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Anatomical basis for acquired fluent aphasia in children.

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Anatomical Basis
for Acquired Fluent
Aphasia in Children
Hugo R. VanDongen, PhD," M. Christa B. Loonen, MD,'
and Krijn J. VanDongen, M D t
Three girls aged 9 to 11 years developed fluent aphasia
associated with acute brain lesions. As localized by computed tomography, the abnormalities i n all three resided in the posterior part of the left hemisphere, encroaching upon Wernicke's area.
VanDongen HR, Loonen MCB, VanDongen KJ:
Anatomical basis for acquired fluent aphasia in
children. Ann Neurol 17:306-309, 1985
I t has been widely stated that acquired aphasia in childhood is invariably nonfluent, that is, that aphasic children have speech articulation problems, show syntactical errors, and speak in a telegraphic style; however,
victims do n o t use neologisms or jargon and logorrhea
is absent 12, 3, 9, 10, 14, 151. Exceptions have been
observed 116, 20-221, but neither t h e characteristics
of t h e aphasia nor the site of the lesion were documented in these cases.
O v e r a period of four years, 27 children (15 boys
and 12 girls; age range, 3 t o 15 years) referred t o our
department for speech problems were classified as
aphasic according t o published criteria 18, 18, 191. The
most common cause was head trauma (9 patients), followed by vascular disorders (6),infectious diseases (4),
brain tumors (4), and convulsive disorders and acquired aphasia (4). From this series we describe the
language defect and radiographic findings in 3 righthanded girls, aged 9 t o 11 years, who had fluent
aphasia. Before t h e onset of the aphasia, n o n e of t h e
children had shown neurological signs or learning
suggesting a hematoma (Fig 1A). Seventeen days later the
extent of the hematoma evident on C T scanning was grossly
reduced, and the hemiplegia gradually resolved. Two months
after onset the patient had a series of tonic-clonic seizures.
Figure 1B shows the residual CT abnormalities one year
after onset.
Spontaneous speech was recorded in a conversational setting and rated for the following characteristics proposed for
the classification of fluent speech: a phrase length exceeding
four words, a rate of speaking of more than ninety words per
minute, and normal prosody, articulation, pauses, and effort
[ l , 11). The Table shows the speech characteristics of the
patient before the onset of the seizures. Although neither
paraphasia nor the use of neologisms was present during the
interview, both were observed during the picture-naming
test (forty items). Indeed, naming difficulties were so severe
that the girl stopped the test after 10 trials. O n repetition
testing she could repeat only three monosyllabic words. O n
auditory comprehension testing using the Token test, she
could perform only six of the ten items in the first (easiest)
series. She was able to read aloud only four letters. Following
the convulsions (mentioned earlier), there was further deterioration in her speech capacities; she spoke effortfully and
could produce only simple words, and these in a telegraphic
style. By this stage she could understand only simple commands, and detailed formal language examination (repeating,
Token test, picture naming) was impossible. During the next
two years virtually no improvement was observed.
Patient 2
From the Divisions of *Neurology and tRadiology, Academic Hospital Rotterdam-Dijkzigt, 40 Dr Molewaterplein, 3015 G D Rotterdam, The Netherlands.
At the age of 10 agirl suffered a CT-demonstrated contusion
in the left temporal lobe just underneath a fracture as the
result of a traffic accident (Fig 2A). The depressed fracture
was corrected surgically six days after the accident, and one
week later the patient was discharged home. The residual C T
abnormalities are shown in Figure 2B.
Detailed language examinations were carried out on the
third and thirteenth days after onset. In her spontaneous
speech (see the Table), as well as in picture naming, the
patient's speech was marked by paraphasia. Repetition of
polysyllabic nouns was impossible, as was the repetition of
three-word sentences. Comprehension of spoken language
during the interview was, however, considered normal, in
contrast with the patient's poor score in auditory comprehension on the Token test (28 out of 61). Writing to dictation revealed many mistakes, including paraphasia. After
craniotomy there was rapid improvement in spontaneous
speech, picture naming, reading aloud, and writing to dictation. Recovery of the ability to repeat polysyllabic nouns and
sentences was less pronounced, however, and the Token test
still demonstrated a receptive disorder (score, 38 out of 61).
Two and one-half months after the trauma, the girl was reexamined; the only deficit was found during writing to dictation, on which she showed some spelling errors. Six months
later these errors were still present, as reported by her tutor,
but the deficit disappeared within the following year.
Received Feb 14, 1984, and in revised form July 13. Accepted for
publication July 15, 1984.
Patient 3
Address reprint requests to Dr Hugo R. VanDongen, Division of
Neurology, Erasmus University Rotterdam, Rm EE 2287, PO Box
1738, 3000 DR Rotterdam, The Netherlands.
An 11-year-old girl had an accident while cycling. O n admission neurological examination showed right knee and ankle
jerks to be somewhat brisker than left, the only abnormality
Case Reports
Patient 1
A 9-year-old girl suffering from aplastic anemia suddenly
developed language difficulties and a right hemiplegia. Computed tomographic (CT) brain scanning showed a hyperdense, space-occupying lesion in the left temporal region
F i g 1, Patient 1. (A)Computed tomographic scan at onset
shows a hematoma posterior to the sylvian fismre. (Bi Scan one
year after onset, demonstrating enlarged ventricles, dilated posterior horn, and possible calc$cation in the left temporo-occipital
words, and her attempts at reading aloud were unintelligible
because of her frequent use of neologisms. She could write
only simple words. Understanding of verbal commands was
considerably limited, as reflected in the Token test score
of 13 out of 61. At discharge, twelve days after onset,
paraphasia and the use of neologisms no longer occurred, but
mild word-finding difficulties were still present. Repetition
of single words was normal, although the patient was still
unable to repeat five-word sentences. Verbal comprehension
had become normal, as reflected in a Token test score of 52
out of 61. By thirty-four days after onset, only very mild
word-finding difficulties were present, and one year after the
trauma, her tutor reported normal school performance.
Analysis of Spontaneous Speech
Patient 1
Patient 2
Patient 3
Phrase length (mean
no. of words)
Rate of speaking
noted. C T scanning showed a small area of mixed density in
the left posterior temporal region (Fig 3).
Detailed language assessments were carried out on the
fourth and twelfth days after onset. O n the fourth day the
patient's spontaneous speech (see the Table) showed frequent paraphasias but only infrequent neologisms. Clinically
her speech was empty of meaning, and the girl was found to
be severely anomic. She could repeat only two monosyllabic
The three reported children with fluent paraphasic
speech challenge the view that acquired aphasia is always nonfluent and devoid of paraphasia C7, 141. A
boy with a neologistic jargon aphasia is also known t o
us; his utterances could not be analyzed because of the
rapid emission of inappropriate words. Thus, 4 of 27
aphasic children admitted to our department during a
period of four years showed a fluent aphasia. This discrepancy can perhaps be explained as follows:
1. In most studies of acquired aphasia in children, a
clinical sign that raises the possibility of aphasia has
been a right-sided paresis or paralysis; this motor
Brief Communication: VanDongen et al: Fluent Childhood Aphasia
Fig 3. Patient 3. Computed tomographic scan jive days after onset, demonstrating a small, mixed density contusion (arrows) in
the left teinporal lobe behind the sylvian fi.f.sure.
deficit has been caused by an anterior lesion, producing an associated nonfluent aphasia [22].
2. The ability of the CT scan to demonstrate a left
temporal lesion may lead to a more careful search
for associated speech disturbances, increasing the
recognition of fluent aphasia in children and differentiating it from confusion.
3. If head trauma is the underlying cause of the
aphasia, recovery may be observed within a short
time [13}, so that the fluent characteristics of the
aphasia may be either not recognized or not recorded.
Fig 2. Patient 2. (A) Computed tomographic scan at onset
shows a left temporal depressed fracture. a subgaleal hematoma in
the vicinity ofthe fracture$anda mixeddensity contusion in the
left temporal lobe posterior to the sylvian jssure. (B}Scan two
months after onset, showing localatrophy in the posteriorpart of
the left temporal lobe.
308 Annals of Neurology Vol 17 No 3 March 1985
The current view that the left temporal hemisphere
is already specialized for language at birth { 5 } does not
specify the influence of age, Sex, and location of the
lesion on the clinical picture of childhood aphasia. The
patients described here demonstrate that before 10
years of age, a language deficit resembling fluent
aphasia in adults can occur; furthermore, repetition
ability during recovery remained disproportionately
severely impaired, suggesting a conduction aphasia,
which is considered to be one of the fluent aphasias
[S}. That the 3 reported patients are all girls raises the
question of sex differences in the cerebral organization
E S patient 1
k B patient 2
mpatient 3
1 precentral gyrus
2 postcentral g y r u s
3 supramarginal g y r u s
4 s u p e r i o r temporal g y r u s
5 middle temporal g y r u s
A f r o n t a l lobe
€3 p a r i e t a l lobe
C temporal lobe
D occipital lobe
Fig 4. ksions evident on computed tomographic scanning at onset in patients I , 2, and 3 . The sylvianjssure was identified using the anatomical Ptudies of Matsui and Hirano {17} and of
Gad0 and associates {6}, and taking into account slight d i f f e r ences in the plane of orientation.
of language functions [4}.This is a controversial issue,
but our findings, based on an admittedly small sample,
do not support the claim that lesions posterior to the
sylvian fissure rarely produce aphasia in women 112).
The patients reported all have posterior lesions (Fig 4),
i.e., lesions in Wernicke’s area. In the case of the 2
patients with head injury, however, the lesions could
have been more diffuse. Moreover, we have observed
a child with nonfluent aphasia caused by a glioma in
the posterior part of the temporal lobe, indicating that
posterior lesions do not invariably result in fluent
The authors thank Dr F. VanHarskamp, Mrs E. Yousef-Bak, and
Mrs W. M. E. VandeSandt-Koenderman for their helpful advice, Dr
D. N. Brooks for revising the English text, and Mrs J. DoornboschKonijn for preparing the manuscript.
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Brief Communication: VanDongen et al: FIuent Childhood Aphasia
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