Frontal-opercular aphasia.

The standard nomenclature divides nonfluent aphasic syndromes with relatively spared comprehension into Broca's aphasia and transcortical motor aphasia. We report on a patient with a persistent nonfluent aphasia from a discrete, primarily cortical, frontal-opercular lesion who had impaired syntax but intact repetition and, therefore, did not conform to the traditional classification. Based on this patient's behavior and a review of other cases, we have divided the nonfluent aphasias with intact comprehension into five disorders. (1) Verbal akinesia-exhibiting diminished intention or drive to speak and associated with medial frontal lesions (supplementary motor area and cingulate gyrus) or with lesions damaging the efferent projections from these areas. (2) Disorders of syntax-telegraphic and agrammatic utterances that may be associated with dominant pars opercularis lesions. (3) Phonemic disintegration-a failure to correctly produce phonemes, which may be associated with injury to the opercular primary motor cortex or efferent projections from this area. (4) Defects of lexical access-patients who struggle to find words and are impaired at timed word-generation tasks. Defects of lexical access may be associated with lesions of the pars triangularis and adjacent prefrontal cortex. (5) Mixed defects. According to this model, the traditional patient with Broca's aphasia would exhibit disorders of syntax, phonemic disintegration, and defects of lexical access, whereas the traditional patient with transcortical motor aphasia would have verbal akinesia or defects of lexical access or both. Our patient had defects of lexical access and syntax, but only mild symptoms of phonemic disintegration, suggesting that his opercular primary motor cortex was relatively intact. Our patient's ability to repeat normally while his propositional speech remained telegraphic suggests that different neural mechanisms subserve these functions.