Aphasia

You are assigned to the report of a CVA in a skyscraper downtown. You arrive on scene of the 23^rd floor to find a 64-year-old attorney complaining of a headache and difficulty speaking. She seems to start sentences, try to think of the right words, fail to find the vocabulary, and shake her head in silent frustration. There are no deficits to her grips, no arm drift, and her speech is clear. There is no recent history of head trauma, car accidents, falls, shark attacks, or bar fights. She just doesn’t seem to be able to find the right words and it is pissing her off.

What's going on? Are you worried?

Aphasia is a general term that describes language problems that range from mild to severe. It is related to brain damage (as compared to mouth or other damage), usually involves the left hemisphere, and may affect any form of communication. Aphasia means that a patient can have problems with speaking, comprehending speech, writing, reading, and even gesturing.

Language comprehension arises in two main areas of the brain. Broca’s area is in the inferior-posterior portion of the frontal lobe. It is important in the translation of thoughts into speech. Wernicke’s area is involved in understanding speech and writing, and is located in the posterior portion of the superior temporal gyrus. Both areas are located in the dominant hemisphere of the affected patient, which is usually the left hemisphere.

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Aphasia can be chronic or acute. Chronic aphasia usually involves tumors, infections, and dementias. That isn’t what we are talking about here, though. Acute aphasia is usually the result of acute processes, such as CVA, migraine, or head injury. The patient in the scenario, being a working lawyer, is experiencing acute aphasia. She uses verbal and written communication in her job on a daily basis. She doesn’t report recent head trauma, so the likelihood of stroke or migraine being the cause of her aphasia increases. 

There are a ton of different aphasias:

• Expressive aphasia is the inability of a patient to speak or write. It is the inability to put out language and is related to damage in Broca’s area. It is a problem with the brain, not with the tongue, mouth, or vocal cords.
• Receptive aphasia is also known as Wericke’s aphasia or sensory aphasia. It is characterized as the inability to understand spoken or written language. Patients with receptive aphasia speak normally; they just don't understand you. (Think about how frightening it is to have everyone around you look like you expect, but speak in an unintelligible foreign language.)
• Anomic aphasia is characterized by the inability to remember certain words or names. Patients with anomic aphasia will sometimes talk around a subject in order to describe it (i.e. describing big white ducks that honk rather than quack, rather than using the word ‘goose’).  It is odd to see someone not be able to recall the word 'pencil'.  It is scary to them, too.
• Global aphasia is the combination of receptive and expressive aphasia, meaning that patients experience difficulty with both speech and understanding at the same time. It is usually the result of widespread left-sided damage (sometimes described as a ‘left-side blowout’).
• Conduction aphasia is pretty rare. It is characterized by difficulties in repeating speech. Patients can speak their own thoughts without difficulty, and they understand everything that is said to them. But there are problems with speech repetition.
• Primary progressive aphasia is a form of chronic aphasia related to dementia. It presents with gradual problems with object naming, problems with simple math, and changes in abilities to execute learned movements (like writing or walking, for example).
• There are others. A lot of others. A whole metric ton of others. But concentrate on the ones above. Especially the first three or four.

There is a lot of research that looks at how rehab reverses aphasia, and long-term topics like that. There isn’t a whole lot of research on acute aphasia that relates to the prehospital setting.

• Laska and a bunch of others¹ wrote up a study of 119 consecutive patients with aphasia. They found that about one-third of stroke patients presented with some form of aphasia. Eighteen month mortality was twice that of non-aphasic patients, and atrial fibrillation was associated with worse outcomes. There is about a 25% rate of complete recovery at 18 months. 
• Pedersen’s group² looked at almost 900 consecutive stroke patients, specifically looking for aphasia. About 38% of stroke patients had aphasia at admission and 18% of stroke patients had aphasia at discharge.
• Berthier³ performed a review of aphasia. The important finding here is that aphasia is present in 21-38% of acute stroke patients, plus is associated with increased morbidity, mortality, and costs.
• Tsouli, et al.⁴, reported on 2,300 stroke patients in Greece.  Of those, 35% had aphasia. The authors found that increasing age, atrial fibrillation, worsening severity of the stroke, and hypertension were associated with higher rates of aphasia. This study indicates that the presence of aphasia was an independent predictor of dependence at one year.

In the end, there are a few main lessons about aphasia for you to remember. First, acute aphasia should equal stroke in your mind, especially in the absence of other causes. It is a big deal. Second, it is also a big deal to not be able to use language or otherwise communicate. It is part of what makes us human. It takes a significant lesion in the brain to remove this ability from us. Keep in mind that a person has to be really, really deeply drunk to lose the ability to speak, right? Essentially people become unconscious before they quit being able to talk. So the inability to talk is a big deal. The inability to understand is worse. And finally, aphasia is deeply frustrating and frightening to patients, as well as being irritating to medics. The inability to speak is terrible. Be patient, calm, and reassuring with these patients. Just because they can't speak doesn't mean that they don't understand.

1. Laska AC, Hellblom A, Murray V, Kahan T, VonArbin M. Aphasia in acute stroke and relation to outcome. J Intern Med 2001;249(5): 413-22.

2. Pedersen PM, Jørgensen HS, Nakayama H, Raaschou HO, Olsen TS. Aphasia in acute stroke: Incidence, determinants, and recovery. Ann Neurol 1995 Oct;38(4):659-66.

3. Berthier ML. Poststroke aphasia: epidemiology, pathophysiology and treatment. Drugs Aging. 2005;22:163–82.

4. Tsouli S, Kyritsis AP, Tsagalis G, Virvidaki E, Vemmos KN. Significance of aphasia after first-ever acute stroke: impact on early and late outcomes. Neuroepidemiology. 2009;33:96–102.