2 2. Case 1 A 27-year-old english-speaking right-handed Irish male was involved in a road traﬃc accident in which he was projected thirty meters from his motorbike following a head-on collision with an approaching vehicle at 1700 hours. He was wearing a helmet and full protective clothing. On arrival in the accident and emergency department at 1830 hours his Glasgow coma scale (GCS) was 4/15. He was intubated and ventilated. His pupils were equal and reactive to light. His vital signs were within normal limits. He had bilateral periorbital haematomas (Racoon eyes) and a right-sided hemiparesis. Computed Axial Tomography (CT) scan as shown in Figure 1 revealed an intracerebral haemorrhage in the left temporal lobe corresponding to Wernicke’s area. Other radiological ﬁndings included fractures of the base of the right thumb, the right radial styloid, the right ulnar styloid, the radial and ulnar diaphyses, and comminuted fractures of the right humerus and femur. Following discussion with the National Neurosurgical Centre he underwent operative ﬁxation of his orthopaedic injuries. He was managed initially in the intensive care unit and was gradually weaned oﬀ sedation. His GCS returned to 15/15 on the 16th day. He had signiﬁcant expressive diﬃculties (Wernicke’s aphasia). His speech was ﬂuent but contained paraphasias and jargon. He was unaware of these abnormalities. He was unable to read text aloud and understand written language. A speech and language assessment reported severe comprehensive diﬃculties. The patient gave inaccurate yes/no answers to either personal or general orientation questions. He required extra-verbal cues to facilitate auditory comprehension. His lack of awareness of his reduced communicative abilities resulted in frustration. It was diﬃcult to ascertain whether semantic memory compromise was evident. At the time of discharge his receptive aphasia had improved slightly and he was referred for further speech and language rehabilitation. A formal psychological evaluation was unavailable. He was seen at two-week intervals by the speech therapist. His speech and language improved but he demonstrated decreased attention and tangential speech with compro- mised reading ability (40% reading comprehension of single words). He also had a signiﬁcant reduction in ﬂuency with pronunciation diﬃculties and circumlocution. His receptive function was unaﬀected. His short-term memory was also impaired. Categorisation and odd-one-out activities were used to stimulate semantic processing and represen- tations. At six-month follow-up his ﬂuency of speech had improved signiﬁcantly. He was able to construct complete sentences with occasional circumlocution. His comprehen- sion of single words improved to 90%. He produced errors only during higher level semantic tasks. He continues to improve. 3. Case 2 A 32-year-old english-speaking right-handed intoxicated Irish male presented following a fall onto a concrete path with a GCS score of 9/15. Both pupils were equal and reactive Case Reports in Medicine Figure 1: There is an area of high attenuation involving the left temporal lobe anterosuperiorly corresponding with Wernicke’s area. to light. His blood alcohol levels were 383 mcg per litre, which clouded the clinical picture (a serum alcohol level >80 mcg per litre is equivalent to 2 units of alcohol). His vital signs were within normal limits. He had multiple facial abrasions and a soft tissue swelling on the left occipital region and blood was seen emanating from his left ear. Auroscopy revealed haemotympanum. He was commenced on prophylactic intravenous antibiotics. CT brain (Figure 2) demonstrated a haematoma of the left frontal, temporal and parietal lobes superimposed upon a previous haematoma along with subarachnoid extension with slight midline shift to the right and evidence of air in the posterior cranial fossa. The National Neurosurgical Centre recommended supportive therapy and serial clinical assessments. The following morning his GCS deteriorated to 7/15 and he was intubated and ventilated. A right-sided hemiparesis was noted. His pupils and haemodynamic parameters were unchanged. A follow-up CT brain was unchanged. He was transferred to National Neurosurgical Unit in view of this clinical deterioration. A craniotomy was performed with evacuation of the temporal lobe haematoma and insertion of an intracranial pressure monitor. He was extubated on the 14th postoperative day and initially obeyed commands. He returned to our institution for further rehabilitation. Initially he had features of a motor aphasia (Broca’s). He was able to respond nonverbally by blinking his eyelids. Assessment of auditory comprehension was diﬃcult but appeared intact. As his clinical condition improved his expressive capabilities improved but did not fully recover. After 12 weeks he suc- cessfully made his ﬁrst verbal response. He was transferred to the National Rehabilitation Centre. At 3-month follow-up he had ongoing circumlocution and reported diﬃculty with reading and writing. He reported persistence of posttrau- matic amnesia. His mobility problems related to hemiparesis had resolved and he was independent in all activities of daily living.