APHASIA

30/03/2017
Aphasia refers to a disorder of language, including
various combinations of impairment in the
ability to spontaneously produce, understand
and repeat speech, as well as defects in the
ability to read and write.
• The oldest known document on neurologic
localization concers Aphasia.

• In the period between 2500-3000 BC in an

Egyptian Papyrus by their surgeons.
 1824-1880
French neurosurgeon.

1861 did autopsy of Tan’s

brain

Did several case studies

1865- Left sided brain is for

language
Inferior frontal gyrus
Paul Broca
 1848-1905
German Neurologist

1874- wrote that

Perisylvian area is
concerned with language.
Also described conduction
aphasia.

Carl Wernicke
Anatomy and physiology
• Perisylvian.

• Two language areas are receptive and two are

executive

• Left hemisphere – 99% of right handed person

and 60% of left handed person.
The perisylvian language areas are also connected with the
striatum and thalamus and with corresponding areas in
the nondominant cerebral hemisphere through the corpus
callosum and anterior commissure.
 22,41,42 ( Heschl Auditory
gyrus) stimulus

Angular gyrus Visual

stimulus

22

Arcuate F 44
• Language: complex system of communication
symbols and have rules for there use.
APHASIA.

• Speech: Articulation and phonation of language.

DYSARTHRIA, DYSPHONIA, STUTTERING,
SPEECH APRAXIA.
Causes
• Stroke- Most distinctly observed in ischemic
stroke
• Primary or secondary neoplasms
• Abscesses, infections.
• Trauma
• Diffuse lesions such as dementia.
• Seizure.
 625/1796 (34.8%)

Journal of Stroke and Cerebrovascular Diseases, Vol. 22, No. 8 (November),

2013: pp 1385-1392
Journal of Stroke and Cerebrovascular Diseases, Vol. 22, No. 8
(November), 2013: pp 1385-1392
Journal of Stroke and Cerebrovascular Diseases, Vol. 22, No. 8 (November),
2013: pp 1385-1392
• The frequencies of the different types
of aphasia in acute stroke:
• global 32%,
• Broca's 12%,
• transcortical motor 2%,
• Wernicke's 16%,
• transcortical sensory 7%,
• conduction 5%
• anomic 25%.

Aphasia after stroke: type, severity and prognosis. The

Copenhagen aphasia study, Pedersen PM1, Vinter K, Olsen TS.
Cerebrovasc Dis. 2004;17(1):35-43
Examination of language function
Classification
• Fluent vs Non fluent

• Expressive vs Receptive
Wernicke-Geschwind model (Boston
classification)
1) Broca’s
2) Wernicke’s
3) Conduction
4) Global
5) Transcortical motor
6) Transcortical sensory
7) Transcortical mixed
8) Anomic
Alternate classification
1) Aphasia with repetition disturbances.
Broca’s aphasia
Wernicke’s aphasia
Conduction aphasia

2) Aphasia with preserved repetition

Transcortical motor aphasia.
Transcortical sensory aphasia.
Anomic aphasia.
3) Disturbance of reading and writing.
Alexia with agraphia

4) Total Aphasia
Global aphasia.

5) Disturbance of single language modality.

Pure word deafness
Alexia without agraphia
Broca’s aphasia
• Nonfluent
• Meaning-containing nouns and verbs but
omitting small grammatical words and
morphemes.
• Agrammatism or telegraphic speech.
• Repetition is hesitant in these patients,
resembling their spontaneous speech.
• Third alexia.
• The lesions responsible for Broca aphasia
usually include the traditional Broca area in the
posterior part of the inferior frontal gyrus, along
with damage to adjacent cortex and subcortical
white matter.
BROCA’s APHASIA
Wernicke’s aphasia
• Excessively fluent (logorrhea).
• Verbal paraphasias, neologisms, and jargon
productions.
• Naming in Wernicke aphasia is deficient, often
with bizarre, paraphasic substitutions for the
correct name.
• Reading comprehension is usually affected
similarly to auditory comprehension.
• Depression is less common.
• The lesions of patients with Wernicke aphasia
usually involve the posterior portion of the
superior temporal gyrus, sometimes extending
into the inferior parietal lobule.
• Inferior division of the left middle cerebral
artery.
WERNICKE’S APHASIA
Conduction Aphasia
• Normal spontaneous speech, although some
make literal paraphasic errors and hesitate
frequently for self-correction.
• Naming may be impaired.
• Repetition impaired.
• Some patients have limb apraxia, creating a
misimpression that comprehension is impaired.
• Patients with limb apraxia have parietal lesions.
CONDUCTION APHASIA
Global Aphasia
• The lesions of patients with global aphasia are
usually large, involving both the inferior frontal
and superior temporal regions, and often much
of the parietal lobe in between.
• This lesion represents most of the territory of the
left middle cerebral artery.
GLOBAL APHASIA
Pure word deafness
• Isolated loss of auditory comprehension and
repetition.
• Isolation of Wernicke’s area from input from the
primary auditory cortex, in the bilateral Heschl’s
gyri.
Anomic Aphasia
• Spontaneous speech is normal except for the
pauses and circumlocutions produced by the
inability to name.
• Common but less specific in localization than
other aphasic syndromes.
• Anomia is also seen with mass lesions elsewhere
in the brain, and in diffuse degenerative
disorders, such as Alzheimer disease.
• Inability to produce nouns is characteristic of
temporal lobe lesions, whereas inability to
produce verbs occurs more with frontal lesions.
ANOMIC APHASIA
Transcortical aphasias
• Repetition is normal.
• Disrupt connections from other cortical centers
into the language circuit.
• Three types
Mixed transcortical aphasia
• Syndrome of the isolation of the speech area.
• Global aphasia in which the patient repeats,
often echolalically, but has no propositional
speech or comprehension.
Transcortical Motor Aphasia
• analogue of Broca aphasia in which speech is
hesitant or telegraphic, comprehension is
relatively spared, but repetition is fluent.
• lesions in the frontal lobe, anterior to the Broca
area, in the deep frontal white matter, or in the
medial frontal region, in the vicinity of the
supplementary motor area.
• Territory of the anterior cerebral artery.
Transcortical Sensory Aphasia
• Analogue of Wernicke aphasia in which fluent,
paraphasic speech, paraphasic naming, impaired
auditory and reading comprehension, and
abnormal writing coexist with normal repetition.
• Left temporo-occipital area.
Subcortical Aphasia
• two major groups of aphasic symptomatology
have been described: aphasia with thalamic
lesions and aphasia with lesions of the
subcortical white matter and basal
ganglia.
• Left thalamic hemorrhages frequently produce a
Wernicke like fluent aphasia, with better
comprehension than cortical Wernicke aphasia.

• Thalamic aphasia can occur even with a right

thalamic lesion in a left-handed patient,
indicating that hemispheric language dominance
extends to the thalamic level.
• Anterior putamen, caudate nucleus, and anterior
limb of the internal capsule.
• “Anterior subcortical aphasia syndrome”
• Dysarthria, decreased fluency, mildly impaired
repetition, and mild comprehension
disturbance.
• This syndrome most closely resembles Broca
aphasia, but with greater dysarthria and less
language dysfunction.
• Lesions involving the putamen and deep
temporal white matter, referred to as the
temporal isthmus, are associated with fluent,
paraphasic speech and impaired comprehension
resembling Wernicke aphasia.

• Larger subcortical lesions involving both the

anterior and posterior lesion sites produce
global aphasia.
Pure Alexia without Agraphia
• Alexia, or acquired inability to read.
• Patients can write but cannot read their own
writing.
• Naming may be deficient, especially for colours.
• Quickly understand words spelled orally to
them, and they can spell normally.
• Territory of the left posterior cerebral artery,
with infarction of the medial occipital lobe, often
the splenium of the corpus callosum, and often
the medial temporal lobe.
Pure Alexia without Agraphia
Alexia with Agraphia
• Acquired illiteracy, previously educated patient
is rendered unable to read or write.
• The lesions typically involve the inferior parietal
lobule, especially the angular gyrus. Etiologies
include strokes in the territory of the angular
branch of the left middle cerebral artery or mass
lesions in the same region.
Alexia with Agraphia
RIGHT HEMISPHERE DISORDERS
• Right-handed patients occasionally become
aphasic after right hemisphere strokes, a
phenomenon called crossed aphasia.
• Aprosodia.
• Metaphor, humor, sarcasm, irony, and related
constituents of language that transcend the
literal meaning of words are especially sensitive
to right hemisphere dysfunction.
 • Aphasia is a dynamic syndrome because
reorganization sets in, and the evolution of
aphasia subtypes into others is well documented.

• Global improves to Broca (35%), anomic (22%),

normal (15%), Wernicke (7%), and no change
(22%).

Evolution of the deficit in total aphasia, Mohr JP, Sidman M, Stoddard

LT, Leicester J, Rosenberger PB; Neurology. 1973 Dec;23(12).
Differential diagnosis
• Muteness-Total loss of speech.
Dysarthria
Frontal lobe dysfunction
Parkinsons
Psychologic.

• A good rule of thumb is that if the patient can

write or type and the language form and content
are normal, the disorder is probably not aphasic
in origin.
• Hesitant speech.
dysarthria or stuttering.
psychogenic disorder.

• Rule of thumb is that if one can transcribe the

utterances of a hesitant speaker into normal
language, the patient is not aphasic.
• Anomia

Can be because of memory loss.

• Fluent, paraphasic speech.
aphasia- Patients usually not confused
or agitated
psychosis-Behaviour and speech
content abnormal, good grammer.
acute encephalopathy or delirium-
Agitation, hallucinations, grammatical error is
minimum.
dementia- Memory and visuospatial
processes will be impaired.
Apraxia of speech
• Syndrome of misarticulation of phonemes,
especially consonant sounds.
• inconsistent distortions and substitutions of
phonemes.
• Clinically, speech-apraxic patients produce
inconsistent articulatory errors, usually worse on
the initial phonemes of a word and with
polysyllabic utterances.
Investigations
• Imaging
• EEG
• Functional MRI
RECOVERY AND REHABILITATION OF
APHASIA
• First 3 months.
• Language recovery may be mediated by shifting
of functions to the right hemisphere or to
adjacent left hemisphere regions.
Speech therapy
• Repeated practice in articulation and
comprehension tasks has traditionally been used
to stimulate improvement.
• Melodic intonation therapy.
• Visual action therapy.
• Treatment of aphasic perseveration,
• Functional communication therapy,
• cVIC or Lingraphica, a computer program.
• Dopaminergic drug bromocriptine, does it have
a role?
• Transcranial magnetic Stimulation.
• Direct cortical stimulation.
THANK YOU
References
• Bradleys neurology in clinical practice, 7th
edition.
• Adam and victor’s principle of neurology, 10th
edition.
• DeJong’s the neurologic examination, 7th
edition.
• Practical neurology by Jose Biller, 4th edition.
• Localization in clinical neurology by Paul
W.Brazis, 6th edition.