October 30, 2010

Q&A: Investigating Speech Problems

Language is a distinctive human facility for communication through symbols. Aphasia is the loss of ability to produce and/or understand language. This usually manifests as a difficulty speaking or understanding spoken language, but reading and writing are also usually impacted. Aphasia can also impact the use of manual sign language and Braille.

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In this article:
Clinical assessment
MCQ: clinical scenario
MCQ: answer
MCQ: explanation

Clinical assessment

A large, complex neurocognitive network, usually located in the left hemisphere, subserves the capacity for human language. Any insult or pathologic process that results in damage or dysfunction of the language network may cause aphasia. Aphasias are classically subdivided based on observed vascular syndromes, cerebral infarction being the most common etiology of aphasia. These are categorized as fluent or nonfluent aphasias, and then are further subdivided according to observed deficits in content, repetition, naming, comprehension, reading, and writing. Fluency is usually assessed qualitatively by listening to the patient's spontaneous speech.

MCQ: clinical scenario

A young man develops nonfluent, effortful speech with dysarthria. He is able to understand speech. He fails to repeat the sentence "no ifs, ands or buts about it". A CT scan is normal.

The investigation of choice at this stage would be:

a) contrast CT scan brain
b) MR cerebral angiography
c) MRI with emphasis on the frontal lobe
d) MRI of the pituitary gland
e) MRI with emphasis on the temporal lobe

MCQ questions & answers on medicalnotes.info

MCQ: answer

The correct answer is C

MCQ: explanation

The clinical features are suggestive of what is known as Broca's aphasia. It is also known as expressive aphasia. It is characterized by nonfluent, effortful speech with dysarthria. Comprehension is usually good. It is typically caused by frontal lobe lesions. Typical tasks on examination that they fail is to repeat the sentence "no ifs, ands or buts about it". These patients may only have (for example), a single word left in their vocabulary. Aphemia means mute but writes fluently.

All patients with a newly identified aphasia should undergo a structural brain scan, usually magnetic resonance imaging (MRI). If the presentation is abrupt, suggesting an acute cerebrovascular event, or if there are other findings that suggest an intracranial mass lesion, the examination may be urgent. The presence of an ischemic stroke should trigger further evaluation. Other identified structural brain lesions will usually also warrant further testing.

Episodes of transient aphasia should prompt investigation of possible seizures or transient cerebral ischemia (TIA). Electroencephalography (EEG) and/or cerebrovascular imaging may be helpful in such patients. Prolonged EEG monitoring may be required to detect active seizure activity in some patients with aphasic status epilepticus.

Aphasia with an insidious onset and gradual progression, especially in middle-aged or older adults, suggests neurodegenerative disease (ie, primary progressive aphasia [PPA]) but a slowly growing mass lesion should be excluded in these patients as well.

1). UpToDate: Approach to the patient with aphasia. Available online: https://www.uptodate.com/contents/approach-to-the-patient-with-aphasia

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