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Postoperative foreign language syndrome
Journal of Clinical Anesthesia 38 (2017) 7–8
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Postoperative foreign language syndrome
Foreign language syndrome (FLS), a substitution of native language (first language, L1) with person's later learned language (second language, L2) may rarely occur after serious injury to the brain which renders victims unconscious. There have been few reported cases of the FLS since it was first reported in the 1940s. The most famous case was a Norwegian woman, hit by shrapnel (World War II), who subsequently developed a German accent. Other cases include two British woman, one developed a Chinese accent following a migraine, and another had a stroke and gainedz a French accent (Foreign accent syndrome).(http://www.npr.org/ sections/health-shots/2011/06/01/136824428/a-curious-case-offoreign-accent-syndrome). Very rarely ‘language switches’ were described during emergence from anesthesia, and we would like to report such a case. Case report: A 64 year-old Caucasian man with bladder cancer presented for radical cystectomy. He had no other comorbidities, and had never had surgery or anesthesia. The patient's L1 language was English, and his L2, Norwegian, was acquired later in life. He spoke exclusively English throughout his life, and spoke American English the morning of surgery. His wife reported that he reactivated and refreshed his Norwegian language skills more lately through internet communication with relatives. Preoperatively intrathecal opioid was administered for pain control. Conversation during this procedure happened to turn to language, and the patient learned the anesthesiologist was from Croatia. The last words before anesthetic induction the patient commented that ‘there are similarities between German and Nordic languages’. Anesthesia was induced with propofol and maintained with volatile agents and fentanyl. The patient's mean arterial pressure was maintained above 65 mmHg. Intraoperative labs were notable for hyperglycemia at 210 mg/dL for which insulin was given. Upon emergence, the patient followed commands his trachea was extubated and he was taken to the recovery room, where a nurse, who happened to speak Norwegian, noticed the patient was speaking only Norwegian. The anesthesiology team was summoned due to concern that the patient was unable to speak English (cerebral incident). All efforts to elicit a single English word from him were unsuccessful. The neurological exam was unremarkable. Repeat random blood glucose was 218 mg/dL. During recovery room stay the patient was speaking exclusively Norwegian, without any success on our side to elicit responses in English. Approximately 5 h postoperatively he was able to speak both English and Norwegian volitionally. Interestingly, interview, next day, revealed that he was unaware that he had been speaking Norwegian in the immediate postoperative period. His wife communicated to anesthesiologist that her husband's Norwegian language was not fluent, while PACU nurse stated that he spoke it fluently. We conducted a literature search and found 4 case reports of language switching after general anesthesia, interestingly all were in men
http://dx.doi.org/10.1016/j.jclinane.2017.01.008 0952-8180/© 2017 Elsevier Inc. All rights reserved.
(Table 1) [1–3]. Studies suggest the organization of the brain's language system is effected by age of acquisition of L2. In bilingual brains, Wernicke's area houses both L1 and L2, but in early bilinguals L1 and L2 occupy overlapping areas, while in late bilinguals L1 and L2 are stored in distinct regions [4]. Investigations suggest brain structural differences, specifically increased grey matter volume and density in Heschl's gyrus, left caudate, and left inferior parietal structures in bilinguals with L2 acquired before age 7 compared with L2 acquired later in life [4]. Our patient may be classified as ‘late L2’ acquisition, therefore one may assume that event that transiently affected L1 area of the brain (English) spared L2 region (Norwegian). Furthermore, we observed that all reports of postoperative FLS describe males only, and while this may be a coincidence, another plausible explanation may be considered. Language is more strongly lateralized in males than females, and women have bilateral activation during speech versus men who have left dominant activation [5–7]. It has also been described that males have a higher incidence of aphasia after lesions to the left hemisphere [8,9]. While our hypothesis or role of brain laterality in expression of FLS is speculative, our report may aid in future investigations into this rare phenomenon. References [1] Ward ME, Marshall JC. ‘Speaking in tongues’. Paradoxical fixation on a non-native language following anaesthesia. Anaesthesia 1999;54(12):1201–3. [2] Webster CS, Grieve RO. Transient fixation on a non-native language associated with anaesthesia. Anaesthesia 2005;60(3):283–6. [3] Akpek EA, Sulemanjii DS, Arslan G. Effects of anesthesia on linguistic skills: can anesthesia cause language switches? Anesth Analg 2002;95:1119–28. [4] Wei M, Joshi AA, Zhang M, Mei L, Manis FR, He Q, et al. How age of acquisition influences brain architecture in bilinguals. J Neurolinguistics 2015;36:35–55. [5] Kansaku K, Kitazawa S. Imaging studies on sex differences in the lateralization of language. Neurosci Res 2001;41(4):333–7. [6] Kansaku K, Yamaura A, Kitazawa S. Sex differences in lateralization revealed in the posterior language areas. Cereb Cortex 2000;10(9):866–72. [7] Marian V, Shildkrot Y, Blumenfeld HK, Kaushanskaya M, Faroqi-Shah Y, Hirsch J. Cortical activation during word processing in late bilinguals: similarities and differences as revealed by functional magnetic resonance imaging. J Clin Exp Neuropsychol 2007; 29(3):247–65. [8] Inglis J, Lawson JS. Sex differences in the effects of unilateral brain damage on intelligence. Science 1981;212(4495):693–5. [9] McGlone J. Sex differences in the cerebral organization of verbal functions in patients with unilateral brain lesions. Brain 1977;100(4):775–93.
Emily M. Pollard Toby N. Weingarten Juraj Sprung* Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States *Corresponding author. E-mail address: [email protected] (J. Sprung). 22 November 2016
8
Correspondence
Table 1 Reports of postoperative foreign language syndrome.
Author Webster Ward
Demographics 2
1
Akpek
3
Akpek3
Our case
55 year-old Caucasian ♂ (New Zealand) 54 year-old Caucasian ♂ (England) 68 year-old Caucasian ♂ (Czechoslovakian, lived abroad) ♂ of undocumented race and age (Turkey, lived in USA) 64 year-old Caucasian ♂ (USA)
Abbreviation: ♂ male.
Native language (L1)
Second language (L2)
Outcome
English
Spanish
Initially Spanish-speaking, recovered English-speaking ability in 1 h
English
Spanish
Czechoslovakian English
Initially Spanish speaking, associated with possible seizure and hypoglycemia, recovered English-speaking once glucose replenished Did not understand English commands, recovery time not documented
Turkish
English
English only speaking post-operatively for 24–28 h, then recovered speaking Turkish
American English
Norwegian Norwegian only speaking post-operatively, recovered English-speaking in 5 h
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Postoperative foreign language syndrome
Foreign language syndrome (FLS), a substitution of native language (first language, L1) with person's later learned language (second language, L2) may rarely occur after serious injury to the brain which renders victims unconscious. There have been few reported cases of the FLS since it was first reported in the 1940s. The most famous case was a Norwegian woman, hit by shrapnel (World War II), who subsequently developed a German accent. Other cases include two British woman, one developed a Chinese accent following a migraine, and another had a stroke and gainedz a French accent (Foreign accent syndrome).(http://www.npr.org/ sections/health-shots/2011/06/01/136824428/a-curious-case-offoreign-accent-syndrome). Very rarely ‘language switches’ were described during emergence from anesthesia, and we would like to report such a case. Case report: A 64 year-old Caucasian man with bladder cancer presented for radical cystectomy. He had no other comorbidities, and had never had surgery or anesthesia. The patient's L1 language was English, and his L2, Norwegian, was acquired later in life. He spoke exclusively English throughout his life, and spoke American English the morning of surgery. His wife reported that he reactivated and refreshed his Norwegian language skills more lately through internet communication with relatives. Preoperatively intrathecal opioid was administered for pain control. Conversation during this procedure happened to turn to language, and the patient learned the anesthesiologist was from Croatia. The last words before anesthetic induction the patient commented that ‘there are similarities between German and Nordic languages’. Anesthesia was induced with propofol and maintained with volatile agents and fentanyl. The patient's mean arterial pressure was maintained above 65 mmHg. Intraoperative labs were notable for hyperglycemia at 210 mg/dL for which insulin was given. Upon emergence, the patient followed commands his trachea was extubated and he was taken to the recovery room, where a nurse, who happened to speak Norwegian, noticed the patient was speaking only Norwegian. The anesthesiology team was summoned due to concern that the patient was unable to speak English (cerebral incident). All efforts to elicit a single English word from him were unsuccessful. The neurological exam was unremarkable. Repeat random blood glucose was 218 mg/dL. During recovery room stay the patient was speaking exclusively Norwegian, without any success on our side to elicit responses in English. Approximately 5 h postoperatively he was able to speak both English and Norwegian volitionally. Interestingly, interview, next day, revealed that he was unaware that he had been speaking Norwegian in the immediate postoperative period. His wife communicated to anesthesiologist that her husband's Norwegian language was not fluent, while PACU nurse stated that he spoke it fluently. We conducted a literature search and found 4 case reports of language switching after general anesthesia, interestingly all were in men
http://dx.doi.org/10.1016/j.jclinane.2017.01.008 0952-8180/© 2017 Elsevier Inc. All rights reserved.
(Table 1) [1–3]. Studies suggest the organization of the brain's language system is effected by age of acquisition of L2. In bilingual brains, Wernicke's area houses both L1 and L2, but in early bilinguals L1 and L2 occupy overlapping areas, while in late bilinguals L1 and L2 are stored in distinct regions [4]. Investigations suggest brain structural differences, specifically increased grey matter volume and density in Heschl's gyrus, left caudate, and left inferior parietal structures in bilinguals with L2 acquired before age 7 compared with L2 acquired later in life [4]. Our patient may be classified as ‘late L2’ acquisition, therefore one may assume that event that transiently affected L1 area of the brain (English) spared L2 region (Norwegian). Furthermore, we observed that all reports of postoperative FLS describe males only, and while this may be a coincidence, another plausible explanation may be considered. Language is more strongly lateralized in males than females, and women have bilateral activation during speech versus men who have left dominant activation [5–7]. It has also been described that males have a higher incidence of aphasia after lesions to the left hemisphere [8,9]. While our hypothesis or role of brain laterality in expression of FLS is speculative, our report may aid in future investigations into this rare phenomenon. References [1] Ward ME, Marshall JC. ‘Speaking in tongues’. Paradoxical fixation on a non-native language following anaesthesia. Anaesthesia 1999;54(12):1201–3. [2] Webster CS, Grieve RO. Transient fixation on a non-native language associated with anaesthesia. Anaesthesia 2005;60(3):283–6. [3] Akpek EA, Sulemanjii DS, Arslan G. Effects of anesthesia on linguistic skills: can anesthesia cause language switches? Anesth Analg 2002;95:1119–28. [4] Wei M, Joshi AA, Zhang M, Mei L, Manis FR, He Q, et al. How age of acquisition influences brain architecture in bilinguals. J Neurolinguistics 2015;36:35–55. [5] Kansaku K, Kitazawa S. Imaging studies on sex differences in the lateralization of language. Neurosci Res 2001;41(4):333–7. [6] Kansaku K, Yamaura A, Kitazawa S. Sex differences in lateralization revealed in the posterior language areas. Cereb Cortex 2000;10(9):866–72. [7] Marian V, Shildkrot Y, Blumenfeld HK, Kaushanskaya M, Faroqi-Shah Y, Hirsch J. Cortical activation during word processing in late bilinguals: similarities and differences as revealed by functional magnetic resonance imaging. J Clin Exp Neuropsychol 2007; 29(3):247–65. [8] Inglis J, Lawson JS. Sex differences in the effects of unilateral brain damage on intelligence. Science 1981;212(4495):693–5. [9] McGlone J. Sex differences in the cerebral organization of verbal functions in patients with unilateral brain lesions. Brain 1977;100(4):775–93.
Emily M. Pollard Toby N. Weingarten Juraj Sprung* Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States *Corresponding author. E-mail address: [email protected] (J. Sprung). 22 November 2016
8
Correspondence
Table 1 Reports of postoperative foreign language syndrome.
Author Webster Ward
Demographics 2
1
Akpek
3
Akpek3
Our case
55 year-old Caucasian ♂ (New Zealand) 54 year-old Caucasian ♂ (England) 68 year-old Caucasian ♂ (Czechoslovakian, lived abroad) ♂ of undocumented race and age (Turkey, lived in USA) 64 year-old Caucasian ♂ (USA)
Abbreviation: ♂ male.
Native language (L1)
Second language (L2)
Outcome
English
Spanish
Initially Spanish-speaking, recovered English-speaking ability in 1 h
English
Spanish
Czechoslovakian English
Initially Spanish speaking, associated with possible seizure and hypoglycemia, recovered English-speaking once glucose replenished Did not understand English commands, recovery time not documented
Turkish
English
English only speaking post-operatively for 24–28 h, then recovered speaking Turkish
American English
Norwegian Norwegian only speaking post-operatively, recovered English-speaking in 5 h