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Aphasia
- 2. LANGUAGE AND SPEECH • Language – machanism for expressing thoughts, ideas • By speech • By writing • By gestures • Speech is dependent on – Interpretation of the auditory and visual images – Association of these images with motor centers – Expression of the motor elements • Aphasia – disorder of language • Dysarthria – disorder of articulation of speech
- 3. • Three cortical levels of comprehension Composition of language Level of arrival Level of knowing Level of recognition • Three cortical levels of motor speech function Emotional level Automatic level Propositional level
- 4. Broca’s speech area Wernicke’s speech area Arcuate fasciculus Angular gyrus Supramarginal gyrus Exner’s center Anatomy of language centers
- 5. Broca’s area • Posterior inferior frontal gyrus • just anterior to primary motor area • left precentral gyrus of insula, motor planning area
- 6. Wernicke’s area • superior temporal gyrus • just posterior to primary auditory cortex
- 7. Arcuate fasciculus • deep white matter tract • connects WA to BA around posterior end of the Sylvian fissure, through subcortical white matter of the insula to the BA
- 8. Angular gyrus • part of inferior parietal lobule • between WA and Visual cortex •Important for reading adn nonverbal language functions
- 9. Supramarginal gyrus • between visual cortex and posterior perisylvian language areas •Visual language functions
- 10. Exner’s center • middle frontal gyrus •Just anterior to primary motor cortex for the hand.
- 11. Handedness • 90-95% are right handed – left hemisphere dominant in 99% of them • Left handers – 60-70% - left hemisphere dominant • Remaining left handers – half have mixed dominance, half have right dominant • Anamolous dextrals / shifted sinistrals – right dominant Examination for aphasia
- 12. • Handedness and dominant status is paramount • Failure of dominance development – dyslexia, stuttering, mirror writing, learning difficulty • Aphasia tend to be less severe in left handers and recover better • Just a family history of left handedness may recover.
- 13. • Which language recovers best is variable • Pitre’s law – best recovery for the language used the most • Ribot’s rule – recovery will be best for the native language. • Most patients show parallel recovery for both languages. Multilinguals ...
- 14. • Spontaneous speech • Auditory comprehension • Naming • Reading • Writing • repetition Components of examination
- 15. • Emotional speech ... ‘ouch’, swear or curse ... • Automatic speech ... Count, days of the week, alphabets, own name, nursery rhymes • Monophasia ... Retained segment .. “Tan”, “do-do”, “oh God” ... • Can be real word or neologism. Spontaneous speech
- 16. • Paraphasia ... • Phonemic paraphasia – “watch” “blotch” • Semantic paraphasia – “watch” “ring” • Neologism ... – Phonemic paraphasia – anterior lesion – Semantic paraphasia – posterior or perisylvian lesion
- 17. • Note the fluency, pronounciation, sentence formation, rhythm, prosody, ommission or transposition, repetition, perseveration, paraphasia, jargon and neologisms. • Fluency – 100 to 115 words per minute • <10 to 15 – nonfluent aphasia • Best approach – ask open ended questions esp. For nonfluent aphasias
- 18. • Simple verbal commands – “show your teech”, close your eyes”, “point to the ceiling” • Failure may not necessarily prove, may be apraxia • If not, establish if he can say yes or no • If not, ask ridiculously simple questions • Is a mother older than a daughter? • To old lady “ r u pregnant?”, she giggles! • Ask enough questions for yes/no to exclude being lucky comprehension
- 19. • Marie’s paper test – comprehension and retention • Impaired comprehension have difficulty in passive constructions • Lion was killed by the tiger, which animal died? • They may comprehend to gestures, mime – place finger to the nose or show ur tongue • However, this is more lower level function than comprehension
- 20. Left right orientation • Especially posterior lesions • Gerstmann’s syndrome • show me your right thumb • Touch your right ear with your left thumb
- 21. • Confrontation naming • Simple objects – keys, watch, pen, coin • Responsive naming • Audition rather than vision • Where do teachers work? • How does sugar taste? • Methods • Word list generation – min 12 items in category/min • Think of all words with particular letter • FAS test – 12 or more words/letter/min, 36 words total/3 min naming
- 22. • Proportional to comprehension/fluency • Screening test for aphasia • Simple tasks • Counting, avoiding numbers, repeat single words • Complex tasks • Polysyllabic words, phrases, tongue twisters • Popular phrase – “no if, ands, or buts” • Better – “they heard him on the radio last night” • Preserved in anomic, transcortical and some subcortical aphasias. Repetition
- 23. • Preserved in dysarthria/verbal apraxia • All aphasias, reading/writing worse than understanding/speaking • Spontaneous writing • Few words, sentence, paragraph • Dictative writing • Analogous to repeat verbal command • Copying written material tests • Information transfer from visual to language areas • Connections betn receptive language areas and Exner’s center Writing
- 24. • Dysfunction of the language centers or interuption of the connection with the visual system – alexia • Alexia without any accompanying inability to comprehend speech – pure word blindness • Alexia without agraphia • Alexia with agraphia • Reading aloud • Like copying, repetition Reading
- 25. • Problematic because – Disorders vary in severity – Strictly anatomic classification does not apply – Similar lesions may produce different syndromes – Different lesions may produce similar results • Different ways – Expressive/receptive – Fluent/non-fluent – Motor/sensory – Anterior/posterior – Central/paracentral classification
- 26. • Wernicke – Geschwind model • Eight types Boston classification
- 29. • Non-fluent, Expressive, Motor, Anterior, Pre-rolandic, Executive • Lesion – • Anterior peri-sylvian speech area in the PIF region. • Labored, non-fluent speech with a decreased amount of linguistic output. • tendency to leave out nonessential words such as adjectives, prepositions that serve primarily to provide sentence structure (telegraphic speech) • ability to comprehend speech is relatively unimpaired. Broca’s Aphasia
- 30. • preservation of emotional and automatic speech, and the patient may be able to sing. • contralateral hemiparesis or faciobrachial paresis but no visual field deficit.
- 31. • Fluent, Receptive, Sensory, Posterior, Postrolandic • Lesion – • in the PST region that involves the auditory association cortex and the angular and supra-marginal gyri • unable to understand speech (word deafness) or read (word blindness) • fluent, with a normal or even increased word output (logorrhea, hyperlalia), but there is loss of the ability to comprehend the significance of spoken words or recall their meaning. • cannot understand his own speech Wernicke’s Aphasia
- 32. • “The frequent paraphasias and neologisms, combined with agrammatism, along with the high word output, may lead to completely unintelligible gibberish, termed jargon aphasia, or word salad.” - Hughlings Jackson • often have a visual field deficit but no hemiparesis. • Frequently thought to be psychotic.”
- 34. • Total, Expressive-Receptive, Complete • lesion • destroyed the entire perisylvian language center, or separate lesions have destroyed both the PIF and PST regions • Grossly nonfluent speech is combined with a severe comprehension deficit and inability to name or repeat. • Typically, there is both a hemiplegia and a field cut • usually due to internal carotid or proximal MCA occlusion” Global Aphasia
- 35. • Associative, Commissural, Central, Deep • lesion • interrupts the conduction of impulses between Wernicke’s and Broca’s areas • poor repetition with relative preservation of other language functions. • Patients have difficulty reading aloud and writing to dictation. • The etiology is usually an embolic occlusion of a terminal branch of the MCA. Conduction Aphasia
- 36. • Amnesic, Amnestic, Nominal • deficit in naming ability with preservation of other language functions. • fluent, have good comprehension, and are able to repeat. • lesion cannot be readily localized to any particular cortical area. (non localising syndrome) • Lesion – • language disorder suggests a lower temporal lobe lesion. Anomic Aphasia
- 37. • The perisylvian language area is preserved but disconnected from the rest of the brain • etiology is usually BZI. (border-zone infarcts) • aphasic but paradoxical preservation of repetition. • isolation of the speech area, or mixed TCA – entire perisylvian language complex is separated from the rest of the brain, the patients are not fluent in spontaneous speech and are unable to comprehend.” Transcortical Aphasia
- 38. • Lesions—usually vascular—involving the thalamus, caudate, putamen, periventricular white matter, or internal capsule of the language dominant hemisphere. • Two types have been described: •Anterior syndrome (caudate or striatocapsular aphasia) - slow dysarthric speech with preserved phrase length, that is, not telegraphic, preserved comprehension, and poor naming •Posterior syndrome (thalamic aphasia) - there is fluent speech without dysarthria, poor comprehension, and poor naming Subcortical Aphasia (extrasylvian)
- 39. • affect the nonlinguistic elements of language • There is loss or impairment of the rhythm and emotional elements of language. • unable to say the same neutral phrase (e.g., “I am going to the store”) in an angry or happy way. Non-dominant Hemisphere Language Disturbances
- 40. • Loss of the ability to read in the absence of actual loss of vision is alexia (word blindness, visual receptive aphasia, visual sensory aphasia). • Lesion – • angular or supramarginal gyrus, or its connections to the visual cortex • Loss of the ability to write not due to weakness, incoordination, or other neurologic dysfunction of the arm or hand is called agraphia. – There are three types of agraphia: aphasic, constructional (due to visuospatial compromise), and apractic. ” • Agraphia is seen in all types of aphasia except pure word blindness and pure word mutism. Alexia and Agraphia
- 41. • Loss of musical ability, either production or comprehension, may occur in patients with aphasia or agnosia, or acquired amusia may develop independently. • One classification of amusia includes vocal amusia, instrumental amnesia, musical agraphia, musical amnesia, disorders of rhythm, and receptive amusia. Amusia
- 42. Thank you