Category: Clinical Sciences/Health Conditions
Case Diagnosis: Speech apraxia due to open traumatic brain injury
A 24-year-old male with open traumatic brain injury (TBI) due to gunshot wound (GSW). Initial evaluation revealed a GCS of 3 with GSW to left arm, left abdomen, left flank, and left skull. Initial work up with CT-Head showed extensive subarachnoid hemorrhage and cerebral edema with residual bullet fragments in the posterior fossa.
Thirty days later he was transferred to our rehabilitation hospital. His examination was notable for significant bilateral limb ataxia. He was also noted to have mutism without facial weakness. Speech-language pathology (SLP) evaluation noted effortful groping, frustration, mild facial weakness, and severe impairment most consistent with speech apraxia.
The patient was started on amantadine 25-100mg twice daily on day 40. On day 46 of rehabilitation he was able to consistently answer yes-no questions with ataxic head nods and attempted spontaneous communication but was unable to do so due to apraxia of speech. His speech did not improve further and on day 54 his carbidopa-levadopa was increased to 25-100mg three times daily. After two doses he was able to make unintelligible voice.
He again plateaued and on day 64, carbidopa-levadopa was titrated to 50-200mg three times daily and on the same day he was able to phonate the entire alphabet with max cueing. Over the next few weeks he had improved intelligibility, consistently produced simple 2-3 word sentences, answered questions of preference with a single word, and correctly identified 50% of one-word images on articulation cards, 75% with phonemic or phrase closure cues, and 100% with verbal model.
This case presents a patient with speech apraxia that had a dose-dependent response to carbidopa-levadopa. Carbidopa-levadopa should be considered for treatment of speech apraxia.