Dynamic aphasia: clinical picture, diagnosis and principles of therapy

Aphasia is a disorder of speech function, which can be caused by an organic disorder of the cortex and subcortical structures of the brain. The diagnosis is made based on characteristic clinical signs and symptoms, and is also confirmed by special research methods (MRI, CT).

There is no specific therapy for the disease, but timely rehabilitation contributes to the full or partial restoration of speech functions.

What is dynamic aphasia

Dynamic aphasia was identified as a separate form of speech dysfunction by German psychiatrists in the 1930s. years. Subsequent studies established that this form of the disorder occurs when the frontal region of the left hemisphere is damaged in right-handed people. This department is responsible for the regulation, activation and planning of speech function.

A feature of this form of aphasia is the difficulty or complete inability to develop an active statement. Such a patient can correctly pronounce individual sounds, syllables, words, and even individual short sentences. At the same time, the communicative function still suffers and full communication with such a person is impossible.

Interesting! Patients with these forms of the disease cannot independently construct a long sentence. They have certain difficulties in performing certain thought processes. Difficulty in perceiving verbs and problems in following commands and orders are often noted.

Semantic aphasia

Semantic aphasia occurs when the parieto-occipital region of the dominant hemisphere is damaged. The patient has difficulty finding the right word when naming objects; instead of a noun, they may say a verb or an adjective that describes the properties or functions of this object. Replace a word with a whole phrase (verbal paraphasia). For example, instead of the word chair they say white sit. They lose their understanding of proverbs, metaphors, and catchphrases, and form lexical and grammatical structures incorrectly. With limited vocabulary, articulation is preserved. Written speech is characterized by agrammatism, stereotypical phrases, the absence of complex sentences and a reduced number of adjectives.

Speech apparatus device

The speech apparatus is a complex mechanism that represents the interaction of many organs and structures to produce speech. It consists of peripheral and central sections.

The peripheral speech apparatus includes several sections that act synergistically and provide sound reproduction. These include the respiratory organs, vocal folds, teeth, lips, tongue, palate, lower jaw and others.

The central speech apparatus is located in the brain. It is a complex system of interaction of neurons that allows a person not to think every second about the spoken phrases.

The key role in speech formation is played by the frontal, temporal and parietal lobes, mainly in the left hemisphere.

Interesting! Broca's area is located in the frontal gyri and is the center of the formation of one's own oral speech. Wernicke's center is located in the temporal lobe, which is the speech-auditory center and perceives incoming sound stimuli.

Causes of dynamic aphasia

The main pathogenetic mechanisms include disruption of the functioning of cortical structures directly in the area of the speech center. This form of aphasia is characterized by damage to the posterior-frontal parts of the left hemisphere, in the area of Broca's center.

There are many possible causes of diseases, among which the leading positions are occupied by:

vascular pathology (stroke and other acute disorders of cerebral blood supply, dyscirculatory encephalopathy);
traumatic brain injury and concussion;
infectious and inflammatory diseases (meningitis, meningoencephalitis, brain abscess, sepsis);
chronic diseases of the nervous system (Alzheimer's disease);
benign and malignant brain tumors.

There are a number of contributing factors that increase the likelihood of developing this disease. These include:

genetic predisposition (cases of aphasia among close relatives);
atherosclerotic vascular lesions;
episodes of increased blood pressure or a history of arterial hypertension in the patient;
metabolic disorders.

In addition, the disease can develop as a complication after brain surgery.

Treatment

First of all, you need to cure the underlying disease that caused the development of aphasia. To correct emerging symptoms, an integrated approach is used, including drug therapy, physiotherapeutic treatment, active rehabilitation, speech correction together with a speech therapist, as well as neuropsychological correction. Rehabilitation therapy should begin as early as possible, from the first days or weeks after the incident, as soon as the patient’s general condition allows. This is necessary to prevent the consolidation of pathological speech symptoms, the main of which are:

Paraphasia is a speech disorder in which the logical structure of a sentence is disrupted and its semantic load is lost;
Agrammatism is a difficulty in understanding sentences, especially those with complex syntax. Agrammatism occurs with a pathological focus localized in the Sylvian fissure;

At each stage of rehabilitation therapy, the joint work of the attending physician, psychologist, speech therapist, and especially the patient’s relatives is necessary. Only constant contact and communication will help achieve maximum effectiveness of treatment and rehabilitation procedures, as well as stabilize the patient’s general condition and mood. The speed of recovery processes and the mood in line with the patient’s wishes depend on how often and how much close and relatives communicate with the victim.

Drug therapy

Treatment of the underlying disease is carried out under the supervision of a neurologist or neurosurgeon. Drug therapy includes the following classes of drugs:

Antioxidants and vitamins. These drugs are necessary to maintain a sufficiently active metabolic function of neurocytes. Antioxidants help accelerate regenerative and repair processes at the ultracellular level, stabilize cell membranes and protect them from lipid peroxidation. Among vitamins, a special role is played by B vitamins, which have a pronounced neuroprotective effect. B vitamins include: pyridoxine, pyrimidine, thiamine, folic acid, cyanocobalamin, riboflavin. Complex preparations of vitamins and antioxidants effective for dynamic aphasia include: Mexidol, Glycine (Lipoic acid), Aspirin, Emoxipin.
Nootropic drugs. This group of drugs improves cerebral circulation and has a positive effect on metabolism in brain tissue. Nootropics have an antihypoxic and tranquilizing effect without inhibiting the activity of the central nervous system, which makes their use safe for everyday independent use. Taking nootropics is not accompanied by drowsiness, lethargy and relaxation of skeletal muscles. In addition, the drugs have a psychostimulating effect, restore mental performance and physical activity. This group of drugs includes all racetam derivatives (Piracetam, Nootropil), Picamelon, Cerebrolysin.
Cerebroprotectors. Prescribed to prevent the development of complications and irreversible damage to neurocytes as a result of metabolic disorders or hypoxic shock, it affects metabolism, thereby improving blood supply to the brain. The main representatives are Vinpocetine, Cinnarizine, Coplamin.
Vasoactive drugs - improve cerebral blood supply. This includes several different groups of drugs: antiplatelet agents (Clopidogrel, Plavix), anticoagulants (Sincumar, Warfarin, Heparin), calcium channel blockers (Nimodipine), methylxanthines (Pentoxtrental).

Speech therapy correction

The choice of a correctional work program primarily depends on the volume of the affected area of the brain and the severity of the clinical manifestations of dynamic aphasia. At the very beginning of rehabilitation, a restoration process is carried out, which begins with passive work with the patient, while methods are used to promote speech disinhibition and prevent the development of further speech disorders. Subsequently, the speech therapist draws up an individual plan and selects individual exercises for a particular patient. The duration of speech therapy correction for disorders associated with the development of aphasia averages about two to three years. The work uses special techniques for constructing sentences that allow the patient to reconstruct a detailed statement on his own. Work is also underway to correct the communicative function and self-control over it. Only when the patient understands the nature of his grammatical errors can one create opportunities for him to independently control his speech, the course of the narrative, and correct paraphasias.

The main emphasis of speech therapy work for dynamic aphasia is the elimination of defects in internal planning and programming of speech, as well as stimulation of speech activity.

Neuropsychic correction

Neuropsychological correction of speech in dynamic aphasia, regardless of the form of aphasia, deals with correction of all aspects of speech, namely its understanding, reproduction, writing and reading. The goal of neuropedagogical speech restoration for aphasia is to generally disinhibit speech, reduce the number of errors, improve the patient’s mental state and his interest in communication, as well as activity in general. The program plan is developed taking into account the individual characteristics of the lesion and the severity of the pathology. For this purpose, specific techniques are used, such as:

“Having completed the mind” - the poem is read to the patient several times, after which the specialist begins the sentence, and the patient finishes it;
Verbalization of one’s own actions - the patient is asked to talk about the progress of his day using drawing, reading and writing;
Rhythmic-myological exercises – the patient learns light rhythmic songs, tongue twisters;
Techniques of conjugate and reflected repetition;
Semantic selection of words.

Physiotherapeutic treatment

Physiotherapy is prescribed in cases of traumatic brain injury, stroke and neurosurgery. The majority of patients are prescribed neuromyostimulation, which helps restore and strengthen the tone and strength of the facial muscles. Thanks to this method, myocytes are stimulated due to electric current pulses, which makes it possible to restore the lost motor function of the facial muscles.

Patients are also recommended to engage in physical therapy according to an individually drawn up plan together with a personal approach to each person. After physical therapy exercises, tissue metabolism and a wide variety of metabolic processes are activated in the body and cerebral blood flow increases. At the same time, the patient becomes more active and his mood improves.

Another significant means of physiotherapeutic treatment is therapeutic massage. Massage has a tonic, relaxing, antispasmodic effect, activates the excitability of the nervous system, and increases muscle performance.

What are the severity levels of dynamic aphasia?

It is important for clinicians to understand at what stage the speech process fails. Based on their ability to recover, there are two groups of patients:

I group. Most often patients are elderly and senile. Violation of the primary link in the formation of internal statements. Low motivation to recover. Rehabilitation is long.
II group. Disorder of grammatical sentence construction. Self-criticism remains, and motivation in this group is increased. Rehabilitation is easier and faster.

Depending on the severity, the following types of dynamic aphasia are distinguished:

Easy. There are occasional spontaneous statements in expanded form. Speech is stereotypical, the patient often skips verbs or replaces them with other parts of speech. There is no understanding of phraseological units and the figurative meaning of most words.
Medium (medium-heavy). Speech is presented in short grammatical phrases, which are often stereotyped. Typical are grammatical errors and missing verbs. There is a decrease in speech activity.
Heavy. There are no spontaneous phrases. The patient requires constant stimulation of the speech center. At this level, the patient gives monosyllabic answers and speaks in short, abrupt speech cliches.

Symptoms of dynamic aphasia

A key symptom of the disease is the difficulty of forming an active statement. Such a patient does not independently contact strangers with questions or requests. His speech requires constant stimulation from the interlocutor from the outside.

The use of verbs decreases (verbal weakness), most nouns are used in the nominative case, and grammatical errors are often made. In mild forms, the patient communicates using standard stereotypical phrases and short, abrupt sentences.

When answering the interlocutor’s questions, the patient limits himself to short, monosyllabic answers or uses stereotypies.

Clinical example: Patient M., 45 years old. To the specialist’s question: “What did you eat today,” he answers a few seconds later: “I ate today.” Speech is characterized by a telegraphic style. The patient tries to repeat the movements and words of the interlocutor during a conversation, but does not make contact on his own. Other activities are not affected.

In severe forms of the disorder, the patient may not be available for productive contact; he prefers to remain silent. Communication is limited to the use of unrelated words or individual syllables and sounds.

There is a rapid depletion of concentration and attention, and a number of patients are characterized by increased irritability or apathy.

Written speech remains intact in most cases. Difficulties are observed when writing long, grammatically complex structures or texts of one’s own composition.

Such patients write words under dictation almost correctly, making minor grammatical errors; they retain the ability to count and read. When reading long phrases, omission of words, phrases and impaired reading comprehension are noted.

There is no ability to retell what you read in your own words or explain the meaning of the texts.

Instrumental diagnostics

To make a correct diagnosis, instrumental diagnostics is necessary. The patient is prescribed electroencephalography. This is a technique for studying the electrical activity of the brain by placing electrodes in specific areas on the surface of the head.

To clearly see the structure of the brain, to identify traces of hemorrhages, inflammation, and malignant neoplasms, computed tomography (CT) or magnetic resonance imaging (MRI) is prescribed. If it is necessary to clarify the integrity of blood vessels, identify aneurysms and other vascular disorders, then angiography may be required. Carrying out a comprehensive diagnosis makes it possible to differentiate aphasia from alalia, hearing loss and other pathologies.

Treatment of the disease directly depends on the form. It takes a long time to restore speech. It depends on a number of conditions: the cause of its appearance, the exact location of the damage, the degree of speech disorder, and the age of the patient.

An individual treatment plan is developed for the patient, which pays attention to drug therapy, physiotherapy, art therapy and classes with a speech pathologist. Drug therapy includes the prescription of antibacterial drugs, nootropics and other drugs (depending on the clinical picture). For example, in case of massive pathological changes that cause vasogenic edema, the doctor prescribes corticosteroids. To prevent epilepsy attacks, it is necessary to take anticonvulsants.

Exercises for correction

For some, it is easier to start pronouncing sounds and then move on to more complex words, while for others, on the contrary, it is much easier to say words and then isolate sounds. There are many exercises that significantly contribute to the correction of the disease. If you have problems understanding speech, it is recommended to first take three steps:

Show in the picture where a specific detail of the image is located.
Answer simple questions. For example: “Are you sitting on a chair now?”, “Are you walking in the fresh air now?”
Take simple steps. For example, open a notebook and clench your fist.

This is an approximate plan; a speech pathologist-speech pathologist may give other tasks. In this case, the main thing is that the person learns to understand what is required of him. Articular gymnastics are often performed. A speech therapist teaches a person the correct pronunciation of sounds and composing phrases using special exercises. The doctor carries out work aimed at remembering the names of various objects and their purposes.

Impressive speech

Sensory or impressive speech - understanding and perception of speech. In the cerebral cortex in the temporal gyrus there is an area (Wernicke's area) that is responsible for the perception of sensory speech.

In this zone, the assimilation and accumulation of all previously acquired words and their sound images occurs. When this zone is damaged, a person hears words, but ceases to understand their meaning. With normal hearing intact, the patient does not perceive words addressed to him, since they are meaningless to him.

Post-stroke aphasia: clinical picture, differential diagnosis, treatment

Speech disturbances are a common symptom of stroke (15–38%). They often lead to permanent disability, significantly complicate rehabilitation during the recovery period, reduce the quality of life of both the patients themselves and those around them, cause negative psycho-emotional reactions, and increase the economic costs of treatment. Compared to patients with stroke but without speech disorders, patients with post-stroke aphasia have a higher mortality rate and stay in hospital longer. Predictors of good recovery of speech function are mild to moderate severity of speech disorders in the acute period of stroke, the amount of brain damage (the smaller the ischemic focus, the higher the chances of recovery), young age, high Barthel index, and high level of education. In addition to the treatment of the underlying vascular disease, patients with speech disorders need systematic speech therapy sessions and medications in order to optimize cerebral neuroreparative processes.

Table. Types of aphasia

Aphasia is a disorder of a person’s higher mental functions, which consists of a loss or decrease in the ability to verbally communicate, including constructing one’s own speech utterance and/or understanding spoken speech. As a rule, patients with aphasia have pathology in both oral and written speech (reading, writing), and also have difficulties in using sign language and Braille (a dotted font for writing and reading for the blind).

Neuroanatomy of aphasia

Speech areas are a complex neurocognitive network located in the dominant hemisphere. In approximately 95% of people, the left hemisphere is dominant in speech, and in 5% of cases, either both hemispheres are involved in the innervation of speech, or the right hemisphere becomes dominant. Already at birth, in more than half of newborns, the cortex in Wernicke’s area and the angular gyrus in the left hemisphere is approximately 50% larger in volume than in the right [1]. If for some reason in very early childhood the left speech areas suffer, then the right hemisphere of the brain acquires signs of dominance [1].

Speech centers include the posterior parts of the left frontal lobe (Broca's area) and the left superior temporal gyrus (Wernicke's area), as well as connections between these areas. The motor program for speech utterance is formed in Broca's area. Broca's area projects directly to the neurons of the precentral gyrus, which innervate the muscles of the larynx and oral cavity. Wernicke's area is responsible for comparing auditory information with visual and kinesthetic images, which is necessary for understanding spoken speech. Comparison of information is provided by connections between Wernicke's area and the occipital and parietal cortex. Another cerebral region important for speech is the angular gyrus in the inferior parietal lobule, which is responsible for the perception of written speech and sign language.

In addition to the classical speech centers, other areas of the brain also play an important role in the formation of speech. These include the insula (important for articulation), zones of the frontal and temporal lobe (processing sentences), as well as zones of the occipital and parietal cortex of the brain (responsible for memory for the meanings of words) [2–5].

The subcortical nuclei of the brain also make a significant contribution to maintaining normal speech function. Diffusion-weighted and perfusion-weighted magnetic resonance imaging (MRI) of the brain in patients with ischemic damage to the basal ganglia and aphasia showed a secondary decrease in perfusion in the subcortical gray ganglia. However, the prognosis for subcortical aphasia is more favorable than for cortical damage [6]. In recent years, the role of cerebellar damage has also been actively discussed, since it can also lead to dysphasic disorders in the form of disturbances in the grammatical structure of speech [7].

Etiology of aphasia

The most common cause of aphasia is ischemic stroke. Less commonly, speech disorders are observed with hemorrhagic strokes, space-occupying brain lesions, infectious lesions (abscess, encephalitis), and traumatic brain injury. Rare cases of the development of aphasia in demyelinating diseases have been described [8, 9].

Transient aphasia can be observed with transient ischemic attacks, epilepsy, migraine. The presence of aphasia during a transient ischemic attack is one of the high risk factors for developing stroke in the coming days and weeks [10].

Gradually progressive aphasia may also be a manifestation of a neurodegenerative disease. Most often, gradually progressive aphasia is associated with frontotemporal degeneration, less often with Alzheimer's disease or other dementing diseases. Moreover, in some cases, the clinical picture does not show any other cognitive and/or behavioral disorders for many years (the so-called primary progressive aphasia) [11–13].

Speech status study

To diagnose and analyze the characteristics of dysphasia, it is necessary to carefully listen to the patient’s speech, examine the understanding of spoken speech, reading and writing. You should pay attention to the number of words spoken per minute (speech fluency), unmotivated repetitions of individual words and phrases (perseverations), shortened phrases (less than five words), errors in the grammatical construction of statements (case endings, prepositions, conjunctions, word order in a sentence etc.) and/or difficulties in understanding grammatical structures. In addition, it is necessary to assess the ability to control the movements of articulatory muscles (speech praxis). To do this, you can ask the patient to repeat the phrase “artillery brigade” several times.

An important part of speech research is the assessment of its nominative function.

. The patient is shown certain objects and asked to name them, starting with familiar ones (for example, a spoon, pen, mug) and moving on to unusual ones (for example, a phonendoscope). Insufficiency of the nominative function of speech is noted in many aphasias, sometimes becoming one of the main manifestations of dysphasia.

Assessing oral language comprehension

is carried out by checking the execution of verbal commands, first simple and then complex (“close your eyes”, “show me two fingers”, “touch your left ear with your right hand”). We can then move on to explore understanding of more complex grammatical structures (“Are my brother’s father and my father’s brother the same person?” or “Is my aunt’s uncle a man or a woman?”). Final trials may reveal a lack of understanding, including in those who have followed simple verbal commands.

When checking the reading function

the patient is asked to read aloud a paragraph from a newspaper or magazine, assessing the correct pronunciation of the words. Comprehension of written language can be tested using written commands (eg, “take this piece of paper, fold it in half and place it on the floor” or “close your eyes”).

Letter evaluation

– the patient is asked to write any sentence. You can also dictate any text to the patient or offer to write the names of objects drawn in the pictures.

The above methods make it possible to diagnose dysphasia without leaving the patient’s bedside, which is of great importance in the acute period of stroke. When diagnosing speech disorders in a patient, it is necessary to examine them in more detail, analyze quantitative and qualitative features, and also evaluate other higher brain functions: attention, memory, praxis, visual-spatial orientation, etc.

Epidemiology and types of aphasia

According to the literature, aphasia is a common symptom of stroke (15–38%). Typically, the clinical picture also includes other symptoms of damage to the dominant hemisphere (right-sided hemiparesis, hemihypesthesia, hemianopsia) [14]. Let's look at the main types of aphasia (table).

Broca's aphasia (motor aphasia)

characterized by a violation of the construction of one’s own speech utterance, as well as the repetition of phrases. The patient's speech is laconic, poorly articulated, and characterized by auditory and verbal perseverations. The letter is broken. Comprehension of addressed speech may be incomplete in the first few days after acute cerebrovascular accident, but then quickly recovers. Motor aphasia develops as a result of acute ischemic stroke in the anterior branches of the left middle cerebral artery and is often combined with hemiparesis and hemihypesthesia.

Wernicke–Kozhevnikov aphasia (sensory aphasia)

characterized primarily by impaired understanding of oral and written speech. The patient’s own speech, as a rule, maintains normal tempo and intonation, but is meaningless, as it contains numerous replacements of syllables and words with similar ones in sound, but meaningless in meaning (literal and verbal paraphasias), as well as new unusual words (neologisms). With significant severity of these disorders, speech production takes on the character of so-called verbal okroshka. However, many patients are not aware of their defect. Sensory aphasia develops when the upper parts of the temporal lobe and the lower parts of the parietal lobe are damaged as a result of a stroke in the territory of the left middle cerebral artery. It is often combined with right upper quadrant hemianopia.

Total sensorimotor aphasia

– a set of symptoms of motor and sensory aphasia. Develops as a result of extensive strokes in the left middle cerebral artery, usually combined with hemiparesis, hemihypesthesia and hemianopsia. Rarely, encephalitis and late manifestations of neurodegenerative processes can be the cause of total aphasia.

Dynamic aphasia (transcortical motor aphasia)

is largely reminiscent of Broca's motor aphasia. There is a violation of the initiation of speech activity, perseveration and grammatical errors occur, while the understanding of addressed speech does not suffer. The main difference between dynamic aphasia and motor aphasia is preserved repeated speech: the patient can repeat words and phrases after the doctor. Typically, dynamic aphasia develops with a heart attack in the territory of the left anterior cerebral artery.

Transcortical sensory aphasia

is characterized by a violation of the understanding of addressed speech, which resembles Wernicke–Kozhevnikov aphasia, but the severity of these disorders is somewhat lesser. The patients’ own speech is fluent, but lacks content, and verbal paraphasia may be observed. However, unlike Wernicke's aphasia, repeated speech is preserved in transcortical sensory aphasia. Patients may also read aloud, but without understanding the meaning of what they read. Transcortical sensory aphasia develops with damage to the temporo-occipital or temporo-parietal areas adjacent to Wernicke's area as a result of a stroke, and can be combined with hemianopsia.

Transcortical mixed aphasia

– patients have signs of transcortical motor and sensory aphasia, but the ability to repeat words and phrases after the doctor remains intact. Understanding of written and spoken language also deteriorates significantly. Occurs when there is damage in the anterior and posterior cerebral arteries during repeated cerebral embolisms, infarctions in areas of adjacent blood supply associated with systemic circulatory disorders, such as acute heart failure.

Amnestic aphasia

– patients with amnestic aphasia cannot name a word or object, but they can describe the meaning and functions of the object. Spontaneous speech is characterized by pauses, word substitutions, and paraphasias are possible. Repetition of words and understanding of oral speech are not impaired. Amnestic aphasia has been described with damage to various anatomical areas, including the basal temporal lobe, anterior temporal lobe, temporo-parieto-occipital junction, and inferior parietal lobe.

Alexia without agraphia

– patients can write, but not read. Understanding of oral speech is intact, spontaneous speech is not affected. It develops when the left occipital lobe and splenium of the corpus callosum are damaged during an ischemic stroke in the territory of the left posterior cerebral artery [15].

Differential diagnosis

In most cases, in patients with risk factors for stroke (in old age, in the presence of arterial hypertension, diabetes mellitus, hypercholesterolemia, concomitant cardiac pathology, atrial fibrillation, etc.) with the acute development of neurovascular syndrome, characteristic of damage to the middle and/or posterior cerebral artery dominant hemisphere, the diagnosis of ischemic stroke is not in doubt. Neuroimaging methods are used to verify the diagnosis.

Impaired understanding of speech and speaking, reminiscent of dysphasia, can develop with acute dysmetabolic encephalopathy (delirium)

. In this case, difficulties often arise in understanding the spoken speech; the patient does not follow commands. Grammatical errors and paraphasia appear in the patient’s own speech. Signs of a confused state of consciousness, the presence of hallucinations, tremors, psychomotor agitation and delirium help in diagnosis.

Akinetic mutism

develops when the medial frontal region is damaged. In such patients, there is an absence or extreme paucity of spontaneous speech, poor execution of commands, a decrease in motor reactions, and signs of catatonia (waxy flexibility).

Patients suffering from depression

, may avoid communicating with others. They do not look the doctor in the eyes, they lie with their faces turned away from the people around them. In this case, anamnesis collected from the patient’s relatives and/or loved ones plays an important role in the differential diagnosis.

If the patient has episodes of transient aphasia

The differential diagnosis is made between
transient ischemic attack and epilepsy
. 24-hour electroencephalographic monitoring, angiography of cerebral vessels, and duplex scanning of the brachiocephalic arteries are performed.

Aphasias with gradual onset and slow progression, especially in middle-aged and elderly people, require a differential diagnosis between neurodegenerative diseases and brain space-occupying lesions

. In this case, an MRI of the brain is indicated.

Treatment and prognosis of post-stroke aphasia

Speech disorders significantly disable patients, reduce the quality of life of both themselves and those around them, interfere with full neurorehabilitation, and increase the economic costs of treatment. In addition, patients with post-stroke aphasia, compared with patients with stroke but without speech disorders, have higher mortality rates and stay in hospital longer [16].

The degree of speech restoration depends primarily on the location and extent of damage to the brain. For example, sensorimotor aphasia as a result of ischemic stroke of the cardioembolic type, usually in combination with right-sided hemiparesis and hemihypesthesia, has a less favorable prognosis than motor aphasia as a result of a stroke in the anterior cortical branches of the middle cerebral artery [17].

Predictors of good recovery of speech function are young age, high Barthel index, high level of education and hemorrhagic nature of the stroke [17].

Management of a patient with aphasia involves, in addition to treating the underlying vascular disease, systematic speech therapy exercises [17–19]. They are carried out by patients independently under the supervision of relatives. The clinical effectiveness of speech rehabilitation has been assessed in a number of studies [20, 21]. It has been shown that the specific method of speech therapy correction is not of fundamental importance, while the frequency and intensity of classes significantly influence the prognosis [22, 23]. Speech therapy exercises must be started already in the acute phase of a stroke and continued throughout the entire recovery period, as long as the patient continues to have speech disorders. Currently, computer programs and applications for phones and tablets have been developed that allow the patient to communicate with others and independently perform speech exercises.

Restoration of speech in the first months after a stroke is associated with reperfusion of the corresponding cortical centers, activation of adjacent cortical areas and homologous brain areas in the contralateral hemisphere. This is evidenced by studies using diffusion-weighted and perfusion MRI methods [24, 25].

Drug therapy in patients with aphasia should be aimed at metabolic support of neuroreparative processes and improvement of cerebral blood flow.

To date, several randomized, double-blind studies of medications for post-stroke aphasia have been conducted. The effectiveness of bromocriptine [26] and amphetamine [27] has not been proven, and a meta-analysis of clinical studies of piracetam indicated a rather modest effect of this drug [28]. There is little clinical experience with the use of anticholinesterase inhibitors such as donepezil and galantamine, but their clinical effectiveness requires further study [29, 30].

Currently, the use of citicoline in patients with post-stroke aphasia seems promising. Citicoline (Ceraxon) is an endogenous mononucleotide containing ribose, cytosine, pyrophosphate and choline in its chemical structure. Being a necessary intermediate substance in the synthesis of structural phospholipids of the cytoplasmic and mitochondrial membranes of neurons, citicoline restores their integrity during ischemic damage. A number of experimental studies have shown that citicoline inhibits the enzyme phospholipase A2, normalizes energy processes in mitochondria, restoring the functioning of membrane sodium-potassium and mitochondrial adenosine triphosphatases. In addition, it enhances the activity of antioxidant systems, thereby providing a neuroprotective effect and preventing the processes of oxidative stress and apoptosis. Another mechanism of action of Ceraxon is to replenish cerebral acetylcholinergic deficiency, which is of great importance for metabolic support of cognitive activity in general. Finally, this drug affects dopamine and glutamatergic neurotransmission. Citicoline has a pleiotropic effect, also due to its influence on neurorepair processes, which play a key role in restoring lost functions [31]. A number of experiments demonstrated the effect of the drug on the processes of neuroglial activation, enhancement of post-ischemic neurogenesis, angiogenesis and neuroplasticity [32, 33]. It has been established that citicoline reduces the volume of brain damage during experimental ischemia and hypoxia, increases learning ability and has a beneficial effect on memory in experimental animals with age-related changes in the brain.

In clinical studies, Ceraxon improved functional recovery and accelerated rehabilitation of patients with ischemic stroke [34]. Currently, the effectiveness of citicoline in post-stroke cognitive and motor disorders has been shown [35, 36]. Moreover, the drug is characterized by a satisfactory safety and tolerability profile. The positive effect of the drug on speech disorders in patients after stroke has not been separately assessed. However, it can be assumed that the neuroregenerative properties of Ceraxon and its effects in the cognitive sphere will contribute to the improvement of speech functions due to the close relationship of these disorders.

Conclusion

When treating patients with aphasia, regular speech therapy sessions and long-term drug therapy are required, aimed at metabolic support of neuroreparative processes and improvement of cerebral blood flow.

Expressive speech

Motor or expressive speech is the pronunciation of individual sounds by the person himself. Broca's center, located in the frontal gyri, is responsible for this type.

When the frontal region is affected, the patient loses the ability to pronounce words and produces only inarticulate sounds. At the same time, he understands speech addressed to him and can respond to it with gestures or movements.

Interesting! When Broca's area is damaged, persistent speech impairments are observed, but it can be restored. Damage to Wernicke's center leads to irreversible speech disorders.

Classification

Currently, there are a large number of different classifications of aphasia. In the Russian Federation, the classification most often used is A.R. Luria, which reflects all clinical types of aphasia:

Efferent motor aphasia, this form occurs in case of damage to the lower parts of the cortex - Broca's center. It is characterized by the collapse of grammatical structures into sentences and the difficulty of restructuring from one word to another. Serious reading and writing impairments occur.
Afferent motor aphasia. Occurs when an area of the parietal cortex or posterior area is affected. The key disorder in this aphasia is the inability to detect the necessary articulatory position of the lips, tongue and speech facial muscles for the correct pronunciation of a word.
Dynamic aphasia - occurs when the prefrontal or perifrontal part of the cerebral cortex is damaged. It is manifested by the lack of possibility of adequate construction of internal speech and its implementation aurally.
Semantic aphasia - it is based on a defect in understanding complex speech structures and simultaneous analysis of information.

Complications

The lack of ability for independent active speech and the inability to express one’s thoughts leads to a decrease or loss of communication skills.

The patient cannot complain of pain or discomfort. He is unable to ask others for help or express his concerns. In the absence of adequate, attentive support from loved ones or medical personnel, such a patient may not satisfy basic needs for a long time, which leads to the development of other somatic diseases.

Persistent impairment of speech function makes professional implementation impossible, and the patient becomes disabled.

Sensory aphasia

Acoustic-gnostic (sensory) aphasia

occurs when the superior temporal gyrus is damaged.
A distinctive symptom of sensory aphasia is a lack of listening comprehension of the speech
of others.
Not only phonemic hearing is lost, but also the ability to distinguish voice timbre, intonation, and differentiate non-speech sounds: the sound of water, the creaking of a door, etc. Writing is grossly impaired, acalculation is observed - inability to count.
In patients with sensory aphasia, as a rule, motor function is not impaired, and the lack of self-control of speech leads to the fact that they do not immediately realize their illness, so they become mobile and talkative.
The understanding of the meaning of words also changes; names with different meanings are perceived equally (cane-guest-nail). When asked to show a barrel in the picture, they point to a kidney. , literal paraphasia
occurs - inappropriate use of sounds in a word or their replacement. Reading remains the most preserved function, since the optical and kinesthetic analyzers are involved.

Diagnostics

Suspicion of speech disorders is detected during the first attempts at contact between the patient and the specialized specialist. Further studies are aimed at clarifying the location of the lesion, the degree of speech disorder and other characteristics of the patient.

Which doctors examine patients with such disorders:

neurologist. If you suspect speech disorders associated with vascular disorders, traumatic brain injuries and other organic brain lesions. Examines the characteristics of behavior and thinking, checks the safety of reflexes and motor activity. If necessary, refers the patient to a neurosurgeon;
speech therapist. Diagnostics of oral speech and writing. This specialist, using various methods for assessing speech dynamics in aphasia, determines its degree, form and allows it to be differentiated from other disorders;
psychiatrist. Conducting psychological tests, observing the patient’s behavior, this doctor excludes or confirms the presence of psychiatric diseases, which are also manifested by the “frontal psyche” (Pick’s disease, etc.).

To clarify the exact affected area and the possible cause of the pathology, the patient is prescribed additional examinations:

MRI or CT scan of the brain.
Vascular studies: ultrasound, Doppler sonography, duplex scanning, angiography
Cerebrospinal fluid puncture. Performed if an infectious-inflammatory pathology is suspected.

Let's understand the reasons

The diagnosis is made by a neurologist, but a mandatory component of the diagnosis is a consultation with a speech therapist. He must establish to what extent various functions are preserved or, conversely, lost: understanding speech, diction, writing, counting. The doctor pays attention to the patient’s general condition and reflexes.

A consultation with a child psychiatrist may also be required. This specialist will determine whether the patient’s condition is associated with mental disorders and whether his nervous system requires medication support to achieve the best results.

A consultation with a psychologist completes the diagnosis. His task is to understand whether help is needed in adapting to his condition and whether the child needs support to actively participate in rehabilitation activities.

Treatment of dynamic aphasia

A neurologist deals with the treatment of dynamic aphasia. The disease is observed and treated in neurological departments or specialized centers. In addition to the neurologist, such patients are treated by a speech therapist, psychologist and rehabilitation specialist.

Therapy is aimed at eliminating the cause that caused the speech disorder. In parallel with this, specialists carry out correction of developed symptoms and rehabilitative training of lost skills.

Drug treatment includes:

Drugs that improve blood supply to the brain (Piracetam, Sermion).
Antioxidants and B vitamins.
Medicines with cerebroprotective properties (Cinnarizine, Vinpocetine).
Agents that prevent the formation of blood clots and improve the rheological properties of blood (antiplatelet agents and anticoagulants).

The speech rehabilitation program consists of:

Classes with a speech therapist. Working with a specialist lasts for several years. He draws up an individual correction plan and develops exercises to restore the patient’s speech.
General strengthening therapy. This includes various physiotherapeutic treatment methods, normalization of lifestyle, physical therapy, and massage.
Neuropsychic correction. The correction program plan is developed taking into account the individual characteristics of the patient. It includes various techniques, such as semantic selection of words, learning rhythmic songs, poems, repetition of tongue twisters.

Specialists

Aphasia is a neurological disease, which means that this pathology is treated by a specialist - a neurologist. Aphasia is treated either in multidisciplinary municipal hospitals in neurological departments, or in specialized centers. One of the most progressive and largest neurological centers is the Clinical Brain Institute. The clinic has a polyclinic, day and 24-hour hospitals that provide prevention, treatment and rehabilitation of patients with a wide variety of neurological pathologies. A speech restoration center operates on the basis of the rehabilitation block. It is in this center that patients who have suffered traumatic brain injuries, acute cerebrovascular accident and suffering from various forms of aphasia undergo treatment and correction.

In addition to the neurologist, a rehabilitation specialist, psychotherapist and speech therapist must take part in the treatment of patients with aphasia.

Prognosis and prevention

Restoration of speech in dynamic aphasia depends on the characteristics of the patient’s psyche, the location and extent of the lesion, as well as on a number of other factors. A statistically more favorable prognosis is found in young people and patients with high motivation for recovery.

Prevention consists of eliminating risk factors, regular diagnosis and correction of vascular diseases at the initial stages. Patients who have completed a full course of recovery from aphasia should be observed by neurologists for several more years.

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He understands everything, but cannot say

The main characteristic of dynamic aphasia is the inability to speak.
A person understands what is said, pronounces sounds correctly, repeats what others say, but cannot construct his own presentation of thoughts. With this disease, the regulatory function of speech is impaired - the patient is not able to construct a phrase plan and conduct an internal monologue, hence the impossibility of speaking. Therefore, the patient tries not to start a dialogue with strangers first: he is unable to construct a question or ask for something, and he is aware of this. Speech grammar is impaired, patients avoid verbs, prepositions and pronouns are omitted. Nouns are often used only in the nominative case.

Analysis of addressed speech in dynamic aphasia shows that reading and counting are not impaired, but when reading aloud, people with this disease may miss words and phrases and are unable to explain the meaning of the text. The ability to communicate through writing is retained in most cases, but only in simple phrases. Difficulties begin if you need to compose something yourself or write a complex grammatical structure from dictation.

Patients almost always lose the ability to maintain concentration on something for a long time and often become irritable or, conversely, indifferent because of this.

Motor and sensory aphasia – Abstract on psycholinguistics