How stroke affects speech and language

To know why a stroke can cause so many different

problems, it is helpful to understand how speech works.
Communicating a message means you think about
what you want to say, put your thoughts into words and
say the words out loud. Understanding a message
means you know someone wants to say something,
you keep the words in mind and put the words together.
Your brain controls the complex steps needed to speak
and understand language. That's why injury to the
brain - such as a lack of blood flow during a stroke -
can get in the way of your ability to do these
steps. Different problems result depending on the
location and severity of the stroke. If you have
aphasia... If you have aphasia (a-FAY-zha), you
should have your speech and language checked. A
speech-language pathologist (or speech therapist)
must see how well you can speak and understand.

Effects of left-sided stroke: Aphasia and language The exam includes four areas:
apraxia speaking out loud
writing
Stroke (also known as a cerebrovascular accident or listening comprehension
CVA) usually affects one side of the brain. Movement reading comprehension
and sensation for one side of the body is controlled by You may have problems in some or all four areas. For
the opposite side of the brain. This means that if your example, you may have problems reading and writing
stroke affected the left side of your brain, you will have but not in talking. This exam can also show which
problems with the right side of your body. Some areas of speech and language have been least
problems that happen after stroke are more common affected. Language apraxia When you have
with stroke on one side of the brain than the other. The language apraxia (aPRAYX-ee-a), you know the right
left side of the brain controls the ability to speak and words but you have problems forming words or putting
understand language in most people. The right side of sounds together. Muscle weakness or loss of feeling
the brain controls the ability to pay attention, recognize
things you see, hear or touch, and be aware of your does not cause this. If you have mild apraxia, you will
own body. In some left-handed people, language is have clear speech with inconsistent sound
controlled by the right side of the brain and awareness substitutions. For example, a "cup of coffee" may come
by the left side of the brain. out as "a puck of pappy" or a "bup of foppe." If you
have severe apraxia, your speech may sound like
jargon or you may only be able to repeat a single
Aphasia You may have problems with:
syllable or phrase over and over. For example, "do-do-
speaking do" or "I dunno."
listening
reading Left Hemispheric Damage
writing Left hemispheric damage may produce a right
dealing with numbers hemianopsia or quadranopsia, but may also impact
understanding speech mood and behavior. Some patients may appear
thinking of words when talking or writing compulsive, disorganized and easily
frustrated. Patients may demonstrate problems in
How much trouble you have with aphasia depends on memory, speech, writing, and cognitive processing.
the type and severity of your braininjury. Aphasia Left brain damage results in problems on the right side
of the body including paralysis. Reading ability may be
means you have problems speaking and impaired at a cognitive level. Often this loss of reading
understanding language. You may be unable to find the
and speech can be rehabilitated with speech therapy,
words you need to put sentences together. This is like
but in some cases this loss is permanent. The visual
having a word 'on the tip of your tongue.' Not all field loss on the right side may also be a cause of
strokes cause aphasia. About 20 percent of stroke reading impairment. Learn more about this in our
survivors have a loss of speech and language. section on reading problems.
 With time the hypo-attenuation and swelling become
The middle cerebral artery territory is the most more marked, and in patients with the majority of the
commonly affected territory in a cerebral infarction, MCA territory affected the mass effect is often
due to the size of the territory and the direct flow from dramatic and life threatening, sometimes requiring a
internal carotid artery into the middle cerebral artery, decompressive craniectomy.
providing the easiest path for thromboembolism. As time passes the infarct undergoes a gradual
Clinical presentation reduction in swelling and mass effect (see cerebral
The neurological deficit will depend on the extent of infarction).
the infarct and hemispheric dominance, and include:
contralateral hemiparesis MRI
contralateral hemisensory loss Other than demonstrating the typical distribution of
hemianopia affected tissue or occlusion of the vessel on MRA,
aphasia: if the dominant hemisphere is involved; appearances of a middle cerebral artery infarct are
may be expressive in anterior MCA territory similar to those of infarcts anywhere else (see
infarction, receptive in posterior MCA stroke, cerebral infarction).
or global with extensive infarction
neglect: non-dominant hemisphere Treatment and prognosis
Treatment of middle cerebral artery infarcts is the same
Radiographic features as infarcts anywhere else (see cerebral infarction)
Generally the features are those of cerebral infarction, except that due to the size of the involved territory the
similar to those seen in any other territory. As such degree of mass effect resulting from infarction can be
these features are discussed in generic article: marked and life threatening. As such decompressive
cerebral infarction. craniectomy is advocated by many as a life-saving
There are however certain features specific to middle procedure.
cerebral artery infarct, and these are discussed below.
For both CT and MRI it is worth dividing the features Overview
according to time course. Middle cerebral artery (MCA) stroke describes the
It should also be noted that middle cerebral artery sudden onset of focal neurologic deficit resulting from
infarcts are often incomplete affecting only perforator brain infarction or ischemia in the territory supplied by
branches or one or more distal branches. As such in the MCA.
many cases only parts of the middle cerebral artery para, childcount:0
territory is affected. The MCA is by far the largest cerebral artery and is
the vessel most commonly affected by
CT cerebrovascular accident. The MCA supplies most of
The earliest finding of middle cerebral artery occlusion the outer convex brain surface, nearly all the basal
is: ganglia, and the posterior and anterior internal
hyperdense middle cerebral artery sign 3 capsules. Infarcts that occur within the vast
seen immediately and represents direct distribution of this vessel lead to diverse neurologic
visualisation of the thromboembolism. sequelae. Understanding these neurologic deficits
presence of calcification is important as it is and their correlation to specific MCA territories has
a contraindication to angioplasty long been researched.
Early parenchymal signs include subtle blurring, para, childcount:1
decreased attenuation and swelling of the grey-white Research has also focused on the correlation
matter junction of affected regions. It should be noted between specific neurologic deficits after MCA stroke
that deep grey matter structures are affected before and differing outcomes and prognoses. Such efforts
the cortex due to lenticulostriate arteries being end are important in ascertaining who may benefit from
arteries, and cytotoxic oedema (intracellular fluid emergent antithrombotic therapies. Furthermore,
accumulation) occurring earlier 2, 4: these research efforts may later allow physiatrists to
lentiform nucleus; caudate nucleus target rehabilitative efforts more effectively in
as early as 1 hour after occlusion 4 appropriately selected patients who may derive
visible in 75% of patients at 3 hours 4 benefit.
insular ribbon para, childcount:1
This article focuses more on the postacute care and
although cortical it is the furthest cortex from
rehabilitation of patients with MCA stroke. However,
collateral circulation and is therefore also
evidence-based practice of acute stroke care obviously
affected early 4
needs to be carried over into the rehabilitation setting.
the insular ribbon sign describes loss of
This is particularly true since patients are ideally being
normal grey-white differentiation
admitted to such settings quite early after their event.
surface cortex (including peri-rolandic cortex) The American Heart Association guidelines are an
collateral flow retards the development of CT excellent resource for standards of stroke care.
signs with only 20% of cases demonstrating Certified centers for stroke care have proven to have
changes at 3 hours 4 better outcomes in terms of morbidity, mortality, and
eventual functional outcome relative to those without patient is admitted for stroke, barring additional medical
such specialization. issues aside from the stroke itself. reference_ids_tool_tip
reference_ids [3]

Rehabilitation Setting Selection and Indications

sect1 @id not labs, single page, $sect-id: a2 para, Best Practices
childcount:0 sect1 @id not labs, single page, $sect-id: a3 para,
Knowing and using objective criteria in recommending childcount:0
a rehabilitation plan best suited for a patient is The American Heart Association (AHA) guidelines
imperative. This effort to maximize functional outcome have become a widely used standard of care for
and independence and targeting expensive resources individuals with both ischemic and hemorrhagic
to patients who will benefit is a very important role for stroke. Comprehensive review of these guidelines is
physiatrists and other rehabilitation specialists. outside of the postacute stroke focus of this article.
However, certain elements are quite relevant to the
para, childcount:0 rehabilitation setting.
Acute, inpatient rehabilitation is the most intense and
expensive rehabilitation setting in terms of hours of Certified stroke center
therapy provided each day. Comparison to subacute para, childcount:1
rehabilitation, typically provided in a skilled nursing Patients should be directed to medical centers
facility, in terms of functional outcome, is discussed designated and accredited for the interdisciplinary
later in this article. However, the basic criteria for care of stroke patients. Improved outcome in terms of
admission to acute rehabilitation are as follows: mortality, length of stay, return to home, patient
itemizedlist function, and cost of care have all been shown to be
listitem superior in care centers consistent in AHA guideline
para, childcount:0Potential for significant functional based practices. reference_ids_tool_tip reference_ids [4] These
improvement requiring at least 2 therapy disciplines in centers must track and document consistent
a reasonable period interdisciplinary practices in the care of stroke patients
listitem that are shown to improve outcomes. This care
para, childcount:0Realistic and safe includes but is not exclusive to the following:
discharge plan with family support and itemizedlist
housing that allows return to the community listitem
rather than to a skilled nursing facility or para, childcount:0Appropriate and expedient
long-term care use of thrombolytic therapy*
listitem listitem
para, childcount:0Medical stability, para, childcount:0Dysphagia screening
willingness, and ability to participate in at listitem
least 3 hours of therapy/day para, childcount:0Venous thromboembolism
prophylaxis
para, childcount:0 listitem
Inpatient, subacute rehabilitation is generally offered para, childcount:0Discharged on
at a skilled nursing facility or long-term acute care antithrombotic therapy*
hospital. Patients with more complex medical care listitem
such as mechanical ventilation or advanced wound para, childcount:0Anticoagulation therapy for
care often undergo at least their initial rehabilitation at atrial fibrillation/flutter*
a long-term acute care hospital. Both skilled nursing listitem
facility and long-term acute care hospital therapy is
para, childcount:0Discharged on statin
generally, but not always, with fewer hours of therapy
medication*
offered per week. Such facilities are not bound to a
listitem
minimum hours of therapy per day.
para, childcount:0Discharged on
para, childcount:0 antihypertensive medication or
Home health and outpatient therapy are provided to documentation stating why contraindicated
patients after they complete their inpatient therapy or listitem
for those who are less impaired after their stroke. para, childcount:0Stroke education
listitem
Contraindications para, childcount:0Smoking cessation
para, childcount:0 education
Frankly, there are very few indications for no therapy listitem
and evidence does suggest that earlier mobilization para, childcount:0Assessed for rehabilitation
translates to better long-term patient outcome.
*Denotes care for ischemic but not hemorrhagic
para, childcount:1 stroke.
Ideally, rehabilitation should begin immediately after a
 gastric acid, as well as bacterial infection, both likely
Pharmaceutical management contribute. reference_ids_tool_tip reference_ids [8]

para, childcount:0 para, childcount:1

Thrombolytic therapy should be administered in a very Deep venous thrombosis and pulmonary embolism
orchestrated and consistent manner, relying on
emergent imaging and screening to ensure only para, childcount:2
patients with ischemic stroke and no contraindications Pulmonary embolism (PE) accounts for 10-25 % of
receive such therapy. After ischemic stroke, patients mortality of patients after stroke. In addition,
should be discharged from acute care on a statin, symptomatic deep venous thrombosis (DVT) and
antihypertensive, and appropriate antithrombotic postphlebitis syndrome impede recovery and function
and/or anticoagulation medicines to prevent recurrent for patients after stroke. reference_ids_tool_tip reference_ids [9]
stroke. The selection of such medications is Prevention of DVT and PE is achieved either by
dependent on the presence of comorbidities, including patient mobilization or pharmaceutical intervention.
atrial fibrillation, coronary artery disease, congestive Dehydration, hemorrhagic stroke, severity of
heart failure, and diabetes. paralysis, and age are all additional risk factors
associated with increased likelihood of DVT.
reference_ids_tool_tip reference_ids [10]
para, childcount:1
Dysphagia management and prevention and
significance of aspiration pneumonia para, childcount:1
Recent evidence has shown that graded compression
para, childcount:2 stockings are of no benefit in preventing DVT and
The importance of recognizing and proactively increase incidence of skin breakdown. reference_ids_tool_tip
reference_ids [11] Research on the benefit of pneumatic
managing impaired swallowing should not be
underestimated. Dysphagia is seen in 42-67% of compression devices is so far inconclusive.
patients within the first 72 hours post stroke.
reference_ids_tool_tip reference_ids [5] Per stroke guidelines, a para, childcount:1
basic swallow screen should be performed by nursing Daily, low-dose, low molecular weight heparin
staff before any initial food or drink is provided to a administered subcutaneously has been shown to
patient. reference_ids_tool_tip reference_ids [6] Patients with reduce the incidence of DVT compared with
findings suggestive of dysphagia, including cough, unfractionated heparin. The rate of intracranial and
voice changes, level of consciousness, prolonged major extracranial hemorrhage, 1%, was equal with
mastication, should be further evaluated by a speech low molecular weight heparin and unfractionated
therapist. To be clear, the initial screening process is heparin. Expense of adverse drug events per patient
not equivalent to a thorough evaluation of swallowing associated with low molecular weight heparin is also
impairment. significantly lower than unfractionated heparin in
patients with ischemic stroke. reference_ids_tool_tip reference_ids
[12]
para, childcount:0
A modified barium swallow or videofluoroscopy is used
to ascertain if any feeding is safe and, if so, what para, childcount:0
consistency of solids and liquids are appropriate. Consideration of DVT prevention in patients with
Aspiration is defined as the penetration of food or saliva hemorrhagic stroke is challenging owing to the
beyond the vocal chords and is termed silent if the significantly higher rate of DVT and risk of rebleeding.
patient is without symptoms such as cough when this Anticoagulation, using either low molecular weight
penetration occurs. Bedside evaluation for dysphagia heparin or unfractionated heparin has only shown a
is certainly limited by the fact that as many as 40% of small and nonsignificant reduction in both DVT and
patients who aspirate do so silently. Accordingly, mortality. Class IV evidence indicates it is most likely
modified barium swallow is likely needed in all but a few safe to start low molecular weight heparin in patients
cases of patients with any suspicion for dysphagia. with nonexpanding hemorrhage 3-4 days post
hemorrhagic stroke.
Aspiration pneumonia, resultant from penetration of
food, saliva, and gastric acid, has very serious para, childcount:1
ramifications, including high mortality, increased Ongoing research is examining the impact of early
length of hospital stay, and poor functional outcome. mobilization of stroke patients in terms of DVT
reference_ids_tool_tip reference_ids [7] Early recognition and prevention and other benefits. No clear data exist to
treatment of the condition with antibiotics and indicate adequate mobility in deciding when to stop
pulmonary toilet are vital to improving survival. chemoprophylaxis. reference_ids_tool_tip reference_ids [13]
Organisms responsible are often anaerobic and thus
require differing antibiotic coverage than typical para, childcount:1
community-acquired pneumonia. The exact Hypertension management
pathophysiology is still somewhat debated, as
bronchial inflammation resultant from exposure to para, childcount:1
More passive blood pressure management is pursued
in acute care for ischemic stroke owing to concern for
endangering the penumbra or area immediately
adjacent to infarcted brain tissue. The target blood
pressure for acute ischemic stroke within the first 24-
72 hours is below 220/120 mm Hg. In the case of
hemorrhagic stroke, pressure management is much
more critical and remains important long term.
Generally, the target is below 160/90 mm Hg,
although new research shows benefit of lowering
blood pressure even more aggressively.
reference_ids_tool_tip reference_ids [14]

para, childcount:1
Again, the focus of this article is postacute stroke
treatments. After 72 hours, it is prudent and safe to
begin normalizing blood pressure, except in the rare
case that the stroke is thought to have been caused
by hemodynamic instability. Target blood pressures
are below 140/90 mm Hg, except in patients with
nephropathy or diabetes, for which the target is below
130/80 mm Hg. reference_ids_tool_tip reference_ids [15]

para, childcount:1
Smoking cessation

para, childcount:0
The patient should receive ongoing efforts and
education to achieve and encourage discontinuation
of tobacco use.

para, childcount:1
Stroke education

para, childcount:0
Patients should receive education regarding the
causes of stroke to promote behaviors that will help
prevent recurrence. This education also potentially
serves to promote better community awareness of the
signs and symptoms of stroke, with the hope of leading
to earlier recognition and treatment.