Module 3 ch13 acquired neurogenic language

What causes brain damage?

Stroke (CVA, most common cause of aphasia); TBI; brain tumors; brain infections

CVA (cerebrovascular accident)

Stroke: blood flow to part of the brain is interrupted; cells begin to die within minutes

Ischemic stroke

Blocked artery; about 87% of strokes; mechanisms are embolism and thrombosis

Hemorrhagic stroke

Ruptured or leaking vessel (e.g., aneurysm); about 13% of strokes; damage from lost blood flow and pressure on tissue

Embolism

Clot forms elsewhere (often the heart, e.g., atrial fibrillation), travels to the brain, and blocks a smaller artery; sudden onset

Thrombosis

Clot forms locally inside a brain artery at a site of plaque until it blocks the vessel; symptoms may build gradually

Hemorrhage (stroke mechanism)

Weakened vessel (aneurysm) ruptures or leaks; the problem is bleeding, not blockage; contributors: chronic high blood pressure, aneurysms

Embolism and thrombosis vs. hemorrhage

Embolism and thrombosis = blockage (ischemic); hemorrhage = bleeding (hemorrhagic)

TBI (traumatic brain injury)

Brain damage from an external mechanical force: a blow, jolt, or object penetrating the skull

Common causes of TBI

Falls, motor vehicle accidents, sports injuries, assaults

Closed (blunt) TBI vs. open (penetrating) TBI

Closed: skull stays intact; Open: an object pierces the skull and brain

Focal vs. diffuse TBI

Focal: one specific area; Diffuse: widespread

How does TBI differ from stroke in cause?

In TBI the damaging force comes from outside the body

Concussion symptoms

Headache, nausea, dizziness, blurred vision, light/noise sensitivity, low energy, mentally foggy, irritability, unusual emotionality

Concussion

Functional disturbance; a form of mild TBI; temporary symptoms; usually no visible damage on CT/MRI

Contusion

Bruise of brain tissue: localized bleeding and swelling; lesion usually visible on CT/MRI; can worsen over the first 24-72 hours

Contusion vs. concussion: key difference

Both are TBIs; the difference is whether the tissue itself is visibly damaged (contusion = yes, concussion = usually no)

Coup injury

Damage at the site of impact

Contrecoup injury

Damage on the opposite side of the brain from the impact; the brain rebounds and hits the opposite inner skull wall

Fall backward hitting the occipital lobe: coup vs. contrecoup

Coup: occipital region (point of contact); Contrecoup: frontal and temporal poles

Cognitive-communication problems after contrecoup frontal/temporal damage

Executive function deficits, disinhibition/changed social behavior, memory problems, pragmatic difficulties

Key point for TBI assessment

Do not assess only the point of impact; assess the functions of the areas opposite it too

What cognitive-communication skills do SLPs treat after TBI?

Attention and processing speed; memory and learning; executive function (planning, organization, problem solving, self-monitoring); pragmatics (turn-taking, topic maintenance, social cues)

Why are communication problems after TBI usually cognitive?

Thinking skills drive language use, so the root problem is cognitive

Right hemisphere stroke: effects

Impaired emotion recognition; sensory neglect; impaired narrative and conversational discourse skills

Dementia

Neurocognitive disorder; Alzheimer's is the most frequent cause; progressive degeneration of both hemispheres; problems with working memory, orientation, reasoning, judgment

Aphasia

Acquired language disorder caused by brain damage (usually left hemisphere); affects speaking, comprehension, reading, writing; not a loss of intelligence and not a motor speech disorder

Most common cause of aphasia

Stroke, especially in the language areas of the brain

Other causes of aphasia

TBI (focal damage to language areas), brain tumors, brain infections

Artery that supplies the perisylvian language region

Middle cerebral artery (MCA); MCA strokes commonly cause aphasia

Broca's area: location and function

Posterior frontal lobe; speech production and expression

Wernicke's area: location and function

Posterior temporal lobe; language comprehension

Arcuate fasciculus

Pathway connecting Broca's and Wernicke's areas; important for repeating words and phrases

Fluent aphasia

Smooth speech at normal or increased rate; longer sentences; incorrect, unnecessary, or made-up words; poor comprehension; may not realize speech doesn't make sense

Non-fluent aphasia

Slow, effortful, short phrases; trouble putting words together; word-finding difficulty; comprehension usually better than expression

Broca's aphasia: lesion site

Posterior frontal lobe (Broca's area)

Broca's aphasia: speech output and comprehension

Nonfluent, effortful speech; comprehension relatively preserved

Broca's aphasia: hallmark

Short, telegraphic phrases; slow rate; agrammatism

Wernicke's aphasia: lesion site

Posterior temporal lobe (Wernicke's area)

Wernicke's aphasia: speech output and comprehension

Fluent but empty speech; poor comprehension

Wernicke's aphasia: hallmark

Jargon; unaware of errors; verbal paraphasia; neologisms (making up new words)

Global aphasia: lesion site

Entire perisylvian region (large MCA lesion)

Global aphasia: speech output, comprehension, hallmark

Severely limited output; severely impaired comprehension; most severe type (including poor repetition)

Conduction aphasia: lesion site

Arcuate fasciculus

Conduction aphasia: speech output, comprehension, hallmark

Fluent; comprehension relatively preserved; repetition is disproportionately poor

Anomic aphasia: lesion site

Variable; often left temporal lobe

Anomic aphasia: speech output, comprehension, hallmark

Fluent; comprehension preserved; word-finding difficulty is the main problem

Which aphasia has fluent speech, poor comprehension, and jargon?

Wernicke's

Which aphasia has poor repetition with fluent speech and good comprehension?

Conduction

Restorative approach to aphasia/TBI

Goal: restore impaired functions; success measured at the impairment level (better test scores); also called traditional or impairment-based ("fix what is broken")

Constraint-Induced Language Therapy

Restorative approach that inhibits use of intact language skills and encourages use of impaired ones

Compensatory approach to aphasia/TBI

Goal: maximize communicative effectiveness despite the impairment; success measured at the activity and participation level; also called functional therapy

PACE (Promoting Aphasics' Communicative Effectiveness)

Compensatory approach that facilitates use of multiple communication modalities

Supported Communication for Aphasia

Compensatory approach focused on training conversational partners

TBI restorative strategies

Direct attention training with structured exercises; repeated practice of naming, reasoning, and problem-solving tasks

TBI compensatory strategies

External aids (notebooks, calendars, alarms, checklists); strategy training (goal-plan-do-review); training family and caregivers

Errorless learning

Used for severe memory impairment to prevent the patient from practicing mistakes

Treatment plans: restorative or compensatory?

Most mix both: restore what can improve, compensate for what remains

Aphasia treatment: cues and prompts

Pictures, phonemic cues, phonological rhyming

Functional aphasia therapy

Enhances communication by any means; encourages caregiver support; natural interactions with real-life communication challenges

Semantic Feature Analysis (SFA)

Word-finding strategy: think about features of the target word (group, use, action, properties, location, association)

Phonological Components Analysis (PCA)

Word-finding strategy: think about the sounds of the word (first sound, first-sound associate, final sound, rhyme, number of syllables)

Benefits of aphasia group therapy

Non-threatening supportive setting; practice communication; observe others' strategies; discuss quality-of-life effects; connect with other families

Aphasia group goal

Improve communication, build confidence, connect with others, and participate more fully in everyday life; activities should be meaningful and functional