Awake, appears unconcerned; head and eyes deviated toward right - Neurological: - Mental status: Alert; oriented to self only; neglects left hemispace; denies any deficit (anosognosia) - Visual fields: Does not respond to stimuli in left visual field (extinction to double simultaneous stimulation) - Motor: Left arm 0/5 (does not move, patient unaware); left leg 2/5; right side normal - Sensory: Does not acknowledge stimuli on left; extinguishes left-sided stimuli when presented simultaneously with right - Special testing: Line bisection test - marks far to the right of center; clock drawing - numbers crowded on right side; asked to copy figure - omits left half - NIHSS: 15 **Workup:** - **CT head without contrast:** Early hypodensity in right parietal lobe - **CT angiography:** Right MCA M1 occlusion - **CT perfusion:** Large penumbra with small core - **MRI (24 hours):** Large right parietal and posterior frontal infarct **Diagnosis:** Right MCA territory stroke with hemispatial neglect and anosognosia **Treatment:** - IV thrombolysis followed by mechanical thrombectomy (door-to-groin 65 minutes) - Successful recanalization achieved - ICU monitoring - Aggressive secondary prevention - Intensive rehabilitation focusing on neglect awareness training - Visual scanning therapy - Prism adaptation therapy - Some improvement in neglect at 6 weeks; persistent mild left neglect requiring safety supervision **Clinical Pearl:** Hemispatial neglect is a failure of attention to one side of space, most commonly the left side after right parietal lesions. Unlike hemianopia (visual field loss), neglect represents an attentional deficit - patients fail to attend to, explore, or act upon the neglected side even when visual pathways are intact. Anosognosia (unawareness of deficit) often accompanies right hemisphere lesions. Neglect is more common, severe, and persistent after right hemisphere damage because the right hemisphere attends to both hemispaces while the left primarily attends to the right. Neglect profoundly impacts rehabilitation because patients don't recognize their deficits. --- ## 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 ![Broca and Wernicke areas brain diagram](case_01_image.jpg) **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.