A one year prospective study of neurogenic stuttering following stroke: incidence and co-occurring disorders

Higher Frequency of Stuttered Disfluencies Negatively Affects Communicative Participation in Parkinson's Disease

PURPOSE

Up to 90% of people with Parkinson's disease (PD) develop communication difficulties over the course of the disease. While the negative effect of dysarthria on communicative participation has been well-documented, the impact of the occurrence of acquired stuttered disfluencies on communication in different speech situations is unknown. This study aimed to determine if the frequency of occurrence of stuttered disfluencies affects communicative participation in individuals with PD, and whether such a relationship is mediated by examiner- and self-rated measures of disease severity.

METHOD

Conversational speech samples were collected from 100 people with PD aged 53-91 years to calculate the frequency of occurrence of stuttered disfluencies. Participants completed the Communicative Participation Item Bank to assess participation in communicative situations. Information on overall speech, cognitive, and motor performance was collected using both self-rated and examiner-rated methods.

RESULTS

Participants with PD presented with 0.2%-9.9% stuttered disfluencies during conversation. Overall, participants with PD reported their communicative participation to be impacted "a little" (19.5 ± 7.0), but there was considerable interindividual variation. A higher frequency of stuttered disfluencies was associated with significantly lower communicative participation (ρ = -0.32, p < .01). In addition, examiner-rated frequency of stuttered disfluencies (p < .01), speech (p < .01), and motor severity (p = .04) were all significant predictors of communicative participation. Using self-ratings, speech (p < .01) and cognitive (p < .01) measures significantly predicted communicative participation.

CONCLUSIONS

In people with PD, communicative participation was significantly worse for those with a higher frequency of stuttered disfluencies. Examiner- and self-rated measures of disease severity contributed different information related to communicative constraints. Together, these results highlight the importance of individualized and holistic speech therapy that considers a wide variety of symptoms, including stuttered disfluencies, to ensure positive functional outcomes.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26850169.

Transient Stuttering as a Sole Presentation in a Patient With a Subcentimeter Left Frontal Cortical Ischemic Infarct

Stuttering is a complex speech disorder that is associated with a variety of etiologies, including psychological factors, metabolic disorders, and structural abnormalities. While stuttering is typically not caused by stroke, it is important to include it in the diagnostic evaluation, especially in patients with a history of neurological conditions. Of the clinical presentations of stroke-induced stuttering, transient stuttering following stroke has seldom been documented, as most patients who develop a stutter following a stroke end up developing permanent speech deficits. Additionally, as most cases of stroke-induced stuttering are part of a broader neurological presentation, stuttering generally does not present as an isolated symptom. Furthermore, although strokes of various sizes have been implicated in stuttering, it is quite uncommon for the affected lesion to be smaller than 1 cm. We present a rare case of transient, isolated stuttering following a subcentimeter stroke and a subsequent review of relevant literature. Our case report highlights the diversity of stroke-related speech disorders and the importance of considering even minor strokes in the differential diagnosis of stuttering.

Localization of stuttering based on causal brain lesions

Stuttering affects approximately 1 in 100 adults and can result in significant communication problems and social anxiety. It most often occurs as a developmental disorder but can also be caused by focal brain damage. These latter cases may lend unique insight into the brain regions causing stuttering. Here, we investigated the neuroanatomical substrate of stuttering using three independent datasets: (i) case reports from the published literature of acquired neurogenic stuttering following stroke (n = 20, 14 males/six females, 16-77 years); (ii) a clinical single study cohort with acquired neurogenic stuttering following stroke (n = 20, 13 males/seven females, 45-87 years); and (iii) adults with persistent developmental stuttering (n = 20, 14 males/six females, 18-43 years). We used the first two datasets and lesion network mapping to test whether lesions causing acquired stuttering map to a common brain network. We then used the third dataset to test whether this lesion-based network was relevant to developmental stuttering. In our literature dataset, we found that lesions causing stuttering occurred in multiple heterogeneous brain regions, but these lesion locations were all functionally connected to a common network centred around the left putamen, including the claustrum, amygdalostriatal transition area and other adjacent areas. This finding was shown to be specific for stuttering (PFWE < 0.05) and reproducible in our independent clinical cohort of patients with stroke-induced stuttering (PFWE < 0.05), resulting in a common acquired stuttering network across both stroke datasets. Within the common acquired stuttering network, we found a significant association between grey matter volume and stuttering impact for adults with persistent developmental stuttering in the left posteroventral putamen, extending into the adjacent claustrum and amygdalostriatal transition area (PFWE < 0.05). We conclude that lesions causing acquired neurogenic stuttering map to a common brain network, centred to the left putamen, claustrum and amygdalostriatal transition area. The association of this lesion-based network with symptom severity in developmental stuttering suggests a shared neuroanatomy across aetiologies.

Episodic stuttering as the presenting manifestation of acute ischemic stroke: A case report and systematic literature review

BACKGROUND

Acquired episodic stuttering in adulthood represents a rare condition, which has been infrequently described in the literature.

CASE PRESENTATION

We describe the case of a 62-year-old male who presented to the emergency room with three episodes of new-onset brief isolated stuttering with no other speech impairment or associated focal neurologic deficits. His brain magnetic resonance imaging was notable for the presence of a small acute ischemic stroke involving the left precuneus cortex.

SYSTEMATIC LITERATURE REVIEW

We performed a systematic literature review to evaluate the association between stroke and acquired neurogenic stuttering. The evidence published to this date suggests that the underlying pathophysiology of acquired stutter does not localize to an isolated or focal region. The development of stuttering secondary to strokes may be the result of a disruption at any level in a cortico-striato-cortical integrative pathway mediating speech execution.

CONCLUSION

Here we aimed to emphasize the importance of carefully evaluating new-onset recurrent episodic stuttering to rule out an underlying stroke or another neurogenic etiology. We provide a comprehensive review of acquired stuttering, its differential diagnosis, and its evaluation.

Acquired Stuttering in Parkinson's Disease

Background

Parkinson's disease frequently causes communication impairments, but knowledge about the occurrence of new-onset stuttering is limited.

Objectives

To determine the presence of acquired neurogenic stuttering and its relationship with cognitive and motor functioning in individuals with Parkinson's disease.

Method

Conversation, picture description, and reading samples were collected from 100 people with Parkinson's disease and 25 controls to identify the presence of stuttered disfluencies (SD) and their association with neuropsychological test performance and motor function.

Results

Participants with Parkinson's disease presented with twice as many stuttered disfluencies during conversation (2.2% ± 1.8%SD) compared to control participants (1.2% ± 1.2%SD; P < 0.01). 21% of people with Parkinson's disease (n = 20/94) met the diagnostic criterion for stuttering, compared with 1/25 controls. Stuttered disfluencies also differed significantly across speech tasks, with more disfluencies during conversation compared to reading (P < 0.01). Stuttered disfluencies in those with Parkinson's disease were associated with longer time since disease onset (P < 0.01), higher levodopa equivalent dosage (P < 0.01), and lower cognitive (P < 0.01) and motor scores (P < 0.01).

Conclusion

One in five participants with Parkinson's disease presented with acquired neurogenic stuttering, suggesting that speech disfluency assessment, monitoring and intervention should be part of standard care. Conversation was the most informative task for identifying stuttered disfluencies. The frequency of stuttered disfluencies was higher in participants with worse motor functioning, and lower cognitive functioning. This challenges previous suggestions that the development of stuttered disfluencies in Parkinson's disease has purely a motoric basis.

Delayed encephalopathy after COVID-19: A case series of six patients

RATIONALE

Acute encephalopathy is a severe neurological complication of coronavirus disease 2019 (COVID-19). Most cases of acute encephalopathy associated with COVID-19 occur within several weeks of COVID-19 onset. We describe a case series of 6 patients who developed delayed encephalopathy (DE) after COVID-19.

PATIENT CONCERNS AND DIAGNOSES

We evaluated patients who recovered from COVID-19 and showed acute disturbance of consciousness or focal neurological deficits without recurrence of pneumonitis. Six patients, 2 females and 4 males, with ages ranging from 65 to 83 years were included. Durations of hospitalization due to COVID-19 were between 25 and 44 days. The severity of COVID-19 was moderate in 5 and severe in 1 patient. Patients were rehospitalized for acute disturbance of consciousness concomitant with postural tremor and, abnormal behavior, hemiplegia, aphasia, or apraxia between 34 and 67 days after the onset of COVID-19. Chest computed tomography showed no exacerbation of pneumonitis. Brain magnetic resonance imaging showed no specific findings except in 1 patient with an acute lacunar infarction. Electroencephalogram demonstrated diffuse slowing in all patients. Repeat electroencephalogram after recovery from encephalopathy demonstrated normal in all patients. One of the 6 patients had cerebrospinal fluid (CSF) pleocytosis. CSF protein levels were elevated in all patients, ranging from 51 to 115 mg/dL. CSF interleukin-6 levels ranged from 2.9 to 10.9 pg/mL. The immunoglobulin index was 0.39 to 0.44. Qlim(alb) < QAlb indicating dysfunction of the blood-brain barrier was observed in all patients. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction of CSF was negative in all patients. Neuronal autoantibodies were absent in serum and CSF.

INTERVENTIONS AND OUTCOMES

Immunotherapy including steroid pulses was administered to 3 patients; however, symptoms of encephalopathy resolved within several days in all patients, regardless of treatment with immunotherapy, and their consciousness levels were recovered fully. Notably, postural tremor remained for 2 weeks to 7 months.

LESSONS

In our patients, DE after COVID-19 was characterized by symptoms of acute encephalopathy accompanied with tremor in the absence of worsening pneumonitis after the fourth week of COVID-19 onset. Our findings indicate blood-brain barrier dysfunction may contribute to the pathogenesis of DE after COVID-19.

Prevalence and Determinants of Hoarseness in School-Aged Children

Hoarseness in school-aged children may affect their educational achievement and interfere with their communication and social skills development. The global prevalence of hoarseness in school-aged children ranges between 6% and 23%. To the best of our knowledge, there is a scarcity of studies describing the prevalence or determinates of hoarseness in Saudi school-aged children. Our aim was to measure the prevalence of hoarseness among school-aged children and to identify its determinants. A cross-sectional questionnaire-based survey was used that included randomly selected primary and early childhood schools from private and governmental sectors in Saudi Arabia. The data were collected using a questionnaire which was self-completed by the children's parents and covered the following aspects: sociodemographic features, health and its related comorbidities about children and their families, attendance and performance in school, child's voice tone, past history of frequent crying during infancy, history of letter pronunciation problems and stuttering, the Reflux Symptom Index (RSI) and the Children's Voice Handicap Index-10 for parents (CVHI-10-P). Determinants of hoarseness were investigated using the SPSS software (version 20). The mean age of the study children (n = 428) was 9.05 years (SD = 2.15), and 69.40% of them were male. The rate of hoarseness in the participants was 7.5%. Hoarseness was significantly common in children with a history of excessive infancy crying (p = 0.006), letter pronunciation issues (especially 'R' and 'S'; p = 0.003), and stuttering (p = 0.004) and in those with a previous history of hoarseness (p = 0.023). In addition, having the symptoms of gastrointestinal reflux increased the risk of hoarseness by four times (OR = 4.77, 95% CI = 2.171, 10.51). In summary, hoarseness in children may be dangerously underestimated, as it may reflect the presence of speech problems, in addition to the presence of laryngopharyngeal reflux (LPR). Hoarseness was assumed on the basis of parental complaints. Therefore, further research with diagnoses based on a clinical assessment is needed to understand the magnitude of the hoarseness problem and its consequences in children.

A dual larynx motor networks hypothesis

Humans are vocal modulators par excellence. This ability is supported in part by the dual representation of the laryngeal muscles in the motor cortex. Movement, however, is not the product of motor cortex alone but of a broader motor network. This network consists of brain regions that contain somatotopic maps that parallel the organization in motor cortex. We therefore present a novel hypothesis that the dual laryngeal representation is repeated throughout the broader motor network. In support of the hypothesis, we review existing literature that demonstrates the existence of network-wide somatotopy and present initial evidence for the hypothesis' plausibility. Understanding how this uniquely human phenotype in motor cortex interacts with broader brain networks is an important step toward understanding how humans evolved the ability to speak. We further suggest that this system may provide a means to study how individual components of the nervous system evolved within the context of neuronal networks. This article is part of the theme issue 'Voice modulation: from origin and mechanism to social impact (Part I)'.

Human larynx motor cortices coordinate respiration for vocal-motor control

Vocal flexibility is a hallmark of the human species, most particularly the capacity to speak and sing. This ability is supported in part by the evolution of a direct neural pathway linking the motor cortex to the brainstem nucleus that controls the larynx the primary sound source for communication. Early brain imaging studies demonstrated that larynx motor cortex at the dorsal end of the orofacial division of motor cortex (dLMC) integrated laryngeal and respiratory control, thereby coordinating two major muscular systems that are necessary for vocalization. Neurosurgical studies have since demonstrated the existence of a second larynx motor area at the ventral extent of the orofacial motor division (vLMC) of motor cortex. The vLMC has been presumed to be less relevant to speech motor control, but its functional role remains unknown. We employed a novel ultra-high field (7T) magnetic resonance imaging paradigm that combined singing and whistling simple melodies to localise the larynx motor cortices and test their involvement in respiratory motor control. Surprisingly, whistling activated both 'larynx areas' more strongly than singing despite the reduced involvement of the larynx during whistling. We provide further evidence for the existence of two larynx motor areas in the human brain, and the first evidence that laryngeal-respiratory integration is a shared property of both larynx motor areas. We outline explicit predictions about the descending motor pathways that give these cortical areas access to both the laryngeal and respiratory systems and discuss the implications for the evolution of speech.

Drug induced stuttering: pharmacovigilance data

Background: Stuttering is a speech disorder characterized by poor fluency of speech despite the speech production organs being normal. Numerous factors contribute to stuttering, and it may also be an iatrogenic effect of certain drugs. The aim of this study was to investigate the association between stuttering and drug exposure.Research design and methods: We investigated the association between drugs and stuttering. We analyzed reports in the World Health Organization global individual case safety reports database (Vigibase) up to 31 May 2020 with the MedDRA lower level terms 'stutter' and 'stuttering.' The association between a drug and the occurrence of the adverse drug reaction was estimated by disproportionality analysis. Reporting odds ratios (ROR) were calculated with 95% confidence intervals.Results: In total, 724 notifications were identified using the MedDRA terms selected. The main drugs implicated were methylphenidate (ROR = 19.58; 95% CI: 13.3-28.8), topiramate (ROR = 12.5; 95% CI: 7.1-22.1), olanzapine (ROR = 12; 95% CI: 8-17.9) and golimumab (ROR = 10.2; 95% CI: 5.5-19.1).Conclusions: When stuttering occurs in a patient treated by drugs affecting neurotransmission, a drug-induced origin of the stutter should be considered.

Acquired Stuttering in Veterans of the Wars in Iraq and Afghanistan: The Role of Traumatic Brain Injury, Post-Traumatic Stress Disorder, and Medications

Introduction

Determine the association between acquired stuttering (AS), traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) in a cohort of 309,675 U.S. Iraq and Afghanistan veterans. The secondary aim was to determine the association between AS and medication patterns for veterans in the sample.

Materials and Methods

Retrospective study using data from the Veterans Health Administration National Repository for veterans deployed in support of combat operations in Iraq and Afghanistan and who received Veterans Health Administration care in 2010 and 2011. We identified stuttering using ICD-9 codes to establish the association between AS, TBI, and PTSD, controlling for demographic characteristics and other comorbidities. Multivariable logistic regression was used to determine the association between comorbid conditions and potentially problematic medications associated with stuttering.

Results

Two hundred thirty-five veterans (0.08%) were diagnosed with AS in the cohort. There was the greater likelihood of an AS diagnosis for veterans with concomitant TBI and PTSD when compared with veterans without these diagnoses. Over 66% of those with stuttering were prescribed at least one medication that affected speech fluency (antidepressants, anxiolytics, and antiepileptic drugs) compared with 35% of those without AS.

Conclusion

Veterans with a comorbid diagnosis of TBI and PTSD were more likely to be diagnosed with AS AOR: 9.77 (95% CI = 6.93-13.78, p < 0.05) and more likely to have been prescribed medications known to affect speech production OR: 3.68 (95% CI = 2.81-4.82, p < 0.05). Clinicians treating veterans with these complex comorbid conditions should consider the impact of medications on speech fluency.

Disfluency clusters in speakers with and without neurogenic stuttering following traumatic brain injury

PURPOSE

Analyze the characteristics and rate of disfluency clusters in adults with and without neurogenic stuttering after traumatic brain injury (TBI).

METHOD

Twenty adults with TBI participated in this study, including 10 with neurogenic stuttering (Group B) and 10 without -stuttering (Group A). Disfluency clusters in speech samples were classified into three types: Stuttering-like (SLD), other (OD), and mixed (MIX).

RESULTS

Speakers with and without neurogenic stuttering produced the same mean number of disfluency clusters. In addition, the mean length of clusters did not differ between these speaker groups although the longest clusters did. The most frequently occurring cluster type for people with neurogenic stuttering was MIX and OD for people without stuttering. Although the speakers in Group A produced stuttering-like disfluencies, these never occurred together to form a SLD type cluster. For Group B, the starter units of the clusters were usually stuttering-like disfluencies, while for Group A, the starter units were mostly interruptions.

CONCLUSIONS

Compared to non-stuttering speakers, stuttering after TBI did not increase the number of clusters, but rather lengthened them. In speakers with neurogenic stuttering, the number and length of clusters were related to the manifestation of other communication deficits, not to the frequency of stuttering-like disfluencies. Still, SLD clusters occurred only in those people with neurogenic stuttering. These findings raise questions about the nature of both neurogenic stuttering and the dynamics of disfluency clustering.

Similar within-utterance loci of dysfluency in acquired neurogenic and persistent developmental stuttering

Although the underlying neural mechanisms remain unknown for both persistent developmental stuttering (PSD) and acquired neurogenic stuttering (ANS), few studies have examined similarities/differences between these two disorders. We evaluated in both PDS (n = 35) and ANS (n = 5) phonetic, word class, word length, and word position variables that are widely believed to influence at which loci within utterances PDS speakers' stuttering is most likely to occur. For both groups, (a) word weights based on the combination of variables were greater for stuttered vs. fluent words, and (b) stuttered words were loaded more by individual variables. However, contrary to long-standing views regarding PDS, greater loading for stuttered words was not found for the position variable. Findings suggest similar loci of stuttering in adults with PDS and ANS, and, for both groups, the probability of stuttering on a given word was more influenced by motor production variables than language variables.

Speech Language Pathology Rehabilitation

The speech language pathologist has a vital management role in patients with voice and swallow concerns, as well as stroke patients and patients with fluency problems. This article summarizes the variety of speech and swallow rehabilitation that adult patients may require or seek. The case examples allow the reader to base the clinical decision-making process within the context of a patient presentation and elucidate the role of speech and language pathology services for the primary care provider in order to refer patients with symptoms and concerns to the right provider early in their medical care.

A case of multiple system atrophy-parkinsonian type with stuttering- and palilalia-like dysfluencies and putaminal atrophy

Both developmental and acquired stuttering are related to the function of the basal ganglia-thalamocortical loop, which includes the putamen. Here, we present a case of stuttering- and palilalia-like dysfluencies that manifested as an early symptom of multiple system atrophy-parkinsonian type (MSA-P) and bilateral atrophy of the putamen. The patient was a 72-year-old man with no history of developmental stuttering who presented with a stutter for consultation with our otorhinolaryngology department. The patient was diagnosed with MSA-P based on parkinsonism, autonomic dysfunction, and bilateral putaminal atrophy revealed by T2-weighted magnetic resonance imaging. Treatment with levodopa improved both the motor functional deficits related to MSA-P and stuttering-like dysfluencies while reading; however, the palilalia-like dysfluencies were much less responsive to levodopa therapy. The patient died of aspiration pneumonia two years after his first consultation at our hospital. In conclusion, adult-onset stuttering- and palilalia-like dysfluencies warrant careful examination of the basal ganglia-thalamocortical loop, and especially the putamen, using neuroimaging techniques. Acquired stuttering may be related to deficits in dopaminergic function.

Euler H, Bosshardt HG, Cook S, Sandrieser P, Sommer M. The Pathogenesis, Assessment and Treatment of Speech Fluency Disorders

BACKGROUND

Approximately 1% of children and adolescents, 0.2% of women, and 0.8% of men suffer from stuttering, and lesser numbers from cluttering. Persistent speech fluency disorders often cause lifelong problems in communication and social participation.

METHODS

In an interdisciplinary, evidence and consensus based clinical practice guideline, the current understanding of the nature, identification, diagnosis, and treatment of stuttering and cluttering was summarized. A systematic review of the literature was carried out to assess the efficacy and effectiveness of treatments for stuttering. Evidence is lacking on the etiology, pathogenesis, evaluation, and treatment of cluttering.

RESULTS

In view of the fact that common (developmental, idiopathic) stuttering is associated with structural and functional changes of the brain, the guideline recommends that it should be called "originary neurogenic non-syndromic stuttering." Heritability estimates for this disorder range from 70% to over 80%. For preschool children, the Lidcombe therapy has the best evidence of efficacy (Cohen's d = 0.72-1.00). There is also strong evidence for an indirect treatment approach. For children aged 6 to 12, there is no solid evidence for the efficacy of any treatment. For adolescents and adults, there is good evidence with high effect sizes (Cohen's d = 0.75-1.63) for speech restructuring methods such as fluency shaping; weak evidence with intermediate effect sizes for stuttering modification (Cohen's d = 0.56-0.65); and weak evidence for combined speech restructuring and stuttering modification. The evidence does not support the efficacy of pharmacotherapy, rhythmic speaking, or breathing regulation as the sole or main form of treatment, or that of hypnosis or eclectic, unspecified stuttering therapies.

CONCLUSION

Stuttering is often treated in Germany with therapies for which there is inadequate evidence, and the initiation of treatment is often unnecessarily delayed. The guideline presents treatment methods whose efficacy is supported by the current evidence.

Speech-activated Myoclonus Mimicking Stuttering in a Patient with Myoclonus-Dystonia Syndrome

BACKGROUND

Acquired neurogenic stuttering has been considered a fairly uncommon clinical occurrence; speech-activated myoclonus is a rare entity that can mimic stuttering and is caused by a wide array of etiologies.

CASE REPORT

Here we report a patient with myoclonus-dystonia syndrome (MDS), due to an identified disease-causing mutation, who displayed speech-activated myoclonus mimicking stuttering.

DISCUSSION

In MDS, myoclonus has only infrequently been reported to affect speech. This case further expands the spectrum of conditions causing the rare clinical phenomenon of speech-activated myoclonus.

Neural network connectivity differences in children who stutter

Affecting 1% of the general population, stuttering impairs the normally effortless process of speech production, which requires precise coordination of sequential movement occurring among the articulatory, respiratory, and resonance systems, all within millisecond time scales. Those afflicted experience frequent disfluencies during ongoing speech, often leading to negative psychosocial consequences. The aetiology of stuttering remains unclear; compared to other neurodevelopmental disorders, few studies to date have examined the neural bases of childhood stuttering. Here we report, for the first time, results from functional (resting state functional magnetic resonance imaging) and structural connectivity analyses (probabilistic tractography) of multimodal neuroimaging data examining neural networks in children who stutter. We examined how synchronized brain activity occurring among brain areas associated with speech production, and white matter tracts that interconnect them, differ in young children who stutter (aged 3-9 years) compared with age-matched peers. Results showed that children who stutter have attenuated connectivity in neural networks that support timing of self-paced movement control. The results suggest that auditory-motor and basal ganglia-thalamocortical networks develop differently in stuttering children, which may in turn affect speech planning and execution processes needed to achieve fluent speech motor control. These results provide important initial evidence of neurological differences in the early phases of symptom onset in children who stutter.

The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke

Dysphagia, dysarthria and aphasia occur frequently following stroke. Our purpose was to identify the incidence, co-occurrence, and predictors of these impairments after first-ever ischemic stroke. We used the Registry of the Canadian Stroke Network's database (2003-2008) from one stroke center to identify a random sample of 250 patients with acute ischemic stroke confirmed by MR imaging. We further conducted a retrospective medical chart review. We established reliable data capture and identified the presence of the three impairments. We derived incidence and co-occurrence estimates along with 95% confidence intervals (CI) for dysphagia, dysarthria, and aphasia. We then computed odds ratios (OR) through logistic regression to identify predictors. Twenty-nine patient charts were not available for review. Estimates of the incidence of dysphagia, dysarthria, and aphasia were 44% (95% CI, 38-51), 42% (95% CI, 35-48) and 30% (95% CI, 25-37), respectively. The highest co-occurrence of any two impairments was 28% (95% CI, 23-34) for the presence of both dysphagia and dysarthria. Ten percent of all 221 patients had all three impairments. The highest predictors were non-alert level of consciousness for dysphagia (OR 2.6, CI 1.03-6.5), symptoms of weakness for dysarthria (OR 5.3, CI 2.4-12.0), and right-sided symptoms for aphasia (OR 7.1, CI 3.1-16.6). These findings are a first step toward identifying the incidence and predictors of multiple co-occurring impairments in a homogenous stroke sample.

LEARNING OUTCOMES

Learning outcomes: Readers will be able to (1) RECOGNIZE the need for research in stroke, whereby outcomes are reported according to stroke etiology and recurrence patterns, (2) identify the incidence and co-occurrence of dysphagia, dysarthria, and aphasia after a first-ever acute ischemic stroke, and (3) describe clinical precursors of these impairments in the acute stage of stroke.

A crucial role for the cortico-striato-cortical loop in the pathogenesis of stroke-related neurogenic stuttering

Neurogenic stuttering is an acquired speech disorder characterized by the occurrence of stuttering-like dysfluencies following brain damage. Because the onset of stuttering in these patients is associated with brain lesions, this condition provides a unique opportunity to study the neural processes underlying speech dysfluencies. Lesion localizations of 20 stroke subjects with neurogenic stuttering and 17 control subjects were compared using voxel-based lesion symptom mapping. The results showed nine left-hemisphere areas associated with the presence of neurogenic stuttering. These areas were largely overlapping with the cortico-basal ganglia-cortical network comprising the inferior frontal cortex, superior temporal cortex, intraparietal cortex, basal ganglia, and their white matter interconnections through the superior longitudinal fasciculus and internal capsule. These results indicated that stroke-induced neurogenic stuttering is not associated with neural dysfunction in one specific brain area but can occur following one or more lesion throughout the cortico-basal ganglia-cortical network. It is suggested that the onset of neurogenic stuttering in stroke subjects results from a disintegration of neural functions necessary for fluent speech.