Aphasia in multilingual individuals: The importance of bedside premorbid language proficiency assessment

With increased rates of “globalization”, the proportion of individuals who speak more than one language is rapidly expanding, with a projected number of 47 million US citizens speaking at least two languages by 2030 [1]. As a result, language impairment in multilingual persons is likely to become a frequent clinical challenge. Multilingual brains do not merely function as multiple, simultaneous monolingual brains coexisting in one individual [2,3]. Multilingual patients with acquired speech problems may present clinical nuances that underscore the relationship between anatomical lesions and subtypes of language deficits, both in the first aswell as in their second languages. Importantly, a careful history of the premorbid use of each language may be particularly relevant to understand the nature and extent of the acquired language deficits in these subjects. The importance of a comprehensive bedside language assessment is illustrated through the case of a French– English bilingual person who, after an ischemic stroke, became aphasic in English (his second, albeit most frequently used language) while remaining fairly competent in his first language. We describe his language deficits and anatomical distribution of lesion, and discuss their relevance in the context of the diagnosis of aphasia and language recovery after brain injury. A 68-year-old bilingual male (native language—L1: French, second language—L2: English), right-handed as determined by the Edinburg handedness questionnaire [4], presented to the Emergency Department of our institution 24 h after noticing word-finding difficulties. His wife reported frequent intrusions of Frenchwords while speaking in English. She also reported phonological paraphasias, such as saying “gland” for the English word ‘glove’. This pattern was not present when speaking in French. When writing in English, he reported feeling as if he was “writing in a foreign language”. French and English comprehensions were reported to be unaffected. He denied motor, sensory, or visual symptoms. The Language Experience and Proficiency Questionnaire were used for language proficiency evaluation [5]. The patient was born in Algeria and raised in France. He lived in a French-speaking country during the first 24 years of his life. He started to learn English in his mid-late twenties and he estimates becoming fluent in English at around age 30. He has been living in the US for the past 44 years, and reports using English 80% of his time in written communication, and 75% for oral communication. His current use of French is mostly restricted to interacting with family. English is the language he employs