Figures 1A to D: Brain magnetic resonance imaging (T2 weighted image) [1A and C] and susceptibility weighted image [B] demonstrating recent ischaemic infarction (bright signal) with sparing of motor cortex [C] in the left fronto-parieto- temporal region along with haemorrhagic conversion (dark signal) in the basal ganglia [B]. The infarction spares the left motor cortex. Note that there is no significant occlusion of the proximal portion of the left middle cerebral artery in magnetic resonance angiography (time of flight sequence, [D]). A 28 year-old man, while on aversion therapy for alcohol abuse with disulfiram, consumed an alcoholic beverage and developed a sudden onset of difficulty in speaking. Neurologically, he demonstrated global aphasia and right homonymous hemianopia. Right SQU Med J, February 2012, Vol. 12, Iss. 1, pp. 124-125, Epub. 7th Feb 12. Submitted 17th May 11 Revision Req. 19th Jul 11, Revision recd. 25th Jul 11 Accepted 24th Aug 11 Department of Medicine, College of Medicine & Health Sciences, Muscat, Oman. Corresponding Author email: rnandagopal@yahoo.com ُحْبَسٌة شاِمَلة بدون َخَزل ِشقِّّي ترابط عصيب-ُشعاِعّي رامات�سانديران نانداجوبال Global Aphasia without Hemiparesis A neuroradiologic correlation Ramachandiran Nandhagopal INTERESTING MEDICAL IMAGE Ramachandiran Nandhagopal Interesting Medical Image | 125 hemiparesis was conspicuously absent. He had transient atrial fibrillation, but no structural cardiac lesions or other vascular/thrombophilic risk factors. Cranial magnetic resonance imaging (MRI) [Figure 1A] demonstrated recent infarction involving the perisylvian language areas with haemorrhagic transformation in the basal ganglia [Figure 1B] in the distribution of the left middle cerebral artery. The ischaemic infarction spared the motor cortex [Figure 1C], the adjacent subcortical area and the posterior limb of the internal capsule. A magnetic resonance angiogram of the cerebral arteries [Figure 1D] did not reveal any major vessel occlusion. In view of the large infarct and mild haemorrhagic transformation, he was treated with low dose aspirin only. Subsequent cardiac monitoring did not disclose any persistent atrial fibrillation or other arrhythmia. At follow-up, he made a good recovery with significant improvement in auditory comprehension and verbal expression. Hemiparesis typically accompanies global aphasia. There are only rare cases of global aphasia without hemiparesis and the language outcome is quite variable at follow-up.1-3 In our patient, the lesion distribution in the perisylvian language areas with sparing of the motor cortex and posterior limb of internal capsule accounted for this unusual syndrome of global aphasia without hemiparesis. The most common aetiology of the syndrome is embolic infarction.1-3 Disulfiram-alcohol interaction has been associated with cardiac events.4,5 In our patient, this interaction resulted in transient cardiac arrhythmia (atrial fibrillation) and subsequent embolic infarction. To the best of my knowledge, this is the first report of stroke in the unusual setting of disulfiram-alcohol interaction. Caution should be exercised while prescribing drugs that would elicit disulfiram-like reaction in subjects who lack strong motivation for alcohol de-addiction. References 1. Hanlon RE, Lux WE, Dromerick AW. Global aphasia without hemiparesis: language profiles and lesion distribution. J Neurol Neurosurg Psychiatry 1999; 66:365-9. 2. Legatt AD, Rubin MJ, Kaplan LR, Healton EB, Brust JC. Global aphasia without hemiparesis: multiple etiologies. Neurology 1987; 37:201–5. 3. Van Horn G, Hawes A. Global aphasia without hemiparesis: a sign of embolic encephalopathy. Neurology 1982; 32:403–6. 4. Tayyareci Y, Acarel E. Acute myocardial infarction associated with disulfiram-alcohol interaction in a young man with normal coronary arteries. Turk Kardiyol Dern Ars 2009; 37:48–50. 5. Altun G, Altun A, Erdogan O. Acute myocardial infarction due to disulfiram (antabuse)-alcohol interaction. Cardiovasc Drugs Ther 2006; 20:391–2.