Word deafness and Wernicke's aphasia; report of cases and discussion of the syndrome

Situating word deafness within aphasia recovery: A case report

Word deafness is a rare neurological disorder often observed following bilateral damage to superior temporal cortex and canonically defined as an auditory modality-specific deficit in word comprehension. The extent to which word deafness is dissociable from aphasia remains unclear given its heterogeneous presentation, and some have consequently posited that word deafness instead represents a stage in recovery from aphasia, where auditory and linguistic processing are affected to varying degrees and improve at differing rates. Here, we report a case of an individual (Mr. C) with bilateral temporal lobe lesions whose presentation evolved from a severe aphasia to an atypical form of word deafness, where auditory linguistic processing was impaired at the sentence level and beyond. We first reconstructed in detail Mr. C's stroke recovery through medical record review and supplemental interviewing. Then, using behavioral testing and multimodal neuroimaging, we documented a predominant auditory linguistic deficit in sentence and narrative comprehension-with markedly reduced behavioral performance and absent brain activation in the language network in the spoken modality exclusively. In contrast, Mr. C displayed near-unimpaired behavioral performance and robust brain activations in the language network for the linguistic processing of words, irrespective of modality. We argue that these findings not only support the view of word deafness as a stage in aphasia recovery but also further instantiate the important role of left superior temporal cortex in auditory linguistic processing.

Cortical disorders of speech processing: Pure word deafness and auditory agnosia

Selective disorders of auditory speech processing due to brain lesions are reviewed. Over 120 years after the first anatomic report (Dejerine and Sérieux, 1898), fewer than 80 cumulative cases of generalized auditory agnosia and pure word deafness with documented brain lesions are on record. Most patients (approximately 70%) had vascular lesions. Damage is very frequently bilateral in generalized auditory agnosia, and more frequently unilateral in pure word deafness. In unilateral cases, anatomical disconnection is not a prerequisite, and disorders may be due to functional disconnection. Regardless of whether lesions are unilateral or bilateral, speech processing difficulties emerge in the presence of damage to the superior temporal regions of the language-dominant hemisphere, suggesting that speech input is processed asymmetrically at early stages already. Extant evidence does not allow establishing whether processing asymmetry originates in the primary auditory cortex or in higher associative cortices, nor whether auditory processing in the brainstem is entirely symmetric. Results are consistent with the view that the difficulty in processing auditory input characterized by quick spectral and/or temporal changes is one of the critical dimensions of the disorder. Forthcoming studies should focus on detailed audiologic, neurolinguistic, and neuroanatomic descriptions of each case.

Anatomical Correlates of Non-Verbal Perception in Dementia Patients

Purpose: Patients with dementia who have dissociations in verbal and non-verbal sound processing may offer insights into the anatomic basis for highly related auditory modes.

Methods: To determine the neuronal networks on non-verbal perception, 16 patients with Alzheimer’s dementia (AD), 15 with behavior variant fronto-temporal dementia (bv-FTD), 14 with semantic dementia (SD) were evaluated and compared with 15 age-matched controls. Neuropsychological and auditory perceptive tasks were included to test the ability to compare pitch changes, scale-violated melody and for naming and associating with environmental sound. The brain 3D T1 images were acquired and voxel-based morphometry (VBM) was used to compare and correlated the volumetric measures with task scores.

Results: The SD group scored the lowest among 3 groups in pitch or scale-violated melody tasks. In the environmental sound test, the SD group also showed impairment in naming and also in associating sound with pictures. The AD and bv-FTD groups, compared with the controls, showed no differences in all tests. VBM with task score correlation showed that atrophy in the right supra-marginal and superior temporal gyri was strongly related to deficits in detecting violated scales, while atrophy in the bilateral anterior temporal poles and left medial temporal structures was related to deficits in environmental sound recognition.

Conclusions: Auditory perception of pitch, scale-violated melody or environmental sound reflects anatomical degeneration in dementia patients and the processing of non-verbal sounds are mediated by distinct neural circuits.

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.

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.

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.

Clinical and audiological findings in a case of auditory agnosia

A case is reported of severe agnosia for verbal and non-verbal sounds without associated aphasic disorder. A CT scan revealed bilateral, temporal lobe lesions from two ischaemic accidents that had occurred 9 months apart. The search for subtle deficits in the patient showed normal sensitivity to changes in the intensity and frequency of simple sounds; in contrast, his ability to discriminate sound duration and musical note sequences was severely impaired. The simultaneous recording of the whole auditory-evoked response pattern revealed no abnormality in the early components, which reflect the activation of the auditory nuclei and pathways of the brain stem. However, the middle and late components were delayed and slowed. These results and others in the literature suggest that the neocortex in man, as in other mammals, plays an essential role in the temporal aspects of hearing. Also, the two main ingredients commonly recognized in auditory agnosia, i.e. word deafness and the inability to interpret non-verbal sounds, are caused by the disruption of elementary, bilaterally represented cortical functions which start the processing of every kind of auditory information.