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Dysarthria in Acute Ischemic Stroke: Localization and Prognosis

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J.Neurol.Sci.[Turk]

Journal of Neurological Sciences [Turkish] 27:(1)# 22; 020-027, 2010

http://www.jns.dergisi.org/text.php3?id=334
Research Article

Dysarthria in Acute Ischemic Stroke: Localization and Prognosis

Diler H. CANBAZ, Mehmet CELEBİSOY, Tolga OZDEMİRKIRAN, Figen TOKUCOGLU
Department of Neurology, Atatürk Training and Research Hospital, Izmir, Turkey
Summary
Background and purpose: Dysarthria is a speech disorder characterized by dysfunction in
the initiation, control, and coordination of the articulatory structures involved in speech
output. There is little information about anatomic specificity, spectrum of associated clinical
characteristics, etiologic mechanisms, and its prognosis of dysarthria. We aim to search
correlation between the lesion localization and the prognosis.
Methods: Patients with sudden onset of dysarthria due to a single cerebral infarction
confirmed by CT and/or MRI. were included. Articulation was evaluated and graded at the
acute period, at the first and third month after the event took place.
Results: Fifty five consecutive patients were included. The majority of the lesions were
located in corona radiata (36.5%), followed by pontine lesions (25.5 %). The spontaneous
recovery was significant both at first and third months examinations and lesions located in
corona radiata and infratentorial lesions on the right side seemed to have better prognosis.
Conclusions: The studies including high number of patients with different lesion localization
with functional imagings would contribute our understanding about dysarhtria and prognosis.

Key words: Dysarthria, cerebral infarction, articulation, speech disorders

Akut İnmede Dizartri: Lokalizasyon ve Prognoz

Özet
Amaç: Dizartri, konuşmanın başlatılması, kontrolü ve artikülasyonu sağlayan yapıların
eşgüdümünde bozukluklarla karakterize bir konuşma bozukluğudur. Anatomik özgüllüğü,
eşlik eden klinik bulguların özellikleri ve prognozu hakkında pek az bilgi mevcuttur. Biz
lezyon lokalizasyonu ve prognoz arasındaki ilişkiyi araştırmayı amaçladık.
Yöntem: BT ve/ve ya MR ile gösterilen tek bir infarkta bağlı olarak aniden gelişen dizartrisi
olan hastalar çalışmaya katıldı. Artikülasyon akut dönemde, birinci ve üçüncü ayda
değerlendirildi ve derecelendirildi.
Sonuç: Ardışık 55 hasta değerlendirildi. Lezyonların çoğu korona radyatada olup pontin
lezyonlar ikinci sıklıktaydı. Hem birinci hem de üçüncü ay muayenelerinde spontan düzelme
çok belirgindi. Sağda korona radyata ve infratentorieyel lezyonların daha iyi prognozlu
olduğu izlenimi edinildi.
Yorum: Farklı lokalizasyonlarda lezyonu olan daha çok hastanın katıldığı ve fonksiyonel
görüntüleme yöntemlerinin kullanıldığı çalışmalar dizartri prognozu ve lezyon lokalizasyonu
ile ilişkisi konusunda yararlı bilgiler sağlayabilir.

Anahtar Kelimeler: Dizartri, serebral infarkt, artikülasyon, konuşma bozukluğu

20
J.Neurol.Sci.[Turk]
INTRODUCTION
Disarthria is a speech disorder
characterized by dysfunction in the
initiation, control, and coordination of the
articulatory structures involved in speech
output. The dysarthric patient exhibits
intact cortical language mechanisms and
comprehension. He is able to understand
perfectly what he hears and has no
difficulty in reading and writing, although
his speech is inarticulate and may be
unintelligible. Although dysarthria is a
frequent symptom in cerebral ischemia,
there is little information about its
anatomic specificity, spectrum of
associated clinical characteristics, etiologic
mechanisms, and its prognosis.
MATERIAL AND METHODS
We report on 55 consecutive patients (36
males, 19 females, range 18-97 years,
mean age 65.5±15.0 years) with sudden
onset of dysarthria due to a single cerebral
infarction confirmed by CT and/or MRI.
Not included were the patients with stroke
in the subacute or chronic stage, and
patients with disturbance of consciousness,
dementia, aphasia, and anarthria. In this
study 98.2 % of the patients were right, 1.8
% of the patients were left handed.
Articulation was evaluated on the basis of
various samples namely; spontaneous
speech, repetition of sentences and words,
reading a short story, and rapid iteration of
syllables (pa/ta/ka) The evaluation of
dysarthria was performed by two
experienced neurologists (MC, TO)
independently within the first 72 h after
stroke onset, at the end of the first week,
one and three months later. Dysarthria was
graded as mild, moderate or severe.
Location of the lesion was identified by CT
(n=55) and MRI (n=51) scans. MRI was
not done in four patients because of
claustrophobia (n=2), weights>120kg
(n=2). CT was performed with a Hitachi
W950SR X-Ray CT (spiral) System and
21
MRI with a General Electric Vectra Model
1.5 T.
RESULTS
15.0 years (range±Mean age of the 55
patients (36 men and 19 women) was 65.5
18 to 97 years). The patients were graded
into six groups according to their ages. 4
patients were within the <40 years group,
six in the 41-50 years group, nine in the
51-60 years group, 11 in the 61-70 years
group, 20 in the 71-80 years group and five
in the >81 years group. Thirty nine
(70.9%) of our patients had hypertension,
and 33 (60%) had hyperlipidemia, 16
(29.1%) had diabetes mellitus, 11 (20%)
had a history of cigarette smoking, 8
(14.5%) had a history of myocardial
ischemia, 8 (14.5%) had atrial fibrillation,
7 (12.7%) had a history of previous stroke,
and 6 (11%) had a family history of stroke.
The cause of ischemia was cardioembolism
in 41.82 % (n=23), large-vessel occlusive
diseae in 18.18 % (n=10), small-vessel
occlusive disease in 12.73 % (n=7) and
dissection in 1.8 % (n=1). No etiology was
identified in 25.45 % (n=14).
Isolated dysarthria occured in two patients
(3.6 %). These patients had left sided acute
corona radiata infarcts on CT. All other
patients presented with additional signs
(Table 1).
The lesions responsible for dysarthria were
located in the supratentorial region in
69.1%, and in the infratentorial region in
30.9 % of the patients. Supratentorial
infarctions were located in the corona
radiata (36.5%), anterior half of the
posterior limb of the internal capsule (7.3
%), anterior limb of the internal capsule
(1.8%), larger parts of the middle cerebral
artery territory (14.5%), frontal region
(1.8%), thalamus (1.8%), striatocapsular
junction (3.6%) and head of the caudate
nucleus (1.8%) (Table 2). Supratentorial
infarcts were located equally on the right
and the left side (n=19, n=19).
J.Neurol.Sci.[Turk]

Table 1. Clinical findings and associated anatomical localizations.

Findings Supratentorial Brainstem Cerebellum Total

region (n=38) (n=14) (n=3) (n=55)

Pyramidal tract 38 12 - 50 (%90.9)

signs
Central facial 31 11 - 42 (%76.3)
paresis
Hemiparesis 32 12 44 (%)
Hemihypesthesia 10 2 12 (%21.8)
Hemianopia 4 - - 4 (%7.2)
Central palatal - 3 - 3 (%5.45)
paresis
Gait ataxia 1 2 3 (%5.45)
Pure dysarthria 2 - - 2 (%3.6)
Dysmetria 1 1 2 (%3.6)
Nystagmus 1 - 1 (%1.8)
Alexia-agrafi 1 - - 1 (%1.8)

Table 2. Topography of lesions.

Localization n=55 %

Corona radiata 20 36.5

Large hemispheric 8 14.5

Anterior half of the posterior limb of

the internal capsule 4 7.3

Anterior limb of the internal capsule 1 1.8

Striatocapsular junction 2 3.6

Thalamus 1 1.8
Frontal region 1 1.8
Head of the caudate nucleus 1 1.8
Pons 14 25.45
Cerebellum 3 5.45

22
J.Neurol.Sci.[Turk]
In the infratentorial region, brain stem was
affected 25.45% (n=14) of the patients. In
all patients with brain stem involvement
paramedian pontin infarction was present.
Brain stem infarcts were also more
frequent on the right (57.1 %) than on the
left side (42.9%). Cerebellar infarcts were
present in three patients (5.45%), affecting
the superior cerebellar artery region on the
right side in two patients and on the left
side in one.
Dysarthria gradings recorded by the two
investigators did not show any statistically
significant difference in any period
(p<0.01). During the initial examination 21
of the 55 patients had severe, 24 had
moderate and 10 had mild dysarthria. At
the end of the third month in one of the 21
patients with severe dysarthria there was
no change. In seven of them it had
regressed to mild dysarthria. In five,
speech was recorded to be normal (Table
3).
In 24 patients with moderate dysarthria,
nine regressed to mild dysarthria and 15 to
normal speech at the end of the third
month. In 10 patients with mild dysarthria
nine regressed to normal. In 1 no change
was present. Dysarthria grades at the initial
examination and at the end of the third
month can be seen in table 3. In all patients
a statistically significant recovery was
present during the three months follow-up
period (p<0.01). In 55 patients with
dysarthria at the initial examination, 16
showed regression at the end of the first
week. In 39 patients no change was
present. At the end of the first month 41
23
patients showed regression. In 14 no
change was present. At the end of the third
month 53 patients showed regression. In
two of them a difference was not recorded.
In one of those 2 patients an infarction
involving right corona radiata and in the
other an infarction in the left pons was
present. When the prognosis of dysarthria
in supra and infratentorial lesions were
compared prominent recovery was noted in
both localizations. Both the right and the
left sided supratentorial lesions showed
prominent regression (p<0.01). For the
infratentorial lesions right sided lesions
showed a better recovery (p=0.000 for the
right and p=0.003 for the left side).
In 20 patients with infarcts involving
corona radiata dysarthria was severe in
35%, moderate in 35% and mild in 30% at
the initial examination. At the end of the
third month it was severe in 5%, moderate
in 10%, and mild in 25%. Speech was
recorded to be normal in 60% of the cases.
In 14 patients with pontine infarcts
dysarthria was severe in 35.7 %, moderate
in 50%, and mild in 14.3% at the initial
examination. At the end of the third month
it was recorded as moderate in 28.6% and
mild in 21.4%. No dysarthria was present
in 50% of the cases. In 8 patients with
large middle cerebral artery infarction 62.5
% had severe, 37.5%had moderate
dysarthria at the initial examination. At the
end of the third month 12.5 % had
moderate and 62.5% had mild dysarthria.
In 25% speech was normal. Affected
regions and the prognosis of dysarthria is
given in Table 4.
J.Neurol.Sci.[Turk]

Table 3. Grading of dysarthria at the beginning and at the third month.

Dysarthria during acute period

Severe Moderate Mild Total

3rd month Severe 1 1

Moderate 7 7
Mild 8 9 1 18
Normal 5 15 9 29
Total 21 24 10 55

Table 4.Localization and prognosis of dysarthria. I:initial, n:number of patients, 1w: one
week later, 1m: one month later, 3m: three months later.

Localization Severe (n) Moderate (n) Mild (n) Normal (n)

I 1 1 3m I 1w 1m 3m I 1w 1m 3m I 1w 1m 3m
w m

Corona radiata 7 6 2 1 7 5 4 2 6 9 9 5 5 12

Pons 5 4 3 7 5 1 4 2 5 9 3 1 7

LargeACM 5 2 1 3 4 3 1 1 3 5 1 1 2

Anterior half of 2 1 2 2 1 1 2 2 1 2
the post. limb of
the internal caps
Anterior limb of 1 1 1 1
the internal caps
Cerebellum 1 1 2 1 1 2 2 1 1

Striatocapsular 1 1 2 1 1 2
junction

Frontal region 1 1 1 1

Thalamus 1 1 1 1

Head of the 1 1 1 1
caudate nucleus

Total 21 14 6 1 24 20 11 7 10 20 27 18 0 1 11 29

24
J.Neurol.Sci.[Turk]
DISCUSSION
Dysarthria is a pure motor disorder of
speech, occuring in 8-30% of patients with
cerebral ischemia.(1,5,8) Dysarthria has been
reported in 25% of patients with lacunar
stroke and 30% of patients with strokes in
the internal capsules.(4,6)
Dysarthria has been reported in different
localizations in ischemic stroke. These
include supratentorial, infratentorial and
cerebellar regions. Supratentorial lesions
were observed in the lower motor cortex,
corona radiata, internal capsule and
caudate nucleus. Internal capsule lesions
were in the anterior limb, genu and
posterior limb. The lesions responsible for
dysarthria were located in the
supratentorial region in 45.6% and in the
infratentorial region in 54.4% of patients in
Urban's study.(14) In this study,
supratentorial infarctions were located in
the primary motor cortex (5.9%), corona
radiata (23.5%), genu and anterior half of
the posterior limb of the internal capsule
(8.8%), striatocapsular junction (5.9%), or
affected larger parts of the middle cerebral
artery territory, including the motor cortex
and the corona radiata (1.5%).(14) In a
recent study supratentorial infarcts were
located in the lower motor cortex (14.5%),
and striatocapsular region (46.8%).(15) In
another recent study lesions on DW1 were
reported in the corona radiata (n=18),
middle cerebral artery territory, including
the motor cortex and/or insular cortex
(n=13), striatocaudate nuclei (n=11),
primary motor cortex (n=10), internal
capsule (n=7).(9) In our study, the lesions
responsible for dysarthria were located in
the supratentorial region in 69.1% of
patients and were located in the corona
radiata (36.5%), anterior half of the
posterior limb of the internal capsule
(7.3%), anterior limb of the internal
capsule (1.8%), larger parts of the middle
cerebral artery territory (14.5%), anterior
cerebral artery territory (1.8%), posterior
cerebral artery territory (1.8%),
striatocapsular junction (3.6%) and head of
the caudate nucleus (1.8%) (Table 2). In
25
Urban's study for the infratentorial region,
the brainstem was affected in 33.8% of
patients, with lesions involving the
cerebral peduncle (1.5%), pontine base
(30.9%), and ventral pontomedullary
junction (1.5%).(14) In a newly published
study by Urban pontine base involvement
was reported to be present in 24.2%. In
Kumral's study pons (n=25), pontobulbar
junction (n=5), and the
thalamomesencephalic junction (n=4) were
affected. In our study, the brainstem was
affected 25.45% (n=14) of patients. In all
patients with brain stem involvement
lesions were present in the paramedian
pontine region.(9,15)
Isolated cerebellar infarcts were present in
six patients (8.8%) in Urban's study,
affecting the superior cerebellar artery
region in five patients and superior and
inferior cerebellar artery combination in
one patient. Isolated cerebellar infarcts
have been reported in 14.5% and 5.94% of
the patients in two other studies.(9,14,15) In
our study, cerebellar infarcts were present
in three patients (5.45%), affecting the
superior cerebellar artery region on the
right side in two patients and on the left
side in one.
Urban et al. had found that 81.5% of
extracerebellar infarcts leading to
dysarthria were located in the left
hemisphere and 18.5% on the right side.14
Supratentorial infarcts were found more
often on the left (74.2%) and brainstem
infarcts were also more frequently on the
left side (91.3%) in Urban's study.(14) In a
recent study, they have demonstrated that
dysarthria in extracerebellar infarctions
was more frequently caused by left-sided
lesions (88.7%) and that the severity of
dysarthria was more pronounced in left-
sided lesions independent from the lesion
topography.(15) The analysis of the lesion
side shows that 51.9% of all
extracerebellar infarcts leading to
dysarthria were located on the right and
48.1% on the left side in our study. This is
in contrast with Alexander and Wildgruber
J.Neurol.Sci.[Turk]
who reported that right-sided lesions do
not lead to dysarthria.(2,17) The side
difference might be explained by the
lesions of a common descending
projection, for example the corticobulbar
projections to the articulatory
(11,12,13)
muscles. As it was shown
previously that a lesion of the
corticolingual pathway is crucial in the
pathogenesis of dysarthria in stroke, a
possible explanation might be a more
dominant descending pathway from the left
motor cortex.(14) In our study,
supratentorial infarcts were found equally
on the right and the left side (n=19).
Brainstem infarcts were more frequent on
the right (57.1%) than on the left side
(%42.9).
Different reports about the localization of
the cerebellar infarcts associated with
dysarthria are present. Some propose that
right sided infarcts are more frequently
associated with dysarthria.(1,14) Equal
distribution on the right and the left side
has also been proposed.(3,7) A right-side
dominance, however has not been proven
thus far.(16) As the number of cerebellar
infarcts in our study is small it is difficult
for us to say more.
No spesific study is present until now
about the prognosis of dysarthria and its
association with the localization of the
lesion. Urban et al. recently published a
prospective study of recovery from
poststroke dysarthria. Thirty-eight of sixty-
two consecutive patients with dysarthria
were available for follow-up testing a
minimum of at least 6 months later.(15) All
38 patients had been assigned for 2-4
weeks of poststroke speech therapy. At the
follow-up evaluation, 15 of 38 patients
(39%) were judged to have normal speech
and the remaining 23 patients had only
mild residual dysarthria. Data from this
study also indicated that 88.7% of
noncerebellar strokes causing dysarthria
were left-sided and severity of dysarthria
was worse with left-sided lesions.(15)
26
In 55 of our patients with dysarthria 29.1
% showed regression at the end of the first
week. At the end of the first month this
figure was 74.5 % and at the end of the
third month it was 96.3%. In only 2
patients no prominent change was present
at the end of the third month. In one of
them the infarct was located at the right
corona radiata and in the other it was
located at the left pons.
In our dysarthric patients with either
supratentorial or infratentorial lesions a
prominent spontaneous recovery was noted
at the end of the third month. When the
supratentorial lesions localized on the left
and right side were compared with respect
to prognosis no statistically significant
difference was noted. However,
infratentorial lesions on the right side
seemed to have a better prognosis. In 3
patients with cerebellar infarcts dysarthria
regressed during the follow-up visits.
In infarcts localized in corona radiata, pons
and middle cerebral artery territory
dysarthria showed significant regression.
At the initial examination 35% of the
patients with corona radiata infarcts, 35.7
% of the patients with pontine infarcts and
62.5% of the patients with middle cerebral
artery territory infarcts had severe
dysarthria. At the end of the third month
60% of the patients with corona radiata
infarcts, 50% of the patients with pontine
infarcts and 25% of the patients with
middle cerebral artery territory infarcts had
normal speech. According to these results
corona radiata infarcts seem to have a
better prognosis.
In all three patients with cerebellar infarcts
prominent regression of the dysarthria was
recorded. However, as the number is small
it is difficult to say something about the
prognosis in this group.
Our study had limited numbers of patients
who had lesions other than corona radiata
and pons. Larger studies including higher
numbers of patients with different lesion
localization with functional imagings
 J.Neurol.Sci.[Turk]

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