Are pharmacotherapeutics effective for treating aphasia?

INTRODUCTION

Aphasia is a communication disorder resulting from stroke and/or neurodegenerative conditions which involve the left cerebral hemisphere. It is a debilitating disorder affecting a person's ability to speak, understand, read, and write. Its impact on daily life necessitates therapeutic strategies to aid patients with aphasia.

AREAS COVERED

In this special report, the authors speculate whether current pharmacotherapeutic strategies are effective in treating aphasia. The authors look at aphasia caused by different conditions and how this could impact therapy before providing the reader with their expert perspectives. The aim of this paper is for the reader to gain a clearer understanding of the efficacy of the current pharmacotherapeutic treatment paradigms as well as potential future developments.

EXPERT OPINION

The exploration of pharmacotherapy for aphasia in vascular brain disorders and neurodegenerative diseases has received much attention in recent years with various therapeutic strategies having been put forward. In terms of whether pharmacotherapy is effective for the treatment of aphasia, there is still no clear-cut answer. Further research is needed with more studies requiring a greater emphasis on language and communication deficits. Biomarkers may also help clinicians provide their patients with a more personalized treatment plan.

Case Report: Possible Serotonin Syndrome in a Patient Taking Kratom and Multiple Serotonergic Agents

INTRODUCTION

Kratom, an unregulated herbal supplement, has emerged as self-treatment for anxiety/depression. Kratom exhibits inhibition at multiple cytochrome P450 isozymes involved in metabolism of prescription medications, including serotonergic agents. We report a case of possible serotonin syndrome induced by kratom use in combination with prescription psychotropic medications.

CASE

A 63-year-old male presented with diaphoresis, flushing, aphasia, confusion, dysarthria, right facial droop, and oral temperature of 39.6oC (103.2oF), lactate 2.7 mmol/L, and creatine phosphokinase of 1507 IU/L. Initial differential diagnoses included acute ischemic stroke and bacterial meningitis. Despite partial treatment with alteplase and broad-spectrum antibiotics, symptoms persisted, and subsequent physical exam noted hyperreflexia, clonus, tremors, and temperature of 41.1oC (106oF). Home medications included a chronic regimen for anxiety/depression with bupropion, buspirone, desvenlafaxine, trazodone, and ziprasidone, in addition to kratom. Clinical suspicion for serotonin syndrome led to initiation of cyproheptadine, lorazepam, and cooling blankets. Aphasia, facial droop, and confusion improved after administration of cyproheptadine. Bupropion was restarted during hospitalization; remaining medications restarted at the discretion of the primary care provider.

DISCUSSION

Risk of serotonin syndrome with multiple serotonergic agents is well-known. Kratom is metabolized by cytochrome P40 isozymes 3A4, 2C9, and 2D6, and exhibits inhibition at those enzymes, in addition to 1A2. Pharmacokinetic interactions of kratom with prescription serotonergic agents metabolized through these isozymes has the potential to increase systemic exposure of serotonin, potentially leading to serotonin syndrome.

CONCLUSION

Because substances contained in kratom can inhibit metabolism of prescription serotonergic medications, clinicians must be aware of potential development of serotonin syndrome.

Turning the Spotlight to Cholinergic Pharmacotherapy of the Human Language System

Even though language is essential in human communication, research on pharmacological therapies for language deficits in highly prevalent neurodegenerative and vascular brain diseases has received little attention. Emerging scientific evidence suggests that disruption of the cholinergic system may play an essential role in language deficits associated with Alzheimer's disease and vascular cognitive impairment, including post-stroke aphasia. Therefore, current models of cognitive processing are beginning to appraise the implications of the brain modulator acetylcholine in human language functions. Future work should be directed further to analyze the interplay between the cholinergic system and language, focusing on identifying brain regions receiving cholinergic innervation susceptible to modulation with pharmacotherapy to improve affected language domains. The evaluation of language deficits in pharmacological cholinergic trials for Alzheimer's disease and vascular cognitive impairment has thus far been limited to coarse-grained methods. More precise, fine-grained language testing is needed to refine patient selection for pharmacotherapy to detect subtle deficits in the initial phases of cognitive decline. Additionally, noninvasive biomarkers can help identify cholinergic depletion. However, despite the investigation of cholinergic treatment for language deficits in Alzheimer's disease and vascular cognitive impairment, data on its effectiveness are insufficient and controversial. In the case of post-stroke aphasia, cholinergic agents are showing promise, particularly when combined with speech-language therapy to promote trained-dependent neural plasticity. Future research should explore the potential benefits of cholinergic pharmacotherapy in language deficits and investigate optimal strategies for combining these agents with other therapeutic approaches.

Pharmacotherapy for post-stroke aphasia: what are the options?

INTRODUCTION

Aphasia is a common, long-lasting aftermath of stroke lesions. There is an increased integration of pharmacotherapy as an adjunctive strategy to speech and language therapy (SLT) for post-stroke aphasia (PSA). Nevertheless, more research in pharmacotherapy for acute and chronic PSA is necessary, including the election of drugs that target different neurotransmitter systems and deficits in specific language domains.

AREAS COVERED

This article updates the role of pharmacotherapy for PSA, focusing the spotlight on some already investigated drugs and candidate agents deserving of future research. Refining the precision of drug election would require using multimodal biomarkers to develop personalized treatment approaches. There is a solid need to devise feasible randomized controlled trials adapted to the particularities of the PSA population. The emergent role of multimodal interventions combining one or two drugs with noninvasive brain stimulation to augment SLT is emphasized.

EXPERT OPINION

Pharmacotherapy can improve language deficits not fully alleviated by SLT. In addition, the 'drug-only' approach can also be adopted when administering SLT is not possible. The primary goal of pharmacotherapy is reducing the overall aphasia severity, although targeting language-specific deficits (i.e. naming, spoken output) also contributes to improving functional communication. Unfortunately, there is still little information for recommending a drug for specific language deficits.

Donepezil alone and combined with intensive language-action therapy on depression and apathy in chronic post-stroke aphasia: A feasibility study

This study explored the feasibility and effectiveness of a short-term (10-week) intervention trial using Donepezil administered alone and combined with intensive language action therapy (ILAT) for the treatment of apathy and depression in ten people with chronic post-stroke aphasia. Outcome measures were the Western Aphasia Battery and the Stroke Aphasia Depression Questionnaire-21. Structural magnetic resonance imaging and ¹⁸fluorodeoxyglucose positron emission tomography were acquired at baseline and after two endpoints (Donepezil alone and Donepezil-ILAT). The intervention was found to be feasible to implement. Large treatment effects were found. Donepezil alone and combined with ILAT reduced aphasia severity, while apathy and depression only improved with Donepezil-ILAT. Structural and functional neuroimaging data did not show conclusive results but provide hints for future research. Given these overall positive findings on feasibility, language and behavioral benefits, further studies in larger sample sizes and including a placebo-control group are indicated.

Protocol for Escitalopram and Language Intervention for Subacute Aphasia (ELISA): A randomized, double blind, placebo-controlled trial

In this forthcoming multicenter, prospective, randomized, double-blind placebo-controlled trial, we will investigate the augmentative effects of a selective serotonin reuptake inhibitor, escitalopram, on language therapy in individuals with post-stroke aphasia. We hypothesize that, when combined with language therapy, daily escitalopram will result in greater improvement than placebo in an untrained picture naming task (Philadelphia Naming Test short form) administered one week after the end of language therapy. We also will examine whether escitalopram's effect on language is independent of its effect on depression, varies with lesion location, or is associated with increased functional connectivity within the left hemisphere. Finally, we will examine whether individuals with BDNF met alleles show reduced response to treatment and reduced changes in connectivity. We expect to enroll 88 participants over four years. Participants are given escitalopram or placebo within one week of their stroke for 90 days and receive fifteen 45-minute computer-delivered sessions of language treatment beginning 60 days from the start of drug therapy. Patients then complete a comprehensive assessment of language at one, five, and twenty weeks after the last language therapy session. ELISA is the first randomized, controlled trial evaluating the effect of a selective serotonin reuptake inhibitor on the improvement of language in people with aphasia undergoing language treatment during the acute to subacute post-stroke period. Trial registration: The trial is registered with ClinicalTrials.gov NCT03843463.

[A Case of Skull Base Metastasis of Breast Cancer with Dysphasia, Odynophagia and Dysarthria]

While skull base metastases from breast cancer are not uncommon, there are relatively few reported cases in the literature. We report a case of skull base metastasis of breast cancer that resulted in dysphasia, odynophagia, and dysarthria. The case involved a woman in her 50 s who was diagnosed with cancer of the right breast(cT4N1M0, cStage III B)at another medical institution 9 years previously and who underwent a partial mastectomy and an axillary lymph node dissection following neoadjuvant chemotherapy. She began experiencing neck pain 6 months previously, followed by dysphasia, odynophagia, and dysarthria 1 month previously. The patient was referred to our hospital for detailed examination and treatment. PET-CT and cranial MRI was conducted and detected metastatic lesion from the skull base to the upper cervical vertebrae. An orthopedic surgeon performed a posterior decompression and fusion surgery on the occipital bone, cervical vertebra, and thoracic vertebra. A histological examination of bone tissue extracted during surgery revealed that the breast cancer had metastasized. We then performed irradiation of the cervical vertebra from the cranial base and initiated treatment with zoledronic acid and anastrozole. Symptoms such as dysphasia, odynophagia and dysarthria lessened, and the patient is currently being followedupas an outpatient.

Amphetamine and other pharmacological agents in human and animal studies of recovery from stroke

Neuromodulation with pharmacological agents, including drugs of abuse such as amphetamine, when paired with behavioral experience, has been shown to positively modify outcomes in animal models of stroke. A number of clinical studies have tested the efficacy of a variety of drugs to enhance recovery of language deficit post-stroke. The purpose of this paper is to: (1) present pertinent animal studies supporting the use of dextro-amphetamine sulfate (AMPH) to enhance recovery after experimental lesions with emphasis on the importance of learning dependent activity for lasting recovery; (2) briefly review neuropharmacological explorations in the treatment of aphasia; (3) present a pilot study in aphasia exploring a drug combination of AMPH and donepezil hydrochloride paired with behavioral treatment to facilitate recovery; and (4) conclude with comments regarding the role of adjunctive pharmacotherapy in the rehabilitation of aphasia, particularly AMPH.

Psychophysiological Analysis of the Influence of Vasopressin on Speech in Patients with Post-Stroke Aphasias

Speech is an attribute of the human species. Central speech disorders following stroke are unique models for the investigation of the organization of speech. Achievements in neurobiology suggest that there are possible neuroendocrine mechanisms involved in the organization of speech. It is known that the neuropeptide vasotocin, analogous of vasopressin in mammals, modulates various components of vocalization in animals. Furthermore, the positive influence of vasopressin on memory, which plays an important role in the formation of speech, has been described. In this study, speech organization processes and their recovery with the administration of vasopressin (1-desamino-8-D-arginin-vasopressin) to 26 patients with chronic aphasias after stroke were investigated. Results showed that sub-endocrine doses of the neuropeptide with intranasal administration had positive influence primarily on simple forms of speech and secondarily on composite forms. There were no statistically significant differences between the sensory and integrative components of the organization of speech processes with vasopressin. In all cases, the positive effect of the neuropeptide was demonstrated. As a result of the effects, speech regulated by both brain hemispheres improved. It is suggested that the neuropeptide optimizes the activity both in the left and right hemispheres, with primary influence on the right hemisphere. The persistence of the acquired effects is explained by an induction of compensatory processes resulting in the reorganization of the intra-central connections by vasopressin.

Drug treatment of poststroke aphasia

Impairment of language function (aphasia) is one of the most common neurological symptoms after stroke. Approximately one in every three patients who have an acute stroke will suffer from aphasia. The estimated incidence and prevalence of stroke in Western Europe is 140 and 800 per 100,000 of the population. Aphasia often results in significant disability and handicap. It is a major obstacle for patients to live independently in the community. When recovery from aphasia occurs, it is usually incomplete and patients are rarely able to return to full employment and other social activities. Currently, the main treatment for aphasia is conventional speech and language therapy. However, the effectiveness of this intervention has not been conclusively demonstrated and empirical observations suggest that spontaneous biological recovery may explain most of the improvement in language function that occurs in aphasics. The generally poor prognosis of the severe forms of poststroke language impairment (Broca, Wernicke and global aphasia), coupled with the limited effectiveness of conventional speech and language therapy has stimulated the search for other treatments that may be used in conjunction with speech and language therapy, including the use of various drugs. Dopamine agonists, piracetam (Nootropil), amphetamines, and more recently donepezil (Aricept), have been used in the treatment of aphasia in both the acute and chronic phase. The justification for the use of drugs in the treatment of aphasia is based on two types of evidence. Some drugs, such as dextroamphetamine (Dexedrine), improve attention span and enhance learning and memory. Learning is an essential mechanism for the acquisition of new motor and cognitive skills, and hence, for recovery from aphasia. Second, laboratory and clinical data suggest that drug treatment may partially restore the metabolic function in the ischemic zone that surrounds the brain lesion and also has a neuroprotective effect following acute brain damage. An example of this is the nootropic agent piracetam. Extensive animal studies have demonstrated the beneficial effects of this and other drugs on neural plasticity, but data on humans are still sparse. This review provides a critical analysis of the current evidence of the effectiveness of these drugs in the treatment of acute and chronic aphasia.

[Epilepsy with higher brain dysfunction]

Acquired higher brain dysfunction is for the most part due to cerebral vascular disease, but epilepsy may also be a cause. In this study with five patients, we discuss the advantages of anti-epileptic drugs (AEDs) for persistent higher brain dysfunction. The patients showed chronic amnesia or acute aphasia, with associated symptoms like personality change. All five cases affected automatism or convulsive attack, though only after the emergence of higher brain dysfunction and administration of AEDs. There were underlying diseases like cerebral arteriovenous malformation in four cases, but the other patient had none. Electroencephalogram and single photon emission computed tomography revealed one case of aphasia epilepsy with higher brain dysfunction. These results suggest the potential therapeutic efficacy of AEDs for persistent higher brain dysfunction, and we must differentiate epilepsy with higher brain dysfunction from dementia or cerebral vascular disease.

[Developmental dysphasia: assessment of the drug treatment efficacy]

To assess the efficacy of treatment with encephabol, we examined 40 children, aged from 3 to 5 years, with developmental dysphasia. All patients were randomized into two equal groups: group 1 received encephabol (suspension form, daily dosage 200-250 mg, or 12-15 mg/kg) during 2 months; group 2 did not receive this medication. In the first group, there was a significant improvement of expressive and impressive speech and speech attention; the active vocabulary and a number of phrases in colloquial speech increased by a factor of 3 versus 1.5 in the control group. After the treatment with encephabol, the parents reported the decrease in motor disturbances, psychosomatic disorders, the improvement of attention and the emotional state of the children.

Is recurrent perseveration a product of deafferented functional systems with otherwise normal post-activation decay rates?

Recent work in neuropsychology, clinical aphasiology and neuropharmacology have presented evidence that the causative substrates of recurrent perseveration in adults with aphasia are more recondite and subject to distinct interpretations than originally thought. This article will discuss and evaluate how various proposals from theory, from the clinic and from drug therapy interact and compete in the search for a cause or causes of recurrent perseveration.

Recovery from post-stroke aphasia: lessons from brain imaging and implications for rehabilitation and biological treatments

Aphasia, a condition defined as the partial or complete loss of language function after brain damage, is one of the most devastating cognitive deficits produced by stroke lesions. Over the past decades, there have been great advances in the diagnosis and treatment of post-stroke language and communication deficits. In particular, the advent of functional brain imaging and other brain mapping methods has advanced our understanding of how the intact and lesioned brain takes over the activity of irretrievably damaged networks in aphasic patients. This review examines the contribution of these ancillary methods to elucidate the neural changes that take place to promote improvement of language function in early, late, and very late stages of recovery. Also, functional neuroimaging is helpful to identify brain areas involved in language recovery as well as to characterize the plastic reorganization of neural networks produced by scientifically-based language therapies and biological treatments (drugs, transcranial magnetic stimulation).

Speech and language difficulties in a patient with schizophrenia-like disorder: a case report

Neurocognitive complications, such as speech and language dysfunctions are common comorbids in psychiatric patients with underlying medical conditions, such as stroke. Ascertaining a diagnosis is not usually easy, especially in the hands of the primary physicians who first attend to such patients. In addition, making diagnosis purely on previous psychiatric presentations, without thorough neurological and neurocognitive evaluation, is a mistake psychiatrists should avoid. Cultural belief systems in Nigeria play important role in the choice of care people with psychiatric problems receive, and the dearth in the country's mental health personals is a be-deviling handicap to providers of mental health services in the country. The author presents the case of a 52 year old man with schizophrenia-like psychosis that was complicated by speech and language problems following a cerebrovascular accident. In conclusion, doctors especially psychiatrists should be alert to co morbid physical illnesses in patients with psychiatric presentations.

Does long term use of piracetam improve speech disturbances due to ischemic cerebrovascular diseases?

Aphasia causes significant disability and handicap among stroke survivors. Language therapy is recommended for aphasic patients, but not always available. Piracetam, an old drug with novel properties, has been shown to have mild beneficial effects on post-stroke aphasia. In the current study, we investigated the effects of 6 months treatment with piracetam on aphasia following stroke. Thirty patients with first-ever ischemic strokes and related aphasia were enrolled in the study. The scores for the National Institutes of Health Stroke Scale (NIHSS), Barthel Index (BI), modified Rankin Scale (mRS), and Gülhane Aphasia Test were recorded. The patients were scheduled randomly to receive either 4.8 g piracetam daily or placebo treatment for 6 months. At the end of 24 weeks, clinical assessments and aphasia tests were repeated. The level of improvement in the clinical parameters and aphasia scores was compared between the two groups. All patients had large lesions and severe aphasia. No significant difference was observed between the piracetam and placebo groups regarding the improvements in the NIHSS, BI and mRS scores at the end of the treatment. The improvements observed in spontaneous speech, reading fluency, auditory comprehension, reading comprehension, repetition, and naming were not significantly different in the piracetam and placebo groups, the difference reached significance only for auditory comprehension in favor of piracetam at the end of the treatment. Piracetam is well-tolerated in patients with post-stroke aphasia. Piracetam taken orally in a daily dose of 4.8 g for 6 months has no clear beneficial effect on post-stroke language disorders.

GABAergic but not anti-cholinergic agents re-induce clinical deficits after stroke

Our goal was to determine whether the excitatory (i.e., GABA) neurotransmitter system was important in human stroke recovery. We hypothesized that giving midazolam, a GABA(A) agonist, to patients would re-induce clinical deficits to a greater extent than the anti-cholinergic scopolamine. Twelve patients (7 M) who had recovered from hemiparesis and/or aphasia after first-time stroke and 10 age-matched, healthy controls underwent double-blinded drug challenge with midazolam and 90 days later with scopolamine, or vice versa. Language was scored for comprehension, naming and repetition, and motor function was tested with the 9-Hole Peg Test (9HPT) in each hand. The drugs were administered intravenously in small aliquots until mild awake sedation was achieved. The primary outcome was the change scores from baseline to the two drug conditions, with higher scores denoting greater loss of function. Ten of the 12 patients had recovered from hemiparesis and 7 from aphasia. The median time from stroke to participation was 9.3 months (range=0.3-77.9 months). For motor function, analysis of variance showed that change scores on the 9HPT were significantly greater in patients using the previously paretic hand during the drug state with midazolam (p=0.001). Similarly, language change scores were significantly greater among recovered aphasics during the midazolam challenge (p=0.01). In our study, patients demonstrated transient re-emergence of former stroke deficits during midazolam but not scopolamine. These data provide beginning clinical evidence for the specificity of GABA-sensitive pathways for stroke recovery.

[Neuroimaging and neurorehabilitation for aphasia]

With the development of neuroimaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), many reports revealing the underlying mechanisms of functional recovery from aphasia have been published. Three types of compensatory mechanisms seem to operate in aphasic patients with left hemisphere damage: (1) functional recovery of the damaged area in the left hemisphere, (2) activation of the perilesional area in the left hemisphere, and (3) activation of the right frontal area (area homologous to the language-relevant area). Although there are some pitfalls in the interpretation of neuroimaging, it is recommended that the areas that compensate for impaired language function should be clarified prior to the initiation of neurorehabilitation for aphasia. The clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS) and pharmacotherapy for aphasia has been recently studied. We administered low-frequency rTMS and language therapy to 4 stroke patients with motor-dominant aphasia for 6 consecutive days. The application site of rTMS was determined on the basis of the findings of pretreatment fMRI during word repetition tasks. Our novel approach resulted in significant improvement in language functions. The results of some double-blind placebo-controlled trials on aphasic patients have indicated that levodopa, dextroamphetamine, and donepezil play a critical role in the recovery from aphasia. We anticipate limitless future possibilities for the intensive neurorehabilitation of aphasic patients, including constraint-induced language therapy, rTMS application, and pharmacotherapy. The application of newly developed neuroimaging techniques may provide additional important information for improving neurorehabilitative intervention for aphasia.

[Pharmacotherapy for aphasia]

Classification of aphasia is divided according to clinical symptoms, anatomical analysis or neural network. Research of the past 20 years in basic neuroscience and aphasia rehabilitation has created opportunities for fundamentally different approaches to aphasia therapy, based on applied neurobiology. The idea of treating aphasia with neurotranmitter stimulating agents has historical roots dating to ancient times. Since Albert reported that bromocriptine may improve language deficits in patients with nonfluent aphasia, pharmacotherapy for aphasia is noted. However its effect is contoversial. We hypothesize improvement in naming ability by 1) selectively increasing dopamine to enhance activation and initiation of verbal output, and 2) selectively increasing cholinergic activity to enhance verbal memory. We also hypothesize that the balance of dopaminergic system and cholinergic system controls language function. In most of our recent studies on the pharmacotherapy of aphasia, we made the following observations: 1) we found improvement in either verbal fluency or naming or both; 2) improvement tended be most prominent in patients with mild to moderate severity of aphasia, rather than in patients with severe aphasia; 3) improvement tended to be correlated with reduction in perseveration; 4) improvement was found with dopaminergic, cholinergic, and serotonergic agents.

Pharmacotherapy of aphasia: myth or reality?

Pharmacotherapy of aphasia had been discussed for the last twenty years with first bromocriptine and amphetamine and then serotoninergic, GABAergic and cholinergic agents. Here, we reviewed the MEDLINE available reports of drug therapy for aphasia. So far, proofs of efficiency were found indubitable for none of the studied molecules. However, some of them showed limited efficiency (piracetam and amphetamine). Moreover, drug therapies for aphasia were less efficient alone than when they were associated with speech therapy.

Pharmacological, surgical, and neurovascular interventions to augment acute aphasia recovery

Aphasia recovery has often been attributed to a combination of "spontaneous recovery" and rehabilitation. However, a variety of new pharmacological, surgical, and interventional neuroradiology procedures have been developed that can complement rehabilitation in the first days to weeks after stroke by restoring blood flow to dysfunctional but salvageable brain tissue. This paper will review the medical and surgical interventions to improve regional cerebral blood flow that recently have been shown to (1) augment aphasia recovery by improving tissue function, and (2) prevent expansion of the stroke that would otherwise impede recovery. Success with such treatments facilitates aphasia rehabilitation by improving the baseline language performance that must be improved further with language therapy.

Target symptoms and outcome measures: cognition

The Cognitive section of the Alzheimer's Disease Assessment Scale (ADAS-Cog) remains the most widely used cognitive measure in dementia trials although it does not assess attention, executive function, or agnosia. Designed for use in Alzheimer's disease (AD), it may not be ideal in assessing patients with other diagnoses. The ADAS-Cog differentiates between AD patients, patients with Mild Cognitive Impairment, and normal controls. It has been used in trials of drugs for vascular and mixed dementia and dementia with Lewy bodies. It is not clear that the ADAS-Cog is adequate for assessing cognition in frontotemporal dementia. Well-validated aphasia batteries, such as the Western Aphasia Battery, can be used to assess language. Brief tests of frontal function such as the Frontal Assessment Battery or the Executive Interview might be useful additions in frontotemporal dementia trials. The most widely used assessment tool for patients with advanced dementia is the Severe Impairment Battery. The domains tested are analogous to those assessed by the ADAS-Cog. The Mini-Mental State Exam and the Modified Mini-Mental State Examination are useful in stratifying patients for trial entry. Cognitive measures better tailored to the diseases in question are needed for non-Alzheimer dementias.

[Landau-Kleffner syndrome: an analysis of 10 cases in Venezuela]

INTRODUCTION

Landau-Kleffner syndrome is characterised by acquired aphasia and encephalographic alterations that may or may not be accompanied by epileptic seizures. AIM. To analyse the clinical and encephalographic features and response to treatment of 10 patients with Landau-Kleffner syndrome.

PATIENTS AND METHODS

We reviewed the patient records, encephalograms and treatment administered to patients catalogued as having Landau-Kleffner syndrome.

RESULTS

The mean age of the patients was 44 months. Of these cases, 60% presented epilepsy when the diagnosis was established and 70% were found to have epileptic status during slow-wave sleep in the encephalographic study. Results showed that 40% corresponded to variants of Landau-Kleffner syndrome. No cause of the disease could be established in any of the patients. In the neuroimaging study, only one patient displayed abnormalities in the magnetic resonance imaging of the brain. All the patients received adrenocorticotropic hormone (ACTH)-based treatment, at a dose of 1 IU/kg/day for one month, administered together with antiepileptic drugs such as valproic acid and clobazam. Convulsive seizures and epileptic status during slow-wave sleep disappeared in all the patients. In the patients without epileptic status, epileptic activity became less frequent, although it did not completely disappear. Aphasia improved considerably, which meant that all the patients were able to enroll in normal schools.

CONCLUSIONS

We believe that early diagnosis, together with suitable and timely management of aphasic patients with encephalographic alterations that allow ACTH to be used at low doses, make it possible to offer an early education so as to provide maximum recovery from the disease.

Disorders of speech and language: aphasia, apraxia and dysarthria

PURPOSE OF REVIEW

We review recent important papers pertaining to acquired aphasia, apraxia of speech and dysarthria with special attention to clinically significant work published in the last 12 months.

RECENT FINDINGS

The role of the contralateral inferior frontal gyrus in language recovery after stroke is controversial, but is an area of active research, particularly in functional imaging studies. Recent treatment studies in poststroke aphasia have shown that intensity of language therapy may be more important than the method of therapy. Some studies have indicated that amphetamines, piracetam and repetitive transcortical magnetic stimulation may be effective adjuncts to speech and language therapy. Treatment studies for poststroke dysarthria indicate that speech supplementation strategies may be effective and deserve further study.

SUMMARY

Recent studies of aphasia provide clues regarding language recovery poststroke, but further studies of the role of the ipsi and contralateral inferior frontal gyrus are necessary, and should be longitudinal. There are relatively few recent studies on the treatment of acquired disorders of speech and language, other than poststroke aphasia.

A randomized, placebo-controlled study of donepezil in poststroke aphasia

We studied 26 patients in a randomized, placebo-controlled, double-blind parallel trial to evaluate the efficacy and safety of donepezil in chronic poststroke aphasia. Donepezil (10 mg/day) improved aphasia severity at endpoint (week 16) relative to placebo (p = 0.037).

Pharmakologische Zusatzbehandlung in der Aphasietherapie

Aphasia is one of the most frequent and disabling consequences of stroke. Poor spontaneous recovery and the limited success of conventional speech therapy bring up the question of how current treatment approaches can be improved. Besides increasing training frequency-with daily sessions lasting several hours and high repetition rates of language materials ("massed training")-adjuvant drug therapy may help to increase therapy efficacy. In this article, we illuminate the potential of monoaminergic (bromocriptine, levodopa, d-amphetamine) and cholinergic (donepezil) substances for treating aphasia. For a final evaluation of combined massed training and adjuvant pharmacotherapy, randomized, placebo-controlled (multicenter) clinical trials with sufficient numbers of patients are needed. Furthermore, results of experimental animal studies of functional recovery in brain damage raise hopes that neurotrophic factors or stem cells might find a place in recovery from aphasia in the intermediate future.

[Aphasia in stroke patients: frequency and significance]

Eine Aphasie liegt bei 21–38% aller ischämischer Hirnschlagpatienten vor. Das Risiko, eine Aphasie als Hirnschlagsymtom zu erleiden, steigt mit dem Alter an, während das Geschlecht keinen Risikofaktor darstellt. Aphasiker unter den Hirnschlagpatienten haben eine doppelt so hohe Mortalität wie Nichtaphasiker. Auch sind die Chancen, ein selbständiges, unabhängiges Leben wiederzuerlangen kompromittiert, wenn eine Aphasie vorliegt. Dennoch erreichen bis 40% der Aphasiker eine weitgehende Erholung ihrer Sprachfunktion. Die Frage, ob Logopädie bei aphasischen Hirnschlagpatienten von Nutzen ist, kann basierend auf der Studienlage nicht abschliessend beantwortet werden. Dennoch scheint eine hochfrequente, intensive Sprachtherapie in den ersten Wochen einer niederfrequenten Logopädie über einen längeren Zeitraum überlegen zu sein. Trotz ermutigender Erfahrungen mit unterstützenden Pharmaka werden weitere methodologisch einwandfreie und ausreichend grosse Studien nötig sein, bevor klar ist, ob und wie sich die funktionelle Spracherholung pharmakologisch günstig beeinflussen lässt.

Recovery from aphasia following brain injury: the role of reorganization

Language is predominantly a left hemisphere function, yet patients with extensive damage to known language areas often recover quite well in the days to weeks to even years following focal brain injury. This recovery period can be divided into three overlapping stages: acute, subacute, and chronic, each with different underlying neural mechanisms. Reorganization of structure and function through the expression of neural plasticity plays a crucial role in recovery of language at least during the subacute phase of weeks to months after the occurrence of an injury. In this chapter we review the evidence for reorganization of language function after injury, the role it plays in the recovery of language following brain damage, and how knowledge of the mechanisms of recovery will allow design of more effective methods of rehabilitation.

[Mixed aphasia as a dominating symptom of encephalitis]

Encephalitis has typically a severe course, with psychotic disorders, consciousness disorders, epileptic seizures and meningal signs. The author describes a case of a young male, in whom dominant symptoms of encephalities were aphasia and headache. These symptoms were accompanied by considerable inflammatory changes in cerebral fluid. The outcome of illness was favourable.

Treatment approaches to symptoms associated with frontotemporal degeneration

A systematic review of the literature reveals few randomized, controlled trials for drug therapy in frontotemporal degeneration (FTD). Although there is evidence to support a serotonergic deficit, and clinicians frequently prescribe selective serotonin reuptake inhibitors to patients with FTD, only paroxetine and trazodone have been studied. There is Class II evidence for use of rivastigmine in FTD behavioral disturbances, although there is no consistent evidence of cholinergic deficit in this illness.

Piracetam--an old drug with novel properties?

Piracetam (2-oxo-1-pyrrolidine-acetamide), the most common of the nootropic drugs, is a cyclic derivative of gamma-aminobutyric acid. The treatment with piracetam improves learning, memory, brain metabolism, and capacity. Piracetam has been shown to alter the physical properties of the plasma membrane by increasing its fluidity and by protecting the cell against hypoxia. It increases red cell deformability and normalizes aggregation of hyperactive platelets. Piracetam is an agent with antithrombotic, neuroprotective and rheological properties. The interaction of this molecule with the membrane phospholipids restores membrane fluidity and could explain the efficacy of piracetam in various disorders ranging from dementia and vertigo to myoclonus and stroke.

Long-Term Antidepressant Treatment with Moclobemide for Aphasia in Acute Stroke Patients: A Randomised, Double-Blind, Placebo-Controlled Study

BACKGROUND AND PURPOSE

Pharmacotherapy aimed at stroke rehabilitation through direct central nervous effects may be assumed to work in a similar way for language recovery and sensory-motor recovery. Some data suggest that antidepressant drugs could be beneficial also for functional improvement. This prompted us to investigate whether regression from aphasia after acute stroke could be enhanced by antidepressive drug therapy.

METHODS

We randomised 90 acute stroke patients with aphasia to either 600 mg moclobemide or placebo daily for 6 months, within 3 weeks of the onset of stroke. Aphasia was assessed prior to treatment and at 6 months, using Reinvang's 'Grunntest for afasi' and the Amsterdam-Nijmegen-Everyday-Language-Test (ANELT).

RESULT

The degree of aphasia decreased significantly at 6 months, with no difference between the moclobemide- and the placebo-treated groups. Multivariate regression analysis including treatment group, activities of daily living, aetiology of stroke, ANELT, and Reinvang's coefficient at baseline, and neurological deficit confirmed these results. In all, 13 in the moclobemide and 10 in the placebo group stopped taking the study medication. No further change was found in the 56 aphasic patients followed up for another 6 months with no medication.

CONCLUSIONS

Compared to placebo, treatment with moclobemide for 6 months did not enhance the regression of aphasia following an acute stroke.

Can Drug Therapies Improve Language Functions of Individuals with Aphasia? A Review of the Evidence

The neurochemistry of language and the neuropharmacology of aphasia are two domains of cognitive neuroscience still in their infancy. In this article we review what is known about these two domains, especially with regard to treating aphasia with drugs. Selected neurotransmitters can improve language function in certain patients with aphasia. We discuss which neurotransmitters work for which language functions in which patients, and why.

Acute aphasia in multiple sclerosis: A multicenter study of 22 patients

Aphasia is usually considered to be rare in multiple sclerosis (MS). To determine the clinical and radiologic characteristics of MS patients with acute aphasia, the authors investigated data from 2,700 patients from three MS centers and found 22 patients with acute aphasia (0.81%). Aphasia was the first clinical manifestation of MS in eight patients (36%). Brain MRI showed giant plaques in eight cases (40%). A full recovery was observed in 14 patients (64%). Furthermore, acute aphasia did not appear to be a criterion for poor prognosis.

Treatment of adynamia in aphasia

Transcortical motor aphasia (TCMA) is an acquired impairment of language expression that occurs following neurologic damage that affects left frontal cortex and spares perisylvian regions. In some individuals with TCMA, verbal expression is rendered nonfluent due to difficulty spontaneously initiating and elaborating upon verbal messages. Nonfluency arises from impaired activation of intended messages and inhibition of competing verbal expressions. This impairment of the intentional aspects of language expression can be termed 'adynamia.' Because adynamic forms of TCMA occur infrequently, few systematic treatment investigations have been reported for this condition. Behavioral treatments have been proposed to engage intact frontal regions to improve the ability to initiate spontaneous verbal expression. Some data suggest that nonsymbolic limb movements performed in the context of speaking activities, a form of what Luria termed gestural reorganization, may improve the adynamic verbal expression. (1) In addition, the influence of pharmacologic treatment with bromocriptine, a dopaminergic agonist, has been considered for its effects on verbal nonfluency in aphasia. Individuals classified as TCMA are more likely to benefit than those with other forms of nonfluent aphasia, suggesting an influence of bromocriptine on circuits necessary to activate spontaneous language. Additional studies are warranted that contrast behavioral and pharmacologic interventions to determine optimal conditions to improve verbal expression in adynamic forms of aphasia.

[Neuropeptide induction of compensatory processes at aphasias]

Dynamic changes of speech function were studied in patients with persistence aphatic disorders after stroke under the conditions of application of V2 vasopressin receptor agonist (1-desamino-8-D-arginin-vasopressin). A course of intranasal administration of the medical drug by using the double blind control showed a reliable reduction of frustration severity of expressive and impressive speech in patients with aphasias of different forms and degrees. A correlation of positive influence of vasopressin on speech, verbal memory and attention was found at efferent motor aphasias. The achieved effects preserved during a two-year catamnestic observation period. A repeated course of therapy resulted in an additional improvement of speech. Neuropeptide restored initially, in patients with aphasias, relatively simple forms of speech and later--complicated ones. This resulted in an improvement of speech functions which are regulated by both cerebral hemispheres. Supposedly, neuropeptide optimized the activity of both the right and left cerebral hemispheres. The stability of the obtained effects is explained by induction, due to vasopressin, of compensatory processes leading to reorganization of intercentral connections.

The onset and time course of response of negative symptoms to add-on fluvoxamine treatment

Not enough is known about the propensity of individual negative symptoms to respond to treatment and the dynamics of this change. We have previously shown that adding the selective serotonin reuptake inhibitor fluvoxamine to antipsychotics can improve negative symptoms, and now provide data on the response of individual negative symptoms to such treatment. We examined items on the Schedule for the Assessment of Negative Symptoms for patients participating in two published controlled studies comparing the effect of add-on fluvoxamine and placebo on negative symptoms. Using a mixed regression model, we analysed item scores at each week of the study to identify the first signs of a treatment effect. Potential confounding effects of depressive extrapyramidal and positive symptoms were statistically controlled. Eleven of 16 items tested showed improvement, five within 2 weeks and a further four within 3 weeks of starting treatment. The most rapidly responding items included core negative symptoms such as alogia. The propensity for and rate of improvement with fluvoxamine treatment differs for the various negative symptoms. Many symptoms, including those generally agreed to be core features of the illness such as alogia, improved within 2-3 weeks of treatment initiation.

Autonomic dysreflexia associated with transient aphasia

STUDY DESIGN

Case report of autonomic dysreflexia presenting with transient aphasia in a subject with C4 tetraplegia.

OBJECTIVES

To report a rare case of autonomic dysreflexia.

SETTING

Rehabilitation Service, The Ohio State University, USA.

CASE REPORT

A 21-year-old man with a C4 spinal cord injury (ASIA B) developed aphasia associated with autonomic dysreflexia. He was treated with an adrenergic blocking agent.

CONCLUSION

Autonomic dysreflexia manifested by a transient aphasia and seizures is uncommon.

A double-blind, placebo-controlled study of the use of amphetamine in the treatment of aphasia

BACKGROUND AND PURPOSE

A number of studies suggest that drugs which increase the release of norepinephrine promote recovery when administered late (days to weeks) after brain injury in animals. A small number of clinical studies have investigated the effects of the noradrenergic agonist dextroamphetamine in patients recovering from motor deficits following stroke. To determine whether these findings extend to communication deficits subsequent to stroke, we administered dextroamphetamine, paired with speech/language therapy, to patients with aphasia.

METHODS

In a prospective, double-blind study, 21 aphasic patients with an acute nonhemorrhagic infarction were randomly assigned to receive either 10 mg dextroamphetamine or a placebo. Patients were entered between days 16 and 45 after onset and were treated on a 3-day/4-day schedule for 10 sessions. Thirty minutes after drug/placebo administration, subjects received a 1-hour session of speech/language therapy. The Porch Index of Communicative Ability was used at baseline, at 1 week off the drug, and at 6 months after onset as the dependent language measure.

RESULTS

Although there were no differences between the drug and placebo groups before treatment (P=0.807), by 1 week after the 10 drug treatments ended there was a significant difference in gain scores between the groups (P=0.0153), with the greater gain in the dextroamphetamine group. The difference was still significant when corrected for initial aphasia severity and age. At the 6-month follow-up, the difference in gain scores between the groups had increased; however, the difference was not significant (P=0.0482) after correction for multiple comparisons.

CONCLUSIONS

Administration of dextroamphetamine paired with 10 1-hour sessions of speech/language therapy facilitated recovery from aphasia in a small group of patients in the subacute period after stroke. Neuromodulation with dextroamphetamine, and perhaps other drugs that increase central nervous system noradrenaline levels, may facilitate recovery when paired with focused behavioral treatment.

Restitution of alpha-topography by piracetam in post-stroke aphasia

OBJECTIVE

Electroencephalographic and clinical effects of piracetam in post-stroke aphasia were evaluated in a prospective, randomized, double-blind, placebo-controlled trial.

METHODS

In 24 patients with mild to moderate aphasia after ischemic stroke, quantitative topographic EEG at rest was studied before and after a 6-week treatment period.

RESULTS

In the active treatment group, a significant shift in the alpha-rhythm from frontal to occipital regions was observed which may be due to a restitution of corticothalamic circuits involved in the generation of alpha-activity.

CONCLUSION

Neuropsychological scores improved significantly and markedly in various domains of speech during piracetam treatment, whereas improvements were less marked and restricted to a few categories in the placebo group.

Effects of bromocriptine in a patient with crossed nonfluent aphasia: a case report

OBJECTIVE

Because studies have shown some positive effects of the dopaminergic agent bromocriptine for improving verbal production in patients with nonfluent aphasia, we examined its effect in a patient with an atypical form of crossed nonfluent aphasia from a right hemisphere lesion.

DESIGN

Open-label single-subject experimental ABAB withdrawal design.

PATIENT

A right-handed man who, after a right frontal stroke, developed nonfluent aphasia, emotional aprosodia, and limb apraxia.

INTERVENTION

Escalating doses up to 20mg of bromocriptine in 2 separate phases.

MAIN OUTCOME MEASURES

We measured verbal fluency (words/min in discourse, Thurstone letter fluency), expression of emotional prosody, and gesture production.

RESULTS

The patient showed substantial improvement in both verbal fluency measures and no significant improvement in gesture or emotional prosody. Verbal fluency improvements continued in withdrawal phases.

CONCLUSIONS

Our results are less likely caused by practice or spontaneous recovery because we observed little improvement in emotional prosody and gesture tasks. Verbal fluency improvements during treatment and withdrawal phases suggest that the effects of bromocriptine may be long-lasting in its influence on the neural networks subserving verbal initiation.