One week after quadruple coronary artery bypass, a 62-year-old man with history of coronary artery disease, hypertension, hyperlipidemia, and prior left hemispheric cortical infarct had sudden onset of language difficulties and right-sided weakness.

One week following four-vessel coronary artery bypass graft (CABG) surgery, and while on 81 mg of aspirin daily, our patient had sudden onset of language impairment. Upon arising from bed and going to the restroom, he abruptly became unable to speak. His wife immediately called 911. Past medical history was remarkable for arterial hypertension, hyperlipidemia, three myocardial infarctions, and a left parietal ischemic stroke. The patient was treated with intra-arterial tissue plasminogen activator (tPA).

On subsequent evaluation, he had nonfluent verbal output. Speech was poorly articulated, effortful, and dysprosodic. He was able to utter the most meaningful words of a sentence, but often omitted words (telegraphic speech or agrammatism). Repetition was impaired. There was relative preservation of comprehension of spoken language. There was a faciobrachial distribution of his right hemiparesis. Echocardiography showed left ventricular dilatation, reduced global left ventricular systolic function, left atrial dilatation, regional wall motion abnormality, mild mitral regurgitation, and a thickened aortic valve without significant stenosis. A diagnosis of Broca aphasia due to a cardioembolic left frontal infarction involving branches of the superior division of the middle cerebral artery (MCA) was made and warfarin therapy initiated (target INR range, 2.0 to 3.0).

Aphasia refers to loss or impairment of language processing caused by brain damage. When assessing language function, one must note verbal fluency, auditory comprehension, naming, repetition, reading, and writing. Repetition should include sentences with functor words. “No ifs, ands, or buts” is commonly used. The traditional perisylvian aphasias are (i) Broca aphasia, (ii) Wernicke aphasia, (iii) global aphasia, and (iv) conduction aphasia. The other four traditional aphasic syndromes arise from lesions outside the perisylvian region and include anomic aphasia and the three types of transcortical aphasias (transcortical motor, transcortical sensory, and mixed transcortical) (Table 20.1). The perisylvian aphasias are “nonrepetitive” (repetition is impaired), whereas the extra-perisylvian aphasias are “repetitive” (repetition is preserved).