Case 104
The artery responsible to brain infarction
The infarct area
【Progress】
She is receiving rehabilitation with speech language therapist of our hospital. Her status of hemiparesis and speech disturbance are getting improved compared to that at admission, although the speed of their recovery is quite slow.
【Discussion】
Broca region and Wernicke region are the central areas of brain for language. The dominant Broca region plays a role of language production. Broca area situates at the lateral part of frontal lobe: a part of operculum and a part of triangularis of the inferior frontal gyrus. On axial images of MRI, Broca region exists in upper-front of lateral (Sylvian) fissure and can be identified as a front-superior component of operculum. Pars triangularis situates in front of anterior operculum (1-3).
Wernicke region plays a role of understanding of language that we hear and read. Wernicke region situates at the lateral and most upper part of the temporal lobe, namely in the superior temporal gyrus. It is also adjacent to auditory cortex. Wernicke region forms an edge of posterior-superior part of operculum. Then, on axial images of MRI, Wernicke region can be identified as the area upper-posteriorly relative to insula (4).
Broca area and Wernicke area connect with thick bundle called arcuate fasciculus, indicating interactive communication for understanding and production of words. Further, arcuate fasciculus connects with supra-marginal gyrus and angular gyrus at the parietal lobe which is called the parietal association area (1-4). Words information travels to this area integrating with visual, sensory, and auditory information.
Middle cerebral artery irrigates lateral area of cerebrum including frontal, parietal and posterior lobes, while anterior cerebral artery irrigates anterior medial area of cerebrum and posterior cerebral artery irrigates posterior medial area. Broca region and Wernicke region situate at the different lobe of frontal lobe and temporal lobe, respectively but both regions situate at the lateral site of both lobes, implying these areas are irrigated by the middle cerebral artery. Broca region gets blood supply from the anterior-superior branch of the middle cerebral artery (5). Wernicke region gets blood supply from the inferior terminal branch of the middle cerebral artery (6). Further, the superior cerebral branch of the middle cerebral artery irrigates not only the inferior frontal gyrus but also the precentral gyrus of primary motor cortex: voluntary motor movement.
Our patient experienced left hemiparesis and inability to speak or to organize the muscular movements of speech. She had atrial fibrillation and brain stroke, indicating that emboli from the heart make the superior branches of the middle cerebral artery occluded. Rehabilitation made her hemiparesis and speech disturbance improving slowly but gradually.
【Summary】
We present an eighty two-year-old female who experienced right hemiparesis and motor aphasia caused by occlusion of the superior branch of the left middle cerebral artery. Because she had cardiac fibrillation, emboli from the heart was considered to travel to the middle cerebral artery. MRI with diffusion weighted imaging showed fresh infarction of the frontal lobe corresponded to the left (dominant) Broca area. We should keep in mind that Broca area is in the inferior frontal gyrus and situates at the anterior part of the operculum (anterior relative to insula). While Wernicke area is in the superior temporal gyrus and situates at the superior posterior part relative to insula. Further, not only Broka area and Wernicke regions but also supra-marginal gyrus and angular gyrus are central area for language production and comprehension. Furthermore, superior branches of the middle cerebral artery irrigates both Broca area and precentral gyrus of primary motor cortex, and inferior branch of the middle cerebral artery irrigates Wernicke area.
【References】
1.Keller SS, et al. A comparative magnetic resonance imaging study of the anatomy, variability, and asymmetry of Broca's area in the human and chimpanzee brain. J. Neurosci. 2009;29 (46): 14607-16. doi:10.1523/JNEUROSCI.2892-09.2009 - Free text at pubmed - Pubmed citation
2.Krieg SM, et al. Functional language shift to the right hemisphere in patients with language-eloquent brain tumors. PLoS ONE. 2013;8 (9): e75403. doi:10.1371/journal.pone.0075403 - Free text at pubmed - Pubmed citation
3.Finger S, et al. Does the right hemisphere take over after damage to Broca's area? the Barlow case of 1877 and its history. Brain Lang. 2003;85 (3): 385-95. Pubmed citation
4.Butler P, et al. Applied Radiological Anatomy. Cambridge University Press. (2012) ISBN:0521766664. Read it at Google Books - Find it at Amazon
5.The Internet Stroke Center. Stroke syndromes: Middle cerebral artery - superior division. [Internet]. [updated 1999 July; cited 2011 May 13]. Retrieved from http://www.strokecenter.org/prof/syndromes/syndromePage5.htm
6.The Internet Stroke Center. Stroke syndromes: Middle cerebral artery - inferior division. [Internet]. [updated 1999 July; cited 2011 May 13]. Retrieved from http://www.strokecenter.org/prof/syndromes/syndromePage6.htm
She is receiving rehabilitation with speech language therapist of our hospital. Her status of hemiparesis and speech disturbance are getting improved compared to that at admission, although the speed of their recovery is quite slow.
【Discussion】
Broca region and Wernicke region are the central areas of brain for language. The dominant Broca region plays a role of language production. Broca area situates at the lateral part of frontal lobe: a part of operculum and a part of triangularis of the inferior frontal gyrus. On axial images of MRI, Broca region exists in upper-front of lateral (Sylvian) fissure and can be identified as a front-superior component of operculum. Pars triangularis situates in front of anterior operculum (1-3).
Wernicke region plays a role of understanding of language that we hear and read. Wernicke region situates at the lateral and most upper part of the temporal lobe, namely in the superior temporal gyrus. It is also adjacent to auditory cortex. Wernicke region forms an edge of posterior-superior part of operculum. Then, on axial images of MRI, Wernicke region can be identified as the area upper-posteriorly relative to insula (4).
Broca area and Wernicke area connect with thick bundle called arcuate fasciculus, indicating interactive communication for understanding and production of words. Further, arcuate fasciculus connects with supra-marginal gyrus and angular gyrus at the parietal lobe which is called the parietal association area (1-4). Words information travels to this area integrating with visual, sensory, and auditory information.
Middle cerebral artery irrigates lateral area of cerebrum including frontal, parietal and posterior lobes, while anterior cerebral artery irrigates anterior medial area of cerebrum and posterior cerebral artery irrigates posterior medial area. Broca region and Wernicke region situate at the different lobe of frontal lobe and temporal lobe, respectively but both regions situate at the lateral site of both lobes, implying these areas are irrigated by the middle cerebral artery. Broca region gets blood supply from the anterior-superior branch of the middle cerebral artery (5). Wernicke region gets blood supply from the inferior terminal branch of the middle cerebral artery (6). Further, the superior cerebral branch of the middle cerebral artery irrigates not only the inferior frontal gyrus but also the precentral gyrus of primary motor cortex: voluntary motor movement.
Our patient experienced left hemiparesis and inability to speak or to organize the muscular movements of speech. She had atrial fibrillation and brain stroke, indicating that emboli from the heart make the superior branches of the middle cerebral artery occluded. Rehabilitation made her hemiparesis and speech disturbance improving slowly but gradually.
【Summary】
We present an eighty two-year-old female who experienced right hemiparesis and motor aphasia caused by occlusion of the superior branch of the left middle cerebral artery. Because she had cardiac fibrillation, emboli from the heart was considered to travel to the middle cerebral artery. MRI with diffusion weighted imaging showed fresh infarction of the frontal lobe corresponded to the left (dominant) Broca area. We should keep in mind that Broca area is in the inferior frontal gyrus and situates at the anterior part of the operculum (anterior relative to insula). While Wernicke area is in the superior temporal gyrus and situates at the superior posterior part relative to insula. Further, not only Broka area and Wernicke regions but also supra-marginal gyrus and angular gyrus are central area for language production and comprehension. Furthermore, superior branches of the middle cerebral artery irrigates both Broca area and precentral gyrus of primary motor cortex, and inferior branch of the middle cerebral artery irrigates Wernicke area.
【References】
1.Keller SS, et al. A comparative magnetic resonance imaging study of the anatomy, variability, and asymmetry of Broca's area in the human and chimpanzee brain. J. Neurosci. 2009;29 (46): 14607-16. doi:10.1523/JNEUROSCI.2892-09.2009 - Free text at pubmed - Pubmed citation
2.Krieg SM, et al. Functional language shift to the right hemisphere in patients with language-eloquent brain tumors. PLoS ONE. 2013;8 (9): e75403. doi:10.1371/journal.pone.0075403 - Free text at pubmed - Pubmed citation
3.Finger S, et al. Does the right hemisphere take over after damage to Broca's area? the Barlow case of 1877 and its history. Brain Lang. 2003;85 (3): 385-95. Pubmed citation
4.Butler P, et al. Applied Radiological Anatomy. Cambridge University Press. (2012) ISBN:0521766664. Read it at Google Books - Find it at Amazon
5.The Internet Stroke Center. Stroke syndromes: Middle cerebral artery - superior division. [Internet]. [updated 1999 July; cited 2011 May 13]. Retrieved from http://www.strokecenter.org/prof/syndromes/syndromePage5.htm
6.The Internet Stroke Center. Stroke syndromes: Middle cerebral artery - inferior division. [Internet]. [updated 1999 July; cited 2011 May 13]. Retrieved from http://www.strokecenter.org/prof/syndromes/syndromePage6.htm
2018.5.16