Influence of age, sex, literacy and pathologic lesion on incidence, severity and type of aphasia

Verbal and oral apraxia in patients with acute stroke: Frequency, relationship, and some risk factors

Verbal and oral apraxia are two possible consequences of stroke. It seems that there are not sufficient studies regarding the frequency of these disorders. This study aimed to evaluate the frequency of Verbal and oral apraxia. In addition, the relationship between apraxia and some variables such as age, gender, and education, as well as the relationship between types of apraxia with each other, and damaged areas of the brain in apraxia of the oral system in Persian-speaking patients with stroke were studied. In this descriptive-analytical study, 42 patients participated using the convenient sampling method. Verbal and oral apraxia were assessed using the oral and verbal apraxia tasks for adults test. Data were analyzed using independent t-test, Chi-square, and Fisher's exact test. The frequency of patients with oral apraxia was 35.7%, those with verbal apraxia was 2.3%, and the combination of both verbal and oral apraxia was 4.7%. People with apraxia were significantly older than those without apraxia. There was not any significant relationship between apraxia and gender, apraxia and education, and oral apraxia with verbal apraxia (p < 0.05). The present study's findings showed the high frequency of post-stroke apraxia and the high rate of its incidence with age.

Predictors of Therapy Response in Chronic Aphasia: Building a Foundation for Personalized Aphasia Therapy

Chronic aphasia, a devastating impairment of language, affects up to a third of stroke survivors. Speech and language therapy has consistently been shown to improve language function in prior clinical trials, but few clinicially applicable predictors of individual therapy response have been identified to date. Consequently, clinicians struggle substantially with prognostication in the clinical management of aphasia. A rising prevalence of aphasia, in particular in younger populations, has emphasized the increasing demand for a personalized approach to aphasia therapy, that is, therapy aimed at maximizing language recovery of each individual with reference to evidence-based clinical recommendations. In this narrative review, we discuss the current state of the literature with respect to commonly studied predictors of therapy response in aphasia. In particular, we focus our discussion on biographical, neuropsychological, and neurobiological predictors, and emphasize limitations of the literature, summarize consistent findings, and consider how the research field can better support the development of personalized aphasia therapy. In conclusion, a review of the literature indicates that future research efforts should aim to recruit larger samples of people with aphasia, including by establishing multisite aphasia research centers.

Nutritional ketosis for mild cognitive impairment in Parkinson's disease: A controlled pilot trial

INTRODUCTION

Glucose hypometabolism and insulin resistance increase risk for and accelerate progression in Parkinson's disease and neurocognitive disorders. We conducted a proof of concept trial to determine whether ketogenesis, a metabolic adaptation induced by dietary carbohydrate restriction, can improve cognitive performance in Parkinson's disease patients with mild cognitive impairment.

METHODS

We enrolled patients with mild cognitive impairment associated with Parkinson's disease in an eight-week nutritional intervention with random assignment to either high-carbohydrate consumption typical of the Western dietary pattern (n = 7) or to a low-carbohydrate, ketogenic regimen (n = 7). We assessed changes in cognitive performance as well as motor function, anthropometrics, and metabolic parameters.

RESULTS

Relative to the high-carbohydrate group, the low-carbohydrate group demonstrated improvements in lexical access (p = 0.02, Cohen's f effect size = 0.76) and memory (p = 0.01, f = 0.87) and as well as a trend for reduced interference in memory (p = 0.06, f = 0.60). The low-carbohydrate group also exhibited reduced body weight (p < 0.0001, f = 1.89) and increased circulation of beta-hydroxybutyrate (p = 0.01, f = 0.90). Change in body weight was strongly associated with memory performance (p = 0.001). Motor function was not affected by the intervention.

CONCLUSION

Nutritional ketosis enhanced cognitive performance in Parkinson's disease-associated mild cognitive impairment in this pilot study. This metabolic intervention and its mechanisms deserve further investigation in the context of neurodegeneration.

Sex differences in post-stroke aphasia rates are caused by age. A meta-analysis and database query

BACKGROUND

Studies have suggested that aphasia rates are different in men and women following stroke. One hypothesis says that men have more lateralized language function than women. Given unilateral stroke, this would lead to a prediction of men having higher aphasia rates than women. Another line of observations suggest that women are more severely affected by stroke, which could lead to a higher aphasia rate among women. An additional potential confounding variable could be age, given that women are typically older at the time of stroke.

METHODS & PROCEDURES

This study consists of two parts. First, a meta-analysis of the available reports of aphasia rates in the two sexes was conducted. A comprehensive literature search yielded 25 studies with sufficient information about both aphasia and gender. These studies included a total of 48,362 stroke patients for which aphasia rates were calculated. Second, data were extracted from an American health database (with 1,967,038 stroke patients), in order to include age and stroke severity into a regression analysis of sex differences in aphasia rates.

OUTCOMES & RESULTS

Both analyses revealed significantly larger aphasia rates in women than in men (1.1-1.14 ratio). This speaks against the idea that men should be more lateralized in their language function. When age and stroke severity were included as covariates, sex failed to explain any aphasia rate sex difference above and beyond that which is explained by age differences at time of stroke.

Cognitive response to fish oil, blueberry, and combined supplementation in older adults with subjective cognitive impairment

Given evidence that eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and anthocyanin-rich blueberries provide neurocognitive benefit, we investigated long-term supplementation in older adults with cognitive complaints. In a 24-week randomized, double-blind, placebo-controlled trial, elderly men and women received daily fish oil (FO) or blueberry (BB) or both. Diet records confirmed that participants reduced background consumption of EPA, DHA, and anthocyanins as prescribed. Erythrocyte EPA + DHA composition increased in the FO groups (p = 0.0001). Total urinary anthocyanins did not differ between the groups after supplementation but glycoside and native (food) forms increased only in the BB-supplemented groups. The FO (p = 0.03) and BB (p = 0.05) groups reported fewer cognitive symptoms, and the BB group showed improved memory discrimination (p = 0.04), indicating that supplementation improved cognition. Cognitive benefit in the BB group was associated with the presence of urinary anthocyanins reflecting recent BB intake but not with anthocyanin metabolites. However, combined FO + BB treatment was not associated with cognitive enhancement as expected.

Comparing language outcomes in monolingual and bilingual stroke patients

Hope et al. compare language outcomes in monolingual and bilingual stroke patients, and find that prognostic models based on monolingual data alone overestimate language skills in bilingual patients. Both groups seem sensitive to damage in the same brain regions, but bilinguals appear more sensitive to that damage than monolinguals.

Post-stroke prognoses are usually inductive, generalizing trends learned from one group of patients, whose outcomes are known, to make predictions for new patients. Research into the recovery of language function is almost exclusively focused on monolingual stroke patients, but bilingualism is the norm in many parts of the world. If bilingual language recruits qualitatively different networks in the brain, prognostic models developed for monolinguals might not generalize well to bilingual stroke patients. Here, we sought to establish how applicable post-stroke prognostic models, trained with monolingual patient data, are to bilingual stroke patients who had been ordinarily resident in the UK for many years. We used an algorithm to extract binary lesion images for each stroke patient, and assessed their language with a standard tool. We used feature selection and cross-validation to find ‘good’ prognostic models for each of 22 different language skills, using monolingual data only (174 patients; 112 males and 62 females; age at stroke: mean = 53.0 years, standard deviation = 12.2 years, range = 17.2–80.1 years; time post-stroke: mean = 55.6 months, standard deviation = 62.6 months, range = 3.1–431.9 months), then made predictions for both monolinguals and bilinguals (33 patients; 18 males and 15 females; age at stroke: mean = 49.0 years, standard deviation = 13.2 years, range = 23.1–77.0 years; time post-stroke: mean = 49.2 months, standard deviation = 55.8 months, range = 3.9–219.9 months) separately, after training with monolingual data only. We measured group differences by comparing prediction error distributions, and used a Bayesian test to search for group differences in terms of lesion-deficit associations in the brain. Our models distinguish better outcomes from worse outcomes equally well within each group, but tended to be over-optimistic when predicting bilingual language outcomes: our bilingual patients tended to have poorer language skills than expected, based on trends learned from monolingual data alone, and this was significant (P < 0.05, corrected for multiple comparisons) in 13/22 language tasks. Both patient groups appeared to be sensitive to damage in the same sets of regions, though the bilinguals were more sensitive than the monolinguals.

Operative and nonoperative linguistic outcomes in brain injury patients

OBJECTIVE AND BACKGROUND

Linguistic function is one of vulnerable aspects of traumatic brain injury (TBI) which may have destructive effects on patients' communicative activities and daily life, years following trauma. This paper attempts to answer the controversy whether surgery affects increase and decrease of linguistic impairment or not.

MATERIALS AND METHODS

Two hundred forty-one TBI patients aged 18-65 with abnormal CT findings and at least 20 minute post-trauma amnesia (PTA), who were conscious at discharge, participated in this study. Based on operative intervention, the samples were divided into two groups: operative and nonoperative. Cognitive and aphasic deficits were inspected formally and pragmatic disorder was informally appraised at discharge.

RESULTS

The groups had no significant differences in aphasia incidence and language pragmatic impairment, though they were significantly distinctive in aphasia subcategories and cognitive deficit after trauma. Fluent aphasia was more common in both groups alike. In aphasia subcategories, however, transcortical sensory aphasia (TSA) in operative and anomia in nonoperative group were the most prevalent. Several variables appeared strikingly related to higher aphasia in operative groups as follows: moderate to severe injury, 18-35 and over 50 years of age, more than 1 week PTA, intracranial surgery of multiple lesions in left or bilateral hemisphere fronto-temporal cortex plus post-trauma cognitive and pragmatic impairments, and diffuse axonal injuries.

DISCUSSION

Almost certainly, meaningful drop of cognitive function post surgery roots back in significant loss of initial consciousness level. Related factors to postoperative aphasia suggest taking policies through surgery intervention. Discerning the indispensable contributions of neurosurgeons, neurolinguists, and neuroscientists, results inspire more clinical future studies.

Post-stroke aphasia prognosis: a review of patient-related and stroke-related factors

RATIONALE, AIMS AND OBJECTIVES

Recovery of language function in individuals with post-stroke aphasia is associated with a variety of patient and stroke-related indices. Amidst a complex interaction of a multitude of variables, clinicians are faced with the arduous challenge of predicting aphasia recovery patterns and subsequently, long-term outcomes in these individuals. Unfortunately, predictive factors are highly variable making prognosis of aphasia recovery difficult. Therefore, the objective of this review was to assess the influence of patient-related and stroke-related factors on language recovery in individuals with post-stroke aphasia.

METHODS

We completed a literature review to assess and identify evidence-based patient and stroke-related variables shown to be influential in aphasia recovery.

RESULTS

A range of patient-related (gender, handedness, age, education, socio-economic status and intelligence) and stroke-related indices (initial severity, lesion site and lesion size) were identified as potential influential factors to post-stroke aphasia recovery. Initial severity of aphasia emerged as the factor most predictive of long-term aphasia recovery. Other influential factors of post-stroke language recovery included lesion site and size.

CONCLUSIONS

Stroke-related factors, including aphasia severity, lesion site and lesion size, appear most critical to post-stroke aphasia recovery. The findings presented in this review offer clinicians an evidenced-based framework to assist in prediction of post-stroke aphasia recovery patterns and subsequent long-term functional communication outcomes.

Formal education, socioeconomic status, and the severity of aphasia after stroke

OBJECTIVE

To determine the role of education and socioeconomic status on the severity of aphasia after stroke.

DESIGN

Cross-sectional study.

SETTING

Stroke units of 2 affiliated medical centers.

PARTICIPANTS

Stroke patients (n=173) within 24 hours of symptom development and hospitalized controls (n=62) matched for age, education, and socioeconomic status (SES) with normative brain magnetic resonance imaging.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Percent error on 9 language tasks (auditory and written comprehension, naming [oral, written, and tactile], oral reading, oral spelling, written spelling, and repetition). Education was recorded in years and dichotomized as less than 12 years or 12 years and above for data analysis. Demographic characteristics (age, sex, race) and stroke volume were recorded for adjustment. SES was obtained from census tract data as 2 variables: mean neighborhood household income and family income.

RESULTS

The percentage of errors for participants with 12 or more years of education was significantly lower for auditory and written comprehension, written naming, oral reading, oral spelling, and written spelling of fifth grade vocabulary words, even after adjusting for age, sex, stroke volume, and SES.

CONCLUSIONS

These findings suggest that even once learned, access to written word forms may become less vulnerable to disruption by stroke with increasing years of education.

A general neuropsychological model of delusion

INTRODUCTION

Neurocognitive accounts of delusion have traditionally highlighted perceptual misrepresentation, as the primary trigger in addition to other cognitive deficits that maintain the delusion. Here, a general neurocognitive model of delusional disorder (DSM-IV) is proposed, not so much based on perceptual or cognitive deficits after right hemisphere damage as on cognitive propensities, specifically excessive inferencing (especially jumping to conclusions) and excessive reference to the self, due to left hemisphere overactivity.

METHOD

The functional imaging, topographic EEG, and experimental imaging literatures on delusional disorder are reviewed, and 37 previously published cases of postunilateral lesion delusion (DSM-IV type, grandeur, persecution, jealousy, erotomania, or somatic), are reviewed and analysed multivariately.

RESULTS

Functional imaging and EEG topography data were slightly more indicative of left hemisphere overactivity in delusional disorder. In addition, 73% of the postunilateral lesion cases (χ(2)=7.8, p=.005) of delusional disorder (DSM-IV type) had a right hemisphere lesion, whereas only 27% had a left hemisphere lesion.

CONCLUSION

Left hemisphere release appears to be a more primary cause of delusional disorder than right hemisphere impairment, the latter merely entailing loss of inhibition of delusional beliefs. We propose that most patients with DSM-IV diagnoses of delusional disorder could be afflicted by excessive left hemisphere activity, but further research is necessary.

Lack of generalizability of sex differences in the fMRI BOLD activity associated with language processing in adults

A lack of consensus exists as to whether there are sex differences in the fMRI BOLD signal correlates of language processing in the human brain. Here, whole-brain fMRI was used to examine the neural activity of 46 adults performing one of two sets of language tasks. Conservative quantitative and qualitative criteria identified a handful of statistically significant regions of "sex difference" within each task separately. When each of the two sets of regions was investigated in the group of subjects performing the other task set, however, most of the identified "sex differences" failed to generalize. Identical analyses of the same subjects divided into sex-matched pseudorandom control groups for each task set separately revealed that it is possible to observe a similar number of statistically significant regions of "group difference" in the task-associated BOLD signal, even when the groups do not differ on any of the measured behavioral parameters, or any obvious demographic characteristic. Together, these results suggest that one should be cautious when interpreting studies that purport to have identified regions of difference between groups, whether those groups are divided by sex or by any other criterion. In particular, generalization or replication of a result in independent data sets is necessary for establishing conclusive support for any hypothesis about differences in brain function between groups.

Deficits in Japanese word spelling as an initial language symptom of malignant glioma in the left hemisphere

BACKGROUND

A good performance status at diagnosis is a prognostic factor in patients with malignant glioma whose median survival is 24 months. As early diagnosis may improve their poor prognosis, we looked for currently unknown initial symptoms among patients in good performance status.

METHODS

We chose 17 consecutive patients with malignant glioma in the left frontal and/or temporal lobe whose Karnofsky Performance Status was more than 80. At preoperative evaluation, we administered the Japanese version of the Western Aphasia Battery.

RESULTS

The chief complaint was difficulty in speech (n = 6), headache/nausea (n = 4), seizures (n = 5), and uncinate fits (n = 1); one patient was symptom-free. Of the 17 patients, 14 exhibited no motor deficits. In 15 patients, the aphasia quotient exceeded 80, indicating that the overall language deficits were mild. However, in the reading section, their scores on the "spelled kanji (Japanese ideogram) recognition" test (full score = 10) were selectively low (5.3 +/- 1.6 for right-handed individuals with frontal lesions, 6.1 +/- 1.0 for right-handed patients with temporal lesions, 7.2 +/- 2.0 for left-handed/bimanual individuals with frontal/temporal lesions). Their scores on the "spelling kanji" test were 3.0 +/- 1.6, 4.8 +/- 1.2, and 9.4 +/- 0.6, respectively.

CONCLUSIONS

Our findings point to the importance of recognizing spelling deficits as an initial symptom of left hemisphere glioma in efforts to identify patients in good performance status whose prognosis may be improved. It would be important to determine if the spelling of alphabetic words is also impaired early in the clinical course of left hemisphere glioma.

Effect of socioeconomic status on aphasia severity and recovery

Low levels of educational attainment and low socioeconomic status have been significantly linked to poor health and increased incidence of disease, including Alzheimer's disease and diseases of the cardiovascular, pulmonary, renal, and gastrointestinal systems. Our goal in the present study was to determine the degree to which educational level and socioeconomic status influence initial severity of aphasia and subsequent recovery. We evaluated the records of 39 persons with aphasia twice: at about 4 months and 103 months postonset. We found early severity of aphasia to be significantly greater for subjects in the lower educational and occupational groups. However, rate of recovery (the slope of the recovery curve) was the same regardless of educational or occupational status.

Effects of resective surgery for left-sided intracranial tumours on language function: a prospective study

BACKGROUND

Although language disorders occur in about 50% of patients with a left hemispheric tumour and are a significant cause of morbidity, the effects of resective neurosurgery and their relation to tumour pathology are unclear. We report the immediate effects of resective surgery on language functions in a heterogeneous group of patients with left-sided intracranial tumours.

METHODS

40 patients were studied. The Western Aphasia Battery (WAB) and Boston Naming Test (BNT) were administered preoperatively and before discharge following resective neurosurgery. Dexamethasone dose at time of testing was recorded, as was time taken to complete the tests, and tumour neuropathology.

FINDINGS

15 patients with normal aphasia quotients and language quotients before resective surgery all had normal quotients postoperatively. 25 who were dysphasic (ie, aphasia quotient <93.8) preoperatively showed significant postoperative improvements in both their mean aphasia quotient (from 81.8 to 89.1, p=0.004) and their mean language quotient (from 73.4 to 85.4, p=0.001), though 13 remained dysphasic. Two of the 25 dysphasic patients had their WAB scores lowered by tumour resection. The findings and postoperative changes in BNT scores were almost identical to the pattern of those in WAB scores. At second assessment, dexamethasone therapy was significantly (p<0.01) lower than preoperative dose (reduction from mean 10.3 mg/day to 0.7 mg/day in the dysphasic group). Patients with glioblastoma were more likely to have lower aphasia quotients, language quotients, and BNT scores than patients with anaplastic glioma, metastasis, or meningioma. Although the glioblastoma group had the greatest improvements in WAB operative scores, 57% remained dysphasic after resective surgery. Two additional patients declined postoperative assessment.

INTERPRETATION

Resective surgery for left-sided intracranial tumours significantly improves language function in dysphasic patients, and is unlikely to impair language functions in non-dysphasic patients. Dysphasia and its response to resective surgery are related to the tumour neuropathology.

Stereotactic biopsy of nonpolar tumors in the dominant hemisphere: a prospective study of effects on language functions

A prospective study of patients undergoing computerized tomography (CT)-guided stereotactic biopsy of nonpolar tumors in the dominant hemisphere was undertaken to determine if stereotactic biopsy caused a deterioration of language functions. Language was assessed using the Western Aphasia Battery (WAB) and the Boston Naming Test (BNT) before and after a biopsy sample was obtained. Of 16 patients studied, five (31%) were dysphasic preoperatively. After the biopsy the Aphasia Quotient (AQ), derived from the WAB, had significantly deteriorated in four (80%) of these patients, whereas in the fifth it remained relatively unchanged. One of these patients with an extensive infiltrating hemispheric oligoastrocytoma subsequently recovered normal language function after radiotherapy. In 10 of the 11 patients who had normal language function preoperatively there were no deleterious changes after biopsy in either the WAB subtest or BNT scores. In the other patient whose WAB score was normal preoperatively, there was a significant deterioration in postoperative AQ. This patient, who declined steroid therapy before and after biopsy, had a glioblastoma multiforme in Wernicke's area. A postoperative CT scan revealed no changes from what was shown on preoperative scan. This clinical study shows that CT-guided stereotactic biopsy of nonpolar tumors in the dominant hemisphere using the Brown-Roberts-Wells system and the Sedan-Nashold biopsy cannula carries a 9% risk (95% confidence intervals 0-26%) of impairing language functions if the patient is not dysphasic preoperatively. If the patient is dysphasic preoperatively, there is a very high risk of aggravating the dysphasia with stereotactic biopsy.

Aphasia in acute stroke: incidence, determinants, and recovery

Knowledge of the frequency and remission of aphasia is essential for the rehabilitation of stroke patients and provides insight into the brain organization of language. We studied prospectively and consecutively an unselected and community-based sample of 881 patients with acute stroke. Assessment of aphasia was done at admission, weekly during the hospital stay, and at a 6-month follow-up using the aphasia score of the Scandinavian Stroke Scale. Thirty-eight percent had aphasia at the time of admission; at discharge 18% had aphasia. Sex was not a determinant of aphasia in stroke, and no sex difference in the anterior-posterior distribution of lesions was found. The remission curve was steep: Stationary language function in 95% was reached within 2 weeks in those with initial mild aphasia, within 6 weeks in those with moderate, and within 10 weeks in those with severe aphasia. A valid prognosis of aphasia could be made within 1 to 4 weeks after the stroke depending on the initial severity of aphasia. Initial severity of aphasia was the only clinically relevant predictor of aphasia outcome. Sex, handedness, and side of stroke lesion were not independent outcome predictors, and the influence of age was minimal.

Speech and language disorders in patients with high grade glioma and its influence on prognosis

One hundred and sixteen patients with high grade glioma were entered into a prospective phase two study and treated with accelerated radiotherapy from 1988 to 1993. In this cohort of patients we analysed speech deficit as a subdivision of global functional status in terms of incidence, category and prognosis for survival. Forty three patients (37%) had a speech deficit at presentation. Eighty percent of these had a component of expressive dysphasia, associated with considerable degree of awareness and distress. The overall median survival was 9.5 months. On univariate analysis, median survival in patients with speech difficulties (6 months) was worse than patients with normal speech (10.5 months) (log rang p = 0.005). Multivariate analysis established independent significance from age, Karnofsky Performance Status (KPS), gender, histological grade, extent of surgery and seizures. This paper highlights the importance of assessing individual categories of functional disability which in patients with high grade glioma include mobility, cognitive function and communication. Each of these factors may seriously affect an individual's activities of daily living, hence quality of life and separate analysis has a number of clinical implications. Firstly, with over a third of patients suffering speech difficulties, adequate speech therapy facilities should be freely available to score the degree of deficit, devise coping strategies and institute communication therapy. Secondly, an understanding of prognostic factors aids the critical analysis of phase two studies and the design and stratification of future prospective trials which should include an analysis of speech deficit. Thirdly, separating individual patients into good and bad prognostic groups can assist strategic management decisions.

Resolution of fluent dysphasia following excision of metastatic carcinoma from the arcuate fasciculus

The effect of therapy on aphasic syndromes in patients with brain tumours is poorly documented. A case in which resection of a metastatic lesion led to resolution of a fluent dysphasia that had not responded to corticosteroid therapy is presented. As well as surgical and neurolinguistic interest this case demonstrates that CT diagnosis of malignant glioma can be erroneous and may lead to sub-optimal treatment.

Traumatic aphasia in children and adults: a comparison of clinical features and evolution

We compared the performance on test of language, apraxia, acalculia and intelligence of 32 children--age 5 to 16 years--and 31 adults, seen at our Aphasia Unit for the sequelae of a brain trauma. Logorrhea was never present among children who had nonfluent aphasia more frequently than adults. Apraxia and acalculia were equally present in the two groups. Twelve children and 15 adults of the first study were retested at variable distance from trauma. No group difference was found in the recovery of auditory comprehension (Token Test) or oral expression (oral confrontation naming and telling-of-an-event). On a battery of verbal and spatial memory tests 6 of the 12 children had pathological scores in one or more tests. Scholastic achievements were compared with those of the nearest kin. We conclude that while aphasia profiles are different in children and adults, the incidence of apraxia and acalculia and the recovery rate do not discriminate the two groups.

A case of acquired aphasia and convulsive disorder: some linguistic aspects of recovery and breakdown

Among the cases of acquired aphasia and convulsive disorder several children are reported to have experienced more than one aphasic period. We present such a case in more detail, with emphasis on some characteristics of spontaneous speech. The occurrence of paraphasias, and in particular of neologisms, appeared to be associated with language recovery and breakdown. At the beginning of the period of recovery, a rapid and total disappearance of neologisms was observed, while only literal paraphasias remained. A period of language breakdown was preceded by the return of neologisms. The process was not influenced by drug therapy.