ORIGINAL RESEARCH


https://doi.org/10.5005/jp-journals-10023-1229
International Journal of Phonosurgery & Laryngology
Volume 11 | Issue 2 | Year 2021

Evaluation of Language in Post-CVA Patients: A Clinicophonological Study

Anton Dev X1, Prithvi Das2, Somnath Saha3

1–3Department of ENT, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India

Corresponding Author: Prithvi Das, Department of ENT, Calcutta National Medical College and Hospital, Kolkata, West Bengal, India, Phone: +91 7439211782, e-mail: prithvidas89@gmail.com

ABSTRACT

Aims and objectives: • To assess patients with cerebrovascular accidents (CVA), in order to ascertain the presence and types of language deficits.

• Assess for any possible association between lesion site and pattern and degree of language impairments.

• To determine if the degree of language deficits are more in left hemisphere pathology.

Materials and methods: An observational study was conducted over a period of 1 year in the Department of ENT and Head-Neck Surgery and Department of Neuromedicine in a Tertiary Care Hospital. Poststroke patients were evaluated. Stable patients were selected. Both hemorrhagic and ischemic stroke patients were included. We had used the Western Aphasia Battery (WAB) to assess the faculty of Language in the study population and computed the Aphasia Quotient, based on which we categorized language function.

Results: In our study, the number of patients with Infarction as the pathologic process was greater than those with hemorrhage. A total of 40% of cases had exclusively subcortical lesions. In our study, young stroke (stroke in patient under 50 years of age), was present in 14%. Aphasia was present in 40% of the patients. Crossed aphasia was seen in one patient (4%). Based on the aphasia quotient obtained from WAB, we categorized the aphasia as mild (4%), moderate (12%), and severe (24%). We had a preponderance of nonfluent aphasia.

Conclusion: The frequency of poststroke aphasia was higher in our study (40%) than that seen in earlier studies. We have seen a preponderance of nonfluent aphasia in our study with global aphasia (50%) being the commonest subtype. Significant association (p < 0.05) was found between left-sided lesions and the presence of aphasia.

How to cite this article: X Anton Dev, Das P, Saha S. Evaluation of Language in Post-CVA Patients: A Clinicophonological Study. Int J Phonosurg Laryngol 2021;11(2):54–60.

Source of support: Nil

Conflict of interest: None

Keywords: Aphasia, Post-CVA, Poststroke, WAB

INTRODUCTION

In the US, stroke is the most significant contributor to long-term adult disability and the 5th most common cause of death.1,2

Disability is multifactorial and is determined by the site of the lesion, the degree of neurological recovery, premorbid status, and the environmental support systems.

Localization of the Stroke

In certain stroke varieties, there is a proclivity to occur in particular areas. For example: Lacunar stroke in the Subcortex.3 Damage occurring in one brain region impairs the specialized centers in the affected region and also loss of input from the injured part affects the entire brain. Arterial territories are used to localize stroke.

Arterial Territory-errors Mapping

  • Contralateral hemiparesis/hemiplegia

  • Contralateral sensory loss: ACA

  • Contralateral homonymous hemianopia

  • Left hemispheric: aaphasia

  • Right hemispheric: Visual perceptual deficits including left neglect

  • Contralateral hemiparesis/hemiplegia

  • Contralateral sensory loss: MCA(Superior Division)

  • Left hemispheric: Expressive aphasia

  • Right hemispheric: Visual perceptual disorders

  • Superior quadrantanopia or homonymous hemianopia MCA (Inferior division):

  • Left hemispheric: Wernicke’s aphasia

  • Right hemispheric: Left visual neglect.

Right Hemisphere Disorders

Injury to the right hemisphere results in:

  • Visual-spatial Perceptual Disorders

Left-sided hemi-neglect, constructional apraxia, and asterognosis.

  • Emotional Disorders

Indifference or flat affect, impulsivity, and emotional lability. Lack of insight is characteristic.

  • Communication Problems

Aphasia is common in left hemispheric strokes, however, Aphasia has been observed after right hemispheric strokes in 30% of left-handed people and 5% of right-handed people.4

Left Hemisphere Disorders

Injury to left hemisphere results in:

  • Aphasia

  • Apraxias

  • Emotional disorders: Depression is seen after stroke in 50% of patients 5 and is more common with frontal damage.

Poststroke Aphasia

Of all the impairments in stroke, aphasia is both common and highly debilitating.6,7 Aphasia has a prevalence of about 21–38%, following acute stroke. A majority of individuals are right-handed (93%), of whom the left hemisphere is dominant for language in 99%. Language control in left-handed individuals is in the left hemisphere in 70%, in the right hemisphere in 15%, and in both hemispheres in 15 %.8 Hence, 97% of the population has the seat of language control in the left hemisphere (Table 1).

Table 1: Characteristic features of types of aphasia
Type Fluency Comprehension Repetition
Broca’s Nonfluent Good Poor
Transcortical motor Nonfluent Good Good
Wernicke’s Fluent Poor Poor
Transcortical sensory Fluent Poor Good
Global Nonfluent Poor Poor
Conduction Fluent Good Poor

Assessment of Aphasia Poststroke

Diagnostic criteria for aphasia vary among different studies9 resulting in variations in statistics. Stroke studies show that language pathology is seen in 1510–42%11,12 patients of acute stroke. The number of first-time stroke patients recorded in 2013, was about 10.3 million.13 With such a high global burden, the accurate validation of poststroke aphasia assessments is vital for resource allocation.9

Neuroimaging reveals a correlation between lesion site and aphasia occurrence with recovery being dependably predicted based on lesion site and size.14,15 Imaging methods only characterize the lesion16 and further defining of language impairment will require additional bedside tests and clinical evaluation.17

Commonly used stroke scales are:

  • The ESS- European Stroke Scale 18

  • CNS- Canadian Neurological Scale19

  • NIHSS- National Institutes of Health Stroke Scale.20

Many of these scales have not been specifically validated for use in hyperacute stroke, despite being used for managing the same.21

Brief screening tools such as the Frenchay screening test,22 may be used by health professionals who are not specialists,21,24,25 to identify and promptly refer patients who are at-risk.21,22,23,24,25 Such tools usually do not test writing and reading.23 They are thereby not comprehensive and thereby not useful in isolation, for diagnosis.26

Other common, more elaborate speech pathology tools are:

  • Acute aphasia screening protocol 27

  • Western aphasia battery-bedside28

  • Mount wilga high-level language test29

  • Sklar aphasia scale30

  • Aachen aphasia bedside test31

  • The Bedside evaluation screening test (BEST-2)32

  • Aphasia language performance scales33

  • Aphasia screening test.34

The shortfall of these tests is that their metrics are reported in their test manuals and not within peer-reviewed journals.

WAB has been utilized in our study.

Western Aphasia Battery (WAB)

The WAB is a Language assessment tool, used to test for Aphasia in patients between 18 and 89 years of age. The WAB has positive attributes such as validity and high consistency.35 The WAB, by design, has several subtest criteria and tests all language modalities. It also tests “higher cortical functioning." Pearson Assessments published the revised edition (WAB-R) in 2006, which also included a bedside screening test (Table 2).

Table 2: Taxonomy of WAB
Criteria for classification
Fluency Comprehension Repetition Naming
Global 0–4 0–3.9 0–4.9 0–6
Broca’s 0–4 4–10 0–7.9 0–8
Isolation 0–4 0–3.9 5–10 0–6
Transcortical motor 0–4 4–10 8–10 0–8
Wernicke’s 5–10 0–6.9 0–7.9 0–9
Transcortical sensory 5–10 0–6.9 8–10 0–9
Conduction 5–10 7–10 0–6.9 0–9
Anomic 5–10 7–10 7–10 0–9

MATERIALS AND METHODS

Study Design

An observational study was done at a tertiary center in West Bengal.

Study Population

Patients admitted to the Neurology ward.

Sample Design

Inclusion criteria

Cerebrovascular accident (CVA) patients, including:

  • Patients with ischemic stroke.

  • Patients with hemorrhagic stroke.

  • Medically stable patients.

Exclusion Criteria

  • Recurrent stroke.

  • Hemodynamically unstable patients.

  • Unconscious patients.

  • Subarachnoid hemorrhage.

  • Agitation and possible inability to cooperate.

  • Severe movement disorders (Dyskinesia)

  • Patients with any other progressive neurological condition such as parkinsonism, schizophrenia.

  • Mentally impaired patients who cannot provide proper informed consent and who would be uncooperative for examination.

  • Patients of childhood stroke syndromes with various underlying genetic defects are excluded as they may skew the inferences, as a result of the differences in their baseline physiology.

Sample Size

  • Total 50 cases.

Study Tools

  • History including Past History of any Cerebrovascular event.

  • Basic Hematology includes Complete blood count, platelets, BT/CT, urea, creatinine, and serology.

  • Evaluation of Mode of communication (verbal/nonverbal).

  • Western Aphasia Battery (WAB) for language status evaluation.

Study Technique

  • This is a time-bound cross-sectional study.

  • The study was done for a period of 1 year.

  • Minimum of 50 post CVA patients will be selected consecutively based on inclusion and exclusion criteria.

  • The region of CNS involved will be ascertained based on the expert radiological opinion of the imaging that would have already been done and if documentation is unavailable, the necessary radiological imaging will be performed.

  • Language function will be assessed clinically, to look for the presence and type of defect if any, and then using the WAB scoring system the degree of impairment of language will be ascertained in the four dimensions of fluency, auditory-verbal comprehension, repetition, and naming. Subscores will be based on the taxonomic table. Accordingly, aphasia can be classified and an Aphasia quotient (AQ) can be determined. The language was classified as normal if an AQ of 93.8 or above was achieved.

The findings of our study have been summarized in (Tables 3 to 9). (Fig. 1) represents the ages of subjects in the present study. (Fig. 2) represents the relative percentages of the various types of Aphasia we had observed in the present study. (Fig. 3) depicts the percentage of CVA patients who had normal speech and those with varying degrees of Aphasia as determined by Aphasia Quotient. (Fig. 4) represents the significant association observed between Left sided lesions and presence of Aphasia.

Table 3: Frequency of different cerebrovascular insult in our study
Insult classification Frequency %
Hemorrhage 16 32.0
Infarct 34 68.0
Total 50 100.0

Fig. 1: Representation of ages of subjects

Fig. 2: Distribution of types of aphasia

Fig. 3: Categories of aphasia

Fig. 4: Association of aphasia incidence with lesion side

Table-4 states the relationship with type of pathologic process with presence of Aphasia. There was no statistically significant relationship present (p > 0.05)

Table 4: Type of pathologic process—presence of aphasia
Insult Present Absent Total Results
No % No % No %
Hemorrhage 6 12.0 10 20.0 16 32.0 χ2 =0.061
df = 1
p = 0.804
Infarct 14 28.0 20 40.0 34 68.0
Total 20 40.0 30 60.0 50 100.0

From Table-5, we infer that the parameters were not associated with each other (p > 0.05)

Table 5: Site of lesion with type of aphasia
Type Cortical Corti-cosubcortical Subcortical Total Results
No % No % No % No %
Anomic 2 10.0 0 0 0 0.0 2 10.0 χ2 =16.306
df = 10
P = 0.091
Broca’s 0 0.0 1 5.0 2 10.0 3 15.0
Global 4 20.0 1 5.0 5 25.0 10 50.0
T/C sensory 3 15.0 0 0.0 0 0.0 3 15.0
TCM 0 0.0 1 5.0 0 0.0 1 5.0
Wernicke’s 0 0.0 0 0.0 1 5.0 1 5.0
9 45.0 3 15.0 8 40.0 20 100.0

From Table 6, we observe that the frequencies of Anomic, Broca, Global, T/C sensory, T/C Motor and Wernickes aphasia were 10%,15%, 50%, 15%, 5% and 5%, respectively.

Table 6: Types of aphasia
S. No. Types of aphasia Frequency Percentage
1 Anomic 2 10.0
2 Broca’s 3 15.0
3 Global 10 50.0
4 T/C sensory 3 15.0
5 TCM 1 5.0
6 Wernicke’s 1 5.0
Total 20 100.0

Table-7, states the frequency of the different classes of aphasia in our study. Out of the aphasics, 30 % were fluent, and 70 % were nonfluent

Table 7: Class of aphasia
S. No Types of aphasia Frequency Percentage
1 Fluent 6 30.0
2 Nonfluent 14 70.0
Total 20 100.0

Table-8, categorizes the AQ values from our study. Among them, the values were normal in 60% and mild aphasia was 4%, moderate aphasia was 12% and severe aphasia was 24% (Fig. 3)

Table 8: Category of aphasia according to the AQ values
S. No. Severity AQ values Frequency %
1 Normal 93.8 30 60.0
2 Mild 75–93.8 2 4.0
3 Moderate 50–74 6 12.0
4 Severe < 50 12 24.0
Total 50 100.0

From Table 9 Figure 4 we can infer the association of left side lesions with aphasia incidence (p < 0.05)

Table 9: Association of aphasia incidence with lesion side
Insult side Present Absent Total Significance
No % No % No %
B/L 0 0.0 1 3.3 1 2.0 χ2 =12.508
df = 2
P = 0.002
Left 19 95.0 14 46.7 33 66.0
Right 1 5.0 15 50.0 16 32.0
Total 20 100.0 30 100.0 50 100.0

RESULTS

In our study (Fig. 1),

DISCUSSION

In our study, there was a greater number of patients with Infarction as the pathologic process, than the ones with Hemorrhage as the pathologic process. In a similar study done for poststroke aphasia, the ischemic stroke had predominance.36

Pure subcortical lesions were seen in 40% of our cases. In our study young stroke (stroke in patient under 50 years of age), was present in seven cases (14%) which was lower than the count seen in another earlier study.36

Our study had one patient with crossed aphasia (4%). In earlier stroke studies, crossed aphasia had an observed prevalence between 0.4 and 3.5%.38,39

Overall, 70% of the aphasics in our study had nonfluent aphasia. Prior studies39,40,41 have also reported a similar incidence of nonfluent aphasia.

Anomic aphasia had a frequency of 16–25% in earlier studies40,42 but was seen in only 10% of cases in our study. The frequency of other subtypes was also seen to differ from earlier studies.

CONCLUSION

LIMITATIONS

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