How stroke affects speech and language
To know why a stroke can cause so many different
Effects of left-sided stroke: Aphasia and language
apraxia
Stroke (also known as a cerebrovascular accident or
CVA) usually affects one side of the brain. Movement
and sensation for one side of the body is controlled by
the opposite side of the brain. This means that if your
stroke affected the left side of your brain, you will have
problems with the right side of your body. Some
problems that happen after stroke are more common
with stroke on one side of the brain than the other. The
left side of the brain controls the ability to speak and
understand language in most people. The right side of
the brain controls the ability to pay attention, recognize
things you see, hear or touch, and be aware of your
own body. In some left-handed people, language is
controlled by the right side of the brain and awareness
by the left side of the brain.
Aphasia You may have problems with:
speaking
listening
reading
writing
dealing with numbers
understanding speech
thinking of words when talking or writing
How much trouble you have with aphasia depends on
the type and severity of your braininjury. Aphasia
means you have problems speaking and
understanding language. You may be unable to find the
words you need to put sentences together. This is like
having a word 'on the tip of your tongue.' Not all
strokes cause aphasia. About 20 percent of stroke
survivors have a loss of speech and language.
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.
The exam includes four areas:
speaking out loud
writing
listening comprehension
reading comprehension
You may have problems in some or all four areas. For
example, you may have problems reading and writing
but not in talking. This exam can also show which
areas of speech and language have been least
affected. Language apraxia When you have
language apraxia (aPRAYX-ee-a), you know the right
words but you have problems forming words or putting
sounds together. Muscle weakness or loss of feeling
does not cause this. If you have mild apraxia, you will
have clear speech with inconsistent sound
substitutions. For example, a "cup of coffee" may come
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
syllable or phrase over and over. For example, "do-do-
do" or "I dunno."
Left Hemispheric Damage
Left hemispheric damage may produce a right
hemianopsia or quadranopsia, but may also impact
mood and behavior. Some patients may appear
compulsive, disorganized and easily
frustrated. Patients may demonstrate problems in
memory, speech, writing, and cognitive processing.
Left brain damage results in problems on the right side
of the body including paralysis. Reading ability may be
impaired at a cognitive level. Often this loss of reading
and speech can be rehabilitated with speech therapy,
but in some cases this loss is permanent. The visual
field loss on the right side may also be a cause of
reading impairment. Learn more about this in our
section on reading problems.

The middle cerebral artery territory is the most
commonly affected territory in a cerebral infarction,
due to the size of the territory and the direct flow from
internal carotid artery into the middle cerebral artery,
providing the easiest path for thromboembolism.
Clinical presentation
The neurological deficit will depend on the extent of
the infarct and hemispheric dominance, and include:
contralateral hemiparesis
contralateral hemisensory loss
hemianopia
aphasia: if the dominant hemisphere is involved;
may be expressive in anterior MCA territory
infarction, receptive in posterior MCA stroke,
or global with extensive infarction
neglect: non-dominant hemisphere
Radiographic features
Generally the features are those of cerebral infarction,
similar to those seen in any other territory. As such
these features are discussed in generic article:
cerebral infarction.
There are however certain features specific to middle
cerebral artery infarct, and these are discussed below.
For both CT and MRI it is worth dividing the features
according to time course.
It should also be noted that middle cerebral artery
infarcts are often incomplete affecting only perforator
branches or one or more distal branches. As such in
many cases only parts of the middle cerebral artery
territory is affected.
CT
The earliest finding of middle cerebral artery occlusion
is:
hyperdense middle cerebral artery sign 3
seen immediately and represents direct
visualisation of the thromboembolism.
presence of calcification is important as it is
a contraindication to angioplasty
Early parenchymal signs include subtle blurring,
decreased attenuation and swelling of the grey-white
matter junction of affected regions. It should be noted
that deep grey matter structures are affected before
the cortex due to lenticulostriate arteries being end
arteries, and cytotoxic oedema (intracellular fluid
accumulation) occurring earlier 2, 4:
lentiform nucleus; caudate nucleus
as early as 1 hour after occlusion 4
visible in 75% of patients at 3 hours 4
insular ribbon
although cortical it is the furthest cortex from
collateral circulation and is therefore also
affected early 4
the insular ribbon sign describes loss of
normal grey-white differentiation
surface cortex (including peri-rolandic cortex)
collateral flow retards the development of CT
signs with only 20% of cases demonstrating
changes at 3 hours 4
With time the hypo-attenuation and swelling become
more marked, and in patients with the majority of the
MCA territory affected the mass effect is often
dramatic and life threatening, sometimes requiring a
decompressive craniectomy.
As time passes the infarct undergoes a gradual
reduction in swelling and mass effect (see cerebral
infarction).
MRI
Other than demonstrating the typical distribution of
affected tissue or occlusion of the vessel on MRA,
appearances of a middle cerebral artery infarct are
similar to those of infarcts anywhere else (see
cerebral infarction).
Treatment and prognosis
Treatment of middle cerebral artery infarcts is the same
as infarcts anywhere else (see cerebral infarction)
except that due to the size of the involved territory the
degree of mass effect resulting from infarction can be
marked and life threatening. As such decompressive
craniectomy is advocated by many as a life-saving
procedure.
Overview
Middle cerebral artery (MCA) stroke describes the
sudden onset of focal neurologic deficit resulting from
brain infarction or ischemia in the territory supplied by
the MCA.
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The MCA is by far the largest cerebral artery and is
the vessel most commonly affected by
cerebrovascular accident. The MCA supplies most of
the outer convex brain surface, nearly all the basal
ganglia, and the posterior and anterior internal
capsules. Infarcts that occur within the vast
distribution of this vessel lead to diverse neurologic
sequelae. Understanding these neurologic deficits
and their correlation to specific MCA territories has
long been researched.
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Research has also focused on the correlation
between specific neurologic deficits after MCA stroke
and differing outcomes and prognoses. Such efforts
are important in ascertaining who may benefit from
emergent antithrombotic therapies. Furthermore,
these research efforts may later allow physiatrists to
target rehabilitative efforts more effectively in
appropriately selected patients who may derive
benefit.
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This article focuses more on the postacute care and
rehabilitation of patients with MCA stroke. However,
evidence-based practice of acute stroke care obviously
needs to be carried over into the rehabilitation setting.
This is particularly true since patients are ideally being
admitted to such settings quite early after their event.
The American Heart Association guidelines are an
excellent resource for standards of stroke care.
Certified centers for stroke care have proven to have
better outcomes in terms of morbidity, mortality, and
eventual functional outcome relative to those without
such specialization.
Rehabilitation Setting Selection and Indications
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Knowing and using objective criteria in recommending
a rehabilitation plan best suited for a patient is
imperative. This effort to maximize functional outcome
and independence and targeting expensive resources
to patients who will benefit is a very important role for
physiatrists and other rehabilitation specialists.
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Acute, inpatient rehabilitation is the most intense and
expensive rehabilitation setting in terms of hours of
therapy provided each day. Comparison to subacute
rehabilitation, typically provided in a skilled nursing
facility, in terms of functional outcome, is discussed
later in this article. However, the basic criteria for
admission to acute rehabilitation are as follows:
itemizedlist
listitem
para, childcount:0Potential for significant functional
improvement requiring at least 2 therapy disciplines in
a reasonable period
listitem
para, childcount:0Realistic and safe
discharge plan with family support and
housing that allows return to the community
rather than to a skilled nursing facility or
long-term care
listitem
para, childcount:0Medical stability,
willingness, and ability to participate in at
least 3 hours of therapy/day
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Inpatient, subacute rehabilitation is generally offered
at a skilled nursing facility or long-term acute care
hospital. Patients with more complex medical care
such as mechanical ventilation or advanced wound
care often undergo at least their initial rehabilitation at
a long-term acute care hospital. Both skilled nursing
facility and long-term acute care hospital therapy is
generally, but not always, with fewer hours of therapy
offered per week. Such facilities are not bound to a
minimum hours of therapy per day.
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Home health and outpatient therapy are provided to
patients after they complete their inpatient therapy or
for those who are less impaired after their stroke.
Contraindications
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Frankly, there are very few indications for no therapy
and evidence does suggest that earlier mobilization
translates to better long-term patient outcome.
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Ideally, rehabilitation should begin immediately after a
patient is admitted for stroke, barring additional medical
issues aside from the stroke itself. reference_ids_tool_tip
reference_ids [3]
Best Practices
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The American Heart Association (AHA) guidelines
have become a widely used standard of care for
individuals with both ischemic and hemorrhagic
stroke. Comprehensive review of these guidelines is
outside of the postacute stroke focus of this article.
However, certain elements are quite relevant to the
rehabilitation setting.
Certified stroke center
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Patients should be directed to medical centers
designated and accredited for the interdisciplinary
care of stroke patients. Improved outcome in terms of
mortality, length of stay, return to home, patient
function, and cost of care have all been shown to be
superior in care centers consistent in AHA guideline
based practices. reference_ids_tool_tip reference_ids [4] These
centers must track and document consistent
interdisciplinary practices in the care of stroke patients
that are shown to improve outcomes. This care
includes but is not exclusive to the following:
itemizedlist
listitem
para, childcount:0Appropriate and expedient
use of thrombolytic therapy*
listitem
para, childcount:0Dysphagia screening
listitem
para, childcount:0Venous thromboembolism
prophylaxis
listitem
para, childcount:0Discharged on
antithrombotic therapy*
listitem
para, childcount:0Anticoagulation therapy for
atrial fibrillation/flutter*
listitem
para, childcount:0Discharged on statin
medication*
listitem
para, childcount:0Discharged on
antihypertensive medication or
documentation stating why contraindicated
listitem
para, childcount:0Stroke education
listitem
para, childcount:0Smoking cessation
education
listitem
para, childcount:0Assessed for rehabilitation
*Denotes care for ischemic but not hemorrhagic
stroke.

Pharmaceutical management
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Thrombolytic therapy should be administered in a very
orchestrated and consistent manner, relying on
emergent imaging and screening to ensure only
patients with ischemic stroke and no contraindications
receive such therapy. After ischemic stroke, patients
should be discharged from acute care on a statin,
antihypertensive, and appropriate antithrombotic
and/or anticoagulation medicines to prevent recurrent
stroke. The selection of such medications is
dependent on the presence of comorbidities, including
atrial fibrillation, coronary artery disease, congestive
heart failure, and diabetes.
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Dysphagia management and prevention and
significance of aspiration pneumonia
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The importance of recognizing and proactively
managing impaired swallowing should not be
underestimated. Dysphagia is seen in 42-67% of
patients within the first 72 hours post stroke.
reference_ids_tool_tip reference_ids [5] Per stroke guidelines, a
basic swallow screen should be performed by nursing
staff before any initial food or drink is provided to a
patient. reference_ids_tool_tip reference_ids [6] Patients with
findings suggestive of dysphagia, including cough,
voice changes, level of consciousness, prolonged
mastication, should be further evaluated by a speech
therapist. To be clear, the initial screening process is
not equivalent to a thorough evaluation of swallowing
impairment.
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A modified barium swallow or videofluoroscopy is used
to ascertain if any feeding is safe and, if so, what
consistency of solids and liquids are appropriate.
Aspiration is defined as the penetration of food or saliva
beyond the vocal chords and is termed silent if the
patient is without symptoms such as cough when this
penetration occurs. Bedside evaluation for dysphagia
is certainly limited by the fact that as many as 40% of
patients who aspirate do so silently. Accordingly,
modified barium swallow is likely needed in all but a few
cases of patients with any suspicion for dysphagia.
Aspiration pneumonia, resultant from penetration of
food, saliva, and gastric acid, has very serious
ramifications, including high mortality, increased
length of hospital stay, and poor functional outcome.
reference_ids_tool_tip reference_ids [7] Early recognition and
treatment of the condition with antibiotics and
pulmonary toilet are vital to improving survival.
Organisms responsible are often anaerobic and thus
require differing antibiotic coverage than typical
community-acquired pneumonia. The exact
pathophysiology is still somewhat debated, as
bronchial inflammation resultant from exposure to
gastric acid, as well as bacterial infection, both likely
contribute. reference_ids_tool_tip reference_ids [8]
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Deep venous thrombosis and pulmonary embolism
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Pulmonary embolism (PE) accounts for 10-25 % of
mortality of patients after stroke. In addition,
symptomatic deep venous thrombosis (DVT) and
postphlebitis syndrome impede recovery and function
for patients after stroke. reference_ids_tool_tip reference_ids [9]
Prevention of DVT and PE is achieved either by
patient mobilization or pharmaceutical intervention.
Dehydration, hemorrhagic stroke, severity of
paralysis, and age are all additional risk factors
associated with increased likelihood of DVT.
reference_ids_tool_tip reference_ids [10]
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Recent evidence has shown that graded compression
stockings are of no benefit in preventing DVT and
increase incidence of skin breakdown. reference_ids_tool_tip
reference_ids [11] Research on the benefit of pneumatic
compression devices is so far inconclusive.
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Daily, low-dose, low molecular weight heparin
administered subcutaneously has been shown to
reduce the incidence of DVT compared with
unfractionated heparin. The rate of intracranial and
major extracranial hemorrhage, 1%, was equal with
low molecular weight heparin and unfractionated
heparin. Expense of adverse drug events per patient
associated with low molecular weight heparin is also
significantly lower than unfractionated heparin in
patients with ischemic stroke. reference_ids_tool_tip reference_ids
[12]
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Consideration of DVT prevention in patients with
hemorrhagic stroke is challenging owing to the
significantly higher rate of DVT and risk of rebleeding.
Anticoagulation, using either low molecular weight
heparin or unfractionated heparin has only shown a
small and nonsignificant reduction in both DVT and
mortality. Class IV evidence indicates it is most likely
safe to start low molecular weight heparin in patients
with nonexpanding hemorrhage 3-4 days post
hemorrhagic stroke.
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Ongoing research is examining the impact of early
mobilization of stroke patients in terms of DVT
prevention and other benefits. No clear data exist to
indicate adequate mobility in deciding when to stop
chemoprophylaxis. reference_ids_tool_tip reference_ids [13]
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Hypertension management
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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]

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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]

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Smoking cessation

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The patient should receive ongoing efforts and
education to achieve and encourage discontinuation
of tobacco use.

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Stroke education

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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.