CVA Impairments 3

Lethargy

General slowing of cognitive & motor processes, aroused briefly to moderate stimuli

Obtundation

Dulled or blunted sensitivity, slowed responses to stimulation, difficult to arouse

Stupor

State of semi-consciousness, only arouses with vigorous and repeated stimulation

Coma

unarousable, unresponsiveness

gold standard for assessing levels of consciousness

Glasgow Coma Scale

• eye opening, motor response, verbal response

• score: 3-15

• <8 = severe

• 9-12 = moderate

• 13-15 = mild

Orientation

• Multiple cortical regions involved

• Disorientation denotes general intellectual dysfunction but can reflect difficulties with attention, memory

• Often require increased cues, redirection encouragement

Attention

• Prefrontal cortex, reticular formation

• *Most common cognitive deficit found post stroke (46-92%!)

• Difficulty in processing and assimilating new information and techniques, motor learning, dual task

• Dysfunction correlated with balance impairment, falls

memory

• ST: prefrontal cortex, limbic system

• LT: hippocampus, temporal lobe

• Difficulty with carry-over of newly learned or retained tasks

• Long-term memory typically remains intact

executive function

• prefrontal cortex

• Inappropriate interactions, poor self-monitoring and self-correcting

• Impulsive, inflexible thinking, decreased insight, impaired organization, sequencing and planning abilities, impaired judgement

Emotional Changes

Lesions affecting frontal lobe, hypothalamus, and limbic system can produce notable emotional changes

apathy

shallow affect, blunted emotional responses

euphoria

exaggerated feelings of well being

depression

persistent feelings of sadness accompanied by feelings of hopelessness, worthlessness, and/or helplessness
• Correlation found with left frontal and right parietal lesions
• Also can happen as secondary sequelae of impact of injury

psuedobulbar affect

state of emotional lability due to neurological insult
• Correlated with inferior frontal and inferior parietal lobe damage (R or L)
• Emotional outbursts of uncontrolled or exaggerated laughing or crying
• Inconsistent with actual mood

aphasia

A disturbance of one or more aspects of the complex process of comprehending and formulating verbal messages that result from newly acquired disease of the central nervous system

• DOMINANT hemisphere typically

Wernicke’s Area

Comprehension of oral language (reception of language)

Angular gyrus

integrates visual, auditory, and tactile information and carries out symbolic integration for reading

Broca’s Area

Motor programming for articulation (expression of language)

Primary motor cortex

• Activation of muscles for articulation

Arcuate fasciculus

Transmission of linguistic information to anterior areas from posterior areas

Supramarginal gyrus

Symbolic integration for writing

Corpus callosum

Transmission of information between hemispheres

Thalamus

naming and memory mechanisms

Internal capsule, Striatum, Globus pallidus

play a general role in speech and language

broca’s aphasia

• Sometimes referred to as, “motor aphasia”
• Impaired language production
• Aware of deficits

wernicke’s aphasia

• Impaired language comprehension
• Unaware of deficits

global aphasia

broca’s + wernickes

Transcortical motor aphasia

non-fluent speech with greater effort required than Broca’s; comprehension intact

Transcortical sensory aphasia

fluent speech marked with paraphasia’s (word substitutions), poor comprehension

Mixed transcortical aphasia

severely disordered language except in repetition. Echolalia is common.

Conduction Aphasia

• The main impairment is in the inability to repeat words or phrases.
• Other areas of language are less impaired (or not at all).
• Overall considered a mild form of aphasia
• Caused by a lesion in the arcuate fasciculus,
• Or, less commonly, left temporal lobe in the auditory association area

Anomic Aphasia

• Word finding difficulty within fluent, grammatically well-formed speech
• Speech output is somewhat vague, and patient may use circumlocution as a compensatory strategy
• using wordy and indirect language to express an idea when unable to retrieve the desired word or words.
• “grandfather" instead comes out as "the father of one's father"
• Lesion site is usually variable but is common in left angular gyrus

Alexia

• Impairment in reading ability
• Alexia without aphasia: lesion to the dominant occipital cortex extending to the posterior corpus callosum (often PCA infarct)

agraphia

• Impairment in writing ability
• Agraphia without aphasia: lesions of inferior parietal lobule of language-dominant hemisphere

Dysarthria

• Weakness, paralysis, or incoordination of the motor-speech system
• Often leads to slurred, slowed speech
• Often seen alongside with aphasia
• Can range from minor imprecise consonant sounds to speech completely unintelligible

- Anarthria- speech completely unintelligible
• Treatment strategies:
1. Slow rate of speech
2. Over-articulate
3. Speak louder

speech apraxia

• Labored speech – articulatory difficulty, speech errors, slow rate “halting”, slow
transition between sounds, and impaired prosody in the absence of impaired
strength or coordination of the motor speech system
• Difficult to initiate speech
• Periods of error-free speech followed by errors as speech progresses
• NOT a product of weakness, spasticity, involuntary movements, or language
production/comprehension.
• Difficult to diagnose with aphasia
• Trick: Ask pt to sing happy birthday
• Treatment strategies: Sound shaping, singing, imitation, Minimize stress, writing

dysphagia

• A swallowing disorder caused by various medical conditions in the oral cavity, pharynx, or esophagus.
• Common in a multitude of CNS disorders, and non-CNS pathology too!
• HUGE aspiration risk
• Diagnosis: MBSS versus FEES
• Treatment: SLP-guided diet orders***, swallow strategies**, SLP-initiated strengthening, etc
• If that fails, may require assisted feeding (PEG tube, etc)