Pure word deafness and hemispheric dynamics: a case history

Auditory agnosia with anosognosia

A 66-year-old right-handed female medical doctor suffered two consecutive cardioembolic strokes, initially affecting the right frontal lobe and the right insula, followed by a lesion in the left temporal lobe. The patient presented with distinctive phenomenology of general auditory agnosia with anosognosia for the deficit. She did not understand verbal requests and her answers to oral questions were fluent but unrelated to the topic. However, she was able to correctly answer written questions, name objects, and fluently describe their purpose, which is characteristic for verbal auditory agnosia. She was also unable to recognise environmental sounds or to recognise and repeat any melody. These inabilities represent environmental sound agnosia and amusia, respectively. Surprisingly, she was not aware of the problem, not asking any questions regarding her symptoms, and avoiding discussing her inability to understand spoken language, which is indicative of anosognosia. The deficits in our patient followed a distinct pattern of recovery. The verbal auditory agnosia was the first to resolve, followed by environmental sound agnosia. Amusia persisted the longest. The patient was clinically assessed from the first day of symptom onset and the evolution of symptoms was video documented. We give a detailed account of the patient's behaviour and provide results of audiological and neuropsychological evaluations. We discuss the anatomy of auditory agnosia and anosognosia relevant to the case. This case study may serve to better understand auditory agnosia in clinical settings. It is important to distinguish auditory agnosia from Wernicke's aphasia, because use of written language may enable normal communication.

Auditory Spatial Deficits in the Early Stage of Ischemic Cerebral Stroke

BACKGROUND

Clinical research, together with computed tomography/magnetic resonance imaging findings, proves that ischemic stroke (IS) that damages auditory pathways can cause hearing loss and impairment of higher auditory processes such as sound localization. The goal of the study was to find possible correlations between the IS risk factors, ischemic lesion volume and localization, neurologic status, and the sound localization capability in acute IS patients.

METHODS

We consecutively enrolled 61 IS patients into the study. The control group consisted of 60 healthy volunteers. All neuro-otological evaluations were performed up to 30 days from the incidence of stroke. All the subjects underwent the horizontal minimum audible angle test (HMAAT) and standard tonal and speech audiometric assessments.

RESULTS

HMMAT results were significantly worse in the IS patients and were present in 82.0% of the patients. There were more patients with unilateral disturbances than with bilateral ones (54.1% versus 27.9%). It was the characteristics of the ischemic lesions that correlated strongly with the sound localization deterioration, that is, their bilateral (the 90° azimuth, P = .018; the 180°, P = .002), multiple (the 45°, P = .020; the 180°, P = .007; the 225°, P = .047), and lacunar character (the 90°, P = .015; the 225°, P = .042). Differences in the types of HMAAT results were significant for lesions in the frontal and the temporal lobe (P = .018 and P = .040). In addition, worse sound localization ability was more common in patients with poor speech discrimination and the bilateral sensorineural hearing loss. We have not found statistically significant correlations for other analyzed factors such as the cortical/subcortical character of the lesions, the patients' neurologic status, and cerebrovascular risk factors.

CONCLUSIONS

Sound localization impairment is common in IS patients and it is the multiple, bilateral, and lacunar character of the ischemic lesions that seems to be strongly positively correlated with the disturbance of the sound localization ability.

Auditory agnosia

Auditory agnosia refers to impairments in sound perception and identification despite intact hearing, cognitive functioning, and language abilities (reading, writing, and speaking). Auditory agnosia can be general, affecting all types of sound perception, or can be (relatively) specific to a particular domain. Verbal auditory agnosia (also known as (pure) word deafness) refers to deficits specific to speech processing, environmental sound agnosia refers to difficulties confined to non-speech environmental sounds, and amusia refers to deficits confined to music. These deficits can be apperceptive, affecting basic perceptual processes, or associative, affecting the relation of a perceived auditory object to its meaning. This chapter discusses what is known about the behavioral symptoms and lesion correlates of these different types of auditory agnosia (focusing especially on verbal auditory agnosia), evidence for the role of a rapid temporal processing deficit in some aspects of auditory agnosia, and the few attempts to treat the perceptual deficits associated with auditory agnosia. A clear picture of auditory agnosia has been slow to emerge, hampered by the considerable heterogeneity in behavioral deficits, associated brain damage, and variable assessments across cases. Despite this lack of clarity, these striking deficits in complex sound processing continue to inform our understanding of auditory perception and cognition.

Neural Processing of What and Who Information in Speech

Human speech is composed of two types of information, related to content (lexical information, i.e., “what” is being said [e.g., words]) and to the speaker (indexical information, i.e., “who” is talking [e.g., voices]). The extent to which lexical versus indexical information is represented separately or integrally in the brain is unresolved. In the current experiment, we use short-term fMRI adaptation to address this issue. Participants performed a loudness judgment task during which single or multiple sets of words/pseudowords were repeated with single (repeat) or multiple talkers (speaker-change) conditions while BOLD responses were collected. As reflected by adaptation fMRI, the left posterior middle temporal gyrus, a crucial component of the ventral auditory stream performing sound-to-meaning computations (“what” pathway), showed sensitivity to lexical as well as indexical information. Previous studies have suggested that speaker information is abstracted during this stage of auditory word processing. Here, we demonstrate that indexical information is strongly coupled with word information. These findings are consistent with a plethora of behavioral results that have demonstrated that changes to speaker-related information can influence lexical processing.

Medulloblastoma presenting with pure word deafness: report of one case and review of literature

Pure word deafness (PWD) is a rare disorder characterized by impaired verbal comprehension sparing discrimination and recognition of nonverbal sounds with relatively normal spontaneous speech, writing, and reading comprehension. Etiologies of this syndrome are varied, and there are rare reports about brain tumor with PWD in children. We report a case of medulloblastoma presented with PWD in a 7-year-old girl. She visited our outpatient clinic because of English dictation performance deterioration. PWD was diagnosed by the otolaryngologist after examinations. Posterior fossa tumor and obstructive hydrocephalus were shown in the magnetic resonance imaging of the brain. The diagnosis of medulloblastoma was then made by pathology.

Pure word deafness associated with extrapontine myelinolysis

Extrapontine myelinolysis and pure word deafness are very uncommon disorders. Here, we report a case of a 19-year-old woman who suffered from osmotic demyelination syndrome with coincidence of typical pure word deafness. As a consequence of rapid correction of hyponatremia, the patient demonstrated an initial onset of cortical deafness, and then progressed to generalized auditory agnosia, which eventually developed into confined verbal auditory agnosia (pure word deafness). Bilateral extrapontine myelinolysis was confirmed using brain magnetic resonance imaging. This case suggests that verbal and nonverbal stimuli may involve separate thalamocortical pathways.

Reading comprehension without phonological mediation: further evidence from a Chinese aphasic individual

An important issue in visual word comprehension literature is whether or not semantic access is mediated by phonological processing. In this paper, we present a Chinese individual, YGA, who provides converging evidence to directly address this issue. YGA has sustained damage to the left posterior superior and middle temporal lobe, and shows difficulty in orally name pictures and reading printed words aloud. He makes phonological errors on these tasks and also semantic errors on picture naming, indicating a deficit at accessing the phonological representations for output. However, he is intact at understanding the meaning of visually presented words. Such a profile challenges the hypothesis that semantic access in reading is phonologically mediated and provides further evidence for the universal principle of direct semantic access in reading.

Pure word deafness due to left subcortical lesion: Neurophysiological studies of two patients

OBJECTIVE

This study investigated the auditory processing in two patients with pure word deafness (PWD) using neurophysiological experimental methods.

METHODS

We recorded the auditory brainstem response (ABR), the middle latency auditory-evoked response (MLR) and the auditory-evoked event-related potentials (ERPs) in two patients with PWD after subcortical hemorrhage in the left temporal lobe.

RESULTS

Both patients showed normal response in ABR and abnormality in MLR. The latency of P300 evoked by right-ear stimulation was 51 ms longer in one patient and 26 ms longer in the other patient than that evoked by left-ear stimulation.

CONCLUSIONS

Our results suggested that the prolongation of P300 latency could be caused by the deterioration of auditory stimulus processing and supported the hypothesis that the defect in auditory temporal resolution was an important factor in the development of PWD.

SIGNIFICANCE

This study demonstrated that recordings of ERP with auditory-evoked response such as ABR and MLR are useful to elucidate the deterioration of auditory stimulus processing in patients with PWD.

Human cortical representation of virtual auditory space: differences between sound azimuth and elevation

Sounds convolved with individual head-related transfer functions and presented through headphones can give very natural percepts of the three-dimensional auditory space. We recorded whole-scalp neuromagnetic responses to such stimuli to compare reactivity of the human auditory cortex to sound azimuth and elevation. The results suggest that the human auditory cortex analyses sound azimuth, based on both binaural and monaural localization cues, mainly in the hemisphere contralateral to the sound, whereas elevation in the anterior space and in the lateral auditory space in general, both strongly relying on monaural spectral cues, are analyzed in more detail in the right auditory cortex. The binaural interaural time and interaural intensity difference cues were processed in the auditory cortex around 100-150 ms and the monaural spectral cues later around 200-250 ms.

Perception of dynamic acoustic patterns by an individual with unilateral verbal auditory agnosia

Previous studies have found that subjects diagnosed with verbal auditory agnosia (VAA) from bilateral brain lesions may experience difficulties at the prephonemic level of acoustic processing. In this case study, we administered a series of speech and nonspeech discrimination tests to an individual with unilateral VAA as a result of left-temporal-lobe damage. The results indicated that the subject's ability to perceive steady-state acoustic stimuli was relatively intact but his ability to perceive dynamic stimuli was drastically reduced. We conclude that this particular aspect of acoustic processing may be a major contributing factor that disables speech perception in subjects with unilateral VAA.

Sound lateralization in patients with lesions including the auditory cortex: comparison of interaural time difference (ITD) discrimination and interaural intensity difference (IID) discrimination

We examined sound lateralization using dichotic presentation of noises in 15 patients with left unilateral (12 patients) or bilateral (3 patients) temporal lobe lesions, that included the auditory cortex, and evaluated their abilities to discriminate interaural time and intensity difference (ITD, IID) separately. On the ITD discrimination test, discrimination thresholds in patients with left unilateral lesions were significantly higher than those in normal subjects, but all patients with left unilateral lesions could detect ITD. However, none of 3 patients with bilateral lesions could detect ITD. On the IID discrimination test, all patients with either unilateral or bilateral lesions could detect IID. IID discrimination thresholds in these patients were significantly higher than those in normal subjects. The auditory cortex plays an important role in discriminating both cues, but appears to be necessary for discriminating ITD.

Clinical and neuroradiological findings in a case of pure word deafness

Pure Word Deafness is a clinical syndrome included among the aphasias and is marked by complete deafness of sudden onset with conserved ability to understand and read the written word and with no speech disorders. We report the case of 61 year old man in whom pure word deafness developed after two episodes of acute cerebral ischemia in quick succession. Neuroimaging procedures, that is: computed tomography scan, single photon emission computed tomography and magnetic resonance imaging, revealed the presence of two ischemic lesions in the temporal cortex bilaterally. Neurophysiological investigations (electroencephalogram, brainstem auditory evoked potentials and stapedial reflex) were also studied. We discuss the outcome of all these investigations in the light of the relevant published work.

Acquired word deafness, and the temporal grain of sound representation in the primary auditory cortex

This paper explores the nature of the processing disorder which underlies the speech discrimination deficit in the syndrome of acquired word deafness following from pathology to the primary auditory cortex. A critical examination of the evidence on this disorder revealed the following. First, the most profound forms of the condition are expressed not only in an isolation of the cerebral linguistic processor from auditory input, but in a failure of even the perceptual elaboration of the relevant sounds. Second, in agreement with earlier studies, we conclude that the perceptual dimension disturbed in word deafness is a temporal one. We argue, however, that it is not a generalized disorder of auditory temporal processing, but one which is largely restricted to the processing of sounds with temporal content in the milliseconds to tens-of-milliseconds time frame. The perceptual elaboration of sounds with temporal content outside that range, in either direction, may survive the disorder. Third, we present neurophysiological evidence that the primary auditory cortex has a special role in the representation of auditory events in that time frame, but not in the representation of auditory events with temporal grains outside that range.

Cortical auditory disorders: clinical and psychoacoustic features

The symptoms of two patients with bilateral cortical auditory lesions evolved from cortical deafness to other auditory syndromes: generalised auditory agnosia, amusia and/or pure word deafness, and a residual impairment of temporal sequencing. On investigation, both had dysacusis, absent middle latency evoked responses, acoustic errors in sound recognition and matching, inconsistent auditory behaviours, and similarly disturbed psychoacoustic discrimination tasks. These findings indicate that the different clinical syndromes caused by cortical auditory lesions form a spectrum of related auditory processing disorders. Differences between syndromes may depend on the degree of involvement of a primary cortical processing system, the more diffuse accessory system, and possibly the efferent auditory system.

The aprosodias: further functional-anatomical evidence for the organisation of affective language in the right hemisphere

Fourteen right-handed patients with right hemispheric strokes were examined for disorders of affective language in order to further define the clinical-anatomical correlates of the aprosodias. A bedside evaluation strategy and CT scan mappings were utilised to make these comparisons. There were six patients with motor aprosodia, one with global aprosodia, two with conduction aprosodia, one with sensory aprosodia, one with transcortical sensory aprosodia, one with pure affective deafness and two with normal examinations of affect. Functional-anatomical correlations were consistent with those predicted previously. Recovery of affective language function in selected cases was characterised by improvements in affective-prosodic repetition and/or evolution into other aprosodic subtypes. Our results lend further support to the hypothesis that the organisation of affective language in the right hemisphere mirrors that of propositional language in the left hemisphere.

Word deafness: one hundred years later

Since its original description the diagnosis of word deafness has been greatly expanded. Confusion has arisen with regard to the usage of the related terms pure word deafness, auditory agnosia, and cortical deafness. Three new cases of word deafness are presented including one case with CT and necropsy correlation. These cases are compared with 34 previously reported cases of various cortical auditory disorders. Our review establishes that patients with word deafness who have had formal testing of linguistic and non-linguistic sound comprehension and musical abilities always demonstrated a more pervasive auditory agnosia. Despite the spectrum of auditory deficits and associated language abnormalities, patients with word deafness share common features including aetiology, pathology, clinical presentation and course. These common features justify inclusion of heterogeneous cortical auditory disorders under the rubric of word deafness. Despite some limitations the term "word deafness" should be retained for this syndrome, since inability to comprehend spoken words is the most distinctive clinical deficit. Word deafness is most frequently caused by cerebrovascular accidents of presumed cardiac embolisation, with bitemporal cortico-subcortical lesions. The sequence of cerebral injury is not predictive of resulting auditory deficits. Impairment of musical abilities parallels the severity of the auditory disorder.

Cortical deafness--a case report and review of the literature

A 48-year-old woman with triple cardiac valve prostheses became completely deaf after bitemporal embolism. The lesions were demonstrated radiologically and neurophysiological investigation confirmed intact peripheral and brainstem pathways. Experimental studies of the auditory pathways are briefly reviewed. Reported cases of cortical deafness are discussed and the rarity of the condition emphasised.

Auditory vocabulary of the right hemisphere following brain bisection or hemidecortication

Unilateral scores of two commissurotomy and three (one left and two right) hemispherectomy patients were obtained on standardized auditory language comprehension tests which use pointing responses to a pictorial array. Unilateral performance by the commissurotomy patients was achieved by restricting the pictorial array to one visual half field, using a novel contact lens system which permits ocular scanning of the lateralized stimulus and self-monitoring of task performance. Using the Peabody and Ammons Picture Vocabulary Tests, the auditory vocabulary in the disconnected or isolated right hemispheres was found to be equivalent to that of normal subjects of ages 8:1 to 16:3 with a mean of 11:7 (eleven years and 7 months old). At the same time, standardized aphasia tests showed that the picture vocabulary in the right hemispheres is similar to that of a heterogeneous population of aphasics, even though the right hemispheres did not behave quite like any classical aphasic diagnostic group. No significant differences were found between right hemisphere comprehension of object vs. action names. Results indicated that vocabulary as a function of word frequency followed the same pattern in the right and left hemisphere although the right hemisphere was consistently lower. This parallel between the two hemispheres was conjectured to reflect some similar or even shared lexical structures in the two hemispheres. Together with other data on the performance of the right hemisphere on the Token Test (Zaidel, 1976), the results suggest a complex model of the development of language laterality in the brain, in which some, but not all, auditory language functions continue to develop in the right hemisphere past what is generally regarded as the critical period for language acquistion. In general, auditory language comprehension is better characterized as that of an "average aphasic" than that of a child of a specific age.

Auditory modality-specific anomia: evidence from a case of pure word deafness

In a patient with a classical syndrome of pure word deafness following a cerebrovascular accident detailed neuropsychological examination showed an almost absolute inability to name meaningful non verbal sounds, in spite of normal recognition as demonstrated by ability to match the sound with the corresponding natural source. This selective anomia, confined to auditory modality, is discussed in view of the previous researches regarding the general field in naming disturbances, which showed that for the vaste majority of aphasics, anomia was not modality dependent. Besides that the contrasting performance of the patient who showed complete lack of phonemic analysis matched with normal recognition of some acoustic parameters of speech as prosody and stress is discussed.

Agnosic behavior in anomia: a case of pathological verbal dominance

The interrelation of perceptual and verbral process was explored in a fluent aphasic with a naming disorder. This patient performed extremely well on complex perceptual tasks as long as he was instructed to remain silent or to count aloud. Whe he began to talk about what he was doing, he misnamed many test items and behaved as if they were what he had called them. The verbal interference effect is explained in terms of cerebral dominance and interhemispheric interaction and it is suggested that a similar mechanism may apply in classical cases of agnosia.