Prevalence and Impact of Aphasia among Patients Admitted with Acute Ischemic Stroke

Change of function and brain activity in patients of right spastic arm paralysis combined with aphasia after contralateral cervical seventh nerve transfer surgery

Left hemisphere injury can cause right spastic arm paralysis and aphasia, and recovery of both motor and language functions shares similar compensatory mechanisms and processes. Contralateral cervical seventh cross transfer (CC7) surgery can provide motor recovery for spastic arm paralysis by triggering interhemispheric plasticity, and self-reports from patients indicate spontaneous improvement in language function but still need to be verified. To explore the improvements in motor and language function after CC7 surgery, we performed this prospective observational cohort study. The Upper Extremity part of Fugl-Meyer scale (UEFM) and Modified Ashworth Scale were used to evaluate motor function, and Aphasia Quotient calculated by Mandarin version of the Western Aphasia Battery (WAB-AQ, larger score indicates better language function) was assessed for language function. In 20 patients included, the average scores of UEFM increased by .40 and 3.70 points from baseline to 1-week and 6-month post-surgery, respectively. The spasticity of the elbow and fingers decreased significantly at 1-week post-surgery, although partially recurred at 6-month follow-up. The average scores of WAB-AQ were increased by 9.14 and 10.69 points at 1-week and 6-month post-surgery (P < .001 for both), respectively. Post-surgical fMRI scans revealed increased activity in the bilateral hemispheres related to language centrals, including the right precentral cortex and right gyrus rectus. These findings suggest that CC7 surgery not only enhances motor function but may also improve the aphasia quotient in patients with right arm paralysis and aphasia due to left hemisphere injuries.

Meta-analysis and systematic review of the relationship between sex and the risk or incidence of poststroke aphasia and its types

OBJECTIVE

To analyse and discuss the association of gender differences with the risk and incidence of poststroke aphasia (PSA) and its types, and to provide evidence-based guidance for the prevention and treatment of poststroke aphasia in clinical practice.

DATA SOURCES

Embase, PubMed, Cochrane Library and Web of Science were searched from January 1, 2002, to December 1, 2023.

STUDY SELECTION

Including the total number of strokes, aphasia, the number of different sexes or the number of PSA corresponding to different sex.

DATA EXTRACTION

Studies with missing data, aphasia caused by nonstroke and noncompliance with the requirements of literature types were excluded.

DATA SYNTHESIS

36 papers were included, from 19 countries. The analysis of 168,259 patients with stroke and 31,058 patients with PSA showed that the risk of PSA was 1.23 times higher in female than in male (OR = 1.23, 95% CI = 1.19-1.29, P < 0.001), with a prevalence of PSA of 31% in men and 36% in women, and an overall prevalence of 34% (P < 0.001). Analysis of the risk of the different types of aphasia in 1,048 patients with PSA showed a high risk in females for global, broca and Wenicke aphasia, and a high risk in males for anomic, conductive and transcortical aphasia, which was not statistically significant by meta-analysis. The incidence of global aphasia (males vs. females, 29% vs. 32%) and broca aphasia (17% vs 19%) were higher in females, and anomic aphasia (19% vs 14%) was higher in males, which was statistically significant (P < 0.05).

CONCLUSIONS

There are gender differences in the incidence and types of PSA. The risk of PSA in female is higher than that in male.

Diffusion MRI Fiber Tractography and Benzodiazepine SPECT Imaging for Assessing Neural Damage to the Language Centers in an Elderly Patient after Successful Reperfusion Therapy

BACKGROUND

Intravenous thrombolysis and mechanical thrombectomy are the first-line reperfusion therapies for acute ischemic stroke. Here, we describe the utility of diffusion magnetic resonance imaging (MRI) fiber tractography and 123I-iomazenil benzodiazepine receptor single-photon emission computed tomography to estimate the prognosis of post-stroke aphasia after successful reperfusion therapy.

CASE REPORT

An 81-year-old man was admitted to the hospital approximately 3.5 h after the onset of symptoms, including decreased consciousness, right hemiparesis, and aphasia. An MRI revealed acute cerebral infarction due to M1 segment occlusion. Intravenous alteplase thrombolysis followed by endovascular thrombectomy resulted in recanalization of the left middle cerebral artery territory. A subsequent MRI showed no new ischemic or hemorrhagic lesions. Although the patient's motor hemiparesis gradually recovered, motor aphasia persisted. Diffusion MRI fiber tractography performed 2 weeks after admission revealed partial injury to the left arcuate fasciculus, indicated by lower fractional anisotropy values than on the contralateral side. A decreased benzodiazepine receptor density was also detected in the left perisylvian and temporoparietal cortices. The patient showed no clear signs of further improvement in the chronic stage post-stroke and was discharged to a nursing home after 3 months.

CONCLUSIONS

The application of functional neuroimaging techniques to assess neuronal damage to the primary brain regions 2 weeks after reperfusion therapy for large-vessel occlusion may allow for an accurate prognosis of post-stroke aphasia. This may have a direct clinical implication for navigating subacute-to-chronic phases of rehabilitative care.

Effect of Acupuncture vs Sham Acupuncture on Patients With Poststroke Motor Aphasia: A Randomized Clinical Trial

Importance

Motor aphasia is common among patients with stroke. Acupuncture is recommended as an alternative therapy for poststroke aphasia, but its efficacy remains uncertain.

Objective

To investigate the effects of acupuncture on language function, neurological function, and quality of life in patients with poststroke motor aphasia.

Design, Setting, and Participants

This multicenter, sham-controlled, randomized clinical trial was conducted in 3 tertiary hospitals in China from October 21, 2019, to November 13, 2021. Adult patients with poststroke motor aphasia were enrolled. Data analysis was performed from February to April 2023.

Interventions

Eligible participants were randomly allocated (1:1) to manual acupuncture (MA) or sham acupuncture (SA) groups. Both groups underwent language training and conventional treatments.

Main Outcomes and Measures

The primary outcomes were the aphasia quotient (AQ) of the Western Aphasia Battery (WAB) and scores on the Chinese Functional Communication Profile (CFCP) at 6 weeks. Secondary outcomes included WAB subitems, Boston Diagnostic Aphasia Examination, National Institutes of Health Stroke Scale, Stroke-Specific Quality of Life Scale, Stroke and Aphasia Quality of Life Scale-39, and Health Scale of Traditional Chinese Medicine scores at 6 weeks and 6 months after onset. All statistical analyses were performed according to the intention-to-treat principle.

Results

Among 252 randomized patients (198 men [78.6%]; mean [SD] age, 60.7 [7.5] years), 231 were included in the modified intention-to-treat analysis (115 in the MA group and 116 in the SA group). Compared with the SA group, the MA group had significant increases in AQ (difference, 7.99 points; 95% CI, 3.42-12.55 points; P = .001) and CFCP (difference, 23.51 points; 95% CI, 11.10-35.93 points; P < .001) scores at week 6 and showed significant improvements in AQ (difference, 10.34; 95% CI, 5.75-14.93; P < .001) and CFCP (difference, 27.43; 95% CI, 14.75-40.10; P < .001) scores at the end of follow-up.

Conclusions and Relevance

In this randomized clinical trial, patients with poststroke motor aphasia who received 6 weeks of MA compared with those who received SA demonstrated statistically significant improvements in language function, quality of life, and neurological impairment from week 6 of treatment to the end of follow-up at 6 months after onset.

Trial Registration

Chinese Clinical Trial Registry: ChiCTR1900026740.

The volume and the distribution of premorbid white matter hyperintensities: Impact on post-stroke aphasia

White matter hyperintensities (WMH) are a radiological manifestation of progressive white matter integrity loss. The total volume and distribution of WMH within the corpus callosum have been associated with pathological cognitive ageing processes but have not been considered in relation to post-stroke aphasia outcomes. We investigated the contribution of both the total volume of WMH, and the extent of WMH lesion load in the corpus callosum to the recovery of language after first-ever stroke. Behavioural and neuroimaging data from individuals (N = 37) with a left-hemisphere stroke were included at the early subacute stage of recovery. Spoken language comprehension and production abilities were assessed using word and sentence-level tasks. Neuroimaging data was used to derive stroke lesion variables (volume and lesion load to language critical regions) and WMH variables (WMH volume and lesion load to three callosal segments). WMH volume did not predict variance in language measures, when considered together with stroke lesion and demographic variables. However, WMH lesion load in the forceps minor segment of the corpus callosum explained variance in early subacute comprehension abilities (t = -2.59, p = .01) together with corrected stroke lesion volume and socio-demographic variables. Premorbid WMH lesions in the forceps minor were negatively associated with early subacute language comprehension after aphasic stroke. This negative impact of callosal WMH on language is consistent with converging evidence from pathological ageing suggesting that callosal WMH disrupt the neural networks supporting a range of cognitive functions.

Person-centered care for people with aphasia: tools for shared decision-making

Shared decision-making is a fundamental aspect of person-centered care, and can and should be part of many different aspects of the rehabilitation process. Communication disabilities like aphasia, which affects people's ability to use and understand spoken and written language, can make shared decision-making especially challenging to the resources and skills of rehabilitation practitioners. The purpose of this narrative review is to provide a comprehensive description of tools that can support successful shared decision-making with people with aphasia in the rehabilitation environment. These tools and strategies are appropriate for use by physicians, nurses, social workers, physical therapists (also referred to as physiotherapists), occupational therapists, and other service or care providers. The important role of speech-language pathologists as consultants is also described. Case scenarios throughout the paper illustrate the application of recommended tools and strategies along with best practices.

Measuring Pain in Aphasia: Validity and Reliability of the PACSLAC-D

BACKGROUND

Post-stroke pain in patients with an inability to communicate is not systematically assessed and therefore not sufficiently treated. This stresses the need to study pain assessment instruments that do not require good communication skills.

AIM

To examine the validity and reliability of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate - Dutch version (PACSLAC-D) in stroke patients with aphasia.

METHOD

Sixty stroke patients (mean age 79.3 years, standard deviation [SD] 8.0), of whom 27 had aphasia were observed during rest, activities of daily living (ADL), and physiotherapy using the Pain Assessment Checklist for Seniors with Limited Ability to Communicate - Dutch version (PACSLAC-D). The observations were repeated after two weeks. To examine convergent validity, correlations between the PACSLAC-D, self-report pain scales, and the clinical judgment of a health care professional (pain present yes/no) were used. To examine discriminative validity, differences in pain were investigated between rest and ADL, in patients who use pain medication and those who do not, and in patients with and without aphasia. Internal consistency and test-retest reliability were assessed to determine reliability.

RESULTS

Convergent validity failed to meet the acceptable threshold during rest but was adequate during ADL and physiotherapy. Discriminative validity was only adequate during ADL. The internal consistency was 0.33 during rest, 0.71 during ADL, and 0.65 during physiotherapy. Test-retest reliability varied from poor during rest (intraclass correlation coefficient [ICC] = 0.07; 95% confidence interval [CI]: -0.40-0.51) to excellent during physiotherapy (ICC = 0.95; 95% CI: 0.83-0.98).

CONCLUSIONS

The PACSLAC-D captures pain in patients with aphasia who are unable to self-report, during ADL and physiotherapy, but may be less accurate during rest.

Undetected language deficits in left or right hemisphere post-stroke patients

Previous studies have reported that widely used tests for aphasia identification are unable to detect the subtle language deficits of left hemisphere brain damaged (LHBD) individuals. Similarly, the language disorders of individuals with right hemisphere brain damage (RHBD) usually remain undetected, due to the lack of any specialized test for the evaluation of their language processing skills. The aim of the present study was to evaluate the language deficits of 80 individuals suffering from the effects of either a LHBD or RHBD stroke, who were diagnosed as having no aphasia or language deficits based on the application of Boston Diagnostic Aphasia Examination. Their language abilities were examined with the use of the Adults' Language Abilities Test, which explores morpho-syntactic and semantic phenomena of the Greek language in both the comprehension and production modalities. Results revealed that both groups of stroke survivors performed significantly worse compared to the group of healthy participants. Thus, it appears that the latent aphasia of LHBD and the language deficits of RHBD patients are likely to remain undetected and that patients are at risk of not receiving appropriate treatment if their language abilities are not evaluated by an effective and efficient battery of language tests.

Effect of an extension speech training program based on Chinese idioms in patients with post-stroke non-fluent aphasia: A randomized controlled trial

BACKGROUND

Chinese idioms have potential to act as preliminary training material in studies on post-stroke aphasia.

OBJECTIVE

To explore an extension speech training program that takes Chinese idioms as context and expands them into characters, words, sentences and paragraphs and evaluate the effects of this program in patients with post-stroke non-fluent aphasia.

METHODS

This was a randomized controlled trial. We recruited patients with post-stroke non-fluent aphasia from the Renmin Hospital of Wuhan University from January 2021 to January 2022. Participants were randomly assigned to group I and group II. Patients in group I had treatment with extension speech training based on Chinese idioms, and those in group II had treatment with conventional speech rehabilitation training. The training period in both groups was 40 min daily for 2 weeks.

RESULTS

A total of 70 patients (group I, n = 34; and group II, n = 36) completed the trial and were analyzed according to protocol. There were no significant differences in baseline values between both groups. After intervention, the scores of oral expression, comprehension, and reading in the Aphasia Battery Of Chinese scale and the scores of the Comprehensive Activities of Daily Living questionnaire significantly improved in both groups (P <0.05), with group I benefiting more (P <0.05).

CONCLUSION

This extension speech training program based on Chinese idioms can improve the language function and daily communication ability of the patients with post-stroke non-fluent aphasia.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000031825.

The Excess Costs of Hospitalization for Acute Stroke in People With Communication Impairment: A Stroke123 Data Linkage Substudy

OBJECTIVE

To describe the costs of hospital care for acute stroke for patients with aphasia or dysarthria.

DESIGN

Observational study from the Stroke123 project.

SETTING

Data from patients admitted with stroke (2009-2013) from 22 hospitals in Queensland participating in the Australian Stroke Clinical Registry (AuSCR) were linked to administrative datasets.

PARTICIPANTS

Communication impairments were identified using International Classification of Diseases, 10th Revision, Australian Modification codes. Overall, 1043 of 4195 (25%) patients were identified with aphasia (49% were women; median age 78 years; 83% with ischemic stroke), and 1005 (24%) with dysarthria (42% were women; median age 76 years; 85% with ischemic stroke).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Linked patient-level, hospital clinical costing related to the stroke, were adjusted to 2013/2014 Australian dollars (AU$, US$ conversion x 0.691) using recommended national price indices and multivariable regression analysis with clustering by hospital performed.

RESULTS

Compared with patients without aphasia, the median hospital costs/patient were greater for those with aphasia for medical (aphasia AU$2273 vs AU$1727, P<.001), nursing (aphasia AU$3829 vs AU$2748, P<.001) and allied health services (aphasia AU$1138 vs AU$720, P<.001). Similarly, costs were greater for patients with dysarthria compared with those without dysarthria. Adjusted median total costs were AU$2882 greater for patients with aphasia compared with patients without aphasia (95% confidence interval, AU$1880-3884), and AU$843 greater for patients with dysarthria compared with those without dysarthria (95% confidence interval, AU$-301 to 1987).

CONCLUSIONS

People with communication impairment after stroke incur greater hospital costs, in particular for medical, allied health, and nursing resources.

A precise language network revealed by the independent component-based lesion mapping in post-stroke aphasia

Brain lesion mapping studies have provided the strongest evidence regarding the neural basis of cognition. However, it remained a problem to identify symptom-specific brain networks accounting for observed clinical and neuroanatomical heterogeneity. Independent component analysis (ICA) is a statistical method that decomposes mixed signals into multiple independent components. We aimed to solve this issue by proposing an independent component-based lesion mapping (ICLM) method to identify the language network in patients with moderate to severe post-stroke aphasia. Lesions were first extracted from 49 patients with post-stroke aphasia as masks applied to fMRI data in a cohort of healthy participants to calculate the functional connectivity (FC) within the masks and non-mask brain voxels. ICA was further performed on a reformatted FC matrix to extract multiple independent networks. Specifically, we found that one of the lesion-related independent components (ICs) highly resembled classical language networks. Moreover, the damaged level within the language-related lesioned network is strongly associated with language deficits, including aphasia quotient, naming, and auditory comprehension scores. In comparison, none of the other two traditional lesion mapping methods found any regions responsible for language dysfunction. The language-related lesioned network extracted with the ICLM method showed high specificity in detecting aphasia symptoms compared with the performance of resting ICs and classical language networks. In total, we detected a precise language network in patients with aphasia and proved its efficiency in the relationship with language symptoms. In general, our ICLM could successfully identify multiple lesion-related networks from complicated brain diseases, and be used as an effective tool to study brain-behavior relationships and provide potential biomarkers of particular clinical behavioral deficits.

Does acupuncture therapy improve language function of patients with aphasia following ischemic stroke? A systematic review and meta-analysis

BACKGROUND

Aphasia is one of the most common complications in patients with ischemic stroke. Studies have shown that acupuncture can improve the symptoms of aphasia patients. However, the effect of acupuncture on language function in patients with ischemic stroke is still controversial.

OBJECTIVE

This study aimed to critically assess the efficacy and safety of acupuncture for aphasia following ischemic stroke.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals database were searched. All randomized controlled trials (RCTs) that met the criteria were included.

RESULTS

Meta-analyses showed that mean difference in change of auditory comprehension score (MD = 7.71, 95% CI: 1.83 to 13.59, P = 0.01), spontaneous speech (MD = 2.77, 95% CI: 0.59 to 4.95, P = 0.01), repetition score (MD = 14.48, 95% CI: 11.04 to 17.91, P <  0.00001) and naming score (MD = 14.60, 95% CI: 11.33 to 17.88, P <  0.00001) measured by WAB scale were statistically significant. Subgroup analyses demonstrated that there were statistically significant mean differences in four items of WAB scale in patients with sub-acute stroke, and no statistically significant differences in patients with acute stroke.

CONCLUSION

The present study suggests that acupuncture may improve the language function of patients with aphasia following ischemic stroke, especially during the sub-acute phase. However, due to insufficient sample sizes and information on the safety, more high-quality RCTs are still needed.

Revealing the Neuroimaging Mechanism of Acupuncture for Poststroke Aphasia: A Systematic Review

Background

Aphasia is a common symptom in stroke patients, presenting with the impairment of spontaneous speech, repetition, naming, auditory comprehension, reading, and writing function. Multiple rehabilitation methods have been suggested for the recovery of poststroke aphasia, including medication treatment, behavioral therapy, and stimulation approach. Acupuncture has been proven to have a beneficial effect on improving speech functions in repetition, oral speech, reading, comprehension, and writing ability. Neuroimaging technology provides a visualized way to explore cerebral neural activity, which helps reveal the therapeutic effect of acupuncture therapy. In this systematic review, we aim to reveal and summarize the neuroimaging mechanism of acupuncture therapy on poststroke aphasia to provide the foundation for further study.

Methods

Seven electronic databases were searched including PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, the Wanfang databases, and the Chinese Scientific Journal Database. After screening the studies according to the inclusion and exclusion criteria, we summarized the neuroimaging mechanism of acupuncture on poststroke aphasia, as well as the utilization of acupuncture therapy and the methodological characteristics.

Result

After searching, 885 articles were retrieved. After removing the literature studies, animal studies, and case reports, 16 studies were included in the final analysis. For the acupuncture type, 10 studies used manual acupuncture and 5 studies used electroacupuncture, while body acupuncture (10 studies), scalp acupuncture (7 studies), and tongue acupuncture (8 studies) were applied for poststroke aphasia patients. Based on blood oxygen level-dependent (BOLD) and diffusion tensor imaging (DTI) technologies, 4 neuroimaging analysis methods were used including amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), seed-based analysis, and independent component analysis (ICA). Two studies reported the instant acupuncture effect, and 14 studies reported the constant acupuncture's effect on poststroke aphasia patients. 5 studies analyzed the correlation between the neuroimaging outcomes and the clinical language scales.

Conclusion

In this systematic review, we found that the mechanism of acupuncture's effect might be associated with the activation and functional connectivity of language-related brain areas, such as brain areas around Broca's area and Wernicke's area in the left inferior temporal gyrus, supramarginal gyrus, middle frontal gyrus, and inferior frontal gyrus. However, these studies were still in the preliminary stage. Multicenter randomized controlled trials (RCT) with large sample sizes were needed to verify current evidence, as well as to explore deeply the neuroimaging mechanisms of acupuncture's effects.

Assessment of language impairment and function

This chapter is written for the qualified neurologist or related professional working with persons who have had a stroke or other sudden brain injury. It is critical that the presence of aphasia is detected, no matter how mild the presentation, and to support that assertion, this chapter highlights the plight of persons with latent aphasia. At the individual level, the impact of aphasia is devastating, with overwhelming evidence that aphasia negatively impacts psychosocial outcomes. At the global level, sensitive detection and accurate diagnosis of aphasia are critical for accurate characterization and quantification of the global burden of aphasia. The word "LANGUAGE" is leveraged as an acronym to create a useful and memorable checklist to guide navigation of aphasia screening and assessment: it begins with the definition of language (L), followed by the definition and diagnostic criteria for aphasia (A). Then language abilities and characteristics to be considered in assessment are presented: naming (N); grammar and syntax (G); unintelligible words, jargon, and paraphasias (U); auditory comprehension and repetition (A); graphemic abilities-reading and writing (G); and everyday communication and discourse (E). Recommendations for improving procedural adherence are provided, and a list of potential brief assessment measures are introduced.

Nurses' experiences of communicating with patients with aphasia

AIM

This study explored nurses' experiences of communicating with patients with aphasia.

DESIGN

A naturalistic paradigm approach was adopted to describe the phenomenon of interest.

METHODS

Participants were neurological nurses employed in various neurological departments and recruited using purposive sampling. Group interviews were conducted for 1 hr and 30 min using semi-structured open-ended questions. The Consolidated Criteria for Reporting Qualitative Research checklist was followed.

RESULTS

Four generic categories were derived: "Conversations with the aphasic patients are frustrating, which leads to impatience among nurses, and they eventually dismiss the patients," "Feeling responsible for communicating with aphasic patients but also experiencing guilt for not being able to give adequate care in practice," "Concerns about communication methods with aphasic patients" and "Desire to learn ways to communicate with aphasic patients." Appropriate education and support should be given to nurses to facilitate communication with aphasic patients to ensure that they are not excluded from medical benefits because of communication difficulties.

Efficacy and safety of scalp acupuncture in improving neurological dysfunction after ischemic stroke: A protocol for systematic review and meta-analysis

BACKGROUND

Scalp acupuncture is remarkable in improving neurological dysfunction of ischemic stroke patients. This study aims to systematically evaluate the efficacy and safety of scalp acupuncture in improving neurological dysfunction of ischemic stroke patients.

METHODS

Randomized controlled trials of scalp acupuncture against ischemic stroke patients will be searched in PubMed, Web of Science, Embase, Cochrane Library, the Chongqing VIP Chinese Science and Technology Periodical Database, Chinese Biological and Medical database, China National Knowledge Infrastructure, and Wanfang database from inception to July, 2020. Two researchers will perform data extraction and risk of bias assessment independently. Statistical analysis will be conducted in RevMan 5.3.

RESULTS

This study will summarize the present evidence by exploring the efficacy and safety of scalp acupuncture in improving neurological dysfunction in ischemic stroke patients.

CONCLUSIONS

The findings of the study will help to determine potential benefits of scalp acupuncture against ischemic stroke at different stage.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/T26P8.