Neurops\cholog> Wl.Vd. 5. No. 2.

67-T)

Copyright 1^91 byttw Educational Publishing Foundation 0894-4105/91/53.00

Reversed Laterality and Crossed Aphasia: A Case Study

GLENN J. LARRABEE
Memory Assessment Clinics, Inc. Sarasota, Florida Department of Neurology University of South Florida College of Medicine Tampa, Florida James A. Haley Veterans Administration Hospital Tampa, Florida

DOREEN G. HOLLIMAN
Veterans Administration Medical Center Birmingham. Alabama

SALLY ZACHARIAH
Department of Neurology University of South Florida College of Medicine Tampa. Florida Bay Pines Veterans Administration Hospital Bay Pines, Florida Abstract: Detailed neuropsychological data are presented on a dextral man who, following right anterior temporal lobectomy for astrocytoma, manifested anomic aphasia, preserved ideomotor praxis, and good visuospatial and visual memory skills. This performance pattern is analyzed in reference to other cases of crossed aphasia, and provides further support for the thesis that crossed aphasic syndromes frequently parallel traditional left hemisphere dominant aphasic syndromes. The presence of preserved ideomotor praxis and good visuospatial and visual memory skills is considered in relation to the construct of reversed laterality and more complex models of lateral! zation of cerebral functions. Keywords: Crossed aphasia, case study, astrocytoma, neuropsychological measurements.

Crossed aphasia, or the presence of aphasic symptoms in dextrals with right hemisphere disease, is rare. Estimates of the frequency of such atypical hemispheric dominance range from 0.38% (Hecaen, Mazars, Ramier, Goldblum, & Merienne, Address correspondence te Glenn J. Larrabee, Memory Assessment Clinics, Inc., 1217 East Avenue South, Suite 209, Sarasota, Florida 34239.
67

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Glenn J. Larrabee el at.

1971) to 2.6% (Robert, 1969). Recent investigations of crossed aphasia have focused on three main issues: (a) Is hemispheric dominance reversed, with language represented in the right hemisphere and spatial functions represented in the left? (b) Do crossed aphasia syndromes parallel the typical left hemisphere aphasic syndromes? and (c) Is praxis in crossed aphasics governed by the language dominant hemisphere, or by the hemisphere contralateral to the dominant hand? The term reversed laterally originally was used by Taylor and Solomon (1979) to describe a dextral who developed impaired visuospatial ability without aphasia following a left hemisphere CVA. Subsequent cases with similar manifestations following left hemisphere CVA have been reported (Junque, Litvan, & Vendrell. 1986; Podbros & DePiero. 1985). Brown and Wilson (1973) and Larrabee, Kane, and Rodgers (1982) have reported cases of crossed aphasia in dextrals who did not suffer from visuospatial disturbances. Other cases have been reported, however, where dextrals have presented with aphasia and spatial impairments following right CVA. Although some of these crossed aphasics had auditory comprehension problems that could have contributed to poor spatial performance (Hamsher, 1981). crossed aphasic cases having spatial deficits without comprehension impairment have been reported (Carr. Jacobson, & Boiler. 1981; Clarke & Zangwill. 1965; Haaland & Miranda. 1982). Henderson (1983) and Basso. Capitani, Laiacona, and Zanobio (1985) reported cases of crossed Wernicke aphasia with qualitative errors on constructional tasks suggestive of spatially based constructional apraxia. The issue of whether crossed aphasia represents a unique language syndrome or parallels more traditional aphasic syndromes following left hemisphere damage has been addressed in several studies. Originally. Brown and Wilson (1973) argued that most cases of crossed aphasia manifest a unique language syndrome characterized by agrammatic speech, fair naming and repetition, and moderately impaired comprehension. A similar aphasic pattern has been reported in a case described by Kapur and Dunkley (1984). Others have reported cases that parallel left hemisphere aphasic syndromes including Broca's aphasia, global aphasia and transcortical sensory aphasia (Carr et al.. 1981), conduction aphasia (Haaland & Miranda, 1982). subcortical aphasia (Habib. Joanette, Ali-Cherif, & Poncet, 1983; Sapir, Kokmen, & Rogers, 1986). and Wernicke aphasia (Henderson, 1983). Moreover, CastroCaldas and Confraria (1984) noted that the representation of Broca, global, Wernicke. transcortical. and conduction aphasia in crossed aphasics was not only proportionate to the frequencies observed in uncrossed aphasics. but also reflected the same age-related associations of these aphasic syndromes. Lastly. Basso et al. (1985) have reported crossed aphasia cases with characteristics of Wernicke aphasia and Broca aphasia, with no support for Brown's hypothesis of a unique syndrome of crossed aphasia. Although cases of crossed aphasia have been accompanied by apraxia (Basso et al., 1985; Henderson, 1983), several investigators have suggested that praxis is governed by the hemisphere contralateral to the dominant hand in crossed aphasics, rather than by the language-dominant ipsilateral hemisphere (Brown & Wilson, 1973; Haaland & Miranda, 1982; Kapur & Dunkley. 1984; Larrabee et al., 1982). If this is true, then cases of reversed laterality suffering spatial deficits but no aphasia following left hemisphere damage should demonstrate ideomotor apraxia. Of four cases reported with no aphasia following left CVA, praxis was examined in two (Judd, 1989; Junque et al., 1986) and was found to be impaired. Taylor and Solomon (1979) and Podbros and DePiero (1985) did not evaluate praxis. It is

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69

noteworthy that Podbros and DePiero observed that their patient had perseverative errors in writing. It is possible that these errors were secondary to apraxia. The current case demonstrates a pattern of crossed aphasia with preserved spatial abilities and preserved ideomotor praxis in a 28-year-old, right-handed man, following right frontotemporal craniotomy for an astrocytoma, grade II. The pattern of cerebral organization is related to past studies of crossed aphasia and reversed laterality, and to the various types of cerebral organization of language, spatial functions, and praxis. Case Report The patient, a 28-year-old, right-handed man with a BS degree in physical education, was in his usual state of good health until suffering onset of olfactory hallucinations in September 1985. One month later he suffered a partial complex seizure with secondary generalization. Over this time period, the patient also complained of problems with recent memory. On subsequent evaluation, a computerized tomography (CT) scan was interpreted as depicting a mass lesion in the right frontotemporoparietal area (see Figure 1). Magnetic resonance imaging (MRI) also was conducted and reflected a 6 x 4 cm mass in the right frontoparietal area with extensive subcortical involvement (see Figure 2) of the right caudate nucleus, anterior aspect of the right internal capsule, putamen, external capsule, and globus pallidus. There was a mild right-to-left shift preoperatively.

Figure 1. Computerized tomography scan with contrast showing well-defined nonenhancing bilobulated lesion of decreased attenuation in the right frontotemporal region associated with some mass effect with no midline shift.

70

1'iyurc 2. MRI o l a I weighted image demonstrating the right frontotemporal \\ell-dctincd mass of high signal intensity.

l''i(jurc 3. Computerized tomograph) scan obtained S weeks alter surger\ showing resolution of mass hut an enhancing infaret in the right middle cerebral arters distribution.

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71

In November 1985, the patient underwent right frontotemporal craniotomy, with subtemporal decompression. The right anterior temporal lobe was excised, sparing the communicating vein of Labbe, up to the superior temporal gyrus. The superior surface of the temporal lobe was left to preserve the transverse temporal gyrus of Heschl. Pathological diagnosis was consistent with astrocytoma, grade II. Immediately postoperatively, the patient had a dense left hemiparesis and was lethargic, yet would obey some verbal commands. A global aphasia appeared to be present, and he had a slight right gaze preference. By his third postoperative day, he was able to obey verbal commands but still would not speak. He received 6,000 rads of whole brain radiation over a 6-week period following surgery. In January of 1986, he had continuing aphasic symptoms including significant word-finding problems and spelling problems, although good grammatic comprehension was present. Subsequent CT scan with contrast (Figure 3) showed resolution of the mass but an enhancing infarct in the right middle cerebral artery distribution that subsequently resolved in a later CT scan. The mild, right-to-left shift seen preoperatively was not present postoperatively. Consequently, the aphasia, which only appeared postoperatively, cannot be attributed to preoperative midline shift. The patient was transferred to the James A. Haley Veterans Administration Hospital in April 1986. Detailed language and neuropsychological evaluation was conducted in April, with repeated language examination in August 1986. A handedness inventory (Lezak, 1983) was consistent with strong right hand dominance (20 out of 24 possible points). Both of the patient's brothers are right handed, as are both parents, both sets of grandparents, and his aunts and uncles. Because his aphasia presented only subsequent to his surgery and persisted for 8 months, language deficits were not attributable to remote mass effect on left hemisphere structures. Figure 4 depicts the patient's rating profile of speech characteristics, and Figure 5 reflects subtest profiles on the Boston Diagnostic Aphasia Examination (BDAE; Goodglass & Kaplan, 1983) for the 5-month and 9-month examinations. The patient also was examined with the Multilingual Aphasia Examination (MAE; Benton & Hamsher, 1983) and the Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983). Language evaluation in April 1986 reflected fluent, well-articulated spontaneous speech, with minimal paraphasic errors, but obvious word-finding problems and expressive sentence formulation difficulties. Comprehension generally was good, limited only by verbal memory deficit. Repetition was impaired mildly on formal testing relative to normal subjects (MAE Sentence Repetition subtest = 1 st percentile and Digit Repetition = 7th percentile), but above average relative to other aphasics on the BDAE for repetition skills (see Figure 5). Formal testing reflected good language comprehension skills. In April 1986, performance on the MAE Token Test was at the 33rd percentile relative to normals (91 + relative to other aphasics), with MAE Auditory Comprehension of Words and Phrases at the 71 + percentile relative to normals (his perfect score of 18/18 was at the 91+ percentile relative to other aphasics). Figure 5 reflects his good auditory comprehension on the BDAE. Reading comprehension generally was preserved for the April and August examinations, as reflected in the BDAE performance. Writing performance was variable on the April examination, improving to overall adequate levels on the August testing. Throughout both examinations, most impaired performances were on measures of naming and word-finding ability. On the MAE, Visual Naming and

Patient's Name

K.H.

Date of Rated by APHASIA SEVERITY RATING SCALE

0 1.

No usable speech or auditory comprehension. All communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. The range of information that can be exchanged is limited, and the listener carries the burden of communication. Conversation about familiar subjects is possible with help from (he listener. There are frequent failures to convey the idea, but patient shares the burden of communication with the examiner.

2.

^f\ The patient can discuss almost all everyday problems with little or no assistance. Reduction of speech and/or comprehension, however, makes conversation about certain material difficult or impossible. 4. 5. Some obvious loss of fluency in speech or facility of comprehension, without significant limitation on ideas expressed or form of expression. Minimal discernible speech handicaps; patient may have subjective difficulties that are not apparent to listener. RATING SCALE PROFILE OF SPEECH CHARACTERISTICS
MELODIC LINE mtonaiional contour limrled to short phrases and stereotypes PHRASE LENGTH longest occasional uninterrupted word runs ARTKTULATORY ACUITY facility at phonemic and syllable level

always impaired or impossible

normal onlv m famihai words and phrases

GRAMMATICAL FORM variety o* grammatical constructions ieven <l incomplete > PARAPH ASIA IN RUNNING SPEECH

none available

limited to simple stereotypes

<

present in every utterance

once per minute Ot conversation

I ifi

Rt PETITION score in High-Probability subtest

WORD FINDING informational content m relation to lluencv

fluent without

tn lor mat ion

AUDITORY COMPREHENSION mean of percentiles on 4 Auditory Comprehen sion subtexts VOLUME VOICE RATE 1 Hvpophorm Whisper Hoarse Normal

OTHER COMMENTS

Figure 4. Rating profile of speech characteristics 5 months and 9 months postsurgery. The Aphasia Severity Rating Scale is from The Assessment of Aphasia and Related Disorders (2nd ed.). by H. Goodglass and E. Kaplan. 1983, Malvern. PA: Lea & Febiger. Copyright 1983 by Lea & Febiger. Reproduced by permission.
72

Crossed Aphasia

73

SUBTEST SUMMARY PROFILE^_ _ _Q f | i \ [f

NAME PERCENTILES: MURIT'l RATING
ARTICULATION RATING

DATE OF EXAM:

10

20

30

40

50

60

70

80

90

100

HlfNO

PHRASf LENGTH MELODIC LINE VERBAL AGILITY WORD DISCRIMINATION BODY PART IDLNTIFK ATION
,15

COMPREHENSION

COMMANDS COMPLEX IDF.ATFONAI MATERIAL RESPONSIVE NAMING

5 43

NAMING

CONFRONTATION NAMING ANIMAL NAMING WORD READING ORAL SENT(NC( READING RSPETITION Of WORDS

ORAL READING

REPETITION

HIGH PROBABILITY LOW PROBABILITY NECHCX,ISTK

PARAPHASIA

LITERAL VERBAL EXTENDED A L T O M A T I Z E D SEQUENCES RECITING SYMBOL DISCRIMINATION 0 0

12

40 75

23 12

18 5

AUTOMATIC SPfECH

READING COMPREHENSION

WORD RECOGNITION ( ()MPREHENSION OF ORAL SPELLING WORD PIC T U R E MATCHING READING SENTENCES AND PARAGRAPHS MECHANIC S SERIAL WRITING PRIMER L E V E L DICTATION

WRITING

SPELLING TO DICTATION W R I T T E N CONFRONTATION NAMING S E N T E N C E S TO DICTATION NARRATIVE WRITING MNGING RHYTHM DRAWING TO COMMAND
0 0 0 0 b ) 1 I 7 4

MUSIC

8 fe 4 81 4 b 4 b

9 7 S 93 b 9 8

10
b

-9 u
9 7
108

12 10 8
120

13

STICK MEMORY
1 I) BUM hS

11 9
130

1) 10
141

14

o
(1 i) (1 0 >4 1 J 0 1

:
70 ) i 2 4

6
100

SPATIAL AND COMPUTATIONAL

TOTAL FINGERS RIGHT lf T MAP ORIENTATION ARITHMETIC C L ( K K SETTING

152

8 11 11 8

It

14
14

Ib 27

1i
14 9 17 10

21
12

32

10

20

30

40

50

60

80

90

100

Figure 5. Boston Diagnostic Aphasia Examination subtest profile. 5 months and 9 months postsurgery. The subtest summary profile is from The Assessment of Aphasia and Related Disorders, by H. Goodglass and E. Kaplan. 1983. Malvern. PA: Lea & Febiger. Copyright 1983 by Lea & Febiger. Reproduced by permission.

74

Glenn J. Larrabee et al.

Controlled Oral Word Association scores were at less than the 1 st percentile relative to normal controls, and at the 42nd and 40th percentiles, respectively, relative to other aphasics. On the Boston Naming Test, he achieved 62% correct in April 1986 and 57% correct in August 1986. To summarize, the patient's speech profile characteristics (Figure 4) and objective language performance were consistent with an anomic aphasia syndrome. Comparison of the April and August BDAE examinations reflects some improvement in subtest performances (Commands, Complex Ideational Material, Animal Naming, Sentences to Dictation, and Narrative Writing). Overall, however, speech profile characteristics and Boston Naming Test performance reflect a relatively stable picture of anomic aphasia. Buccofacial and ideomotor praxis were evaluated in April 1986. With the exception of coughing, buccofacial praxis was preserved (he could demonstrate blowing out a match and sucking through a straw). Ideomotor praxis (right hand only was examined because of the left hemiparesis) was preserved for both intransitive limb commands (wave good-by, beckon "come here," and salute) and transitive limb commands (brush your teeth, hammer a nail, and saw a board). All movements were accurately and precisely performed without any body-part-asobject errors. Spatial, perceptual, and constructional performances were well-preserved. There was no evidence of any significant neglect or hemispatial distortion on line bisection or reproduction of a Greek cross. Three Dimensional Block Construction (Benton, Hamsher, Varney, & Spreen, 1983) was performed perfectly (29/29 correct; 79+ percentile). It is noteworthy that the three-dimensional models to be copied by the patient were all placed in the left hemispatial field by the examiner. Ability to discriminate and match shaded photographs of unfamiliar persons (Facial Recognition Test; Benton et al., 1983) was 49 correct, at the 85th percentile. Judgment of the angular orientation of paired line stimuli (Judgment of Line Orientation Test; Benton et al., 1983) was 29/30 correct, at the 86th percentile. Motor and tactile functions of the right hand also were examined. The average finger tapping speed was 42.8 taps in 10 s with the right index finger, a performance at the 19th percentile (Bornstein, 1985). Completion of the Grooved Pegboard required 91 s (8th percentile; Bornstein, 1985), and strength of grip averaged 48 kg (41st percentile, Bornstein, 1985). The first trial on the Purdue Pegboard was in the impaired range (Lezak, 1983) with 11 pegs, whereas the second trial fell in the low-normal range with 13 pegs. Overall, right hand motor functions were reduced, particularly on measures of fine motor dexterity. This testing also was conducted, however, following a full course of radiotherapy, which could have accounted for this decline in performance. Manual tactile functions were preserved for tactile identification of 10 out of 10 sandpaper geometric forms on the Tactile Form Perception Test (Benton et al., 1983). Each design was identified rapidly in 4 s, on average. Memory functioning was variable, and reflected material-specific deficits. Orientation to time was perfect, with zero errors on the Temporal Orientation Test (Benton et al., 1983). Span of digits forward was at the 7th percentile (Benton & Hamsher, 1983). As anticipated, verbal learning and memory was impaired severely on the Verbal Selective Reminding Test (Buschke, 1973). Over six trials, the patient was totally unable to enter words into long-term storage (recall a word at least once without reminding). Consequently, he also was unable to consistently retrieve

Crossed Aphasia

75

words. Both of these performances were below the first percentile (Larrabee, Trahan, & Levin. 1986). In contrast, the patient's visual memory performance was well-preserved. On the Continuous Visual Memory Test (CVMT; Trahan & Larrabee, 1988), which requires detection of recurring abstract visual patterns, scores were above average for d' (62nd percentile), total correct (63rd percentile), and 30-min delayed multiple-choice recognition (90th percentile). Recent and remote memory performance was variable for memory of the last six U.S. presidents (Hamsher, 1982). with the variability closely associated with the verbal demands of the task. On the first three subtests. performance was poor: Free Recall was four of six (9th percentile). Verbal Order (placing cards imprinted with the names of the presidents in the correct order of office) was at the 9th percentile, and Photo Naming was five out of six (1st percentile). On the Photo Naming subtest, he showed obvious difficulties secondary to anomia. In an attempt to name Ronald Reagan, he replied, "He's now." Following this comment, he was again asked to name the picture of Reagan and replied, "Yeah, but IReagan." He was unable to name a picture of Gerald Ford. In attempting to do this, he pointed to the tip of his tongue and said, "It's right here." One flawless performance was on Photo Sequencing. This required placement of photographs of the last six presidents in the correct order of office. It is noteworthy that this performance was better than the attempt to sequence printed names of the presidents, again reflecting the material-specific nature of the memory impairment. The patient's intellectual functioning was evaluated with the Wechsler Adult Intelligence ScaleRevised (WAIS-R: Wechsler, 1981). Subtest performances are displayed in Table 1. The effects of anomic aphasia on measured intellectual functioning are evident, as reflected by the lower Verbal IQ of 75, relative to the Performance IQ of 92. The Performance IQ of 92 also was lower than would be expected on the basis of his educational background. However, there also was considerable Performance IQ subtest variability, ranging from a low of the 5th percentile for the Digit Symbol subtest to the 75th percentile for Picture Completion (which was performed by pointing to the missing objects on 13 of 18 correct responses, because he was frequently unable to name them consequent to the anomia; he did, however, respond "snow on it" to the 20th item). Interestingly, he performed best when he did not need to make a verbal response and when verbal processing demands were minimal (Picture Completion and Block Design subtests). As verbal processing demands increased, performance deteriorated. Hence. Object Assembly, which makes higher verbal encoding demands than Block Design (Larrabee. 1986). was performed at a lower level. Picture Arrangement was the second poorest performance. His poorest performance of all was on the Digit Symbol subtest, which requires graphomotor coding of symbols to numbers and requires learning a new series of graphemes. Discussion The present case provides strong evidence for mediation of language and verbal memory functions by the right hemisphere and spatial and visual memory functions by the left hemisphere in a strongly right hand dominant male. The patient's good spatial abilities are demonstrated by performances on the Judgment of Line Orientation Test, Three Dimensional Block Construction, and the WAIS-R Block Design, and good visual memory (Continuous Visual Memory Test) contrasted

76

Glenn J. Larrabce el a/. Table 1 Performance on Wechsler Adult Intelligence Scale-Revised Subtest Information Digit Span Vocabulary Arithmetic Comprehension Similarities Picture Completion Picture Arrangement Block Design Object Assembly Digit Symbol Scaled score 1 5 6 1 5 4 Age Score scaled percentile 9 6 5 5 9 6 7 16 5 5 2 4

12 8 11 9 4

12 8 11 9 5

75 25 63 37 5

with anomia and verbal memory impairment. This modality-specific pattern argues against an alternative hypothesis of non-language-based word-finding impairment secondary to generalized "adynamia" with reduced arousal and cortical tone resulting from a deep, frontosubcortical lesion (cf. Luria, 1980). Such an adynamia would be expected to have a generalized effect on verbal and nonverbal functions, rather than a modality-specific effect (Crosson. 1984). Moreover, although this man had reduced performance on Picture Arrangement compared with Block Design, which has been observed following right anterior temporal lesions (Meier & French. 1966; Reitan. 1955). this is not a viable explanation for the current test performance pattern when one considers the modality-specific memory impairment. Indeed, visual memory following right anterior temporal lobectomy was above average, contrasted to severely impaired verbal memory skills. Consequently, his reduced Picture Arrangement relative to Block Design is best explained by the lower verbal processing demands of the Block Design subtest (Larrabee, 1986). The current case, which clearly presented as an anomic aphasia, provides further support that crossed aphasia syndromes parallel those seen with left hemisphere language syndromes. In reference to the Boston Veterans Administration Hospital aphasia classification scheme (Benson. 1985), the following syndromes have been observed in crossed aphasia: Wernicke aphasia (Basso et al., 1985: Castro-Caldas & Confraria, 1984: Henderson. 1983: Sweet. Panis, & Levine. 1984). Broca aphasia (Basso et al.. 1985: Castro-Caldas & Confraria, 1984: Carr et al.. 1981). conduction aphasia (Castro-Caldas & Confraria. 1984; Haaland & Miranda. 1982: Henderson, 1983). transcortical aphasia (Carr et al.. 1981: Castro-Caldas & Confraria. 1984). anomic aphasia (present case), global aphasia (Carr et al.. 1981). and subcortical aphasia (Habib et al., 1983: Sapir et al.. 1986). The fact that all of the major left hemisphere aphasic syndromes also have been reported in cases of crossed aphasia strongly argues against Brown and Wilson's (1973) thesis that there is a unique language syndrome characteristic of crossed aphasia. The present case also supports the theoretical construct of reversed laterality, with the exception of the current patient's preserved ideomotor praxis. For laterality

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77

to he truly "reversed." praxis also should be governed by the right hemisphere. Junque et al. (1986) suggested that true reversed laterality can only be manifested in the situation where a left hand dominant individual has speech and praxis governed by the right hemisphere and spatial functions mediated by the left. These authors cite the case reported by Delis. Knight, and Simpson (1983) as an example of true reversed laterality. In contrast. Junque et al. (1986) noted that a complete inversion of neuropsychological functions, including praxis, has never been reported in dextrals. The presence of preserved limb praxis in the current case supports previous data suggesting that praxis is governed by the hemisphere contralateral to the dominant hand (Brown & Wilson. 1973: Haaland & Miranda. 1982: Junque et al.. 1986: Kapur & Dunkley. 1984: Larrabee et al.. 1982). Although this would suggest an invariant pattern of cerebral representation of praxis (i.e.. always represented by the hemisphere contralateral to the dominant hand), the cases reported by Basso et al. (1985) and Henderson (1983) document that apraxia can result from right hemisphere lesions in right-handed crossed aphasic individuals, although this apparently is a much less frequent occurrence in crossed aphasia. The observation by Junque and colleagues (1986) that true reversed laterality only occurs in left-handers with right hemisphere speech representation, and the data of Basso et al. (1985) and Henderson (1983) documenting that praxis can be impaired in crossed aphasia, support a complex pattern of the varieties of cerebral hemispheric representation of neuropsychological functions. As noted by Junque et al. (1986). the variability of lateralization of functions is underscored further by studies reporting spatial deficits in crossed aphasia (Basso et al.. 1985: Carr et al.. 1981: Clarke & Zangwill. 1965: Haaland & Miranda. 1982: Henderson. 1983). The complexity of lateralization of neuropsychological functions was addressed several years ago in an article by Kreindler. Fradis. and Sevastopol (1966). These authors proposed eight types of hemispheric organization (four for right-handers and the converse of these for left-handers): (a) language in the left hemisphere, spatial in the right: (b) language in the right hemisphere, spatial in the.left: (c) language and spatial in the left hemisphere: and (d) language and spatial in the right hemisphere. The second type of cerebral lateralization would correspond to most cases of right hand dominant crossed aphasia (spatial and dominant hand representation in the left hemisphere and language represented in the righthemisphere in a right-hander). Junque et al.'s (1986) "true" reversed laterality (the case of Delis et al.. 1983) would correspond to Kreindler et al.'s (1966) laterality pattern for a left-hander, of spatial functions represented in the left hemisphere and language and dominant hand control represented by the right hemisphere. It is noteworthy that laterality of praxis, or the control of skilled meaningful hand movements, was not addressed by Kreindler et al. (1966). Although, as noted, the majority of right-handers with both typical hemisphere dominance and crossed aphasia appear to have praxis controlled by the hemisphere contralateral to the dominant hand, other representations can occur in which praxis can be governed by the language dominant hemisphere (Basso et al.. 1985: Henderson. 1983). Although this raises the question of the possible existence of one hemisphere representing basic manual dominance, with the other hemisphere representing language, spatial, and ideomotor praxis abilities. Basso et al. (1985) reported three cases of crossed aphasia with additional spatial deficits who did not have accompanying ideomotor apraxia. In closing, the present case study is of interest in several respects. First, it

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Glenn J. Larrabee el al.

provides further evidence to accompany the growing body of literature documenting that language syndromes in crossed aphasia parallel those seen in left hemisphere aphasic syndromes. Additionally, it documents that a frequent hemispheric representation of function in right-handed dominant crossed aphasia is one favoring control of spatial functions and praxis by the left hemisphere. Finally, the exceptions to this frequent pattern of representation of functions in crossed aphasia underscore the complexity of cerebral lateralization of functions in general, and support more complex models of lateralization of functions such as the one proposed by Kreindler etal. (1966). References Basso. A., Capitani, E., Laiacona. M.. & Zanobio. M.E. (1985). Crossed aphasia: One or more syndromes? Cortex. 21. 25-45. Benson. D.F. (1985). Aphasia. In K.M. Heilman & E. Valenstein (Eds.). Clinical neuropsychology (2nd ed.. pp. 17-47). New York: Oxford University Press. Benton, A.L., & Hamsher. K. deS. (1983). Multilingual Aphasia Examination. Iowa City. IA: AJA Associates, Inc. Benton. A.L.. Hamsher, K. deS., Varney. N.R.. & Spreen. O. (1983). Contributions to neuropsychological assessment: A clinical manual. New York: Oxford University Press. Bornstein, R. (1985). Normative data on selected neuropsychological measures in a nonclinical sample. Journal of Clinical Psychology. 41. 651-659. Brown. J.W.. & Wilson. F.R. (1973). Crossed aphasia in a dextral. A case report. Neurologv. 2J. 907-911. Buschke, H. (1973). Selective reminding for analysis of memory and learning. Journal of Verbal Learning and Verbal Behavior. 12. 543-550. Carr, M.S., Jacobson. T., & Boiler. F. (1981). Crossed aphasia: Analysis of four cases. Brain and Language, 14. 190-202. Castro-Caldas. A.. & Confraria, A. (1984). Age and type of crossed aphasia in dextrals due to stroke. Brain and Language. 23. 126-133. Clarke. B., & Zangwill, O. L. (1965). A case of "crossed aphasia" in a dextral. Neuropsycho/ogia,3.Sl-86. Crosson. B. (1984). Role of the dominant thalamus in language: A review. Psychological Bulletin, 96. 491-517. Delis. D.C.. Knight. R.T.. & Simpson. G. (1983). Reversed hemispheric organization in a left-hander. Neuropsychologia. 21. 13-24. Goodglass. H.. & Kaplan. E. (1983). The assessment of aphasia and related disorders (2nd ed.). Philadelphia, PA: Lea & Febiger. Haaland, K.Y., & Miranda. F. (1982). Psychometric and CT scan measurements in a case of crossed aphasia in a dextral. Brain and Language, 17, 240-260. Habib, M.. Joanette. Y., Ali-Cherif. A.. & Poncet, M. (1983). Crossed aphasia in dextrals: A case report with special reference to site of lesion. Neuropsychologia. 21. 413-418. Hamsher, K. (1981). Intelligence and aphasia. In M.T. Sarno (Ed.). Acquired aphasia (pp. 327-359). New York: Academic Press. Hamsher, K. (1982). Presidents Test. Manual of instructions. Milwaukee. Department of Neurology, University of Wisconsin Medical School. Hecaen, H., Mazars, G.. Ramier, A., Goldblum, M..& Merienne. L. (1971). Aphasie croissee chez un sujet droitier bilingue (vietnamien-francais) [Crossed aphasia in a right-handed bilingual subject (Vietnamese-French)]. Revue Neurologique, 124. 319-323. Henderson, V.W. (1983). Speech fluency in crossed aphasia. Brain. 106. 837-857, Judd, T. (1989). Crossed "right hemisphere syndrome" with limb apraxia: A case study. Neuropsychology. 3. 159-173.

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