aphasias in stroke patients

8/10/2019 Aphasias in Stroke Patients

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Dr. Athanasios MamarelisClinical Attachment

Stroke Services


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Dor.S. , 89 year old womanSudden onset confusion

Weakness,

Facial droop,

Pronator driftExpressive aphasia obey commands name objects

CT Left MCA infarct


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A.Ed. , 95 year old womanSudden onset confusion

CNS examination difficult to complete Weakness, Facial droop, Pronator drift

CT Acute infarct in Right lateral temporal lobe Extended to parietal lobe ?Edema in Left temporal lobe


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De.Tur. , 54 year old womanRight sided weakness

Occipital headacheVomitingSigns of intracranial pressure

Sudden deteriorationExpressive aphasia

2-3

hours


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Certain patternsPredictable syndromes

Basis for cortical localizationist modelsReliable diagnosis & prognosis

25% ofstroke patients

Significant aphasia


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Broca (1861)

Wernicke (1874)

Importance of left hemisphere in language

Comprehension deficitSensorimotor organization of language


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Anatomicaly & physiologicaly evidenceOverlapping

Function represented at multiple sites Each area belongs to several networks

All or most of the structurals compontens involved

Severe & lasting deficits


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Phonology(pronunciation rules & sounds perception)Semantics(words meaning)

Syntax or Grammar(relationship & shape of words, phrases, sentences accuratemeaning)Pragmatics(give & take maintenance of conversation)

Sign languageSimilar elementsNO phonology sign morphology

Aphasic syndromesin deaf


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AphasiaNon-Fluent

Limited ability to produce speech;effortful and with few words

Goodunderstanding of

language(spoken & written)

Brocas AphasiaTranscortical Motor

Aphasia

Poorunderstanding of


Mixed Non-FluentAphasia

Global Aphasia

Fluent

Able to produce connectedspeech

Goodunderstanding of


Conduction AphasiaAnomic Aphasia

Poorunderstanding of


Wernickes Aphasia Transcortical Sensory

Aphasia


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Effortful speech outputHesitations & Pauses

Word-finding difficultyPhonemic & Semantic errorsAgrammatismRelatively preserved comprehension


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Lesion Brocas areaGood recovery if only there

PersistingLarge lesion

Brocas area + inferior parietal

subcorticalregions

White matter involvement Fluency deficit


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Loss of speech output & comprehensionDestruction of anterior & posterior

Lesion Large MCA stroke (hemorrhage)

Wernickes area may be spared recover towards Brocas aphasia

White matter lesions may be persistant


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PureAll forms of speech affectedWriting spared (usually)Hesitation, stuttering, dysprosody, initial consonantsubstitution

TranscorticalPoor spontaneous speech & written outputGood repetition & comprehensionVariable naming deficit


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PureBrocas area

Inferior rolandicInsular cortical

TranscorticalSuperior mesial frontal regionSupplementary speech area


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Complex processAnalysis of acoustic & phonological input

propertiesRecognition of syntactic & lexical elementsHighly specializedLeft hemisphereAnalytical


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Fluent & paraphasic speechComprehension, repetition, naming (impaired)Syntax & morphology (relatively preserved)Semantic & phonological paraphasias (not aware)Reading & writing (simlarly affected)

When severe neologistic jargonSubstitution of substantive words with

unintelligible phonological paraphasiasSuperior posterior temporal branch of MCALesions superior temporal & inferior parietalregions


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Complains of not understanding speechHearing, reading, speech output

(undisturbed)

Word form(mishear phonologically similar words) Word meaning(perfoms lexical decision but cannot accesssemantics)


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Poor repetitionRelatively fluentPhonologically paraphasic speechGood comprehension

More fluent varieties More posterior lesions

LesionsPosterior temporoparietal region (end of Sylvian fissure)Involve posterior insula or arcuate fasciculus


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Fluent, semantic jargonPoor comprehensionGood repetition

Lesionswatershed area between middle &

posterior cerebral circulationRapid recovery(unless evolved from a more severe lesion)


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Features of both motor & sensorytranscortical aphasia

Poor prognosis

LesionsTend to surround MCA territory

isolating language area


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The mildest formFluent output

Good comprehensionNaming & word finding difficulty (anomia)

Anterior & central lesionsLexical retrieval deficit

Posterior temporoparietal lesionsNaming difficulty


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Lesions of basal gangliaDysarthria & hypophonia severe global aphasia

Anomic aphasiaTranscortical feature presevertion of repetition

Lesion in putamen & anterior internal capsuleslow, anomic, dysarthric speech

Isolated lesions of caudate & putamen (rare)transient speech deficits


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Damasio et al. (1982)Infarcts anterior limb of internal capsule & striatumNon-aphasics more lateral or claudal lesions

Naeser et al. (1982)9 patients with capsuloputaminal lesions

Anterio-superior periventricular matterGood comprehension & grammaticalSlow, dysarthric speech

Across the temporal isthmusFluent speechPoor comprehension

Both anterio-superior & posteriorGlobal aphasia


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21-33 % acute stroke38-45% hyperacute stage

1. Global aphasia (25%)2. Wernickes aphasia (15 -25%)3. Anomic aphasia4. Transcortical motor aphasia5. Brocas aphasia

Brocas

Conduction

Anomic


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MigraineMultiple sclerosis

Infections (herpes simplex encephalitis)Arteriovenous malformations
http://aphasiology.pitt.edu/archive/00000637/01/02-11a.pdfhttp://aphasiology.pitt.edu/archive/00000637/01/02-11a.pdfhttp://aphasiology.pitt.edu/archive/00000637/01/02-11a.pdfhttp://aphasiology.pitt.edu/archive/00000637/01/02-11a.pdf


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Aphasic stroke syndromes are not stableRecovery take place to a considerable

extentStructural limitationscompensation only in certain areas

Adjacent cortexContralateral cortexHierarchically connected structure(e.g. subcortical ganglia)


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Compensation through R hemispherefunction

Patients who became aphasic with a single Lhemisphere stroke but recovered2nd R hemisphere stroke language deficit againStudies of sodium amytal given to aphasics whohade recovered


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Variation in recovery(Cannot be explained by the extent & location of lesions)

DifferencesLanguageLaterility

Handedness (L handers)AgeGender (more bilateral distribution of language inwomen)


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CBFR-hemisphere hypometabolism in aphasic

patientsMore blood flow in the L hemisphere

more improvement

PETHypometabolismCerebral infarctsRemote areas


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MRI (DWI/PWI)Recovery in the acute stage depends on

improving circulation in surrounding areas


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aphasias in stroke patients

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