Sensory • Motor • Mixed

Lesion: outside classic areas, watershed distribution, severe narrowing of left middle cerebral arteries,

can be identified by CAT scans

Deficits: language, isolation syndromes

Intact: repetition

Lesion: superior parietal lobe

Deficits: echolalia

Intact: fluent, can repeat long phrases they don't understand

Lesion: anterior superior frontal lobe

Deficits: initiation, output

Intact: repetition, auditory comprehension

Lesion: often multiple CVA, watershed distribution

Deficits: initiation

Intact: repetition, can sometimes respond

Lesion: maybe angular gyrus

Deficits: noun retrieval

Similar symptoms as normal aging or early brain tumor

Often the end point for other types of aphasia after therapy and recovery

Lesion: basilar ganglia, thalamus, or cortical lesions extending into these areas

Atypical, components of both Broca's and Wernicke's aphasia

Other disorders that can affect language and the brain

(besides stroke and tumors)

• Infection: abcess (concentrated), meningitis (fever, chills, headache, mental status changes)
• Toxemia: drugs, lead poisoning, botulism
• Metabolic disorders: thyroid disease, hypoglycemia
• Nutritional, especially due to alcohol: vitamin B12 deficiency, Wernicke's encephalopathy (ataxia and confusion due to acute abuse), Korsekof's syndrome (confabulation due to chronic abuse)

Symptoms: incontinence, disturbed gait, mental confusion

• Obstructive: increased intracranial pressures
• Non-obstructive: CSF doesn't get reabsorbed, atrophy with resulting larger ventricles

Treat with short- or long-term shunt; don't sit this patient upright without warning!

Gall - 1800s - craniology

Broca & Wernicke - 1860s - localization

Jackson & Head - non-localizationists

Brodmann - Brodmann map

Propositional

v.

Non-propositional

language

Propositional: language used creatively, hard for CVA victims

Non-propositional: language used automatically, often retained in CVA victims (e.g. swearing, rote counting)

Cerebral Vascular Accident

(CVA)

aka stroke

Interruption of blood supply, causes a loss of oxygen and glucose to the brain

• 80% are ischemic
• 20% are hemorrhagic

Caused by plaque and clots

• Thrombolic: atherosclerotic plaque builds up in brain vessels, progressive disorder
• Embolic: floating clots block arterial distributions

Localized injury, brain swells (edema) to protect itself

Caused by artery weakness and unclipped aneurysms combined with sudden pressure changes, trauma; occasionally caused by arteriovenous malformations

• Extracerebral: stroke in the subarachnoid, subdural, or epidural spaces
• Intracerebral: destroys gray matter but not white matter

Slower initial recovery than ischemic CVA 

Affect cortex and cerebellum, with effects on communication

25-50 year olds

Primary tumors: can metastisize and spread to secondary areas (metastisis usually deadly), often lung to cerebellum

Glioma: can be benign or malignant

Meningioma: benign, attacks meninges, easy to remove

Partially controls reading and writing

When damaged, may be the source of alexia and agraphia

Reading and writing are the most complex skills, usually the last to recover

Broca's Area

v.

Wernicke's Area

Broca's

Inferior frontal lobe, near motor strip

Controls motor speech programming

A stroke in this area can cause motor impairment/paralysis

Wernicke's

Posterior Temporal lobe, near Angular Gyrus and primary auditory cortex

A stroke in this area can cause sensory issues

Broca's and Wernicke's are connected by the Arcuate Fasiculus, which controls speech repetition

Lesion: Broca's Area

Deficits: non-fluent, pauses, telegraphic speech, poor prosody, sometimes confuse semantically-related words, writing mirrors expression, face/arm/leg pyramidal nerves may be affected

Intact: comprehension, error recognition, automatic language

Intervention: carrier phrases help, often vocab building exercises

Lesion: Wernicke's Area

Deficits: comprehension (spoken & written), error recognition, jargon, empty speech, circumlocution, paraphasic errors (literal/phonemic or verbal/semantic), neologisms

Intact: fluent, no motor impairment

Intervention: Don't gague understanding with yes/no, they're too close semantically!

Fluent: no struggle, prosody/melody and syntax are ok, associated with Wernicke's/posterior lesion

Non-fluent: struggle, slow speech with pauses, non-prosodic, associated with Broca's/anterior lesion

Both Broca's and Wernicke's are caused by disruptions of the left-middle cerebral artery

The brain is comprised of a network of nodes, which undergo constant change in response to environmental input. Multiple brain areas work together to accomplish tasks

(opposed to localization)

Lesion: both anterior and posterior, cortical and subcortical, affected by disruption of the left-middle cerebral artery along the entire Left Sylvian Fissure

Deficits: production and comprehension in all modalities

Intact: orientation, visual understanding, socially appropriate; this differentiates it from dementia

Intervention: Routine is useful, fair nonverbal performance is possible if the instructions are repeated

aka Perisylvian Region

Area in left hemisphere, center of a lot of language development

Blood supply from the left-middle cerebral artery

Lesion: Arcuate Fasiculus

Deficits: repetition, some paraphasias, some deficits in abstract comprehension

Intact: fluent, error recognition, basic comprehension

TPA

Administer within 3 hours of an ischemic stroke

• Perseveration
• Compliance
• Behavior disorders

-Frustration →encourage, adjust task

-Combativeness → back up

-Emotional lability → change topic

-Poor attention → redirect 

1. Define the problem (diagnosis)
2. Establish severity level
3. Take baseline data
4. Form treatment/no treatment plan (are they a candidate for rehab?)
5. Determine prognosis for recovery (can they learn? through which modalities?)

• Age
• Type of aphasia (global & transcortical are worst)
• Initial severity
• Past & current medical status (any comorbid disorders?)
• Neurologic disorders
• Associated disorders (e.g. apraxia)

• Functional Independence Measure (FIM): 7-point scale, simplistic but often used)
• Communicative Activities of Daily Living
• Functional Communication Profile: similar to the FIM but situational
• Communication Effectiveness Index: similar to the FIM but situational

1. Auditory comprehension
2. Reading comprehension
3. Language production
4. Writing

• Boston Diagnostic Aphasia Exam (BDAE): normative data used to classify aphasics, used a lot
• Porch Index of Communicative Ability (PICA): normative data used for therapy recommendations, not used much
• Western Aphasia Battery (WAB): Aphasia Quotient and Cortical Quotient used to assign patients to diagnostic categories, not used much

• Token Test: assesses subtleties of auditory comprehension via syntactic complexity, 62 commands with 20 tokens
• Ravens Progressive Matrices: problem-solving, patterns with missing pieces
• LaPointe Reading Comprehension Battery for Aphasics: matching words/pictures/sentences and paragraph-level reading

Symptoms

v.

Signs

v.

Syndromes

Symptoms: patient complaints

Signs: red flags found on exams

Syndromes: groups of signs

multi-infarcts

micro-aneurysms

small stroke-like events in both hemispheres, can lead to a type of dementia

small aneurysms, often affecting the eyes

history of hypertention → aneurysms more likely to rupture

can cause extracerebral hemorrhagic stroke

you're born with it, onset of complications around 20-30 years old

rare condition, <1% of stroke patients

sudden onset

symptoms (dysarthria, swallowing) are temporary

indicate future strokes 1/3 of the time

85% of people have language in the left-hemisphere

The other 15% are mostly left-handed

1. Yes/no questions
2. Point to/gaze at the object
3. Follow 1, 2, 3-step directions
4. Answer discourse questions
5. Token Test

1. Word-level screening
2. Matching pictures/forms/objects

1. Automatic tasks
2. Repetition
3. Cloze procedure
4. Naming
5. Object function
6. Formulate sentences
7. Formulate multiple sentences

1. Copy word/simple shapes
2. Writing an object's name, dictation
3. Writing an object's function, sentences/phrases
4. Writing a paragraph