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.     

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。     

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.     

Aphasia after stroke: type, severity and prognosis. The Copenhagen aphasia study

AIM: To determine the types, severity and evolution of aphasia in unselected, acute stroke patients and evaluate potential predictors for language outcome 1 year after stroke. METHODS: 270 acute stroke patients with aphasia (203 with first-ever strokes) were included consecutively and prospectively from three hospitals in Copenhagen, Denmark, and assessed with the Western Aphasia Battery. The assessment was repeated 1 year after stroke. RESULTS: The frequencies of the different types of aphasia in acute first-ever stroke were: global 32%, Broca's 12%, isolation 2%, transcortical motor 2%, Wernicke's 16%, transcortical sensory 7%, conduction 5% and anomic 25%. These figures are not substantially different from what has been found in previous studies of more or less selected populations. The type of aphasia always changed to a less severe form during the first year. Nonfluent aphasia could evolve into fluent aphasia (e.g., global to Wernicke's and Broca's to anomic), whereas a fluent aphasia never evolved into a nonfluent aphasia. One year after stroke, the following frequencies were found: global 7%, Broca's 13%, isolation 0%, transcortical motor 1%, Wernicke's 5%, transcortical sensory 0%, conduction 6% and anomic 29%. The distribution of aphasia types in acute and chronic aphasia is, thus, quite different. The outcome for language function was predicted by initial severity of the aphasia and by the initial stroke severity (assessed by the Scandinavian Stroke Scale), but not by age, sex or type of aphasia. Thus, a scoring of general stroke severity helps to improve the accuracy of the prognosis for the language function. One year after stroke, fluent aphasics were older than nonfluent aphasics, whereas such a difference was not found in the acute phase.     

Late recovery of auditory comprehension in global aphasia. Improved recovery observed with subcortical temporal isthmus lesion vs Wernicke's cortical area lesion

This study examined the relationship between recovery of auditory comprehension in global aphasia patients after 1 year post onset, and temporal lobe lesion in Wernicke's cortical area vs temporal lobe lesion in the subcortical temporal isthmus area. Computed tomographic scans and language behavior were examined in 14 right-handed globally aphasic stroke patients with lesion in the left hemisphere. Nine patients had large cortical/subcortical frontal, parietal, and temporal lobe lesion that included more than half of Wernicke's cortical area (FPT cases). Five patients had large cortical/subcortical frontal and parietal lobe lesion, but only subcortical temporal lobe lesion, including the temporal isthmus (FPTi cases). All patients were tested acutely at 1 to 4 months post onset and again at 1 to 2 years post onset. There was a significantly greater increase in the amount of recovery that had taken place after 1 to 2 years post onset for the FPTi group vs the FPT group in the overall Boston Diagnostic Aphasia Examination (BDAE) Auditory Comprehension Z score. In four of the five FPTi cases, the late BDAE Auditory Comprehension Z scores were above -0.5 (mild-to-moderate comprehension deficits). Most recovery was in single-word comprehension. In eight of the nine FPT cases, the late BDAE Auditory Comprehension Z-scores were below -0.5 (moderate-to-severe comprehension deficits). There was no significant difference between the two groups in recovery of spontaneous speech, repetition, or naming, where severe deficits remained in most cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lesion localization in aphasia with cranial computed tomography and the Boston Diagnostic Aphasia Exam

Nineteen stable left-hemisphere stroke patients with aphasia were evaluated by the Boston Diagnostic Aphasia Examination (BDAE) and the Token Test (TT), and by cranial computed tomography (CT). The types of aphasia included Broca (three patients), Wernicke (four patients), conduction (four patients), transcortical motor (four patients), and global (four patients). The lesions, as localized by CT scan, were superimposed onto five composite lesion localization maps for these five aphasia syndromes. There was good correlation between BDAE aphasia type and lesion localization. On CT scans, the locations of cortical language areas lie in a specific relationship to parts of the ventricular system.     

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.     

Aphasia and infarction of the posterior cerebral artery territory

Spoken language disorders are rarely mentioned in superficial infarction of the posterior cerebral (PCA) territory. Two clinical types have been reported: transcortical sensory and amnesic aphasia. Between 1979 and 1990, we studied retrospectively 76 patients suffering from an occipitotemporal infarction located in the superficial territory of the posterior cerebral artery, all well documented by CT. Aphasia was one of the first and prominent signs in 18 cases. Middle cerebral artery concomitant infarction could have been the cause of language impairment in 10. In 8 patients aphasia was only explained by a PCA territory infarct. Three patients showed features of transcortical sensory aphasia. CT localization showed internal lobe and thalamic involvement of the dominant hemisphere. Five patients exhibited word finding impairment with various degrees of amnestic syndrome. The dominant internal temporal lobe was always afffected. Dominant thalamus involvement was found in one case only. Some correlations between clinical features and anatomical support (vascular supply and anatomical structure) might be suggested in our 8 cases of aphasic disorders due to PCA infarcts. They are discussed and compared with data in the literature.     

Global aphasia without hemiparesis: language profiles and lesion distribution

OBJECTIVES: Global aphasia without hemiparesis (GAWH) is an uncommon stroke syndrome involving receptive and expressive language impairment, without the hemiparesis typically manifested by patients with global aphasia after large left perisylvian lesions. A few cases of GAWH have been reported with conflicting conclusions regarding pathogenesis, lesion localisation, and recovery. The current study was conducted to attempt to clarify these issues. METHODS: Ten cases of GAWH were prospectively studied with language profiles and lesion analysis; five patients had multiple lesions, four patients had a single lesion, and one had a subarachnoid haemorrhage. Eight patients met criteria for cardioembolic ischaemic stroke. RESULTS: Cluster analysis based on acute language profiles disclosed three subtypes of patients with GAWH; these clusters persisted on follow up language assessment. Each cluster evolved into a different aphasia subtype: persistent GAWH, Wernicke's aphasia, or transcortical motor aphasia (TCM). Composite lesion analysis showed that persistent GAWH was related to lesioning of the left superior temporal gyrus. Patients with acute GAWH who evolved into TCM type aphasia had common lesioning of the left inferior frontal gyrus and adjacent subcortical white matter. Patients with acute GAWH who evolved into Wernicke's type aphasia were characterised by lesioning of the left precentral and postcentral gyri. Recovery of language was poor in all but one patient. CONCLUSIONS: Although patients with acute GAWH are similar on neurological examination, they are heterogeneous with respect to early aphasia profile, language recovery, and lesion profile.     

The resolving stroke and aphasia. A case study with computerized tomography.

A 39-year-old man suffered an intracerebral hemorrhage in the region of the left internal capsule deep to Wernicke's area. The location of the lesion was confirmed by computerized tomography (CT) performed two days postictally. Two weeks after admission, the Boston Diagnostic Aphasia Examination (BDAE) diclosed Wernicke's aphasia. We hypothesize that the hematoma exerted pressure on Wernicke's cortical area, thus causing the resulting Wernicke's aphasia at that time. A CT scan three months later showed absorption of the hematoma, with a residual low-density lesion deep to Wernicke's area, in the region of the arcuate fasciculus. At that time, BDAE testing disclosed a mild conduction aphasia. Serial CT scanning combined with discriminating clinical evaluation of aphasia provides a valuable opportunity for study of the processes underlying stroke resolution and aphasia.     

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.     

The contribution of the left and right hemispheres to early recovery from aphasia: a SPECT prospective study

This prospective study examined the relationship between post-stroke recovery of aphasia and changes in cerebral blood flow (CBF). To address the question of right hemisphere (RH) involvement in restitution of language, we tested the hypothesis that the increase in perfusion of the RH is crucial for early recovery from aphasia. Twenty-four right-handed patients with acute aphasia following left hemisphere (LH) ischaemic stroke were examined twice with a six-month interval. At each session CBF and language scores were measured on the same stroke patients. Language was measured by selected tasks derived from the Boston Diagnostic Aphasia Examination (BDAE). The SPECT scans were obtained using (99m)Tc-ECD on a triple-head gamma camera Multispect-3. Although initial CBF measured for the whole group of aphasic patients was not a predictor for future language recovery for either hemisphere, increased perfusion of the RH during a six-month interval was found to parallel the recovery of aphasic disorders. There was a correlation between the change in the right parietal CBF (but not the left) and a change in numerous language abilities. Nevertheless, only CBF values on the left predicted performance on the language tests at initial and follow-up examinations. When the area damaged on structural imaging was excluded from perfusion analysis, only subcortical CBF change on the left showed a positive correlation with language improvement. Thus, the cerebral mechanism associated with early recovery from aphasia is a dynamic and complex process that may involve both hemispheres. Probably this mechanism involves functional reorganisation in the speech-dominant (damaged) hemisphere and regression of haemodynamic disturbances in the non-dominant (structurally intact) hemisphere.     

Impairments of procedures for implementing complex language are due to disruption of frontal attention processes.

Production of complex discourse-lengthy, open-ended utterances and narratives-requires intact basic language operations, but it also requires a series of learned procedures for construction of complex, goal-directed communications. The progression of clinical disorders from transcortical motor aphasia to dynamic aphasia to discourse impairments represents a progression of procedural deficits from basic morpho-syntax to complex grammatical structures to narrative and a progression of lesions from posterior frontal to polar and/or lateral frontal to medial frontal. Two cases of impaired utilization of language exemplify the range of impairments from clearly aphasic agrammatic, nonfluency to less and less "aphasic" and more and more executive impairments from transcortical motor aphasia to dynamic aphasia to narrative discourse disorder. The clinical phenomenology of these disorders gradually comes to be more accurately defined in the terminology of executive deficits than that of aphasia. The executive deficits are, in turn, based on impairments in various components of attention. Specific impairments in energizing attention and setting response criteria associated, respectively, with lesions in superior medial and left ventrolateral frontal regions may cause defective recruitment of the procedures of complex language assembly.     

Alexia and agraphia in Wernicke''s aphasia.

Three patients with otherwise typical Wernicke's aphasia showed consistently greater impairment of reading than auditory comprehension. While this syndrome resembles alexia with agraphia, the paraphasia of speech, repetition, and naming underline the aphasic nature of the disorder. Together with previous reports of isolated word deafness in Wernicke's aphasia, these cases suggest a relative independence of auditory and visual language processing.     

The contribution of the left and right hemispheres to early recovery from aphasia: A SPECT prospective study

This prospective study examined the relationship between post-stroke recovery of aphasia and changes in cerebral blood flow (CBF). To address the question of right hemisphere (RH) involvement in restitution of language, we tested the hypothesis that the increase in perfusion of the RH is crucial for early recovery from aphasia. Twenty-four right-handed patients with acute aphasia following left hemisphere (LH) ischaemic stroke were examined twice with a six-month interval. At each session CBF and language scores were measured on the same stroke patients. Language was measured by selected tasks derived from the Boston Diagnostic Aphasia Examination (BDAE). The SPECT scans were obtained using ^99mTc-ECD on a triple-head gamma camera Multispect-3. Although initial CBF measured for the whole group of aphasic patients was not a predictor for future language recovery for either hemisphere, increased perfusion of the RH during a six-month interval was found to parallel the recovery of aphasic disorders. There was a correlation between the change in the right parietal CBF (but not the left) and a change in numerous language abilities. Nevertheless, only CBF values on the left predicted performance on the language tests at initial and follow-up examinations. When the area damaged on structural imaging was excluded from perfusion analysis, only subcortical CBF change on the left showed a positive correlation with language improvement. Thus, the cerebral mechanism associated with early recovery from aphasia is a dynamic and complex process that may involve both hemispheres. Probably this mechanism involves functional reorganisation in the speech-dominant (damaged) hemisphere and regression of haemodynamic disturbances in the non-dominant (structurally intact) hemisphere.     

Some anatomo-clinical aspects of phonemic and semantic comprehension disorders in aphasia

60 aphasic patients, affected by localized lesions of the left hemisphere and classed as Broca's, Global, Conduction, Amnestic or Wernicke's aphasia received 1 phoneme discrimination test and 3 semantic-lexical discrimination tests. The aim of the study consisted in investigating the relationships between phoneme and semantic-lexical discrimination disorders, the clinical form of aphasia and the anatomic locus of the cerebral lesion.
The results were not consistent with the claim that comprehension disorders of Wernicke's aphasic patients can be traced back to a phoneme discrimination disorder, since Wernicke's aphasics were not more impaired than other aphasic groups and since patients with lesions localized in the temporal lobe performed quite well in the phoneme discrimination test.
Semantic discrimination disorders were very frequent and severe in patients classified as Wernicke's, Amnesic or Global aphasia, whereas they were much less relevant in patients classified as Broca's or Conduction aphasia.
As for the locus of the lesion, left temporal damage severely impaired semantic-lexical discrimination without affecting phoneme discrimination (a finding which supports the assumption of a selective involvement of the temporal lobe in semantic-lexical memory).
On the other hand, patients with damage localized in the left frontal lobe, obtained poor scores both on semantic-lexical discrimination tasks and on phoneme discrimination tests.     

卒中后失语患者非语言认知功能损害特点的临床研究

目的 探讨卒中后失语患者非语言认知功能损害的特点，并分析卒中后失语患者语言障碍与非语言 性认知功能损害之间的关系。 方法 选择2017年5月-2018年6月就诊的卒中患者共32例，经西方失语症成套测验（western aphasia battery，WAB）评估语言功能，分为失语组和无失语组，其中失语组15例，无失语组17例。洛文斯顿成 套测验中文版（Loewenstein occupational therapy cognitive assessment，LOTCA）第2版评估患者非语言认 知功能。对失语组与非失语组的LOTCA各分项分值及总分分别进行非参数检验；对WAB中各分项得 分及失语商与LOTCA各认知分项得分及总分进行偏相关分析，并行多元逐步回归分析。 结果 失语组的LOTCA总分低于无失语组，差异有统计学意义[85.0（69.0～92.0）分 vs 99.0 （86.0～102.5）分，P <0.05]；失语患者LOTCA总分与WAB各分项及失语商呈正相关（r =0.587～0.883， 均P <0.05），WAB分项中的各分项与LOTCA中各分项之间呈正相关（r =0.521～0.843，均P <0.05）；多 元逐步回归分析显示，影响患者失语商的主要因素为LOTCA总分（β=0.707，P =0.003）。 结论 卒中后失语患者存在非语言认知功能障碍，失语程度越重其非语言认知功能受损程度越重。     

Pharmacotherapy for aphasia

Selected features of aphasia may reflect disruption of specific neurotransmitter systems. Pharmacotherapy focused on these aphasic symptoms may improve language performance following stroke. We attempted to restore speech fluency in a patient with long-standing transcortical motor aphasia by treating his symptoms of hesitancy and impaired initiation of speech with bromocriptine. During therapy his language performance improved substantially, due to reduced latency of response, decreased paraphasias, and increased naming ability. After cessation of drug therapy his language returned to baseline.     

Borderzone Strokes and Transcortical Aphasia

Borderzone infarcts (BZIs) are anatomically defined as ischemic lesions occurring at the junction between two arterial territories, accounting for 2% to 10% of strokes. Three types of hemispheric BZIs are described according to topography (ie, superficial anterior, posterior, and deep). Although published series on related aphasia are rare in the setting of BZI, aphasia is of transcortical (TCA) type, characterized by the preservation of repetition. TCA can be of motor, sensory, or mixed type depending on whether expression, understanding, or both are impaired. Recent studies have reported specific aphasic patterns. BZI patients initially presented with mixed TCA. Aphasia specifically evolved according to the stroke location, toward motor or sensory TCA in patients with respectively anterior or posterior BZI. TCA was associated with good long-term prognosis. This specific aphasic pattern is interesting in clinical practice because it prompts the suspicion of a BZI before the MRI is done, and it helps in the planning of rehabilitation and in providing adapted information to the patient and family concerning the likelihood of language recovery.     

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。