Delusions and mood disorders in patients with chronic aphasia

Sixty-one inpatients manifesting chronic aphasic syndromes were reviewed. Most aphasic patients with behavioral abnormalities sufficiently severe to require hospitalization had posterior hemispheric lesions and fluent disorders. Thirty-eight (62%) had fluent aphasia, eight (13%) had nonfluent aphasia, and 15 (25%) had anomic, global, or transcortical aphasic syndromes. Delusions were more common among patients with fluent aphasias (58%), whereas depression was the most common psychiatric disorder among patients with anterior lesions (63%). Elation occurred in 12 patients, 11 with posterior lesions and 1 with a nonlocalizing syndrome. Neuropsychiatric disturbances in patients with chronic aphasia syndromes correlate with the type of language disorder and with the location of the associated lesion.     

Changing patterns of childhood aphasia

Acquired aphasia in children has been generally characterized as nonfluent, transient, and frequently due to right hemisphere lesions. We studied 65 children with unilateral hemispheric brain lesions occurring after speech acquisition any time from the second through the fourteenth year. Of 34 patients with a left hemisphere lesion, 25 had an initial aphasic speech disturbance, while of 31 patients with a right hemisphere lesion, only 4 (including 2 lefthanders) showed any initial aphasia. All those who became aphasic before the age of 8 years eventually regained speech, but recovery time required ranged from less than a month to more than two years. One 5-year-old boy who recovered had initial jargon aphasia. Our review of the literature indicated that the conflict between our results and the traditional claim of frequent aphasia with right hemisphere lesions was only apparent; the great majority of crossed aphasias are concentrated in reports written before antibiotics were used, and many cases were associated with systemic bacterial infections.     

Clinical and pathological characterization of progressive aphasia

OBJECTIVE: The clinical and neuropathological categorization of patients presenting with progressive aphasia is an area of controversy. This study aimed to characterize a large group of progressive aphasic patients from a single center (n = 38), first clinically by case note review, and then pathologically. METHODS: Hierarchical cluster analysis of the cases according to their clinical language deficits was used to establish an unbiased, data-driven classification. RESULTS: This analysis revealed two groups of cases corresponding to the syndromes of progressive nonfluent aphasia (n = 23) and semantic dementia (n = 15). Postmortem analysis showed a majority in both groups of pathologies from the spectrum of frontotemporal lobar degeneration: the most frequent were non-Alzheimer's disease (AD) tauopathy in the nonfluent cases (10 of 23) and frontotemporal lobar degeneration with ubiquitin-positive, tau-negative inclusions in the fluent cases (8 of 15). Despite rigorous exclusion of cases with clinically significant memory deficits or other cognitive impairments, the pathology of AD was present in approximately one third of each group (overall 12 of 38), although often with an atypical neuroanatomical distribution. INTERPRETATION: Progressive aphasia is best seen as a composite of two conditions, on both clinical and pathological levels: progressive nonfluent aphasia and semantic dementia.     

Aphasia in border‐zone infarcts has a specific initial pattern and good long‐term prognosis

Background: While border‐zone infarcts (BZI) account for about 10% of strokes, studies on related aphasia are infrequent. The aim of this work was to redefine specifically their early clinical pattern and evolution. Methods: We prospectively studied consecutive patients referred to our stroke unit within a 2‐year period. Cases of aphasia in right‐handed patients associated with a MRI confirmed left‐sided hemispheric BZI were included. These patients had a standardized language examination in the first 48 h, at discharge from stroke unit and between 6 and 18 months later. Results: Eight patients were included. Three had anterior (MCA/ACA), two posterior (MCA/PCA), two both anterior and posterior, and one bilateral BZI. All our patients initially presented transcortical mixed aphasia, characterized by comprehension and naming difficulties associated with preserved repetition. In all patients, aphasia rapidly improved. It fully recovered within a few days in three patients. Initial improvement was marked, although incomplete in the five remaining patients: their aphasias specifically evolved according to the stroke location toward transcortical motor aphasia for the three patients with anterior BZI and transcortical sensory aphasia for the two patients with posterior BZI. All patients made a full language recovery within 18 months after stroke. Conclusions: We report a specific aphasic pattern associated with hemispheric BZI, including an excellent long‐term outcome. These findings appear relevant to (i) clinically suspect BZI and (ii) plan rehabilitation and inform the patient and his family of likelihood of full language recovery.     

Effectiveness of Low-Frequency rTMS and Intensive Speech Therapy in Poststroke Patients with Aphasia: A Pilot Study Based on Evaluation by fMRI in Relation to Type of Aphasia

Aim: To assess the safety and clinical efficacy of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) combined with intensive speech therapy (ST) in poststroke patients with aphasia. Subjects and Methods: Twenty-four patients with left-hemispheric stroke and aphasia were subjected. During 11-day hospitalization, each patient received 10 treatment sessions consisting of 40-min 1-Hz LF-rTMS and 60-min intensive ST, excluding Sundays. The scalp area for stimulation was selected based on the findings of fMRI with language tasks and the type of aphasia. LF-rTMS was applied to the inferior frontal gyrus (IGF) for patients with nonfluent aphasia and to the superior temporal gyrus (STG) for patients with fluent aphasia. Results: On pretreatment fMRI, the most activated areas were in the left hemisphere (n = 16) and right hemisphere (n = 8). The types of aphasia were nonfluent (n = 14) and fluent (n = 10). The LF-rTMS was applied to the right STG (n = 5), left STG (n = 5), right IFG (n = 11) and left IFG (n = 3). Nonfluent aphasic patients showed significant improvement of auditory comprehension, reading comprehension and repetition. Fluent aphasic patients showed significant improvement in spontaneous speech only. Conclusion: The fMRI with aphasic type-based therapeutic LF-rTMS/intensive ST for chronic aphasia seems feasible and a potentially useful neurorehabilitative protocol.     

Cerebral glucose metabolism in Wernicke's, Broca's, and conduction aphasia

Cerebral glucose metabolism was evaluated in patients with either Wernicke's (N = 7), Broca's (N = 11), or conduction (N = 10) aphasia using 18F-2-fluoro-2-deoxy-D-glucose with positron emission tomography. The three aphasic syndromes differed in the degree of left-to-right frontal metabolic asymmetry, with Broca's aphasia showing severe asymmetry and Wernicke's aphasia mild-to-moderate metabolic asymmetry, while patients with conduction aphasia were metabolically symmetric. On the other hand, the three syndromes showed the same degree of metabolic decline in the left temporal region. The parietal region appeared to separate conduction aphasia from both Broca's and Wernicke's aphasias. Common aphasic features in the three syndromes appear to be due to common changes in the temporal region, while unique features were associated with frontal and parietal metabolic differences.     

Aphasia in acute stroke.

Previous surveys of stroke populations have offered only cursory information on language disturbance, and, conversely, few surveys of aphasic populations have dealth exclusively with stroke or with acute phenomena. This paper describes aphasia in 850 acute stroke patients consecutively registered by the Harlem Regional Stroke Program, of whom 177 (21%) were aphasic; of these, nine were of Broca's type, 24 were of Wernicke's type, 14 were of anomic, ten were conduction, seven were of "isolation" type, and 107 were "mixed." An unexpected finding was a significant over-representation of men among the nonfluent aphasics. During the following four to 12 weeks, 12% of fluent aphasics died, and 12% remained moderately or severely impaired; among survivors, aphasia improved in 74%, and in 44% it cleared completely. During the same period, 32% of nonfluent aphasics died, and 34% remained moderately or severely impaired; among survivors, aphasia improved in 52%, and in only 13% did it clear completely. In both fluent and nonfluent groups, hemiparesis and/or visual field cut were associated with poor prognosis.     

Contrecoup injury in the misdiagnosis of crossed aphasia

Crossed aphasia is reported to be more frequent in traumatic series than in series of patients with other pathologies. A right-handed young man suffered a closed-head trauma and became aphasic and hemiparetic on the left. CT scan revealed a right frontal-lobe hematoma. Neuropsychological examination revealed a fluent aphasia and a Gerstmann syndrome. These signs were compatible with left supramarginal gyrus syndrome. However, the presence of a right frontal-lobe lesion suggested that this patient could be a crossed aphasic. Subsequent EEG study showed a left occipitotemporal focus and a right frontal one. Aphasic signs could thus be due to the left lesion, which was the result of a contrecoup mechanism. Fluent aphasias have been reported in closed-head trauma with right frontal impact. Attention is called for the possible bias of including cases like this in series of traumatic crossed aphasia.     

Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke

Aphasia, depression, and cognitive dysfunction are common consequences of stroke, but knowledge of their interrelationship is limited. This 1-year prospective study was designed to evaluate prevalence and course of post-stroke aphasia and to study its psychiatric, neurological, and cognitive correlates. We studied a series of 106 consecutive patients (46 women and 60 men, mean age 65. 8 years) with first-ever ischaemic brain infarction. The patients were clinically examined, and presence and type of aphasia were evaluated during the 1st week after stroke and 3 and 12 months later. Psychiatric and neuropsychological evaluations were performed 3 and 12 months after stroke. Aphasia was diagnosed in 34% of the patients during the acute phase, and two thirds of them remained so 12 months later. Seventy percent of the aphasic patients fulfilled the DSM-III-R criteria of depression 3 months and 62% 12 months after stroke. The prevalence of major depression increased from 11 to 33% during the 12-month follow-up period. The non-verbal neuropsychological test performance in the aphasic patients was significantly inferior to that of the patients with dominant hemisphere lesion without aphasia. One third of the patients with ischaemic stroke suffer from communicative disorders which seem to increase the risk of depression and non-verbal cognitive deficits. Although the prevalence of depression in aphasic patients decreases in the long term, the proportion of patients suffering from major depression seems to increase. We emphasize the importance of the multidimensional evaluation of aphasic stroke patients.     

Contrecoup injury in the misdiagnosis of crossed aphasis

Abstract

Crossed aphasia is reported to be more frequent in traumatic series than in series of patients with other pathologies. A right-handed young man suffered a closedhead trauma and became aphasic and hemiparetic on the left. CT scan revealed a right frontal-lobe hematoma. Neuropsychological examination revealed a fluent aphasia and a Gerstmann syndrome. These signs were compatible with left supramarginal gyrus syndrome. However, the presence of a right frontal-lobe lesion suggested that this patient could be a crossed aphasic. Subsequent EEG study showed a left occipitotemporal focus and a right frontal one. Aphasic signs could thus be due to the left lesion, which was the result of a contrecoup mechanism. Fluent aphasias have been reported in closed-head trauma with right frontal impact. Attention is called for the possible bias of including cases like this in series of traumatic crossed aphasia.     

Progressive nonfluent aphasia and subsequent aphasic dementia associated with atypical progressive supranuclear palsy pathology

We describe a right-handed man who developed progressive nonfluent aphasia and apraxia of speech beginning at age 71. By age 74 he had behavioral changes, aphasic dementia, as well as mild parkinsonism; extraocular movements were normal except for mild limitation of upgaze. Serial neuropsychometric testing and single photon emission computed tomography (SPECT) scans showed progressive changes reflecting left>right cerebral hemisphere dysfunction. Neuropathologic examination revealed findings characteristic of progressive supranuclear palsy (PSP) except that the cortical pathology was more widespread than is typical of PSP. We conclude that the clinical manifestations in this case were more similar to the syndrome of progressive nonfluent aphasia with subsequent aphasic dementia and mild parkinsonism, rather than those of PSP. Hence, PSP can present clinically as an atypical dementing syndrome dominated by progressive aphasia/apraxia of speech.     

Primary Progressive Aphasia in a Bilingual Woman

Multilingual aphasias are common because most people in the world know more than one language, but little is known of these syndromes except in patients who have had a stroke. We present a 76-year-old right-handed woman, fluent in English and Chinese, who developed anomia at age 70 and then progressed to aphasia. Functional neuroimaging disclosed mild left temporoparietal hypometabolism. Neurolinguistic testing was performed in both English and Chinese, representing a unique contribution to the literature. Results revealed conduction-like aphasia that was comparable in the two languages, although English was slightly better preserved. Primary progressive aphasia has disrupted 2 languages in a similar manner, suggesting their close neuroanatomic relationship in this case.     

Primary progressive aphasia in a bilingual woman

Multilingual aphasias are common because most people in the world know more than one language, but little is known of these syndromes except in patients who have had a stroke. We present a 76-year-old right-handed woman, fluent in English and Chinese, who developed anomia at age 70 and then progressed to aphasia. Functional neuroimaging disclosed mild left temporoparietal hypometabolism. Neurolinguistic testing was performed in both English and Chinese, representing a unique contribution to the literature. Results revealed conduction-like aphasia that was comparable in the two languages, although English was slightly better preserved. Primary progressive aphasia has disrupted 2 languages in a similar manner, suggesting their close neuroanatomic relationship in this case.     

Clinical evaluation of conversational speech fluency in the acute phase of acquired childhood aphasia: does a fluency/nonfluency dichotomy exist?

Traditional neurologic tenets claim that the clinical picture of acquired childhood aphasia is nonfluent irrespective of lesion location. In the past 20 years, however, several case studies have shown that fluent aphasic patterns can be observed in children with acquired childhood aphasia. But the question remains open as to whether the pattern of their speech characteristics is similar to the one described in adult aphasics as studies addressing spontaneous speech fluency characteristics in larger series of children with acquired childhood aphasia are scarce. The objective of this study was to investigate whether an analysis of spontaneous speech fluency as has previously been performed in adult aphasics by other investigators would also yield two distinct groups of aphasic children and, if so, whether the distribution of the different speech characteristics in both groups would reflect the rank order found in adults, that is, whether nonfluent verbal output characteristics would predominate in one group and fluent features in the other. Audiotaped and videotaped recordings of 24 cooperative children with acute acquired childhood aphasia unselected for age, gender, etiology, and aphasia severity ratings were analyzed according to 10 different speech characteristics. A cluster analysis (two-means clustering) was performed to seek the existence of two distinct groups of aphasic children. Results were confirmed, and exact P values were computed with Mann-Whitney U-tests. A two-means clustering created two distinct classes. Mann-Whitney U-tests ranked the speech characteristics according to their discriminating power between clusters. Comparing this rank order with the one previously found in adults revealed a high correlation (Spearman's rank correlation: r = .915, P < .005), thus indicating that the clusters we found were highly similar to the adult clusters. Thus, the use of the speech variables proposed to evaluate adult aphasic spontaneous speech enabled us to demonstrate a fluent/nonfluent dichotomy in a childhood aphasic population as well. This study shows that the traditional views on the uniformity of the clinical picture of acquired childhood aphasia are obsolete. Our findings corroborate data issued from several case reports of fluent acquired childhood aphasia and from the few studies focusing on speech fluency in acquired childhood aphasia, which all point to the existence of an adultlike heterogeneity of childhood aphasic syndromes. Current clinical evidence no longer supports the hypotheses of equipotentiality and progressive lateralization but favors the notion that the anatomic substrate for language representation in the child is similar to that in adults, even in young subjects.     

Speech Fluency in Aphasia: Regional Cerebral Blood Flow Correlates of Recovery Using Single-Photon Emission Computed Tomography

This study investigated the relationship between diminished regional cerebral blood flow (rCBF) and the recovery of fluent speech in aphasia. Single-photon emission computed tomographic brain scans using [¹²³I]N-isopropyl-p-iodoamphetamine were obtained from 14 nonfluent aphasic patients within 30 days of cerebral infarction. Measurements of speech fluency were acquired initially and at 3 months after infarction. Nearly all of the patients exhibited significant hypoperfusion to combinations of the anterior and posterior regions of the basal ganglion, the periventricular white matter, and the inferior frontal regions. Only the inferior frontal area was significantly associated with recovery of fluent speech. This region was hypoperfused in 4 of 5 patients with poor recovery while 8 of the 9 patients with good speech fluency recovery demonstrated normal rCBF to the inferior frontal region.     

Localisation of lesions in aphasia: clinical-CT scan correlations in stroke patients.

Ninety right-handed patients with present or past evidence of aphasia following a stroke were given a standard language battery and a CT scan examination. Presence and type of aphasia were correlated with the location and extent of the CT scan lesion. Most of the findings were compatible with the traditional views about the localisation of lesions in aphasia (e.g., anterior lesions in nonfluent aphasias with good comprehension, posterior lesions in fluent aphasia, etc.). The possible explanations for some unexpected findings (e.g., purely anterior lesions in global aphasia, or purely deep lesions in Broca's aphasia) are discussed. It is stressed that in establishing clinico-CT scan correlation, careful consideration must be given to the fact that both aphasia and the underlying lesion evolve with time.     

Neuroanatomic correlation of the post-stroke aphasias studied with imaging

BACKGROUND AND PURPOSE: Stroke is the leading cause of disability in many countries. Aphasia is a common sign of stroke that is observed in about one-third of stroke patients and contributes to disease morbidity. However, the relationship between anatomy and different forms of aphasia remains poorly understood. We intend to study the characteristics of aphasia in the acute stage of stroke and to identify neuroanatomical correlates using MRI. METHODS: Lesion sites were selected from 1198 patients with cerebral infarction, who were hospitalized in the stroke unit of our hospital between March 2002 and March 2006. We enrolled 325 patients who fulfilled our criteria. All patients received an MRI examination within 1 week after admission and were evaluated with the Western battery aphasia (WAB) test, in order to determine what type of aphasia they had. The severity of their language deficit was further classified using the Boston diagnostic aphasia examination (BDAE) severity grading standard. RESULTS: Among 1198 cases, five cases with Broca's areas and four cases with Wernicke's areas lesions on MRI works were free of language deficits. Within the 325 patients who demonstrated clinical signs of aphasia, the results of WAB showed that there were 83 Broca' aphasia cases, 48 Wernicke's aphasia cases, 12 conduction aphasia cases, 36 transcortical motor aphasia cases, 17 transcortical sensory aphasia cases, 19 transcortical mixed aphasia cases, 58 global aphasia cases and 52 anomic aphasia cases. Two hundred and eighty-eight cases were located within classical language centers while 37 cases were located at other sites. In 325 aphasia patients with grade criteria of BDAE of grades 0, 1, 2, 3 or 4, there were 84, 79, 77, 63 and 22 cases respectively. Many of cases with grades 0 and 1 were distributed within classical language centers. CONCLUSION: This study showed that it is possible to draw a neuroanatomical map of aphasia that encompasses the 95% of aphasia cases. It also demonstrates that the main determinant of aphasic disorders is the neuroanatomical location of the lesion. Furthermore, this study shows that most lesion locations associated with specific aphasic disorders fit classical data associated with previous aphasia research. More importantly, the language disorders of patients whose lesions were located at classical language centers were more serious. Consequently, this paper demonstrates the power of MRI in prognosticating the potential for a patient to recover from aphasia due to stroke.     

Longitudinal study of single‐word comprehension in semantic dementia: A comparison with primary progressive aphasia and Alzheimer's disease

Background: Although semantic dementia (SD) is characterised by a multimodal loss of semantic knowledge, it has been demonstrated that lexical‐semantic representations are not equally disrupted in SD and that some categories may be recognised better than others. Little is known, however, about the pattern of the category‐specific comprehension deficits in SD and whether it differs from that of other forms of progressive aphasias.

Aims: This exploratory study aimed to investigate the evolution of category‐specific deficits of single‐word comprehension in progressive aphasias.

Methods & Procedures: A total of 19 patients with a clinical diagnosis of SD, 25 patients with primary progressive aphasia with agrammatic and relatively nonfluent speech (PPA), and 25 patients with Alzheimer's disease (AD) with aphasia were studied longitudinally with the Western Aphasia Battery (WAB). The Auditory Word Recognition subtest of the WAB was utilised to assess comprehension of words derived from different semantic categories.

Outcomes & Results: The analysis revealed that, over time, category‐specific deficits of single‐word comprehension were seen in all three groups of patients. Participants with SD as well as those with PPA and AD were impaired on both pointing to fingers and the right–left orientation task. However, patients with SD were the only group that showed defective recognition of their own body parts. Interestingly, individuals with SD had no difficulties identifying colours, letters, and numbers, even during the follow‐up testing. In addition, in all three groups the extent of category‐specific deficits was associated with the severity of aphasia.

Conclusions: These results indicate that category‐specific deficits of single‐word comprehension are frequently seen not only in patients with SD but also in individuals with PPA or AD, and that the extent of these deficits is associated with the severity of aphasia. However, the pattern of these deficits is often different in these three forms of neurodegenerative conditions and more dissociations between semantic categories are observed as each of these diseases progresses.     

Age and type of aphasia in patients with stroke.

The age and gender of a series of patients with different types of aphasia were analysed. Regardless of gender, patients with Broca and conduction aphasias were significantly younger than those with Wernicke and global aphasias. Considering the established cerebral localisation of each of those aphasia types, it appears that, with age, stroke in the territory of the middle cerebral artery will tend to either shift posteriorly (producing Wernicke aphasia) or occupy most of the middle cerebral artery territory (producing global aphasia). But in the absence of concurrent verification of the locus of lesion in each of the cases in our sample, a possible alternative hypothesis must be entertained: that there might be age-related changes in the neurophysiological mechanism subserving language, such that some types of aphasia would tend to be more prevalent with age, regardless of lesion location.