Language

• Aphasia, a disorder of language usage and comprehension, should be

distinguished from dysarthria, impaired articulation, and mutism, the
absence of speech.
• Usually, the presence of aphasia accurately localizes dysfunction to the
cerebral hemisphere concerned with speech.
• To classify an aphasia, it is necessary to determine whether the patient
can (1) speak fluently, with normal articulation and rhythm and without
paraphasic, syntactic or grammatical errors or use of circumlocutory
phrases; (2) accurately repeat spoken sounds, words, and phrases; (3)
understand spoken language, as evidenced by accurate responses to
spoken questions and ability to follow spoken commands (failure to follow
a command may also be due to apraxia or paralysis and does not
necessarily reflect poor comprehension); (4) consistently name common
objects, presented visually, verbally, or tactilely; (5) read aloud accurately
and with comprehension; (6) name words spelled aloud; and (7) write
legibly and grammatically.
• The clinical examination of language should include the assessment
of naming, spontaneous speech, comprehension, repetition,
reading, and writing.
• A deficit of naming (anomia) is the single most common finding in
aphasic patients. When asked to name a common object (pencil or
wristwatch), the patient may fail to come up with the appropriate
word, may provide a circumlocutious description of the object ("the
thing for writing"), or may come up with the wrong word
(paraphasia).
• If the patient offers an incorrect but related word ("pen" for
"pencil"), the naming error is known as a semantic paraphasia; if
the word approximates the correct answer but is phonetically
inaccurate ("plentil" for "pencil"), it is known as a phonemic
paraphasia.
• In most anomias, the patient cannot retrieve the appropriate name
when shown an object but can point to the appropriate object
when the name is provided by the examiner. This is known as a one-
way (or retrieval-based) naming deficit
• Comprehension can be tested by assessing the patient's ability to
follow conversation, asking yes-no questions ("Can a dog fly?",
"Does it snow in summer?") or asking the patient to point to
appropriate objects ("Where is the source of illumination in this
room?"). Statements with embedded clauses or a passive voice
construction ("If a tiger is eaten by a lion, which animal stays
alive?") help assess the ability to comprehend complex syntactic
structure. Commands to close or open the eyes, stand up, sit down,
or roll over should not be used to assess overall comprehension
since appropriate responses aimed at such axial movements can be
preserved in patients who otherwise have profound comprehension
deficits.
• Repetition is assessed by asking the patient to
repeat single words, short sentences, or
strings of words such as "No ifs, ands, or
buts." The testing of repetition with tongue
twisters such as "hippopotamus" and "Irish
constabulary" provides a better assessment of
dysarthria and pallilalia than of aphasia.
• Anomia, or inability to produce a specific name
• Paraphasic speech refers to the presence of errors in the patient's
speech output. Paraphasic errors are divided into literal or
phonemic errors, involving substitution of an incorrect sound
(e.g., “shoon” for “spoon”), and verbal or semantic errors,
involving substitution of an incorrect word (e.g., “fork” for
“spoon”).
• A related language symptom is perseveration, the inappropriate
repetition of a previous response.
• Occasionally, aphasic utterances involve nonexistent word forms
called neologisms (new words). A pattern of paraphasic errors and
neologisms that so contaminate speech that the meaning cannot
be discerned is called jargon speech.
• Aphasia is defined as a disorder of language that is
acquired secondary to brain damage
• aphasia is a disorder of language, rather than speech
• Aphasia is distinguished from motor speech disorders
which include dysarthria, dysphonia (voice disorders),
stuttering, and speech apraxia.
• Dysarthrias are disorders of articulation of single sounds;
(causes of these disorders may include mechanical
disturbance of the tongue or larynx and neurological
disorders such as dysfunction of the muscles,
neuromuscular junction, cranial nerves, bulbar anterior
horn cells, corticobulbar tracts, cerebellar connections, or
basal ganglia.)
• Another cardinal symptom of aphasia is the
failure to comprehend the speech of others.
Most aphasic patients also have difficulty
with comprehension and production of
written language (reading and writing).
• Apraxia of speech is a syndrome of
misarticulation of phonemes, especially
consonant sounds. The disorder is called an
apraxia because there is no primary motor
deficit in articulation of individual phonemes.
Clinically, speech-apraxic patients produce
inconsistent articulatory errors, usually worse
on the initial phonemes of a word and with
polysyllabic utterances. Apraxia of speech, so
defined, is commonly involved in speech
production difficulty in the aphasias.
 Broca's aphasia
• Broca's area, which is located in the frontal lobe.
• Let's start with Broca's area, which is located in
the frontal lobe. Broca's area is the motor speech
area and it helps in movements required to
produce speech. When there is an issue in this
area, a patient can understand the speech of
others, but can't produce any speech him or her
self. This is called Broca's aphasia
• Broca's area (shown in red). Colored region is
pars opercularis and pars triangularis of the
inferior frontal gyrus. Broca's area is now
typically defined in terms of the pars
opercularis and pars triangularis of the inferior
frontal gyrus
 Broca's Aphasia
• The speech pattern is nonfluent; on bedside
examination, the patient speaks hesitantly,
often producing the principal, meaning-
containing nouns and verbs but omitting
small grammatical words and morphemes.
This pattern is called agrammatism or
telegraphic speech. An example is “wife come
hospital.”
• Patients with acute Broca's aphasia may be
mute or may produce only single words, often
with dysarthria and apraxia of speech. They
make many phonemic errors, inconsistent from
utterance to utterance, with substitution of
phonemes usually differing only slightly from
the correct target (e.g., /p/ for /b/). Naming is
deficient, but the patient often manifests a “tip
of the tongue” phenomenon, getting out the
first letter or phoneme of the correct name
• Auditory comprehension seems intact.
• Repetition is hesitant in these patients,
resembling their spontaneous speech
• Writing is virtually always deficient in Broca's
aphasics. Most patients have a right
hemiparesis, necessitating use of the
nondominant, left hand for writing, but this
left-handed writing is far more abnormal.
• Associated neurological deficits of Broca's
aphasia include right hemiparesis,
hemisensory loss, and apraxia of the oral
apparatus and the nonparalyzed left limbs.
Comprehension should be tested by
responses to yes-no questions or commands
to point to an object.
• An important clinical feature of Broca's aphasia
is its frequent association with depression .
• Patients with Broca's aphasia typically are aware
of and frustrated by their deficits.
• At times they become withdrawn and refuse
help or therapy.
• Usually, the depression lifts with recovery from
the deficit, but it may be a limiting factor in
rehabilitation.
• The lesions responsible for Broca's aphasia
usually include the traditional Broca's area in
the posterior part of the inferior frontal
gyrus, along with damage to adjacent cortex
and subcortical white matter.
• Broca's (expressive) aphasia is a type of non-fluent
aphasia in which an individual’s speech is halting and
effortful. Misarticulations or distortions of consonants
and vowels, namely phonetic dissolution, are common.
Individuals with expressive aphasia may only produce
single words, or words in groups of two or three.
• Long pauses between words are common and multi-
syllabic words may be produced one syllable at a time
with pauses between each syllable. The prosody of a
person with Broca's aphasia is compromised by
shortened length of utterances and the presence of
self-repairs and disfluencies
• Yes... ah... Monday... er... Dad and Peter H...
(his own name), and Dad.... er... hospital... and
ah... Wednesday... Wednesday, nine o'clock...
and oh... Thursday... ten o'clock, ah doctors...
two... an' doctors... and er... teeth... yah.[
 Wernicke's Aphasia
• Wernicke's aphasia may be considered the
opposite of Broca's aphasia in that expressive
speech is fluent but comprehension is impaired.
• The speech pattern is effortless and sometimes
even excessively fluent
• A speaker of a foreign language would notice
nothing amiss, but a listener who shares the
patient's language detects speech empty of
meaning, containing verbal paraphasias,
neologisms, and jargon productions
• Naming in Wernicke's aphasia is deficient, often
with bizarre, paraphasic substitutions for the
correct name. Auditory comprehension is
impaired, sometimes even for simple nonsense
questions. Deficient semantics is the major
cause of the comprehension disturbance in
Wernicke's aphasia, along with disturbed access
to the internal lexicon. Repetition is impaired;
whispering a phrase in the patient's ear, as in a
hearing test, may help cue the patient to
attempt repetition. Reading comprehension
usually is affected
• The lesions of patients with Wernicke's
aphasia usually involve the posterior portion
of the superior temporal gyrus, sometimes
extending into the inferior parietal lobule
• Comprehension is impaired for spoken and written language, for single
words as well as sentences. Language output is fluent but is highly
paraphasic and circumlocutious. The tendency for paraphasic errors may
be so pronounced that it leads to strings of neologisms, which form the
basis of what is known as "jargon aphasia." Speech contains large numbers
of function words (e.g., prepositions, conjunctions) but few substantive
nouns or verbs that refer to specific actions. The output is therefore
voluminous but uninformative. For example, a patient attempts to
describe how his wife accidentally threw away something important,
perhaps his dentures: "We don't need it anymore, she says. And with it
when that was downstairs was my teeth-tick. . .a. . .den. . .dentith. . .my
dentist. And they happened to be in that bag. . .see? How could this have
happened? How could a thing like this happen. . .So she says we won't
need it anymore. . .I didn't think we'd use it. And now if I have any
problems anybody coming a month from now, 4 months from now, or 6
months from now, I have a new dentist. Where my two. . .two little pieces
of dentist that I use. . .that I. . .all gone. If she throws the whole thing
away. . .visit some friends of hers and she can't throw them away."
 Anomic aphasia
• Anomic aphasia refers to aphasic syndromes
in which naming, or access to the internal
lexicon, is the principal deficit
 Transcortical Aphasias
• The transcortical aphasias are syndromes in
which repetition is normal, presumably because
the causative lesions do not disrupt the
perisylvian language circuit from Wernicke's
area through the arcuate fasciculus to Broca's
area. Instead, these lesions disrupt connections
from other cortical centers into the language
circuit—hence the name transcortical. The
transcortical syndromes are easiest to think of
as analogs of the syndromes of global, Broca's,
and Wernicke's aphasias, with intact repetition.
• Mixed transcortical aphasia, or the syndrome of the isolation of the speech area,
is a global aphasia in which the patient repeats, often echolalically, but has no
propositional speech or comprehension. This syndrome is rare, occurring
predominantly with large, watershed infarctions of the left hemisphere or both
hemispheres that spare the perisylvian cortex, or in advanced dementias.
• Transcortical motor aphasia is an analog of Broca's aphasia in which speech is
hesitant or telegraphic, comprehension is relatively spared, but repetition is
fluent. This syndrome occurs with lesions in the frontal lobe, anterior to Broca's
area, in the deep frontal white matter, or in the medial frontal region, in the
vicinity of the supplementary motor area. All of these lesion sites are within the
territory of the anterior cerebral artery, separating this syndrome from the
aphasia syndromes of the middle cerebral artery (Broca's, Wernicke's, global, and
conduction aphasia).
• The third transcortical syndrome, transcortical sensory aphasia, is an analog of
Wernicke's aphasia in which fluent, paraphasic speech, paraphasic naming,
impaired auditory and reading comprehension, and abnormal writing coexist
with normal repetition. This syndrome is relatively uncommon, occurring with
strokes of the left temporo-occipital area and in dementias.
 Pure Alexia without Agraphia
• Alexia, or acquired inability to read, is a form
of aphasia
• Agraphia :Like reading, writing may be
affected either in isolation (pure agraphia) or
in association with aphasia (aphasic
agraphia).
 Global Aphasia
• Global aphasia may be thought of as a summation of the deficits of
Broca's aphasia and Wernicke's aphasia. Speech is nonfluent or mute,
but comprehension also is poor, as are naming, repetition, reading, and
writing. Most patients have dense right hemiparesis, hemisensory loss,
and often hemianopia, although occasional patients have mild or no
hemiparesis. Milder aphasic syndromes in which all modalities of
language are affected often are called mixed aphasias. The lesions of
patients with global aphasia usually are large, involving both the inferior
frontal and the 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. Patients in whom the superior temporal
gyrus is spared tend to recover their auditory comprehension, with
evolution of the deficit toward the syndrome of Broca's aphasia.
Recovery in global aphasia may be prolonged; in patients with global
aphasia, more clinical improvement may occur during the second 6
months than in the first 6 months after a stroke. Characteristics of global
aphasia are presented
Nondominant Hemisphere
Higher Cortical Dysfunction