Brief Communication
Language Recovery After Acute Intracerebral Hematoma in Temporoparietal Region
Journal of Child Neurology 2015, Vol. 30(1) 117-119 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073813517264 jcn.sagepub.com
Zdravko Kolundzˇic´, PhD1, Andrea Sˇimic´ Klaric´, MD, PhD1, Marija Krip, MA1, Nikola Gotovac, MD1, Ljerka Banozˇic´, MD1, and Dinah Vodanovic´, MA2
Abstract Arteriovenous malformations are the most common cause of spontaneous intracerebral hemorrhages in older children. Intracerebral hematoma can cause serious lasting neurologic, cognitive, and language deficits, or even possible death. We present the case of a 16-year-old boy who had language impairments after suffering a large hemorrhagic stroke in the left temporoparietal region. All language components, verbal and nonverbal communication, reading, and writing, were found to be affected. These impairments were expected as they are characteristic of the location of the hematoma. After a year of speech language rehabilitation, there was an almost complete recovery of language skills. Quick diagnosis and adequate therapeutic interventions are important to diminish the influence of intracerebral hemorrhage on cognitive and language functions in children. Keywords stroke, language impairment, children Received July 12, 2013. Received revised November 25, 2013. Accepted for publication November 25, 2013.
Arteriovenous malformations are the most common cause of spontaneous intracerebral hemorrhage in older children.1 Spontaneous intracerebral hemorrhage can result in intracerebral hematoma with the possibility of grave consequences, and neurologic, cognitive, and language deficits may occur later in postoperative recovery. In children, possible etiologies are congenital disorders, cardiac, vascular, or hematologic.2 The incidence of hemorrhagic stroke is 1.1 per 100 000 per year.3 Moreover, 20% of children die after a stroke, and 50% to 80% of children have neurologic conditions as a consequence.4 Up to 65% of individuals present with poststroke cognitive impairments.5 In this article, the case reports on the language impairments of a 16-year-old boy after suffering a large hemorrhagic stroke in the left temporoparietal region is shown.
Case Report The patient was a 16-year-old boy, a second-grade high school student, hospitalized in October 2012 in the pediatric department of the General County Hospital in Pozˇega, Croatia. Symptoms included acute headaches, speech difficulties, and disorientation. There was not any motoric impairment. A computed tomography and magnetic resonance imaging (MRI) of the cerebrum showed a large intracerebral hematoma in the left temporoparietal region, which was surgically removed. The bleeding
was due to an arteriovenous malformation, diagnosed with magnetic resonance imaging (Figure 1), and treated with gamma-knife surgery following digital subtraction angiography (Figure 2). Electroencephalogram showed focal paroxysmal discharges with spike wave complexes registered on the left side, predominantly in the front temporoparietal region, which was isolated and in paroxysmal pattern. Speech and psychological testing was carried out 3 months postrecovery, at the age of 16 years 10 months. Neuropsychological testing showed average intellectual achievement and average verbal and nonverbal skills, but with disparity on particular exams. General knowledge, formerly learned skills, ability of former experience evaluation, and conceptual thinking were in average category, assuming primary average potential. The results of neuropsychological assessment refer to the average intellectual skills on particular subtests. Deficits were registered in verbal fluency, mnestic functions, with discretely
1 2
County Hospital Pozˇega, Croatia Clinical Hospital Center Zagreb, Rebro, Croatia
Corresponding Author: Zdravko Kolundzˇic´, PhD, County Hospital Pozˇega Osjecˇka 107, 34000 Pozˇega. Email: [email protected]
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
118
Journal of Child Neurology 30(1)
Figure 2. Digital subtraction angiography. Figure 1. Magnetic resonance fluid-attenuated inversion recovery image.
lower visuoconstructive and visuoperceptual abilities due to organic cerebral dysfunction. Motor aphasia was pronounced.6-9 On the language and speech skills exam, everyday speech comprehension was slow but without difficulty. Language comprehension needed multiple repetitions to be successfully performed. Vocabulary was on the high average level (70th percentile; Peabody Picture Vocabulary Test-HR).10 In the verbal expression domain, dialogue was difficult because of the deficit of naming and paraphasia/perseverations. Naming skills were significantly lower on the second level of the Boston naming test.11 Phonologic processing was lower in the phonological coding and decoding domain. The diagnosis of Broca aphasia was established. Domains of reading, decoding, and grapho-phonologic conversion were normal. Syllables had phonemic perseverations, and words had phonemic and lexical paraphasias. Reading of isolated words was pronouncedly low (51 read word/100-120 expected). Reading out loud was slow, and silent reading was within the expected time frame. Reading comprehension was adequate according to the answers on adjusted questions. Long-term memory recall and the retelling of former text read was difficult because of aphasia. Retelling of text read shortly before was without difficulties. Rewriting was without difficulties. Deficits in hand writing itself were transferred from the speech in a way of lexical and phonemic paraphasias. Retests were carried out by a psychologist and a speech and language pathologist a year after the stroke. During that period of 12 months, the patient was included in an intensive speech language therapy program. Retest results indicated some recovery
of certain language functions. Beside language deficits, neurologic examination was normal. Visual-constructive and visualperceptual abilities showed improvement, in the retest they were without deviation. Difficulties in mnestic functions were diminished; verbal fluency had better results than in the initial testing but still had difficulties that are explained as a consequence of the congenital organic cerebral dysfunction.6-9 Language comprehension had improved, only with the occasional need for repeating. Dialogue was without asperity, but with some remaining difficulties in the domain of retelling, although in a smaller capacity than in the initial testing. Naming abilities were improved to level 4 of the Boston naming test.10,11 Phonological analysis was improved, with only lenient difficulties in phonologic coding and decoding. Reading was without deviation, but still slower in pace (68 words in a minute). Comprehension of just reading and writing were without difficulties.
Discussion The patient had an acute intracerebral hemorrhage due to arteriovenous malformation of the brain. As a consequence, he had meaningful language impairments after the stroke. The most important were naming ability, level of morphosyntactic knowledge, and verbal fluency. Consequently, reading and writing skills could be lost. These impairments were expected according to localization of the hematoma. As with adults, children can exhibit language disorders due to central nervous system injury after a period of normal development. Disorders of lexis are common in both adults12 and children who have suffered brain injury. Childhood-acquired language disorder, or childhood-acquired aphasia, refers to a
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
Kolundzˇic´ et al
119
language impairment evident after a period of normal language acquisition that is precipitated by, or associated with, an identified form of brain injury.13 Intracerebral hemorrhage can have negative influence on all components of language, speech, reading, and writing. According to some authors, they can vary from comprehension difficulties to complete failure in understanding.14 From children with syntactic comprehension deficits, some are able to construct relevant syntactic structures even when they fail to map the products to establish meaning.15 Injury of left hemisphere also has a strong association with syntax. Semantic disorders in children with brain injuries range from severe verbal auditory agnosia for common sounds to problems understanding word meaning16 or oral or written texts.17 In adult studies, language and memory impairments were found after the unilateral left hemispheric stroke.18 In children, a negative impact of stroke was found to affect expressive language skills.19 Kolk et al20 have found that children who have had strokes exhibited worse attention, language, memory, and sensorimotor functions.
Conclusion An acute intracerebral hematoma in the temporoparietal left region has an important impact on a child’s language performance. It is one of the reasons why it is vital to make a quick diagnosis and provide adequate therapeutic interventions in order to diminish the influence on language functions in these children. Author Contributions All authors of this article have participated in all parts of the acquisition, analysis, interpretation, and/or preparation of the data and the article. ZK and ASˇK had the primary responsibility for protocol development and writing the article. MK, NG, and LB had the responsibility for collecting the literature and analysis and interpretation of data. DV had the responsibility of writing of the article and drafting and revising the manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval This study was approved by the Ethics Review Committee of the General County Hospital in Pozˇega (02-7/32-4/2-2013). Informed parental consent was obtained in all cases.
References 1. Niazi TN, Klimo P Jr, Anderson RC, Raffel C. Diagnosis and management of arteriovenous malformations in children. Neurosurg Clin N Am. 2010;21:443-456. 2. Calder K, Kokorowski P, Tran T, Henderson S. Emergency department presentation of pediatric stroke. Pediatr Emerg Care. 2003;19:320-328. 3. Fullerton HJ, Wu YW, Zhao S, Johnston SC. Risk of stroke in children: ethnic and gender disparities. Neurology. 2003;61: 189-194. 4. Roach E.S, Golomb M.R, Adams R, et al. Management of stroke in infants and children. Stroke. 2008;39:2644-2691. 5. Donovan NJ, Kendall DL, Heaton SC, et al. Conceptualizing functional cognition in stroke. Neurorehabil Neural Repair. 2008;22:122-135. 6. Wechsler D. Wechsler-Bellevue Adult Intelligence Scale. Narodne Novine: Zagreb; 1960. 7. Meyers JE, Meyers KR. Rey Complex Figure Test and Recognition Trial, Manual. Odessa, FL: Psychological Assessment Resources; 1995. 8. Strauss E, Sherman EMS, Spreen O. A Compendium of Neuropsychological Tests, Administration, Norms and Commentary. New York: Oxford University Press; 1991. 9. Sˇali B, Bele-Potocˇnik Zˇ, Onicˇ-Novak H. WB-SP Memory Scale I&II. Ljubljana: Center for Psychodiagnostic Means; 1987. 10. Leota MD, Kovacˇevic´ M, Padovan N, et al. Peabody Picture Vocabulary Test–PPVT-III-HR. Naklada Slap: Jastrebarsko; 2010. 11. Goodglass H, Kaplan E. The Assessment of Aphasia and Related Disorders. 2nd edition. Philadelphia, PA: Lea & Febiger; 1996. 12. Libben G. Disorders of lexis. In: Stemmer B, Whitaker HA, eds. Handbook of the Neuroscience of Language. New York: Elsevier; 2008:147-154. 13. Dennis M. Language disorders in children with central nervous system injury. J Clin Exp Neuropsychol. 2011;32:417-32. 14. Dennis M, Barnes MA. Speech acts after mild or severe childhood head injury. Aphasiology. 2000;14:391-405. 15. Linebarger MC. Neuropsychology of sentence parsing. In: Caramazza A, ed. Cognitive Neuropsychology and Neurolinguistics: Advances in Models of Cognitive Function and Impairment. Hove, UK: Psychology Press; 1990:55-122. 16. Dennis M. Word finding in children and adolescents with a history of brain injury. Top Lang Dis. 1992;13:66-82. 17. Barnes MA, Faulkner H, Wilkinson M, Dennis M. Meaning construction and integration in children with hydrocephalus. Brain Lang. 2004;89:47-56. 18. Pulsipher DT, Stricker NH, Sadek JR, et al. Clinical utility of the Neuropsychological Assessment Battery (NAB) after unilateral stroke. Clin Neuropsychol. 2013;27:924-945. 19. Ilves P, Tomberg T, Kepler J, et al. Different plasticity patterns of language functions in children with perinatal and childhood stroke. J Child Neurol. 2013 Nov 27 (Epub ahead of print). 20. Kolk A, Ennok M, Lauqessar J, et al. Long term cognitive outcomes after pediatric stroke. Pediatr Neurol. 2011; 44:101-109.
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
Language Recovery After Acute Intracerebral Hematoma in Temporoparietal Region
Journal of Child Neurology 2015, Vol. 30(1) 117-119 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073813517264 jcn.sagepub.com
Zdravko Kolundzˇic´, PhD1, Andrea Sˇimic´ Klaric´, MD, PhD1, Marija Krip, MA1, Nikola Gotovac, MD1, Ljerka Banozˇic´, MD1, and Dinah Vodanovic´, MA2
Abstract Arteriovenous malformations are the most common cause of spontaneous intracerebral hemorrhages in older children. Intracerebral hematoma can cause serious lasting neurologic, cognitive, and language deficits, or even possible death. We present the case of a 16-year-old boy who had language impairments after suffering a large hemorrhagic stroke in the left temporoparietal region. All language components, verbal and nonverbal communication, reading, and writing, were found to be affected. These impairments were expected as they are characteristic of the location of the hematoma. After a year of speech language rehabilitation, there was an almost complete recovery of language skills. Quick diagnosis and adequate therapeutic interventions are important to diminish the influence of intracerebral hemorrhage on cognitive and language functions in children. Keywords stroke, language impairment, children Received July 12, 2013. Received revised November 25, 2013. Accepted for publication November 25, 2013.
Arteriovenous malformations are the most common cause of spontaneous intracerebral hemorrhage in older children.1 Spontaneous intracerebral hemorrhage can result in intracerebral hematoma with the possibility of grave consequences, and neurologic, cognitive, and language deficits may occur later in postoperative recovery. In children, possible etiologies are congenital disorders, cardiac, vascular, or hematologic.2 The incidence of hemorrhagic stroke is 1.1 per 100 000 per year.3 Moreover, 20% of children die after a stroke, and 50% to 80% of children have neurologic conditions as a consequence.4 Up to 65% of individuals present with poststroke cognitive impairments.5 In this article, the case reports on the language impairments of a 16-year-old boy after suffering a large hemorrhagic stroke in the left temporoparietal region is shown.
Case Report The patient was a 16-year-old boy, a second-grade high school student, hospitalized in October 2012 in the pediatric department of the General County Hospital in Pozˇega, Croatia. Symptoms included acute headaches, speech difficulties, and disorientation. There was not any motoric impairment. A computed tomography and magnetic resonance imaging (MRI) of the cerebrum showed a large intracerebral hematoma in the left temporoparietal region, which was surgically removed. The bleeding
was due to an arteriovenous malformation, diagnosed with magnetic resonance imaging (Figure 1), and treated with gamma-knife surgery following digital subtraction angiography (Figure 2). Electroencephalogram showed focal paroxysmal discharges with spike wave complexes registered on the left side, predominantly in the front temporoparietal region, which was isolated and in paroxysmal pattern. Speech and psychological testing was carried out 3 months postrecovery, at the age of 16 years 10 months. Neuropsychological testing showed average intellectual achievement and average verbal and nonverbal skills, but with disparity on particular exams. General knowledge, formerly learned skills, ability of former experience evaluation, and conceptual thinking were in average category, assuming primary average potential. The results of neuropsychological assessment refer to the average intellectual skills on particular subtests. Deficits were registered in verbal fluency, mnestic functions, with discretely
1 2
County Hospital Pozˇega, Croatia Clinical Hospital Center Zagreb, Rebro, Croatia
Corresponding Author: Zdravko Kolundzˇic´, PhD, County Hospital Pozˇega Osjecˇka 107, 34000 Pozˇega. Email: [email protected]
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
118
Journal of Child Neurology 30(1)
Figure 2. Digital subtraction angiography. Figure 1. Magnetic resonance fluid-attenuated inversion recovery image.
lower visuoconstructive and visuoperceptual abilities due to organic cerebral dysfunction. Motor aphasia was pronounced.6-9 On the language and speech skills exam, everyday speech comprehension was slow but without difficulty. Language comprehension needed multiple repetitions to be successfully performed. Vocabulary was on the high average level (70th percentile; Peabody Picture Vocabulary Test-HR).10 In the verbal expression domain, dialogue was difficult because of the deficit of naming and paraphasia/perseverations. Naming skills were significantly lower on the second level of the Boston naming test.11 Phonologic processing was lower in the phonological coding and decoding domain. The diagnosis of Broca aphasia was established. Domains of reading, decoding, and grapho-phonologic conversion were normal. Syllables had phonemic perseverations, and words had phonemic and lexical paraphasias. Reading of isolated words was pronouncedly low (51 read word/100-120 expected). Reading out loud was slow, and silent reading was within the expected time frame. Reading comprehension was adequate according to the answers on adjusted questions. Long-term memory recall and the retelling of former text read was difficult because of aphasia. Retelling of text read shortly before was without difficulties. Rewriting was without difficulties. Deficits in hand writing itself were transferred from the speech in a way of lexical and phonemic paraphasias. Retests were carried out by a psychologist and a speech and language pathologist a year after the stroke. During that period of 12 months, the patient was included in an intensive speech language therapy program. Retest results indicated some recovery
of certain language functions. Beside language deficits, neurologic examination was normal. Visual-constructive and visualperceptual abilities showed improvement, in the retest they were without deviation. Difficulties in mnestic functions were diminished; verbal fluency had better results than in the initial testing but still had difficulties that are explained as a consequence of the congenital organic cerebral dysfunction.6-9 Language comprehension had improved, only with the occasional need for repeating. Dialogue was without asperity, but with some remaining difficulties in the domain of retelling, although in a smaller capacity than in the initial testing. Naming abilities were improved to level 4 of the Boston naming test.10,11 Phonological analysis was improved, with only lenient difficulties in phonologic coding and decoding. Reading was without deviation, but still slower in pace (68 words in a minute). Comprehension of just reading and writing were without difficulties.
Discussion The patient had an acute intracerebral hemorrhage due to arteriovenous malformation of the brain. As a consequence, he had meaningful language impairments after the stroke. The most important were naming ability, level of morphosyntactic knowledge, and verbal fluency. Consequently, reading and writing skills could be lost. These impairments were expected according to localization of the hematoma. As with adults, children can exhibit language disorders due to central nervous system injury after a period of normal development. Disorders of lexis are common in both adults12 and children who have suffered brain injury. Childhood-acquired language disorder, or childhood-acquired aphasia, refers to a
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
Kolundzˇic´ et al
119
language impairment evident after a period of normal language acquisition that is precipitated by, or associated with, an identified form of brain injury.13 Intracerebral hemorrhage can have negative influence on all components of language, speech, reading, and writing. According to some authors, they can vary from comprehension difficulties to complete failure in understanding.14 From children with syntactic comprehension deficits, some are able to construct relevant syntactic structures even when they fail to map the products to establish meaning.15 Injury of left hemisphere also has a strong association with syntax. Semantic disorders in children with brain injuries range from severe verbal auditory agnosia for common sounds to problems understanding word meaning16 or oral or written texts.17 In adult studies, language and memory impairments were found after the unilateral left hemispheric stroke.18 In children, a negative impact of stroke was found to affect expressive language skills.19 Kolk et al20 have found that children who have had strokes exhibited worse attention, language, memory, and sensorimotor functions.
Conclusion An acute intracerebral hematoma in the temporoparietal left region has an important impact on a child’s language performance. It is one of the reasons why it is vital to make a quick diagnosis and provide adequate therapeutic interventions in order to diminish the influence on language functions in these children. Author Contributions All authors of this article have participated in all parts of the acquisition, analysis, interpretation, and/or preparation of the data and the article. ZK and ASˇK had the primary responsibility for protocol development and writing the article. MK, NG, and LB had the responsibility for collecting the literature and analysis and interpretation of data. DV had the responsibility of writing of the article and drafting and revising the manuscript.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval This study was approved by the Ethics Review Committee of the General County Hospital in Pozˇega (02-7/32-4/2-2013). Informed parental consent was obtained in all cases.
References 1. Niazi TN, Klimo P Jr, Anderson RC, Raffel C. Diagnosis and management of arteriovenous malformations in children. Neurosurg Clin N Am. 2010;21:443-456. 2. Calder K, Kokorowski P, Tran T, Henderson S. Emergency department presentation of pediatric stroke. Pediatr Emerg Care. 2003;19:320-328. 3. Fullerton HJ, Wu YW, Zhao S, Johnston SC. Risk of stroke in children: ethnic and gender disparities. Neurology. 2003;61: 189-194. 4. Roach E.S, Golomb M.R, Adams R, et al. Management of stroke in infants and children. Stroke. 2008;39:2644-2691. 5. Donovan NJ, Kendall DL, Heaton SC, et al. Conceptualizing functional cognition in stroke. Neurorehabil Neural Repair. 2008;22:122-135. 6. Wechsler D. Wechsler-Bellevue Adult Intelligence Scale. Narodne Novine: Zagreb; 1960. 7. Meyers JE, Meyers KR. Rey Complex Figure Test and Recognition Trial, Manual. Odessa, FL: Psychological Assessment Resources; 1995. 8. Strauss E, Sherman EMS, Spreen O. A Compendium of Neuropsychological Tests, Administration, Norms and Commentary. New York: Oxford University Press; 1991. 9. Sˇali B, Bele-Potocˇnik Zˇ, Onicˇ-Novak H. WB-SP Memory Scale I&II. Ljubljana: Center for Psychodiagnostic Means; 1987. 10. Leota MD, Kovacˇevic´ M, Padovan N, et al. Peabody Picture Vocabulary Test–PPVT-III-HR. Naklada Slap: Jastrebarsko; 2010. 11. Goodglass H, Kaplan E. The Assessment of Aphasia and Related Disorders. 2nd edition. Philadelphia, PA: Lea & Febiger; 1996. 12. Libben G. Disorders of lexis. In: Stemmer B, Whitaker HA, eds. Handbook of the Neuroscience of Language. New York: Elsevier; 2008:147-154. 13. Dennis M. Language disorders in children with central nervous system injury. J Clin Exp Neuropsychol. 2011;32:417-32. 14. Dennis M, Barnes MA. Speech acts after mild or severe childhood head injury. Aphasiology. 2000;14:391-405. 15. Linebarger MC. Neuropsychology of sentence parsing. In: Caramazza A, ed. Cognitive Neuropsychology and Neurolinguistics: Advances in Models of Cognitive Function and Impairment. Hove, UK: Psychology Press; 1990:55-122. 16. Dennis M. Word finding in children and adolescents with a history of brain injury. Top Lang Dis. 1992;13:66-82. 17. Barnes MA, Faulkner H, Wilkinson M, Dennis M. Meaning construction and integration in children with hydrocephalus. Brain Lang. 2004;89:47-56. 18. Pulsipher DT, Stricker NH, Sadek JR, et al. Clinical utility of the Neuropsychological Assessment Battery (NAB) after unilateral stroke. Clin Neuropsychol. 2013;27:924-945. 19. Ilves P, Tomberg T, Kepler J, et al. Different plasticity patterns of language functions in children with perinatal and childhood stroke. J Child Neurol. 2013 Nov 27 (Epub ahead of print). 20. Kolk A, Ennok M, Lauqessar J, et al. Long term cognitive outcomes after pediatric stroke. Pediatr Neurol. 2011; 44:101-109.
Downloaded from jcn.sagepub.com at UNIV OF GEORGIA LIBRARIES on June 21, 2015
