Jenieve D. Guevarra, MD, MBS
Resident Physician
Rutgers/Kessler Institute of Rehabilitation
Fair Lawn, New Jersey, United States
Jennifer Russo, MD
Associate Brain Injury Medicine Fellowship Director
Rutgers/Kessler Institute of Rehabilitation
Saddle Brook, New Jersey, United States
Patient is a 48-year-old previously healthy woman who presented to acute inpatient rehabilitation with right hemiparesis and mixed aphasia following a left middle cerebral artery (MCA) aneurysm rupture requiring a hemicraniectomy and cranioplasty. CT showed extensive left MCA territory damage. After discharge, she was followed in outpatient where she continued to show improvement in left-sided weakness and expressive and receptive language. Five months after initial injury, she underwent an elective stent-coiling of a known right MCA aneurysm complicated by an acute right temporal infarct with regional mass effect. On re-admission to inpatient rehabilitation, she had worsened right hemiparesis and significantly impaired receptive and expressive language compared to her preoperative level.
Discussions:
Damage to the language dominant brain hemisphere, traditionally the left, produces language deficits while damage to the right non-dominant hemisphere typically causes hemispatial neglect. The presumed trajectory of language recovery post-stroke is as follows: Acute phase: the hours and days post-stroke where tissue reperfusion and penumbra function is critical; Subacute phase: the weeks and months post-stroke in which reorganization of brain structure-function occurs; and the Chronic phase which establishes new pathways and compensatory mechanisms for lost functions. While there are conflicting reports regarding which specific neural activity changes or reorganization markers are beneficial to language recovery, studies show that reduced activation of remaining left hemisphere areas in the acute phase followed by recruitment of right hemisphere homologues was associated with language recovery in the subacute phase.
Conclusions:
This case involving a dominant left hemispheric brain injury with subsequent aphasia who recovered language function followed by a non-dominant right hemispheric injury with subsequent worsening of aphasia is a unique example of neuroplasticity in post-stroke aphasia. Notably, it is also a case of non-dominant right sided language recovery in the chronic phase of aphasia.
