Annals of Indian Academy of Neurology
  Users Online: 14202 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 428-431

A case of crossed aphasia with apraxia of speech

1 Department of Neurology, G.B. Pant Hospital, New Delhi, India
2 Department of Neurosciences, Max Super Speciality, Hospital, New Delhi, India

Date of Submission06-Sep-2012
Date of Decision10-Nov-2012
Date of Acceptance16-Dec-2012
Date of Web Publication26-Aug-2013

Correspondence Address:
Meena Gupta
Department of Neurology, 5th Floor, Academic Block, G.B. Pant Hospital, JLN Marg, New Delhi 110 002
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-2327.116929

Rights and Permissions



Apraxia of speech (AOS) is a rare, but well-defined motor speech disorder. It is characterized by irregular articulatory errors, attempts of self-correction and persistent prosodic abnormalities. Similar to aphasia, AOS is also localized to the dominant cerebral hemisphere. We report a case of Crossed Aphasia with AOS in a 48-year-old right-handed man due to an ischemic infarct in right cerebral hemisphere.

Keywords: Apraxia of speech, crossed aphasia, crossed apraxia of speech, right-handed

How to cite this article:
Patidar Y, Gupta M, Khwaja GA, Chowdhury D, Batra A, Dasgupta A. A case of crossed aphasia with apraxia of speech. Ann Indian Acad Neurol 2013;16:428-31

How to cite this URL:
Patidar Y, Gupta M, Khwaja GA, Chowdhury D, Batra A, Dasgupta A. A case of crossed aphasia with apraxia of speech. Ann Indian Acad Neurol [serial online] 2013 [cited 2022 Dec 7];16:428-31. Available from:

   Introduction Top

The term "Apraxia of speech" (AOS) was coined by Darley in 1969, and he defined it as "a disorder of motor speech processing, manifested primarily by errors of articulation". [1] It is an articulatory disorder, occurs due to impaired ability to programme the positioning and the sequencing of muscle movements for the volitional production of phonemes, without any significant weakness, slowness, or incoordination in reflex and automatic acts. AOS is rarely present in its pure form. [2],[3] It commonly coexists and is often indistinguishable from Broca's aphasia and dysarthria. The features suggestive of AOS are irregular articulatory errors, attempts of self-correction, and persistent prosodic abnormalities.

Similar to aphasia, the AOS in right-handed individuals is typically localized to the left cerebral hemisphere. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] The concept of crossed apraxia of speech (CAS) was 1 st introduced by Balasubramanian and Max in 2004. [13] We report a case of crossed aphasia with AOS in a 48-year-old right-handed man due to an ischemic infarct in right cerebral hemisphere.

   Case Report Top

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. [Figure 4]a 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.

His 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.

His magnetic resonance imaging (MRI) brain showed acute ischemic infarct in right peri-insular, fronto-temporal, and periventricular white matter including centrum semiovale [Figure 1]a,b. Positron emission tomography (PET) scan revealed hypometabolism in the right cerebral hemisphere and opposite cerebellum [Figure 2]. 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 3]a,b. 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.
Figure 1: (a, b) Magnetic Resonance Imaging MRI brain Diffusion Weighted Imaging/Apparent Diffusion Coefficient DWI/ADC axial images showing acute infarct in right peri-insular and adjacent white matter

Click here to view
Figure 2: Positron emission tomography images showing hypometabolism in right cerebral hemisphere and opposite cerebellum

Click here to view
Figure 3: (a, b) Magnetic Resonance Angiography (MRA) of brain and aorta revealed non-visualization of the right brachiocephalic trunk, common carotid artery, and internal carotid artery with focal stenosis in left proximal subclavian artery

Click here to view

A 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. [Figure 4]b 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 4]c and d.
Figure 4: (a-d) Initially he was not able to write any meaningful words with attempts of self-correction. At follow-up at 8, 16, and 30 weeks, writing improved but with persistent grammatical errors, phonemic paraphasia with self-corrective attempts

Click here to view

   Discussion Top

The hallmark features of AOS are irregular articulatory errors, attempts of self-correction, and abnormal prosody. The other features are difficulty in initiating utterances, articulatory inconsistency on repeating same utterance, frequent error in substitution of sounds; phonetically complex sounds are frequently affected; more errors on non-sense than meaningful words; and volitional than automatic speech. [15],[16]

At the time of presentation, our patient had total inability to speak and write with intact comprehension (verbal and reading), and prominent apraxia (buccofacial and limb); which made us to keep a possibility of Broca's aphasia with AOS as a language dysfunction. The clinical picture is clearer at 2 months (intermediate phase) follow-up evaluation He fulfills all three characteristic features of AOS; irregular articulatory errors, attempts of self-correction, and abnormal prosody, which further confirmed our diagnosis of AOS as a prominent speech dysfunction. The features that suggest coexistent Broca's aphasia are presence of grammatical errors and phonemic paraphasia. The concept of lateralization of language in dominating left hemisphere in a right-handed person and Crossed Aphasia is well established. [17] Neuroanatomical localization of AOS is controversial, has been described with lesions of left inferior frontal, temporoparietal cortex, superior-anterior regions of insula fronto-subcortical white matter, internal capsule, and/or basal ganglia. [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

The concept of 'crossed AOS' (CAS) was recently proposed by Balasubramanian and Max (2004) in a 69-year-old right-handed woman after a hemorrhagic stroke in the right frontal lobe. [13] More recently, Assala et al., (2012) described progressive CAS in a 64-year-old right-handed woman as the 1 st manifestation of corticobasal degeneration, in whom MRI showed right perisylvian and insular atrophy. [14]

Our patient is right-handed by Edinburgh Handedness Inventory and clinically, he had AOS with Broca's aphasia, ideational and ideomotor apraxia which suggests the dominance of the right cerebral hemisphere, which was further established by restricted involvement of the right cerebral hemisphere on neuroimaging (MRI and PET scan). In our case, the involvement of right peri-insular and adjacent fronto-temporal subcortical white matter is most likely responsible for both AOS and Broca's aphasia. The involvement of opposite cerebellar hemisphere as evident on PET scan is likely due to the diaschisis phenomenon. In view of above findings, our patient is a possible case of crossed Broca's aphasia with CAS due to acute ischemic stroke in the right hemisphere involving peri-insular and adjacent subcortical white matter.

The natural history of patients with AOS is not well described. We followed-up our patient up to 8 months. He showed some initial improvement in fluency, start hesitation and word finding; but irregular articulatory errors, attempts of self-correction, dysprosody, grammatical errors, and phonemic paraphasia were persistent.

Also, our patient fulfills the diagnostic criteria of TA (American College of Rheumatology ACR 1990). It is a chronic granulomatous vasculitis of medium-large sized arteries, especially aorta and its branches, usually seen in women, in their 2 nd -3 rd decades. Neurological involvement is seen in 10-20% of cases during the course of TA; but rarely as a first manifestation. [18],[19] Ischemic strokes in a middle-aged man is an uncommon first presentation of TA in our patient.

   Conclusion Top

The overall concept of AOS and localization is now well established. A proper assessment of speech and/or language during follow-up assessment may be helpful to establish the type of disorder. Further studies are needed to establish the outcome of AOS and for comparison with prognosis of aphasic patients.

   References Top

1.Darley FL. The classification of output disturbances in neurogenic communication disorders. In: American Speech and Hearing Association Annual Conference Chicago IL; 1969.  Back to cited text no. 1
2.Square-Storer PA, Roy EA, Hogg SC. The dissociation of aphasia from apraxia of speech, ideomotor limb and buccofacial apraxia. In: Hammond GR, editor. Cerebral Control of Speech and Limb Movements. Advances in Psychology. Amsterdam: North-Holland; 1990. p. 451-76.  Back to cited text no. 2
3.Square PA, Roy AE, Martin RE. Apraxia of speech: Another form of praxis disruption. In: Rothi LJ, Heilman KM, editors. Apraxia: The Neuropsychology of Action. East Sussex: Psychology Press; 1997. p. 173-206.  Back to cited text no. 3
4.Alexander MP, Benson DF, Stuss DT. Frontal lobes and language. Brain Lang 1989;37:656-91.  Back to cited text no. 4
5.Square PA, Martin RE, Bose A. Nature and treatment of neuromotor speech disorders in aphasia. In: Chapey R, editor. Language Intervention strategies in aphasia and related neurogenic communication disorders. 4 th ed.. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 847-82.  Back to cited text no. 5
6.Peach RK, Tonkovich JD. Phonemic characteristics of apraxia of speech resulting from subcortical hemorrhage. J Commun Disord 2004;37:77-90.  Back to cited text no. 6
7.Duffy J. Motor Speech Disorders. St. Louis: Mosby; 1995.  Back to cited text no. 7
8.Dronkers NF. A new brain region for coordinating speech articulation. Nature 1996;384:159-61.  Back to cited text no. 8
9.Hillis AE, Work M, Barker PB, Jacobs MA, Breese EL, Maurer K. Re-examining the brain regions crucial for orchestrating speech articulation. Brain 2004;127:1479-87.  Back to cited text no. 9
10.Kertesz A. Subcortical lesions and verbal apraxia. In: Rosenbek JC, McNeil MR, Aronson AE, editors. Apraxia of Speech: Physiology, Acoustics, Linguistics, Management. San Diego: College-Hill Press; 1984. p. 73-90.  Back to cited text no. 10
11.McNeil MR, Doyle P, Wambaugh J. Apraxia of speech: A treatable disorder of motor planning and programming. In: Nadeau S, Rothi LJ, Crosson B, editors. Aphasia and Language: Theory to Practice. New York: Guilford; 2000. p. 221-66.  Back to cited text no. 11
12.Ogar J, Slama H, Dronkers N, Amici S, Gorno-Tempini ML. Apraxia of speech: An overview. Neurocase 2005;11:427-32.  Back to cited text no. 12
13.Balasubramanian V, Max L. Crossed apraxia of speech: A case report. Brain Cogn 2004;55:240-6.  Back to cited text no. 13
14.Assal F, Laganaro M, Remund CD, Ragno Paquier C. Progressive crossed-apraxia of speech as a first manifestation of a probable corticobasal degeneration. Behav Neurol 2012;25:285-9.  Back to cited text no. 14
15.Wertz RT, La Pointe LL, Rosenbek JC. Apraxia of Speech: The Disorder and its Management. New York: Grune and Stratton; 1984.  Back to cited text no. 15
16.Mc Neil MR, Pratt SR, Fossett TR. The differential diagnosis of apraxia of speech. In: Maassen B, editor. Speech Motor Control in Normal and Disordered Speech. New York: Oxford University Press; 2004. p. 389-412.  Back to cited text no. 16
17.Bramwell B. On crossed aphasia. Lancet 1899;1:1473-9.  Back to cited text no. 17
18.Sikaroodi H, Motamedi M, Kahnooji H, Gholamrezanezhad A, Yousefi N. Stroke as the first manifestation of Takayasu arteritis. Acta Neurol Belg 2007;107:18-21.  Back to cited text no. 18
19.Krishna MV, Namratha RS. Takayasu's Arteritis: Stroke as an initial presentation. J Indian Acad Clin Med 2004;5:274-6.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Response to Letter Regarding Article, “Damage to the Left Precentral Gyrus Is Associated With Apraxia of Speech in Acute Stroke”
Ryo Itabashi, Yoshiyuki Nishio, Minoru Matsuda
Stroke. 2016; 47(4)
[Pubmed] | [DOI]


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (960 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded168    
    Comments [Add]    
    Cited by others 1    

Recommend this journal