A 52 year-old right-handed man, from South India, presented with left hemiparesis of one day duration. He 
had vascular risk factors such as hypertension, 
ethanol consumption and cigarette smoking. 
There was no family history of left handedness. 
Neurologically, he demonstrated left faciobrachial 
(muscle power: grade 0–1/5), crural weakness 
(grade 3–4/5), global aphasia, left hemisensory 

impairment and left hemianopsia, with a National 
Institute of Health (NIH) Stroke Scale score of 19. 
The cardiac evaluation did not disclose valvular 
lesion/vegetation, mural thrombus, or significant 
ischaemic lesion. The computed tomography 
(CT) scan of his brain [Figure 1A] showed recent 
infarction in the distribution of the right middle 
cerebral artery, but there were no additional left 
hemispheric infarcts (also confirmed subsequently 

SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 122-123, Epub. 12th Feb 11
Submitted 30th Jun 10
Accepted 29th Sept 10

Department of Medicine, Sultan Qaboos University Hospital, Muscat Oman; Former affiliation: Department of Neurology, Sri 
Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India.
*Corresponding Author email: rnandagopal@yahoo.com

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Acquired Crossed Aphasia in a Dextral
Ramachandiran Nandhagopal

INTERESTING MEDICAL IMAGE

Figure 1: A: Cranial computed tomography scan obtained on the day of the stroke demonstrates ill-defined hypodensity 
(arrow pointing to the low signal) in the right fronto-parieto-temporal region, corona radiate and capsulo-ganglionic area 
consistent with a recent infarct in the distribution of right middle cerebral artery. B: The lesion is well delineated with a 
density similar to that of cerebrospinal fluid (arrow) along with dilatation of ipsilateral ventricle in the scan performed 7 
months after the event indicating chronic infarction. Note the absence of an additional lesion in the left hemisphere in 
both figures A and B.  



by a diffusion weighted magnetic resonance 
imaging scan). As he presented beyond the time 
window for thrombolytic therapy, he was treated 
with an antiplatelet drug, statins, antihypertensive 
medication, speech therapy and physiotherapy. A 
repeat computed tomography CT brain scan [Figure 
1B], performed 7 months later, demonstrated a 
chronic infarction in the same location with no 
additional left hemispheric lesion. Athough his left 
hemiparesis had significantly improved (arm power: 
grade 3–4/5), his global aphasia continued to pose 
significant problem for verbal communication over 
the subsequent years.

Crossed aphasia (CA) refers to a language 
(symbolic communication with words) disorder 
resulting from a unilateral right hemispheric 
lesion in dextrals (right-handers).1-3 CA is rare 
with an estimated prevalence of 0.4–3.5% of  
all aphasic syndromes.2 In right handers,  
language function is often lateralised to the  
left hemisphere. Atypical cerebral dominance 
for language in our patient accounted for  
the right hemispheric stroke-related aphasia  
that was persistent and functionally disabling.  
The pattern of his clinical course suggested  
complete lateralisation of language to his right 
hemisphere. Apart from ischaemic strokes,  
other aetiologies include aneurysmal subarchnoid 
haemorrhage, multiple sclerosis, direct cortical 
stimulation, migraine with aura and focal 

dementia.4-8

References
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3. Marien P, Engelborghs S, Vignolo LA, De Deyn 
PP. The many faces of crossed aphasia in dextrals: 
report of nine cases and review of the literature. Eur 
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4. Demirkiran M, Ozeren A, Sonmezler A, Bozdemir 
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6. Oishi M, Suzuki K, Sasaki O, Nakazato S, Kitazawa 
K, Takao T, et al. Crossed aphasia elicited by direct 
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7. Repetto C, Manenti R, Cotelli M, Calabria M, Zanetti 
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8. Seckin H, Yigitkanli K, Kapucu O, Bavbek M. Crossed 
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19:77–81.

Ramachandiran Nandhagopal

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