Speech Ataxia Due to Apneustic Breathing Patterns: Lessons from a Unique Presentation of a Pontine Cerebrovascular Accident

Case Diagnosis: Apneustic breathing affecting speech patterns from a pontine infarction.

Case Description or Program Description: 49-year-old female presenting to acute care with left hemiparesis and dysarthria. MRI/MRA brain revealed subacute right pontine infarct and chronic bilateral basal ganglia, left thalamic lacunar infarcts. Acute course complicated by subjective paroxysmal nocturnal and positional dyspnea leading to difficulty with language expression. Patient diagnosed with dysarthria and possible obstructive sleep apnea due to body habitus. She was discharged to inpatient rehabilitation with pulmonology follow-up.

Setting: Stroke unit, IPR facility

Assessment/Results: During rehabilitation, patient had continued issues of dyspnea. All pulmonologic/cardiologic workup was unremarkable including radiologic studies, echocardiogram and blood work. Patient unresponsive to diuresis, methylprednisolone or breathing treatments. She had no history of Obstructive Sleep Apnea or Congestive Heart Failure. Patient exhibited deep inspiration, pause in breathing at full inspiration, insufficient expiration leading to difficulties with speech. Patient was diagnosed with ataxic speech secondary to apneustic breathing patterns due to her pontine infarction.

Discussion (relevance): The pontine respiratory centers play roles in the control of rhythm and pattern of normal breathing. These include the pneumotaxic and apneustic centers which help regulate activity of inspiratory neurons in the medulla. Insult to the apneustic center in the lower pons may lead to prolonged inspiratory effort. Our patient demonstrated apneustic breathing patterns that hindered her ability to control her speech. It can be hypothesized that an apneustic breathing pattern can hinder various speech characteristics including intonation, rhythm, tempo, quality and fluency.

Conclusions: Dyspnea is a common symptom implicated in a variety of pathologies. Clinicians need to be cognizant that dyspnea may be a sequela of acute infarctions, especially, those that involve the brainstem. This would allow prompt diagnosis and possibly remove unnecessary workup for more common causes of dyspnea. Furthermore, knowledge of pathologic breathing patterns may support diagnoses of speech pathology, and vice versa, in acute infarctions.