APHASIA [Dysphasia] Aphasia, impaired expression or comprehension of written or spoken language, reflects disease or injury of the brain's language

centers. (See Where language originates.) Depending on its severity, aphasia may slightly impede communication or may make it impossible. It can be classified as Broca's, Wernicke's, anomic, or global aphasia. Anomic aphasia eventually resolves in more than 50% of patients, but global aphasia is usually irreversible. Where language originates Aphasia reflects damage to one or more of the brain's primary language centers, which, in most persons, are located in the left hemisphere. Broca's area lies next to the region of the motor cortex that controls the muscles necessary for speech. Wernicke's area is the center of auditory, visual, and language comprehension. It lies between Heschl's gyrus, the primary receiver of auditory stimuli, and the angular gyrus, a way station between the brain's auditory and visual regions. Connecting Wernicke's and Broca's areas is a large nerve bundle, the arcuate fasciculus, which enables the repetition of speech.

EMERGENCY INTERVENTIONS Quickly look for signs and symptoms of increased intracranial pressure (ICP), such as pupillary changes, a decreased level of consciousness (LOC), vomiting, seizures, bradycardia, widening pulse pressure, and irregular respirations. If you detect signs of increased ICP, administer mannitol I.V. to decrease cerebral edema. In addition, make sure that emergency resuscitation equipment is readily available to support respiratory and cardiac function, if necessary. You may have to prepare the patient for emergency surgery. History and physical examination If the patient doesn't display signs of increased ICP or if his aphasia has developed gradually, perform a thorough neurologic examination, starting with the patient history. You'll probably need to obtain this history from the patient's family or companion because of the patient's impairment. Ask if the patient has a history of headaches,

hypertension, seizure disorders, or drug use. Also ask about the patient's ability to communicate and to perform routine activities before aphasia began. Identifying types of aphasia LOCATION OF TYPE LESION Anomic Temporal-parietal aphasia area; may extend to angular gyrus, but sometimes poorly localized Broca's aphasia (expressive aphasia)

Global aphasia

Wernicke's aphasia (receptive aphasia)

SIGNS AND SYMPTOMS The patient's understanding of written and spoken language is relatively unimpaired. His speech, although fluent, lacks meaningful content. Wordfinding difficulty and circumlocution are characteristic. Rarely, the patient also displays paraphasias. Broca's area; usually The patient's understanding of written and spoken in third frontal language is relatively spared, but speech is convolution of the nonfluent, evidencing word-finding difficulty, left hemisphere jargon, paraphasias, limited vocabulary, and simple sentence construction. He can't repeat words and phrases. If Wernicke's area is intact, he recognizes speech errors and shows frustration. He's commonly hemiparetic. Broca's and The patient has profoundly impaired receptive and Wernicke's areas expressive ability. He can't repeat words or phrases and can't follow directions. His occasional speech is marked by paraphasias or jargon. Wernicke's area; The patient has difficulty understanding written and usually in posterior spoken language. He can't repeat words or phrases or superior temporal and can't follow directions. His speech is fluent, but lobe may be rapid and rambling, with paraphasias. He has difficulty naming objects (anomia) and is unaware of speech errors.

Check for obvious signs of neurologic deficit, such as ptosis or fluid leakage from the nose and ears. Take the patient's vital signs and assess his LOC. Be aware, however, that assessing LOC is usually difficult because the patient's verbal responses may be unreliable. Also, recognize that dysarthria (impaired articulation due to weakness or paralysis of the muscles necessary for speech) or speech apraxia (inability to voluntarily control the muscles of speech) may accompany aphasia; therefore, speak slowly and distinctly, and allow the patient ample time to respond. Assess the patient's pupillary response, eye movements, and motor function, especially his mouth and tongue movement, swallowing ability, and spontaneous movements and gestures. To best assess motor function, first demonstrate the motions and then have the patient imitate them. Medical causes Alzheimer's disease. With Alzheimer's, a degenerative disease, anomic aphasia may begin insidiously and then progress to severe global aphasia. Associated signs and symptoms include behavioral changes, loss of memory, poor judgment, restlessness, myoclonus, and muscle rigidity. Incontinence is usually a late sign.

 Brain abscess. Any type of aphasia may occur with brain abscess. Usually, aphasia develops insidiously and may be accompanied by hemiparesis, ataxia, facial weakness, and signs of increased ICP. Brain tumor. A brain tumor may cause any type of aphasia. As the tumor enlarges, other aphasias may occur along with behavioral changes, memory loss, motor weakness, seizures, auditory hallucinations, visual field deficits, and increased ICP. Creutzfeldt-Jakob disease. Creutzfeldt-Jakob disease is a rapidly progressive dementia accompanied by neurologic signs and symptoms, such as myoclonic jerking, ataxia, aphasia, visual disturbances, and paralysis. It generally affects adults ages 40 to 65. Encephalitis. Encephalitis usually produces transient aphasia. Its early signs and symptoms include fever, headache, and vomiting. Seizures, confusion, stupor or coma, hemiparesis, asymmetrical deep tendon reflexes, positive Babinski's reflex, ataxia, myoclonus, nystagmus, ocular palsies, and facial weakness may accompany aphasia. Head trauma. Any type of aphasia may accompany severe head trauma; typically, it occurs suddenly and may be transient or permanent, depending on the extent of brain damage. Associated signs and symptoms include blurred or double vision, headache, pallor, diaphoresis, numbness and paresis, cerebrospinal otorrhea or rhinorrhea, altered respirations, tachycardia, disorientation, behavioral changes, and signs of increased ICP. Seizures. Seizures and the postictal state may cause transient aphasia if the seizures involve the language centers. Stroke. The most common cause of aphasia, stroke may produce Wernicke's, Broca's, or global aphasia. Associated findings include decreased LOC, right-sided hemiparesis, homonymous hemianopsia, paresthesia, and loss of sensation. (These signs and symptoms may appear on the left side if the right hemisphere contains the language centers.) Transient ischemic attack. Transient ischemic attacks can produce any type of aphasia, which occurs suddenly and resolves within 24 hours of the attack. Associated signs and symptoms include transient hemiparesis, hemianopsia, and paresthesia (all usually right-sided), dizziness, and confusion. Special considerations Immediately after aphasia develops, the patient may become confused or disoriented. Help to restore a sense of reality by frequently telling him what has happened, where he is and why, and what the date is. Carefully explain diagnostic tests, such as skull Xrays, computed tomography scan or magnetic resonance imaging, angiography, and EEG. Later, expect periods of depression as the patient recognizes his disability. Help him to communicate by providing a relaxed, accepting environment with a minimum of distracting stimuli. Be alert for sudden outbursts of profanity by the patient. This common behavior usually reflects intense frustration with his impairment. Deal with such outbursts as gently as possible to ease embarrassment.

When you speak to the patient, don't assume that he understands you. He may simply be interpreting subtle clues to meaning, such as social context, facial expressions, and gestures. To help avoid misunderstanding, use nonverbal techniques, speak to him in simple phrases, and use demonstration to clarify your verbal directions. Remember that aphasia is a language disorder, not an emotional or auditory one, so speak to the patient in a normal tone of voice. Make sure that he has necessary aids, such as eyeglasses or dentures, to facilitate communication. Printed communication cards can assist him to communicate his basic needs. Refer the patient to a speech pathologist early to help him cope with his aphasia. Patient counseling Discuss alternate means of communication and ways to reduce the risk factors for stroke.

PEDIATRIC POINTERS Recognize that the term childhood aphasia is sometimes mistakenly applied to children who fail to develop normal language skills but who aren't considered mentally retarded or developmentally delayed. Aphasia refers solely to a loss of previously developed communication skills. Brain damage associated with aphasia in children most commonly follows anoxiathe result of near-drowning or airway obstruction.