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.     

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.     

卒中后失语症类型及其影响因素分析

目的 通过探讨性别、年龄、病变部位及卒中病因等与失语症类型之间的关系,探索影响卒中后失 语类型的因素。 方法 回顾性分析2004年1月-2018年12月于首都医科大学附属北京天坛医院就诊、因语言障碍进行 西部失语成套测验（western aphasia battery,WAB）的卒中后失语症患者临床资料。分析失语症类型与 性别、年龄、卒中类型、卒中病因及发病机制之间的关系。 结果 共纳入失语症患者681例,按照失语症类型分为完全性失语（global aphasia,GA）（n =185）、 运动性失语（broca’s aphasia,BA）（n =148）、经皮质混合性失语（mixed transcortical aphasia,MTCA） （n =30）、经皮质运动性失语（transcortical motor aphasia,TCMA）（n =67）、感觉性失语（werni cke’s aphasia,WA）（n =69）、经皮质感觉性失语（transcortical sensor aphasia,TCSA）（n =21）、传导性失 语（conduction aphasia,CA）（n =32）和命名性失语（anomic aphasia,NA）（n =129）。将患者分为青年组 （18～44岁）、中年组（45～59岁）、老年组（≥60岁）,校正其他因素影响后,三组人群间失语症类型 无统计学差异。男性和女性患者的失语症类型也无统计学差异。各类型失语症患者的病变部位具有 异质性,除合并经典语言区损伤外,还可合并左侧基底节及丘脑损伤。在脑出血所致的各类型失语 症患者中,最常见的病因均为高血压（77.8%～100.0%）。脑梗死后GA患者中,最常见的卒中发病机制 是混合型（42.4%）和动脉-动脉栓塞（27.3%）,而BA、WA及CA患者以动脉-动脉栓塞（分别占51.5%, 71.4%和40.0%）最常见,TCMA、TCSA及NA以低灌注/栓子清除能力下降（分别占65.9%,58.3%和 38.4%）最常见。 结论 年龄及性别对失语症类型均无明显影响。男性和女性患者均以GA、BA和NA最为常见。病变 部位对失语症类型具有重要影响,卒中病因及发病机制对失语症类型的影响可能与特定血管及血管 供血区损伤有关。     

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.     

A case of mixed transcortical aphasia with intact naming.

Altholgh Lichtheim recognized that Wernicke's 'reflex arch' (primary auditory area, to Wernicke's area, to Broca's area, to primary motor area) was important for repetition, he recognized that other areas of the brain (for example, area of concepts or semantic area) must be important in comprehension and voluntary speech. He suggested that Wernicke's area (phonemic area) not only projected to Broca's area (as Wernicke suggested) but that it also projected to the area of concepts. A lesion of this latter pathway or in the area of concepts would produce a syndrome where repetition was intact but comprehension was impaired (e.g. transcortical sensory aphasia). Lichtheim also thought that the area of concepts projected directly to Broca's area and that voluntary speech was mediated by this pathway. Although Lichtheim's model could explain the mechanism underlying transcortical aphasia, his schema could not explain anomic aphasia. Unlike Lichtheim's schema, Kussmaul's schema suggested that the area of concepts projects back to Wernicke's area before projecting to Broca's area. With this schema, a patient with a hypothetical lesion which interrupted the pathway from the area of concepts to Wernicke's area (but did not interrupt the pathway from Wernicke's area to the area of concepts) should be anomic, with normal comprehension and repetition. In order for this latter schema to be plausible there should also be a lesion which interrupts the pathway from Wernicke's area to the area of concepts but does not interrupt the pathway which goes from the area of concepts to Wernicke's area. A patient with this hypothetical lesion should comprehend poorly; however, in spite of poor comprehension, naming and repetition should be intact. We report a patient who demonstrates poor comprehension with intact naming and repetition. This patient could also read aloud but could not comprehend written language. Not only could this patient name objects but he could demonstrate their use. These observations suggest that comprehension of written language is mediated by a different pathway than the recognition of visually presented objects.     

Young adult stroke: neuropsychological dysfunction and recovery

Etiology, neuropsychological deficits, aphasia type, and recovery were retrospectively studied in 254 young adults with stroke. Cardiac embolism was the most common cause of stroke in patients younger than 40, while atherosclerosis was the most frequent etiology among those aged 41-50 years. In 166 aphasic patients, Broca's aphasia was the most common while Wernicke's and transcortical aphasias were rare. Compared with an older aphasic population, young patients had significantly more nonfluent aphasias and fewer comprehension deficits. These differences were related to stroke localization: the majority of infarcts localized by computed tomography in 37 patients involved either the entire middle cerebral artery territory or its superior or deep branches, explaining the preponderance of nonfluent aphasia. Prognosis of aphasia in our patients was better than has been reported for non-age-selected aphasia populations. Roughly one third of our patients recovered completely, one third improved, and one third had an unresolved language deficit. Complete recovery and significant improvement were observed even greater than 6 months after stroke. In some patients, recovery was much better than might have been predicted from lesion site and size depicted on computed tomograms.     

Numerical skills and aphasia.

The aim of this study was to investigate numerical difficulties in 50 patients with left hemispheric lesions. Aphasic patients were grouped according to their type of aphasia diagnosed by the Aachener Aphasia Test. The overall error rate in various transcoding and calculation tasks was clearly correlated with the severity of the language deficit, global aphasics being the most impaired patients. Broca's and Wernicke's aphasics scored similarly at the quantitative level, and amnesic aphasics were less impaired. Interestingly, qualitative analysis of the errors indicated that each group presented with specific difficulties, partially reflecting the nature of the language problems. In simple calculation, multiplication was found to be the most impaired operation, in particular in Broca's aphasics. This result supports the hypothesis that the retrieval of multiplication facts is preferentially mediated by verbal processing. Calculation procedures were mainly impaired in Wernicke's and global aphasics.     

Dissociations of language functions in aphasics with speech automatisms (recurring utterances)

The linguistic performance of 27 aphasics with frequent production of non-lexical speech automatisms (recurrent utterances; e.g. do-do-do...) in spontaneous speech was investigated. Of the 26 patients examined with the Aachen aphasia test (AAT), 24 cases suffered from global aphasia, one from Broca's aphasia, and one was not classifiable but most resembled the fluent types as Wernicke's or conduction aphasia. While most patients were severely impaired in language comprehension, a subgroup showed impairments on a moderate level. In four cases clear dissociations between oral and written output performance were found. Only one patient, and very rarely so, interspersed his written output with his speech automatism. Analysis of written output within the theoretical framework of the logogen model provided evidence for the possibility of a partially intact phonological system in patients with speech automatisms. Results are interpreted as supporting a sub-phonemic hypothesis of the generation of non-lexical speech automatisms.     

Classification of aphasic phenomena.

A brief but comprehensive survey of classifying aphasia reveals that most investigators describe at least four major groups, conveniently labelled Broca's, Wernicke's, anomic and global. Conduction and transcortical aphasias are less generally described and modality specific syndromes rarely, if ever, exist purely. The controversy between unifiers and splitters continues but objective numerical taxonomy may solve some of the problems of classification.     

Localization of lesions in aphasia: clinical-CT scan correlations (Part 1)

Using a microcomputer, the locus and extent of the lesions, as demonstrated by computed tomography for 127 cases with various types of aphasia were superimposed onto standardized matrices. The relationship between the foci of the lesions and the types of aphasia was investigated. Broca ++aphasics (n = 39): Since the accumulated site of the lesions highly involved the deep structures of the lower part of the precentral gyrus as well as the insula and lenticular nucleus, only 60% of the Broca aphasics had lesions on these areas. This finding has proved to have little localizing value. Wernicke aphasics (n = 23): The size of the lesion was significantly smaller than Broca's aphasia. At least 70% of the patients had the superior temporal lesions involving Wernicke's area and subcortical lesions of the superior and middle temporal gyri. The site of lesion corresponded roughly to the previous clinico-pathological reports but located a little deep. Amnestic aphasics (n = 18): The size of the lesion was smaller than any other types. While there was some concentration of the lesions (maximum 40%) in the area of the subcortical region of the anterior temporal gyrus adjacent to Wernicke's area and the lenticular nucleus, the lesions were distributed throughout the left hemisphere. Amnestic aphasia was thought to be the least localizable. Conduction aphasics (n = 11): The lesions were relatively small in size. Many patients had posterior speech area lesions involving at least partially Wernicke's area. In particular, more than 80% of the conduction aphasics had lesions of the supramarginal gyrus and it's adjacent deep structures. Global aphasics (n = 36): In general, the size of the lesion was very large and 70% of the global aphasics had extensive lesions involving both Broca's and Wernicke's areas. However, there were observations showing that the lesions can be small and confined. Because of the large variability in lesion patterns and speech disturbances, it is necessary to expand the number of cases for relate detailed neuropsychological examinations with morphological CT-findings. Our method permits it easily to process and to analyze a large number of cases. By studying larger series, the better definition in the relationship between anatomic lesion location and aphasia type, even for less common aphasia syndromes could be obtained.     

Comparative classification of aphasic disorders

This study compares aphasia classification of 20 aphasics who were evaluated with the Western Aphasia Battery (WAB) and the Lisbon Aphasia Examination Battery (LAEB). High correlations were found between tests evaluating the same functions in both batteries. Aphasia types derived from these two batteries showed only a partial overlap. This was due to the use of different numerical diagnostic criteria. When these criteria were used to specify aphasia types of 179 acute and 113 chronic aphasics grouped by cluster analysis, similar discrepancies were noted. Two major differences were found: some LAEB global aphasics turned out to be WAB Broca's and some LAEB anomics were classified as WAB conduction aphasics. These disagreements reflect difficulties in delimiting Broca's and conduction aphasia. The importance of the numerical approach to aphasia classification is stressed, as it is a reliable method to classify aphasic patients in order to allow comparison of data from different centers.     

Control mechanisms of aphasic patients in verbal and phonemic paraphasias (author's transl)]

In the current literature on aphasia, two explanations of paraphasic errors are suggested: one is based on the idea of conscious verbal substitutions, and the other on that of uncontrolled faults in production. The purpose of this study was to relate both explanations to a) the usual classification of verbal and phonemic paraphasias, b) the different types of aphasia, and c) the severity of the aphasic disturbance. In free reproductions of 19 fluent aphasics A(F) and 21 nonfluent aphasics A(NF), the immediate verbal context of paraphasias was examined in relation to a) the nature and severity of the paraphasic errors and b) the severity of the aphasia. The A(NF) group made significantly more hesitations before both verbal and phenemic paraphasias. There was no significant difference between the two groups in control after phonemic paraphasias, but the A(NF) showed a significantly higher rate of control incidents after verbal paraphasias. Thus the two explanations of paraphasia may correspond to different kinds of paraphasic behavior, which are symptomatic of two varieties of aphasia, fluent and nonfluent.     

交叉性失语

右利手者右大脑半球病变所致的失语称为交叉性失语。交叉性失语少见。我科八年来共诊断八例（占我组失语症患者２５０例的２．８％），均为男性右利手者，头颅ＣＴ扫描均证实右大脑半球单发病灶，其中脑梗塞７例，脑出血１例。均于发病三个月内作失语检查。其中交叉性Ｂｒｏｃａ失语一例，交叉性传导性失语一例，交叉性Ｗｅｒｎｉｃｋｅ失语一例，交叉性经皮质运动性失语一例，交叉性经皮质感觉性失语三例，交叉性丘脑性失语一例。此８例各型交叉性失语之临床表现与右利手左大脑半球病变产生的各相应类型失语无根本不同。产生交叉性失语是患者的大脑半球语言中枢的逆转所致（不在左侧而在右侧大脑半球的对称部位），它与遗传有关。失语症类型与患者年龄和性别的关系有待进一步研究。     

失语患者听理解中的特殊范畴语义障碍

目的：探讨失语患者听理解中特殊范畴语义障碍的特点。方法：（1）用汉语失语检查法（ABC）检查42例卒中后失语患者，其中，Broca失语（BA）8例，Wernicke失语9WA）5例，传导性失语（CA）11例，经皮质运动性失语（TCM）8例，经皮质感觉性失语（TCS）7例，命名性失语（AA）3例；（2）分别统计各型失语患者ABC中听辨认9项的得分，并用SPSS软件处理数据。结果：（1）BA、TCM和AA患者听辨认9项间差异无显著性意义（P＞0．05）。（2）WA、CA、TCS患者对9个项目的听辨认存在不同程度困难；物品和动作听理解障碍的程度较轻，而颜色和（或）身体部位的听理解障碍较重。差异有显著意义的（P＜0．05）是：WA患者在物品（M＝4分）、物品图（M＝6分）、动作图（M＝4分）与颜色（M＝0）分、家具（M＝0分）及身体部位（高、低频和左／右）（M＝2，0，0分）间，几何图（M＝2分）与物品图及身体部位（低频）间；CA患者在物品（M＝10分）、物品图（M＝10分）、动作图（M＝10分）与身体部位（高、低频和左／右）（M＝9，8，4分）间，几何图（M＝9分）与物品图间，颜色（M＝10分）、家具（M＝10分）与身体部位（低频）间；TCS患者在物品（M＝10分）与家具（M＝5分）和身体部位（低频）（M＝6分）间，动作图（M＝10分）、家具和身体部位（低频）间。结论：（1）失语患者听理解中特殊范畴语义障碍主要见于有明显听理解障碍者，（2）不同型失语患者的听辨认中有相似的特殊范畴语义障碍。     

Transcortical sensory aphasia due to extensive infarction of left cerebral hemisphere]

We report a case of transcortical sensory aphasia occurred after extensive infarction of left cerebral hemisphere. A 68-year-old, right-handed man with atrial fibrillation suddenly developed cerebral embolism of left middle cerebral artery. He was treated conservatively, and the right hemiplegia, aphasia, apraxia in a slight degree and right hemispatial neglect in a slight degree consequently existed. MRI showed a large cortical and subcortical infarct lesion including the left Broca's area, central region, perisylvian area with Wernicke's area and temporal lobe. In contrast, neuropsychological evaluation using the Western Aphasia Battery (WAB) demonstrated transcortical sensory aphasia, e.g., fluency 8, auditory comprehension 1. repetition 10 and object naming 2.4. In addition to preserved repetition, both linguistic prosody and affective prosody were well preserved. Most cases with transcortical sensory aphasia are known to occur with the lesion including temporo-parieto-occipital junction of dominant hemisphere. Our patient and a few other reported cases of transcortical sensory aphasia had a lesion in perisylvian area including Wernicke's area. Therefore, it is possible that their minor hemisphere worked selectively for repetition. Furthermore, we suggest that this patient presented dissociative aphasia that all the process of repetition and the function of linguistic and emotional prosody were represented in the right hemisphere and the other functions including comprehension of word meanings were existed in the left hemisphere. We believe that our case of transcortical sensory aphasia with dissociative aphasia gives a suggestion about the mechanism and localization of repetition and prosody in the whole system of language.     

Recovery processes in 2 cases of bilingual aphasia]

Recovery processes of two English-Japanese bilingual aphasics were investigated with special emphasia on the effect of language therapy. Although the two patients had different types of aphasia (one Broca's aphasia and the other Wernicke's aphasia), the degree of the language impairment initially manifested in English and Japanese was almost equivalent in each case with the pattern of impairment corresponding to the respective types of aphasia. In either case, language therapy was conducted in English, and the course of recovery during the first six months was analyzed. The results indicated that auditory comprehension improved almost simultaneously in both treated (English) and untreated (Japanese) languages regardless of the type of the patients' aphasia. In contrast, oral language production in Broca's aphasia improved only for the treated language while that in Wernicke's aphasia improved simultaneously for both languages. Writing ability seemed to improve as a function of language therapy in both cases. The implications for the relationship between spontaneous recovery and the effects of treatment were discussed.     

Localization of aphasic symptoms: preliminary observations with C.T. scanner (author's transl)

Twenty patients with aphasia and left-hemisphere damage were examined with a standard language battery, and Computerized Axial Tomography. Patients were divided into fluent (N = 9) and nonfluent (N = 6) on the basis of the language examination; 5 patients who could not be classified in either category were excluded. Lesions were retrorolandic in 8 out of 9 fluent aphasics while extending anteriorly in all 6 nonfluent aphasics. Some unexpected lesions were also found. Five cases -- 3 fluent and 2 nonfluent -- are discussed in detail.     

Recovery in aphasia (Part 1)

In order to elucidate the factors which have an influence on the prognosis of aphasia, a correlation was studied in 76 right-handed aphasic patients between recovery rates and various factors: i.e. aphasia type, age, educational level, time between onset of aphasia and institution of therapy and initial severity. Initial evaluations on Standard Language Test of Aphasia (SLTA) were obtained within 5 months after the cerebrovascular accident and reevaluations were obtained 3 months after the initial evaluation. Recovery rates were determined by comparing scores of these 2 tests in order to coincide with clinical impression. The results obtained were as follows: Aphasia type: The highest recovery rates were seen in conduction aphasics, followed by amnestic, Wernicke, and Broca aphasics. Global aphasics had significantly lower recovery rates. It was suggested that anarthria in Broca's aphasia and jargon in Wernicke's aphasia had a significant ratarding effect on recovery rates. Age: Age and recovery rates showed a significant negative correlation: younger patients recovered better, and this trend was remarkable in Wernicke aphasics but not Broca aphasics. Education: Patients with more education tended to improve more, and this trend was most remarkable in amnestic aphasics. Time between onset of aphasia and institution of therapy: Time elapsed from onset and recovery rates showed a significant negative correlation; recovery rates decreased as the time interval from onset increased. Initial severity: Correlation between the initial severity of aphasia, measured by the initial SLTA scores and recovery rates was very high; severily affected aphasics recovered to a lesser extent than mildly affected ones and this trend was remarkable in Wernicke and Broca aphasics.     

Study on the pathogenic mechanism of Broca's and Wernicke's aphasia

OBJECTIVE: To study the mechanisms of aphasia by observing cerebral blood flow and metabolism changes in language functional areas of the brain using imaging, in order to develop a language rehabilitation plan for aphasia patients. METHODS: Fifty-eight patients who suffered from Broca's or Wernicke's aphasia secondly to cerebral infarction were evaluated using the Western aphasia battery and Frenchay dysarthria assessment. CT and MRI were obtained to identify the location of lesions, and the language areas were analysed with magnetic resonance spectroscopy (MRS) and perfusion-weighted imaging (PWI). The results were compared with those of the contralateral hemisphere. RESULTS: Of the 58 patients, there were 23 Broca's aphasia patients, 29 Wernicke's aphasia patients and six other aphasia types. We excluded five patients accompanied by dysarthria, six patients with other aphasia types and 14 patients with much more disease lesions. Finally, we analysed the remaining 12 Broca's aphasia and 21 Wernicke's aphasia patients by MRS and PWI. MRS shows that the N-acetylaspartate, choline and creatine of the Broca's or Wernicke's area were reduced than those of the contralateral hemisphere, while PWI results show that the damaged Broca's or Wernicke's areas were in a hypoperfusion state. CONCLUSIONS: Broca's or Wernicke's area of aphasia patients exhibits hypoperfusion and hypometabolism, indicating that they might be the mechanisms of Broca's or Wernicke's aphasia.