Vascular aphasias: main characteristics of patients hospitalized in acute stroke units

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.

Investigating Aphasia Recovery: Demographic and Clinical Factors

Post-stroke language recovery remains one of the main unresolved topics in the field of aphasia. In recent years, there have been efforts to identify specific factors that could potentially lead to improved language recovery. However, the exact relationship between the recovery of particular language functions and possible predictors, such as demographic or lesion variables, is yet to be fully understood. In the present study, we attempted to investigate such relationships in 42 patients with aphasia after left hemisphere stroke, focusing on three language domains: auditory comprehension, naming and speech fluency. Structural imaging data were also obtained for the identification of the lesion sites. According to our findings, patients demonstrated an overall improvement in all three language domains, while no demographic factor significantly contributed to aphasia recovery. Interestingly, specific lesion loci seemed to have a differential effect on language performance, depending on the time of testing (i.e., acute/subacute vs. chronic phase). We argue that this variability concerning lesion-deficit associations reflects the dynamic nature of aphasia and further discuss possible explanations in the framework of neuroplastic changes during aphasia recovery.

The Moroccan Arabic Bedside Western Aphasia Battery-Revised: Linguistic and Psychometric Properties

PURPOSE

The objectives of this study were (a) to linguistically and culturally adapt the English bedside version of the Western Aphasia Battery-Revised (Bedside WAB-R) into Moroccan Arabic (MA) and (b) to assess its psychometric properties.

METHOD

The Bedside MA-WAB-R was piloted on a population of 20 participants after a process of linguistic adaptation from English to MA. To verify the psychometric properties of the test, a group of healthy controls (n = 106) and a group of persons with chronic aphasia (n = 52) completed the Bedside MA-WAB-R. The test's content validity, construct validity, and the concurrent validity of the aphasia classification system were examined. In addition, the interrater reliability, intrarater reliability, test-retest reliability, and internal consistency of the instrument were evaluated.

RESULTS

The results indicated that the Bedside MA-WAB-R overall met standard criteria for excellent psychometric properties, as evinced by high content and construct validity and concurrent validity with independent measures of aphasia diagnosis (speech-language pathologists' impression and lesion location) as well as high internal consistency, inter- and intrarater reliability, and test-retest reliability. The test was also found to have very high sensitivity and specificity for the detection of aphasia, as revealed by the performance of controls. By controlling for age and educational level effects, specific cutoff values were determined to optimize the aphasia diagnosis.

CONCLUSIONS

The Bedside MA-WAB-R is the first standardized quick aphasia assessment tool with associated psychometric properties for clinical use with an MA-speaking population, particularly within the 26- to 58-year age range. It meets standard criteria for a valid and reliable measure than can have a variety of clinical and research applications.

Functional architecture of executive processes: Evidence from verbal fluency and lesion mapping in stroke patients

The functional organization and related anatomy of executive functions are still largely unknown and were examined in the present study using a verbal fluency task. The objective of this study was to determine the cognitive architecture of a fluency task and related voxelwise anatomy in the GRECogVASC cohort and fMRI based meta-analytical data. First, we proposed a model of verbal fluency in which two control processes, lexico-semantic strategic search process and attention process, interact with semantic and lexico-phonological output processes. This model was assessed by testing 404 patients and 775 controls for semantic and letter fluency, naming, and processing speed (Trail Making test part A). Regression (R² = .276 and .3, P = .0001, both) and structural equation modeling (CFI: .88, RMSEA: .2, SRMR: .1) analyses supported this model. Second, voxelwise lesion-symptom mapping and disconnectome analyses demonstrated fluency to be associated with left lesions of the pars opercularis, lenticular nucleus, insula, temporopolar region, and a large number of tracts. In addition, a single dissociation showed specific association of letter fluency with the pars triangularis of F3. Disconnectome mapping showed the additional role of disconnection of left frontal gyri and thalamus. By contrast, these analyses did not identify voxels specifically associated with lexico-phonological search processes. Third, meta-analytic fMRI data (based on 72 studies) strikingly matched all structures identified by the lesion approach. These results support our modeling of the functional architecture of verbal fluency based on two control processes (strategic search and attention) operating on semantic and lexico-phonologic output processes. Multivariate analysis supports the prominent role of the temporopolar area (BA 38) in semantic fluency and the F3 triangularis area (BA 45) in letter fluency. Finally, the lack of voxels specifically dedicated to strategic search processes could be due to a distributed organization of executive functions warranting further studies.

Picnic, Accident or Cookies? A Systematic Approach to Guide the Selection of the Picture Definition Tasks in Linguistic Assessment

OBJECTIVE

Picture description tasks are used to elicit language samples in individuals with aphasia and other cognitive disorders. However, task selection may affect the type of language variables elicited. In this study, our goal is to compare the strengths and the weaknesses of the two internationally used picture description tasks with a novel picture description task developed specifically for Turkish-speaking individuals.

MATERIALS AND METHODS

In sum, 20 cognitively healthy individuals with a mean age of 52 ± 14/3 were included. Three different picture description tasks composed of single pictures were used: The Picnic Scene from the Western Aphasia Battery-Revised, the Cookie Theft picture from the Boston Diagnostic Aphasia Examination and the Accident Scene from the Turkish Language Assessment Test for Aphasia. All language samples were recorded using a digital voice recorder. Automated and semi-automated approaches were used for the systematic analysis of the language features that were classified into four levels: general language measures, the morphosyntactic level, the lexicosemantic level and the sentence level.

RESULTS

Participants showed greater efficiency and produced the greatest number of subordinate clauses, derivational suffixes, passive voice suffixes and relative past tense construction during the Accident Scene description. On the lexicosemantic level, the Picnic Scene was particularly superior to the Cookie Theft Picture in eliciting nouns. Imperfective aspect use was less frequent in the Accident Scene description.

CONCLUSION

All three tasks had limitations and advantages compared with each other. We recommend the development of novel picture description tasks that would be more effective in eliciting specific language features in Turkish-speaking individuals.

Neuropsychiatric outcomes and caregiver distress in primary progressive aphasia

BACKGROUND

In this study, we aimed to outline the neuropsychiatric consequences of primary progressive aphasia (PPA) and to understand how neuropsychiatric symptomatology affects distress in caregivers.

METHODS

The Neuropsychiatric Inventory (NPI) including the distress index (NPI-Distress) was used. Additional information about the caregiver burden was obtained using Zarit Burden Interview (ZBI). NPI, NPI-Distress, and ZBI data from 17 patients with a clinical diagnosis of PPA were compared with 10 stroke aphasia patients. Neuropsychiatric symptomatology was investigated based on three clusters; Mood, Frontal/Comportmental, and Psychotic/Disruptive. Additionally, the Activities of Daily Living Questionnaire (ADLQ) was used to outline the functional impairment. Twelve healthy controls were included to compare the neurocognitive test scores with PPA and stroke aphasia groups.

RESULTS

A greater number of neuropsychiatric symptoms were observed in the PPA group compared to the stroke aphasia group. The number of symptoms in Mood, and Frontal/Comportmental clusters were greater than the number of symptoms in Psychotic/Disruptive clusters in the PPA group, whereas no significant relationship between the number of symptoms and symptom clusters was found in the stroke aphasia group. In the PPA group, a strong correlation was found between the NPI-Frequency × Severity scores and the NPI-Distress scores. Moreover, the NPI-Distress scores in the PPA group strongly correlated with the ZBI scores. Scores for anxiety, irritability/lability, and apathy had a stronger correlation with the NPI-Distress scores compared to the other NPI symptoms. The Communication subscale was the most impaired domain in the PPA group. Travel, and Employment and Recreation subscales showed greater functional impairment in the stroke aphasia group compared to the PPA group.

CONCLUSIONS

Neuropsychiatric symptoms in PPA in our study were more frequent than previously reported. Furthermore, the distress index of the NPI was not only correlated with the severity of the neuropsychiatric symptoms but also reflected the overall burden on the caregivers in the PPA group.

Predictors beyond the lesion: Health and demographic factors associated with aphasia severity

BACKGROUND

Lesion-related factors are associated with severity of language impairment in persons with aphasia. The extent to which demographic and health factors predict language impairment beyond traditional cortical measures remains unknown. Identifying and understanding the contributions of factors to predictive models of severity constitutes critical knowledge for clinicians interested in charting the likely course of aphasia in their patients and designing effective treatment approaches in light of those predictions.

METHODS

Utilizing neuroimaging and language testing from our cohort of 224 individuals in the chronic stage of recovery from a left-hemisphere stroke in a cross-sectional study, we first conducted a lesion symptom mapping (LSM) analysis to identify regions associated with aphasia severity scores. After controlling for lesion volume and damage to pre-identified areas, three models were created to predict severity scores: 1) Demographic Model (N = 147); 2) Health Model (N = 106); and 3) Overall Model (N = 106). Finally, all identified factors were entered into a Final Model to predict raw severity scores.

RESULTS

Two areas were associated with aphasia severity-left posterior insula and left arcuate fasciculus. The results from the Demographic Model revealed non-linguistic cognitive ability, age at stroke, and time post-stroke as significant predictors of severity (P = .005; P = .02; P = .001, respectively), and results from the Health Model suggested the extent of leukoaraiosis is associated with severity (P = .0004). The Overall Model showed a relationship between aphasia severity and cognitive ability (P = .01), time post-stroke (P = .002), and leukoaraiosis (P = .01). In the Final Model, which aimed to predict raw severity scores, demographic, health, and lesion factors explained 55% of the variance in severity, with health and demographic factors uniquely explaining nearly half of performance variance.

CONCLUSIONS

Results from this study add to the literature suggesting patient-specific variables can shed light on individual differences in severity beyond lesion factors. Additionally, our results emphasize the importance of non-linguistic cognitive ability and brain health in aphasia recovery.

Predictors of Therapy Response in Chronic Aphasia: Building a Foundation for Personalized Aphasia Therapy

Chronic aphasia, a devastating impairment of language, affects up to a third of stroke survivors. Speech and language therapy has consistently been shown to improve language function in prior clinical trials, but few clinicially applicable predictors of individual therapy response have been identified to date. Consequently, clinicians struggle substantially with prognostication in the clinical management of aphasia. A rising prevalence of aphasia, in particular in younger populations, has emphasized the increasing demand for a personalized approach to aphasia therapy, that is, therapy aimed at maximizing language recovery of each individual with reference to evidence-based clinical recommendations. In this narrative review, we discuss the current state of the literature with respect to commonly studied predictors of therapy response in aphasia. In particular, we focus our discussion on biographical, neuropsychological, and neurobiological predictors, and emphasize limitations of the literature, summarize consistent findings, and consider how the research field can better support the development of personalized aphasia therapy. In conclusion, a review of the literature indicates that future research efforts should aim to recruit larger samples of people with aphasia, including by establishing multisite aphasia research centers.

Differential Effects of Speech and Language Therapy and rTMS in Chronic Versus Subacute Post-stroke Aphasia: Results of the NORTHSTAR-CA Trial

Background & objective

Contralesional 1-Hz repetitive transcranial magnetic stimulation (rTMS) over the right pars triangularis combined with speech-language therapy (SLT) has shown positive results on the recovery of naming in subacute (5–45 days) post-stroke aphasia. NORTHSTAR-CA is an extension of the previously reported NORTHSTAR trial to chronic aphasia (>6 months post-stroke) designed to compare the effectiveness of the same rTMS protocol in both phases.

Methods

Sixty-seven patients with left middle cerebral artery infarcts (28 chronic, 39 subacute) were recruited (01-2014 to 07-2019) and randomized to receive rTMS (N = 34) or sham stimulation (N = 33) with SLT for 10 days. Primary outcome variables were Z-score changes in naming, semantic fluency and comprehension tests and adverse event frequency. Intention-to-treat analyses tested between-group effects at days 1 and 30 post-treatment. Chronic and subacute results were compared.

Results

Adverse events were rare, mild, and did not differ between groups. Language outcomes improved significantly in all groups irrespective of treatment and recovery phase. At 30-day follow-up, there was a significant interaction of stimulation and recovery phase on naming recovery (P <.001). Naming recovery with rTMS was larger in subacute (Mdn = 1.91/IQR = .77) than chronic patients (Mdn = .15/IQR = 1.68/P = .015). There was no significant rTMS effect in the chronic aphasia group.

Conclusions

The addition of rTMS to SLT led to significant supplemental gains in naming recovery in the subacute phase only. While this needs confirmation in larger studies, our results clarify neuromodulatory vs training-induced effects and indicate a possible window of opportunity for contralesional inhibitory stimulation interventions in post-stroke aphasia.

NORTHSTAR trial registration

https://clinicaltrials.gov/ct2/show/NCT02020421.

Verbal and Nonverbal Memory in Neurodegenerative and Stroke Aphasia: Evidence From the Turkish Version of the Three Words Three Shapes Test

BACKGROUND

Although language impairment is the most salient feature of cognitive impairment in both primary progressive aphasia (PPA) and stroke aphasia (SA), memory can also be impaired in both patient populations.

OBJECTIVE

To identify distinctive features of verbal and nonverbal memory processing in individuals with PPA and those with SA.

METHOD

We gave individuals with PPA (n = 14), those with SA (n = 8), and healthy controls (HC; n = 13) a comprehensive neuropsychological test battery and the Turkish version of the Three Words Three Shapes Test (3W3S-Turkish). The 3W3S-Turkish Test includes five subtests: Copy, Incidental Recall, Acquisition, Delayed Recall, and Recognition. High-resolution brain scans were performed in a subset of individuals with PPA and those with SA. Lesion distribution was limited to the dorsal language areas in the SA group, whereas peak atrophy areas in the PPA group extended beyond the language network, including the medial temporal lobe, precuneus, and posterior/medial portions of the cingulate cortex.

RESULTS

Both the PPA and SA groups showed impairment in incidental recall, and the PPA group showed additional impairment in delayed recall. Greater impairment for verbal stimuli suggestive of material-specific memory impairment was evident in the PPA group's scores on the Incidental Recall and Delayed Recall subtests. Both aphasia groups retained the acquired information regardless of material type.

CONCLUSION

Although both aphasia groups shared similarities in the involvement of the dorsal prefrontal working memory/attention network, the PPA group showed greater impairment in delayed recall compared with the SA group.

Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Women have worse outcomes than men after stroke. Differences in presentation may lead to misdiagnosis and, in part, explain these disparities. We investigated whether there are sex differences in clinical presentation of acute stroke or transient ischemic attack.

METHODS

We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Inclusion criteria were (1) cohort, cross-sectional, case-control, or randomized controlled trial design; (2) admission for (suspicion of) ischemic or hemorrhagic stroke or transient ischemic attack; and (3) comparisons possible between sexes in ≥1 nonfocal or focal acute stroke symptom(s). A random-effects model was used for our analyses. We performed sensitivity and subanalyses to help explain heterogeneity and used the Newcastle-Ottawa Scale to assess bias.

RESULTS

We included 60 studies (n=582 844; 50% women). In women, headache (pooled odds ratio [OR], 1.24 [95% CI, 1.11-1.39]; I²=75.2%; 30 studies) occurred more frequently than in men with any type of stroke, as well as changes in consciousness/mental status (OR, 1.38 [95% CI, 1.19-1.61]; I²=95.0%; 17 studies) and coma/stupor (OR, 1.39 [95% CI, 1.25-1.55]; I²=27.0%; 13 studies). Aspecific or other neurological symptoms (nonrotatory dizziness and non-neurological symptoms) occurred less frequently in women (OR, 0.96 [95% CI, 0.94-0.97]; I²=0.1%; 5 studies). Overall, the presence of focal symptoms was not associated with sex (pooled OR, 1.03) although dysarthria (OR, 1.14 [95% CI, 1.04-1.24]; I²=48.6%; 11 studies) and vertigo (OR, 1.23 [95% CI, 1.13-1.34]; I²=44.0%; 8 studies) occurred more frequently, whereas symptoms of paresis/hemiparesis (OR, 0.73 [95% CI, 0.54-0.97]; I²=72.6%; 7 studies) and focal visual disturbances (OR, 0.83 [95% CI, 0.70-0.99]; I²=62.8%; 16 studies) occurred less frequently in women compared with men with any type of stroke. Most studies contained possible sources of bias.

CONCLUSIONS

There may be substantive differences in nonfocal and focal stroke symptoms between men and women presenting with acute stroke or transient ischemic attack, but sufficiently high-quality studies are lacking. More studies are needed to address this because sex differences in presentation may lead to misdiagnosis and undertreatment.

Individualized response to semantic versus phonological aphasia therapies in stroke

Attempts to personalize aphasia treatment to the extent where it is possible to reliably predict individual response to a particular treatment have yielded inconclusive results. The current study aimed to (i) compare the effects of phonologically versus semantically focussed naming treatment and (ii) examine biographical and neuropsychological baseline factors predictive of response to each treatment. One hundred and four individuals with chronic post-stroke aphasia underwent 3 weeks of phonologically focussed treatment and 3 weeks of semantically focussed treatment in an unblinded cross-over design. A linear mixed-effects model was used to compare the effects of treatment type on proportional change in correct naming across groups. Correlational analysis and stepwise regression models were used to examine biographical and neuropsychological predictors of response to phonological and semantic treatment across all participants. Last, chi-square tests were used to explore the association between treatment response and phonological and semantic deficit profiles. Semantically focussed treatment was found to be more effective at the group-level, independently of treatment order (P = 0.041). Overall, milder speech and language impairment predicted good response to semantic treatment (r range: 0.256-0.373) across neuropsychological tasks. The Western Aphasia Battery-Revised Spontaneous Speech score emerged as the strongest predictor of semantic treatment response (R ² = 0.188). Severity of stroke symptoms emerged as the strongest predictor of phonological treatment response (R ² = 0.103). Participants who showed a good response to semantic treatment were more likely to present with fluent speech compared to poor responders (P = 0.005), whereas participants who showed a good response to phonological treatment were more likely to present with apraxia of speech (P = 0.020). These results suggest that semantic treatment may be more beneficial to the improvement of naming performance in aphasia than phonological treatment, at the group-level. In terms of personalized predictors, participants with relatively mild impairments and fluent speech responded better to semantic treatment, while phonological treatment benefitted participants with more severe impairments and apraxia of speech.

Convergence of heteromodal lexical retrieval in the lateral prefrontal cortex

Lexical retrieval requires selecting and retrieving the most appropriate word from the lexicon to express a desired concept. Few studies have probed lexical retrieval with tasks other than picture naming, and when non-picture naming lexical retrieval tasks have been applied, both convergent and divergent results emerged. The presence of a single construct for auditory and visual processes of lexical retrieval would influence cognitive rehabilitation strategies for patients with aphasia. In this study, we perform support vector regression lesion-symptom mapping using a brain tumor model to test the hypothesis that brain regions specifically involved in lexical retrieval from visual and auditory stimuli represent overlapping neural systems. We find that principal components analysis of language tasks revealed multicollinearity between picture naming, auditory naming, and a validated measure of word finding, implying the existence of redundant cognitive constructs. Nonparametric, multivariate lesion-symptom mapping across participants was used to model accuracies on each of the four language tasks. Lesions within overlapping clusters of 8,333 voxels and 21,512 voxels in the left lateral prefrontal cortex (PFC) were predictive of impaired picture naming and auditory naming, respectively. These data indicate a convergence of heteromodal lexical retrieval within the PFC.

Investigating the effect of changing parameters when building prediction models for post-stroke aphasia

Neuroimaging has radically improved our understanding of how speech and language abilities map to the brain in normal and impaired participants, including the diverse, graded variations observed in post-stroke aphasia. A handful of studies have begun to explore the reverse inference: creating brain-to-behaviour prediction models. In this study, we explored the effect of three critical parameters on model performance: (1) brain partitions as predictive features, (2) combination of multimodal neuroimaging and (3) type of machine learning algorithms. We explored the influence of these factors while predicting four principal dimensions of language and cognition variation in post-stroke aphasia. Across all four behavioural dimensions, we consistently found that prediction models derived from diffusion-weighted data did not improve performance over models using structural measures extracted from T1 scans. Our results provide a set of principles to guide future work aiming to predict outcomes in neurological patients from brain imaging data.

A hospital-based study of post-stroke aphasia: frequency, risk factors, and topographic representation

Background and objective

The crude prevalence rate of stroke in Qena, Egypt, is high (922/100,000). For the first time, we estimate the frequency of aphasia following the first-ever ischemic stroke and its relationship to the site of lesion in Arabic-speaking countries.

Methods

The study was conducted on 180 acute or subacute ischemic stroke patients. Aphasia was diagnosed with the short form of the Boston Diagnostic Aphasia Examination after establishment of the cases (at least 10 days of stroke onset). Computed tomography and/or magnetic resonance imaging were performed for topographic localization of stroke, and routine laboratory investigations were done to evaluate the possible stroke risk factors.

Results

The frequency of post-stroke aphasia was recorded in 20%, and atrial fibrillation (AF) represents a high-risk factor for ischemic stroke with aphasia. The following categories were observed: global aphasia in 50%, motor aphasia in 27.7%, sensory aphasia in 11.1%, nominal aphasia in 2.8%, and conductive aphasia in 8.3%. Global aphasia was mainly associated with complete middle cerebral artery (MCA) territories infarction. Motor aphasia was associated mainly with frontal or frontoparietal operculum lesions as well as basal ganglionic lesions. Sensory aphasia was associated with temporal lobe lesions, inferior parietal lobe, and basal ganglia. Conductive aphasia showed lesions in the deep white matter of the frontal and parietal lobes. Anomic aphasia was associated with inferior parietal lobe lesion.

Conclusion

Our data are consistent with other reports as regards the frequency and risk factors of post-stroke aphasia. Atrial fibrillation represents a high-risk factor for ischemic strokes with aphasia. Global and motor aphasia are the major subtypes. The lesion locations are predictive of aphasia subtypes.

Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.

Neuroimaging Determinants of Poststroke Cognitive Performance

Background and Purpose- We aimed to define the neuroimaging determinants of poststroke cognitive performance and their relative contributions among a spectrum of magnetic resonance imaging markers, including lesion burden and strategic locations. Methods- We prospectively included patients with stroke from the GRECogVASC study (Groupe de Réflexion pour l'Évaluation Cognitive Vasculaire) who underwent 3-T magnetic resonance imaging and a comprehensive standardized battery of neuropsychological tests 6 months after the index event. An optimized global cognitive score and neuroimaging markers, including stroke characteristics, cerebral atrophy markers, and small vessel diseases markers, were assessed. Location of strategic strokes was determined using a specifically designed method taking into account stroke size and cerebral atrophy. A stepwise multivariable linear regression model was used to identify magnetic resonance imaging determinants of cognitive performance. Results- Data were available for 356 patients (mean age: 63.67±10.6 years; 326 [91.6%] of the patients had experienced an ischemic stroke). Six months poststroke, 50.8% of patients presented with a neurocognitive disorder. Strategic strokes (right corticospinal tract, left antero-middle thalamus, left arcuate fasciculus, left middle frontal gyrus, and left postero-inferior cerebellum; R²=0.225; P=0.0001), medial temporal lobe atrophy ( R²=0.077; P=0.0001), total brain tissue volume ( R²=0.028; P=0.004), and stroke volume ( R²=0.013; P=0.005) were independent determinants of cognitive performance. Strategic strokes accounted for the largest proportion of the variance in the cognitive score (22.5%). The white matter hyperintensity burden, brain microbleeds, and dilated perivascular spaces were not independent determinants. Conclusions- Optimized global cognitive score and combined approach of both quantitative measures related to structure loss and qualitative measures related to the presence of strategic lesion are required to improve the determination of structure-function relationship of cognitive performance after stroke.

Characterizing language outcomes following childhood basal ganglia stroke

The basal ganglia are important for movement and executive function, but its contribution to language is less understood. This study explored language outcomes associated with childhood basal ganglia stroke. A detailed language coding scheme, which examined expressive and receptive language, verbal fluency, narrative discourse, pragmatic/applied language, and academics, was developed from qualitative and quantitative data acquired from neuropsychological testing and reports. Overall intellectual functioning and verbal comprehension was in the average range. Twelve participants had psychological diagnoses, including Learning Disorder. No one had a Language Disorder diagnosis. Among the 18 children who did not receive a diagnosis, many exhibited language issues in the mild to severe range according to our coding scheme. These children had higher-order language difficulties in verbal fluency, narrative, and pragmatic language rather than overt expressive difficulties noted in Diagnostic and Statistical Manual (DSM) diagnostic criteria. There was an association between infarct size and ESL/immersion education, math performance, and presence of a psychological diagnosis. Psychological diagnosis was also associated with literacy skills. The results highlight that language issues following basal ganglia stroke may not be fully captured by standardized neuropsychological tests and psychological diagnoses. Findings reinforce the need to integrate quantitative and qualitative findings when examining language functioning.

Language recovery following stroke

Objective: To review the research literature pertaining to post-stroke language recovery, and to discuss neurocognitive assessment in patients in the context of aphasia, time course of language recovery, factors associated with language recovery, and therapeutic techniques designed to facilitate language recovery. Method: Articles were identified through PubMed, MEDLINE, PsychINFO, and Google Scholar searches. Examples of utilized keywords include "post-stroke aphasia," "post-stroke language recovery," "post-stroke neurocognitive assessment," and "neuropsychology and aphasia." Results: Most language recovery occurs in the first few weeks following stroke, but residual recovery may occur for many years. Although initial aphasia severity is the single largest determinant of post-stroke language recovery, a number of other variables also contribute. Several techniques have been developed to aid in the recovery process including speech-language therapy and noninvasive brain stimulation, although the effectiveness of acute and subacute treatment remains unclear. Some degree of valid neurocognitive assessment is possible in patients with aphasia, and the information gained from such an evaluation can aid the rehabilitative process Conclusions: Significant recovery of language function is possible following a stroke, but prediction of level of recovery in an individual patient is difficult. Information about initial aphasia severity and the integrity of cognitive domains other than language can help guide the rehabilitation team, as well as manage expectations for recovery.

Sex differences in post-stroke aphasia rates are caused by age. A meta-analysis and database query

BACKGROUND

Studies have suggested that aphasia rates are different in men and women following stroke. One hypothesis says that men have more lateralized language function than women. Given unilateral stroke, this would lead to a prediction of men having higher aphasia rates than women. Another line of observations suggest that women are more severely affected by stroke, which could lead to a higher aphasia rate among women. An additional potential confounding variable could be age, given that women are typically older at the time of stroke.

METHODS & PROCEDURES

This study consists of two parts. First, a meta-analysis of the available reports of aphasia rates in the two sexes was conducted. A comprehensive literature search yielded 25 studies with sufficient information about both aphasia and gender. These studies included a total of 48,362 stroke patients for which aphasia rates were calculated. Second, data were extracted from an American health database (with 1,967,038 stroke patients), in order to include age and stroke severity into a regression analysis of sex differences in aphasia rates.

OUTCOMES & RESULTS

Both analyses revealed significantly larger aphasia rates in women than in men (1.1-1.14 ratio). This speaks against the idea that men should be more lateralized in their language function. When age and stroke severity were included as covariates, sex failed to explain any aphasia rate sex difference above and beyond that which is explained by age differences at time of stroke.

Subcortical Aphasia After Stroke

Objective

To evaluate the types and severity of subcortical aphasia after stroke and to determine the predictors of the degree of aphasic impairment.

Methods

Medical records of 38 patients with post-stroke subcortical aphasia (19 males; mean age, 61.7±13.8 years) were reviewed retrospectively with respect to the following tests: the Korean version of the Western Aphasia Battery (K-WAB), the Korean version of the Modified Barthel Index (K-MBI), and the Fugl-Meyer Index (FMI). The severity of aphasia was evaluated by the aphasia quotient (AQ) and the language quotient (LQ).

Results

Anomic aphasia was the most frequent type of aphasia (n=15, 39.5%), and the lesion most frequently observed in subcortical aphasia was located in the basal ganglia (n=19, 50.0%). Patients with lesions in the basal ganglia exhibited the lowest scores on the FMI for the upper extremities (p=0.04). Severity of aphasia was significantly correlated with the K-MBI (Pearson correlation coefficient: γ=0.45, p=0.01 for AQ and γ=0.53, p=0.01 for LQ) and FMI scores for the lower extremities (γ=0.43, p=0.03 for AQ and γ=0.49, p=0.05 for LQ). In a multivariate logistic regression analysis, K-MBI remained the only explanatory variable closely associated with aphasia severity.

Conclusion

This study showed the general characteristics of post-stroke subcortical aphasia, and it revealed that K-MBI was an associated and explanatory factor for aphasia severity.

The unbridged gap between clinical diagnosis and contemporary research on aphasia: A short discussion on the validity and clinical utility of taxonomic categories

Even if the traditional aphasia classification is continuously questioned by many scholars, it remains widely accepted among clinicians and included in textbooks as the gold standard. The present study aims to investigate the validity and clinical utility of this taxonomy. For this purpose, 65 left-hemisphere stroke patients were assessed and classified with respect to aphasia type based on performance on a Greek adaptation of the Boston Diagnostic Aphasia Examination. MRI and/or CT scans were obtained for each patient and lesions were identified and coded according to location. Results indicate that 26.5% of the aphasic profiles remained unclassified. More importantly, we failed to confirm the traditional lesion-to-syndrome correspondence for 63.5% of patients. Overall, our findings elucidate crucial vulnerabilities of the neo-associationist classification, and further support a deficit-rather than a syndrome-based approach. The issue of unclassifiable patients is also discussed.

[The restoration of speech in patients with aphasia depending on the manifestations of carotid atherosclerosis in stroke]

AIM

To study an effect of stenosing lesions of carotid arteries on the recovery of speech functions in acute stroke patients.

MATERIAL AND METHODS

Medical histories of 253 patients (median age 58 [52,63]) with acute left hemispheric ischemic and hemorrhagic stroke and motor or sensorimotor aphasia were analyzed. The severity of atherosclerotic lesion of brachiocephalic arteries was assessed using color duplex scanning. According to the results of duplex scanning, patients were divided into 3 groups: 1 - without stenosis of extracranial arteries; 2 - with ≤50% stenosis of carotid arteries; 3 - with >50% stenosis of carotid arteries.

RESULTS

Stenosis greater than 50% (group 3) was a predictor of the poor recovery of speech function while stenosis less than 50% (groups 1 and 2) had no effect on the outcome.

CONCLUSION

The severe atherosclerosis of carotid arteries had a negative effect on speech recovery in acute stroke patients.

Clinicoanatomical correlation in stroke related aphasia

Context:

With advances in neuroimaging, traditional views regarding the clinicoanatomic correlation in stroke patients with aphasia are being challenged and it has been observed that lesions at a given cortical or subcortical site may manifest with different aphasia profiles.

Aims:

To study as to whether there is a strict clinicoanatomical correlation between the type of aphasia and lesion site in patients with first ever stroke.

Settings and Design:

Observational study, based in a tertiary care center.

Materials and Methods:

Stroke patient's ≥18 years of age were screened and those with first ever stroke and aphasia were subjected to a detailed stroke workup and language assessment using the Hindi version of Western Aphasia Battery (WAB). Statistical analysis was done with χ² test with Yates correction and Kruskal-Wallis test. The level of significance was set at P < 0.05.

Results:

Overall aphasia was detected in 27.9% of the 260 screened cases with stroke. Amongst 60 cases with first ever stroke and aphasia, the aphasia type was: Global (33.33%), Broca's (28.3%), transcortical motor (13.33%), transcortical sensory (10%), Wernicke's (8.33%), anomic (5%), and conduction (1.67%) aphasia. A definite correlation between the lesion site and the type of aphasia as per the traditional classification was observed in 35% cases only.

Conclusions:

No absolute correlation exists between the lesion site and the type of clinical aphasia syndrome in majority of the patients with cortical and subcortical stroke.

Quantifying cerebral asymmetries for language in dextrals and adextrals with random-effects meta analysis

Speech and language-related functions tend to depend on the left hemisphere more than the right in most right-handed (dextral) participants. This relationship is less clear in non-right handed (adextral) people, resulting in surprisingly polarized opinion on whether or not they are as lateralized as right handers. The present analysis investigates this issue by largely ignoring methodological differences between the different neuroscientific approaches to language lateralization, as well as discrepancies in how dextral and adextral participants were recruited or defined. Here we evaluate the tendency for dextrals to be more left hemisphere dominant than adextrals, using random effects meta analyses. In spite of several limitations, including sample size (in the adextrals in particular), missing details on proportions of groups who show directional effects in many experiments, and so on, the different paradigms all point to proportionally increased left hemispheric dominance in the dextrals. These results are analyzed in light of the theoretical importance of these subtle differences for understanding the cognitive neuroscience of language, as well as the unusual asymmetry in most adextrals.

Validation of an integrated method for determining cognitive ability: Implications for routine assessments and clinical trials

INTRODUCTION

Although accurate diagnosis of deficit of mild intensity is critical, various methods are used to assess, dichotomize and integrate performance, with no validated gold standard. This study described and validated a framework for the analysis of cognitive performance.

METHODS

This study was performed by using the Groupe de Réflexion sur L'Evaluation des Fonctions EXécutives (GREFEX) database (724 controls and 461 patients) examined by 7 tests assessing executive functions. The first phase determined the criteria for the cutoff scores, the second phase, the effect of test number on diagnostic accuracy and the third phase, the best methods for combining test scores into an overall summary score. Four validation criteria were used: determination of impaired performance as compared to expected one, false-positive rate ≤5%, detection of both single and multiple impairments with optimal sensitivity.

RESULTS

The procedure based on 5th percentile cutoffs determined from standardized residuals was the most appropriate procedure. Although area under the curve (AUC) increased with the number of scores (p = .0001), the false-positive rate also increased (p = .0001), resulting in suboptimal sensitivity for detecting selective impairment. Two overall summary scores, the average of the seven process scores and the Item Response Theory (IRT) score, had significantly (p = .0001) higher AUCs, even for patients with a selective impairment, and provided higher resulting prevalence of dysexecutive disorders (p = .0001).

CONCLUSIONS

The present study provides and validates a generative framework for the interpretation of cognitive data. Two overall summary score met all 4 validation criteria. A practical consequence is the need to profoundly modify the analysis and interpretation of cognitive assessments for both routine use and clinical research.

Why is it difficult to predict language impairment and outcome in patients with aphasia after stroke?

One of the most devastating consequences of stroke is aphasia. Communication problems after stroke can severely impair the patient's quality of life and make even simple everyday tasks challenging. Despite intense research in the field of aphasiology, the type of language impairment has not yet been localized and correlated with brain damage, making it difficult to predict the language outcome for stroke patients with aphasia. Our primary objective is to present the available evidence that highlights the difficulties of predicting language impairment after stroke. The different levels of complexity involved in predicting the lesion site from language impairment and ultimately predicting the long-term outcome in stroke patients with aphasia were explored. Future directions and potential implications for research and clinical practice are highlighted.

Vascular aphasia outcome after intravenous recombinant tissue plasminogen activator thrombolysis for ischemic stroke

INTRODUCTION

No data about the specific outcome of aphasia after thrombolysis are available. Our aim was to describe the severity and type of aphasia after stroke thrombolysis.

METHODS

This retrospective cohort study included consecutive aphasic patients hospitalized in the Stroke Unit of Dijon (University Hospital, France) between 2004 and 2009 for a first-ever ischemic stroke of the left middle cerebral artery. Aphasic syndromes and their severity (French version of the Boston Diagnostic Aphasia Examination) were evaluated during the first week and 3 months after stroke.

RESULTS

In multivariate analyses, the severity of aphasia in the 37 thrombolysed patients was milder than in the 38 nonthrombolysed patients during the first week (adjusted OR = 10.13, 95% CI: 2.43-42.28, p = 0.002) and at 3 months (adjusted OR = 8.44, 95% CI: 2.76-25.80, p = 0.001). The frequency of mild aphasia (conduction or atypical) was not significantly higher in thrombolysed patients during the first week after stroke (adjusted OR = 5.80, 95% CI: 0.82-41.16, p = 0.079).

CONCLUSION

The severity of aphasia during the first week and 3 months after stroke is milder in thrombolysed than in nonthrombolysed patients, perhaps because of a greater frequency of conduction and mild atypical aphasia.

Neuropsychological assessment and cerebral vascular disease: the new standards

Vascular cognitive impairment (VCI) includes vascular dementia (VaD), vascular mild cognitive impairment (VaMCI) and mixed dementia. In clinical practice, VCI concerns patients referred for clinical stroke or cognitive complaint. To improve the characterization of VCI and to refine its diagnostic criteria, an international group has elaborated a new standardized evaluation battery of clinical, cognitive, behavioral and neuroradiological data which now constitutes the reference battery. The adaption of the battery for French-speaking subjects is reported as well as preliminary results of the on-going validation study of the GRECOG-VASC group [Clinical Trial NCT01339195]. The diagnostic accuracy of various screening tests is reviewed and showed an overall sub-optimal sensitivity (<0.8). Thus, the general recommendation is to perform systematically a comprehensive assessment in stroke patients at risk of VCI. Furthermore,the use of a structured interview has been shown to increase the detection of dementia. In addition to the well known NINDS-AIREN criteria of VaD, criteria of VCI have been recently proposed which are based on the demonstration of a cognitive disorder by neuropsychological testing and either history of clinical stroke or presence of vascular lesion by neuroimaging suggestive of a link between cognitive impairment and vascular disease. A memory deficit is no longer required for the diagnosis of VaD as it is based on the cognitive decline concerning two or more domains that affect activities of daily living. Both VaMCI and VaD are classified as probable or possible. These new criteria have yet to be validated. Considerable uncertainties remain regarding the determinant of VCI, and especially the lesion amount inducing VCI and VaD. The interaction between lesion amount and its location is currently re-examined using recent techniques for the analysis of MRI data. The high frequency of associated Alzheimer pathology is now assessable in vivo using amyloid imaging. The first studies showed that about a third of patients with VaD due to small vessel disease or with poststroke dementia have amyloid PET imaging suggestive of AD. These new techniques will examine the interaction between vascular lesions and promotion of amyloid deposition. Although results of these on-going studies will be available in few years, these data indicate that efforts should be done in clinical practice to reduce underdiagnosis of VCI; VCI should be examined using a specific protocol which will be fully normalized soon for French-speaking patients; the sub-optimal sensitivity of screening tests prompts to use a structured interview to grade Rankin scale and to perform systematically a comprehensive assessment in stroke patients at risk of VCI; poststroke dementia occurring after 3 months poststroke may be preventable by treatment of modifiable vascular risk factors and secondary prevention of stroke recurrence according to recent recommendations.

Cognitive impairment after cerebral venous thrombosis: a two-center study

The objective of this observational study of consecutive patients hospitalized for cerebral venous thrombosis (CVT) was to determine the prevalence of post-CVT cognitive impairment and identify factors associated with this condition. Out of a total of 73 patients hospitalized for CVT, 52 were included in the study and 44 were assessed with a comprehensive neuropsychological battery. At the last outpatient visit (mean ± SD time since CVT: 22 ± 13 months), a standardized, neuropsychological assessment was administered. Cognitive impairment was defined as significant impairment (with a cut-off at the 5th percentile) in at least two of the cognitive domains tested in the neuropsychological battery or severe aphasia or cognitive disorders with MMSE score ≤ 17 out of 30. Cognitive impairment was observed in 16 patients (31 %; 95 % CI 18-43 %): 4 with major disability precluding comprehensive assessment (3 with severe aphasia, 1 with MMSE ≤ 17) and 12 with significant impairments in at least two cognitive domains. Determinants of long-term cognitive impairment were straight sinus involvement (OR 22.4; 95 % CI 1.79-278.95; p = 0.016) and the presence of parenchymal lesions on follow-up magnetic resonance imaging (OR 7.8; 95 % CI 1.40-43.04; p = 0.019). The sole predictor of failure to return to full-time employment was cognitive impairment (OR 21.0; 95 % CI 3.35-131.44; p = 0.001). Cognitive impairment persists in up to one-third of cases of CVT. It is more frequent in patients with deep CVT and persistent parenchymal lesions and is associated with failure to return to full-time employment.

Role of aphasia in discharge location after stroke

OBJECTIVE

To evaluate language deficits after acute stroke and their association with post-acute care at a setting other than home. We hypothesized that deficits in language comprehension would be associated with discharge to a setting other than home after adjustment for physical/occupational therapy (PT/OT) needs.

DESIGN

Secondary analysis of prospectively collected data. Discharge location, demographic characteristics (age, sex, race), and the presence of PT/OT recommendations were abstracted from the medical record.

SETTING

Acute stroke unit at a tertiary medical center.

PARTICIPANTS

Left hemispheric stroke patients (N=152) within 24 hours of event.

INTERVENTIONS

The following tasks were administered: (a-b) oral and written naming of pictured objects, (c) oral naming with tactile input (tactile naming), (d-f) oral reading, oral spelling, and repetition of words and pseudowords, (g) written spelling to dictation, (h) spoken word-picture verification (ie, auditory comprehension), and (i) written word-picture verification (ie, written word comprehension).

MAIN OUTCOME MEASURE

Discharge to a setting other than home.

RESULTS

Of 152 cases, 88 were discharged home and 64 to another setting. Among stroke subjects discharged to a setting other than home, 63.6% had auditory comprehension deficits compared with 42.9% of those discharged home (P=.03). Deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a setting other than home after adjustment for age and PT/OT recommendations.

CONCLUSIONS

Cases with deficits in auditory comprehension, reading comprehension, and oral spelling to dictation had increased odds of being discharged to settings other than home. Early evaluation of these language deficits and prompt treatment may allow patients who would otherwise be discharged to an institution to go home. Further research is needed to design and evaluate individualized treatment protocols and their effect on discharge recommendations.

Post-stroke aphasia prognosis: a review of patient-related and stroke-related factors

RATIONALE, AIMS AND OBJECTIVES

Recovery of language function in individuals with post-stroke aphasia is associated with a variety of patient and stroke-related indices. Amidst a complex interaction of a multitude of variables, clinicians are faced with the arduous challenge of predicting aphasia recovery patterns and subsequently, long-term outcomes in these individuals. Unfortunately, predictive factors are highly variable making prognosis of aphasia recovery difficult. Therefore, the objective of this review was to assess the influence of patient-related and stroke-related factors on language recovery in individuals with post-stroke aphasia.

METHODS

We completed a literature review to assess and identify evidence-based patient and stroke-related variables shown to be influential in aphasia recovery.

RESULTS

A range of patient-related (gender, handedness, age, education, socio-economic status and intelligence) and stroke-related indices (initial severity, lesion site and lesion size) were identified as potential influential factors to post-stroke aphasia recovery. Initial severity of aphasia emerged as the factor most predictive of long-term aphasia recovery. Other influential factors of post-stroke language recovery included lesion site and size.

CONCLUSIONS

Stroke-related factors, including aphasia severity, lesion site and lesion size, appear most critical to post-stroke aphasia recovery. The findings presented in this review offer clinicians an evidenced-based framework to assist in prediction of post-stroke aphasia recovery patterns and subsequent long-term functional communication outcomes.

Borderzone strokes and transcortical aphasia

Borderzone infarcts (BZIs) are anatomically defined as ischemic lesions occurring at the junction between two arterial territories, accounting for 2% to 10% of strokes. Three types of hemispheric BZIs are described according to topography (ie, superficial anterior, posterior, and deep). Although published series on related aphasia are rare in the setting of BZI, aphasia is of transcortical (TCA) type, characterized by the preservation of repetition. TCA can be of motor, sensory, or mixed type depending on whether expression, understanding, or both are impaired. Recent studies have reported specific aphasic patterns. BZI patients initially presented with mixed TCA. Aphasia specifically evolved according to the stroke location, toward motor or sensory TCA in patients with respectively anterior or posterior BZI. TCA was associated with good long-term prognosis. This specific aphasic pattern is interesting in clinical practice because it prompts the suspicion of a BZI before the MRI is done, and it helps in the planning of rehabilitation and in providing adapted information to the patient and family concerning the likelihood of language recovery.

A topographic study on the evaluation of speech and language in the acute phase of a first stroke

Evaluation of speech and language may help in localization of site and extension of brain lesions, particularly in the absence of other neurological signs or radiologically defined injuries. OBJECTIVE: To verify what language tasks are best correlated to which brain regions, in order to develop a test for neurologists in emergency settings. METHOD: Thirty-seven adult first-stroke patients were submitted to cognitive and language tests, and then paired with thirty-seven healthy controls. Patients underwent CT and/or MRI for topographic correlation with test results (p<0.05). RESULTS: All tests were able to distinguish patients from controls, but only word/sentence repetition, naming, ideomotor praxis and, non-significantly, comprehension and counting 1-20 predicted left hemisphere lesions. Repetition was related to perisylvian structures, comprehension to the posterior portion of the middle cerebral artery territory, and fluency to frontal lesions, while naming was accurate only for lesion side. CONCLUSION: Language and cognitive tasks can help in the localization of acute stroke lesions.

Aphasia in border-zone infarcts has a specific initial pattern and good long-term prognosis

BACKGROUND

While border-zone infarcts (BZI) account for about 10% of strokes, studies on related aphasia are infrequent. The aim of this work was to redefine specifically their early clinical pattern and evolution.

METHODS

We prospectively studied consecutive patients referred to our stroke unit within a 2-year period. Cases of aphasia in right-handed patients associated with a MRI confirmed left-sided hemispheric BZI were included. These patients had a standardized language examination in the first 48 h, at discharge from stroke unit and between 6 and 18 months later.

RESULTS

Eight patients were included. Three had anterior (MCA/ACA), two posterior (MCA/PCA), two both anterior and posterior, and one bilateral BZI. All our patients initially presented transcortical mixed aphasia, characterized by comprehension and naming difficulties associated with preserved repetition. In all patients, aphasia rapidly improved. It fully recovered within a few days in three patients. Initial improvement was marked, although incomplete in the five remaining patients: their aphasias specifically evolved according to the stroke location toward transcortical motor aphasia for the three patients with anterior BZI and transcortical sensory aphasia for the two patients with posterior BZI. All patients made a full language recovery within 18 months after stroke.

CONCLUSIONS

We report a specific aphasic pattern associated with hemispheric BZI, including an excellent long-term outcome. These findings appear relevant to (i) clinically suspect BZI and (ii) plan rehabilitation and inform the patient and his family of likelihood of full language recovery.

The prognosis for aphasia in stroke

BACKGROUND

Aphasia is a disabling chronic stroke symptom, but the prognosis for patients presenting with aphasia in the hyperacute window has not been well characterized. The purpose of this study is to assess the prognosis for recovery of language function in subjects presenting with aphasia caused by ischemic stroke within 12 hours of symptom onset.

METHODS

Subjects presenting with aphasia were identified from a prospective cohort study of 669 subjects presenting emergently with acute stroke. Subjects were characterized by demographics, serial clinical examinations, unenhanced computed tomography, and computed tomographic angiography. Aphasia severity was assessed by National Institutes of Health Stroke Scale (NIHSS) examinations performed at baseline, discharge, and 6 months. Demographic, clinical, and imaging factors were assessed for prognostic impact.

RESULTS

Aphasia was present in 30% of subjects (n = 204). Of the 166 aphasic patients alive at discharge (median 5 days), aphasia improved in 57% and resolved in 38%. In the 102 aphasic subjects evaluated at 6 months, aphasia improved in 86% and completely resolved in 74% of subjects. Among aphasic subjects with "mild" stroke (initial NIHSS <5), aphasia resolved in 90% of subjects by 6 months. Factors significantly associated with better outcome included clinically and radiographically smaller strokes and lower prestroke disability.

CONCLUSIONS

The prognosis for full recovery of aphasia present in the hyperacute window is good. Radiographic and clinical markers indicating lesser extent of ischemia correlated to greater recovery. Given the excellent prognosis for language recovery in mild stroke, the net benefit of thrombolysis in such cases is uncertain.