Dr.

Athanasios Mamarelis
Clinical Attachment
Stroke Services
Dor.S. , 89 year old woman
Sudden onset confusion
Weakness, Facial droop, Pronator drift
Expressive aphasia
obey commands
name objects
CT Left MCA infarct
A.Ed. , 95 year old woman
Sudden onset confusion
CNS examination difficult to complete
Weakness, Facial droop, Pronator drift

CT Acute infarct in Right lateral temporal lobe
Extended to parietal lobe
?Edema in Left temporal lobe
De.Tur. , 54 year old woman
Right sided weakness
Occipital headache
Vomiting
Signs of intracranial pressure


Sudden deterioration
Expressive aphasia
2-3
hours
Certain patterns
Predictable syndromes
Basis for cortical localizationist models
Reliable diagnosis & prognosis
25% of
stroke patients
Significant aphasia
Broca (1861)
Wernicke (1874)
Importance of left hemisphere in language
Comprehension deficit
Sensorimotor organization of language
Anatomicaly & physiologicaly evidence
Overlapping
Function represented at multiple sites
Each area belongs to several networks
All or most of the structurals compontens involved

Severe & lasting deficits
Phonology
(pronunciation rules & sounds perception)
Semantics
(words meaning)
Syntax or Grammar
(relationship & shape of words, phrases, sentences accurate
meaning)
Pragmatics
(give & take maintenance of conversation)
Sign language
Similar elements
NO phonology sign morphology
Aphasic syndromes
in deaf
Aphasia
Non-Fluent
Limited ability to produce speech;
effortful and with few words
Good
understanding of
language
(spoken & written)
Brocas Aphasia
Transcortical Motor
Aphasia
Poor
understanding of
language
(spoken & written)
Mixed Non-Fluent
Aphasia
Global Aphasia
Fluent
Able to produce connected
speech
Good
understanding of
language
(spoken & written)
Conduction Aphasia
Anomic Aphasia
Poor
understanding of
language
(spoken & written)
Wernickes Aphasia
Transcortical Sensory
Aphasia
Effortful speech output
Hesitations & Pauses
Word-finding difficulty
Phonemic & Semantic errors
Agrammatism
Relatively preserved comprehension
Lesion Brocas area
Good recovery if only there

Persisting
Large lesion
Brocas area + inferior parietal subcortical
regions

White matter involvement Fluency deficit
Loss of speech output & comprehension
Destruction of anterior & posterior

Lesion Large MCA stroke (hemorrhage)

Wernickes area may be spared
recover towards Brocas aphasia

White matter lesions may be persistant

Pure
All forms of speech affected
Writing spared (usually)
Hesitation, stuttering, dysprosody, initial consonant
substitution

Transcortical
Poor spontaneous speech & written output
Good repetition & comprehension
Variable naming deficit
Pure
Brocas area
Inferior rolandic
Insular cortical

Transcortical
Superior mesial frontal region
Supplementary speech area
Complex process
Analysis of acoustic & phonological input
properties
Recognition of syntactic & lexical elements
Highly specialized
Left hemisphere
Analytical

Fluent & paraphasic speech
Comprehension, repetition, naming (impaired)
Syntax & morphology (relatively preserved)
Semantic & phonological paraphasias (not aware)
Reading & writing (simlarly affected)

When severe neologistic jargon
Substitution of substantive words with
unintelligible phonological paraphasias
Superior posterior temporal branch of MCA
Lesionssuperior temporal & inferior parietal
regions
Complains of not understanding speech
Hearing, reading, speech output
(undisturbed)

Word form
(mishear phonologically similar words)
Word meaning
(perfoms lexical decision but cannot access
semantics)

Poor repetition
Relatively fluent
Phonologically paraphasic speech
Good comprehension

More fluent varieties More posterior lesions

Lesions
Posterior temporoparietal region (end of Sylvian fissure)
Involve posterior insula or arcuate fasciculus
Fluent, semantic jargon
Poor comprehension
Good repetition

Lesions
watershed area between middle &
posterior cerebral circulation

Rapid recovery
(unless evolved from a more severe lesion)
Features of both motor & sensory
transcortical aphasia
Poor prognosis

Lesions
Tend to surround MCA territory
isolating language area
The mildest form
Fluent output
Good comprehension
Naming & word finding difficulty (anomia)

Anterior & central lesions
Lexical retrieval deficit
Posterior temporoparietal lesions
Naming difficulty
Lesions of basal ganglia
Dysarthria & hypophonia severe global aphasia

Anomic aphasia

Transcortical feature presevertion of repetition

Lesion in putamen & anterior internal capsule
slow, anomic, dysarthric speech

Isolated lesions of caudate & putamen (rare)
transient speech deficits
Damasio et al. (1982)
Infarcts anterior limb of internal capsule & striatum
Non-aphasics more lateral or claudal lesions

Naeser et al. (1982)
9 patients with capsuloputaminal lesions
Anterio-superior periventricular matter
Good comprehension & grammatical
Slow, dysarthric speech
Across the temporal isthmus
Fluent speech
Poor comprehension
Both anterio-superior & posterior
Global aphasia
21-33 % acute stroke
38-45% hyperacute stage

1. Global aphasia (25%)
2. Wernickes aphasia (15-25%)
3. Anomic aphasia
4. Transcortical motor aphasia
5. Brocas aphasia
Brocas
Conduction
Anomic
Migraine
Multiple sclerosis
Infections (herpes simplex encephalitis)
Arteriovenous malformations
Aphasic stroke syndromes are not stable
Recovery take place to a considerable
extent
Structural limitations
compensation only in certain areas
Adjacent cortex
Contralateral cortex
Hierarchically connected structure
(e.g. subcortical ganglia)
Compensation through R hemisphere
function
Patients who became aphasic with a single L
hemisphere stroke but recovered
2
nd
R hemisphere stroke language deficit again
Studies of sodium amytal given to aphasics who
hade recovered
Variation in recovery
(Cannot be explained by the extent & location of lesions)

Differences
Language
Laterility
Handedness (L handers)
Age
Gender (more bilateral distribution of language in
women)
CBF
R-hemisphere hypometabolism in aphasic
patients
More blood flow in the L hemisphere
more improvement

PET
Hypometabolism
Cerebral infarcts
Remote areas
MRI (DWI/PWI)
Recovery in the acute stage depends on
improving circulation in surrounding areas