Aphasia: Prognosis and treatment
- David Glenn Clark, MD
David Glenn Clark, MD
- Associate Professor of Neurology
- Medical University of South Carolina
Aphasia is a loss of ability to produce or understand language. The most common cause of aphasia is cerebrovascular disease, particularly cerebral infarction. Aphasia complicates 15 to 38 percent of ischemic strokes [1-4]. Other structural pathologies (infection, trauma, neoplasm) and certain neurodegenerative diseases (primary progressive aphasia) can also cause aphasia.
Aphasia can be a devastating condition and is one of the most feared consequences of cerebral infarction and other brain injuries . Although quality of life in patients with aphasia is difficult to measure directly, the disruption in communication with its likely effects on employment status and social networks suggests that its impact can be profound [6-8]. Caregivers of stroke survivors are likely to experience more stress when caring for a family member with, rather than without, aphasia [9,10]. Comprehension deficits can also limit rehabilitation efforts targeting other post-stroke deficits such as hemiparesis [11,12]. Patients with post-stroke aphasia have greater morbidity and mortality than stroke patients without aphasia . While most, if not all, patients with post-stroke aphasia have some functional recovery, residual deficits are common. Unfortunately, there is limited evidence that therapeutic interventions are effective.
This topic reviews the prognosis and management of aphasia, focusing on post-stroke aphasia, which is the most common etiology. The evaluation of aphasia, the management of primary progressive aphasia and other aspects of stroke prognosis and management are discussed separately. (See "Approach to the patient with aphasia" and "Initial assessment and management of acute stroke" and "Frontotemporal dementia: Clinical features and diagnosis".)
Recovery from aphasia is influenced by lesion location and type of aphasia. As an example, large lesions in the left hemisphere with global aphasia have a much poorer recovery than small, subcortical lesions with anomia.
The prognosis for aphasia recovery depends in large part upon the underlying etiology. This has been best studied in cerebrovascular disease. Most patients with post-stroke aphasia improve to some extent [1-4,14,15]. Most improvement occurs within the first few months and plateaus after one year. The severity of the initial aphasia strongly correlates with the long-term deficit; those with milder degrees of aphasia at onset are the most likely to recover completely [16-18]. In one study of post-stroke aphasia, baseline phonology was the linguistic component that was most predictive of recovery at one year; other factors associated with good one year outcomes were younger age, higher Barthel Index, higher educational level and hemorrhagic (as opposed to ischemic) stroke . Patients with significant aphasia may benefit from intensive treatment regimens even after the period of spontaneous recovery [20,21]. Smaller studies in patients with aphasia resulting from traumatic brain injury indicate that the clinical course is similar to post-stroke aphasia .
- Inatomi Y, Yonehara T, Omiya S, et al. Aphasia during the acute phase in ischemic stroke. Cerebrovasc Dis 2008; 25:316.
- Berthier ML. Poststroke aphasia : epidemiology, pathophysiology and treatment. Drugs Aging 2005; 22:163.
- Wade DT, Hewer RL, David RM, Enderby PM. Aphasia after stroke: natural history and associated deficits. J Neurol Neurosurg Psychiatry 1986; 49:11.
- Pedersen PM, Jørgensen HS, Nakayama H, et al. Aphasia in acute stroke: incidence, determinants, and recovery. Ann Neurol 1995; 38:659.
- Solomon NA, Glick HA, Russo CJ, et al. Patient preferences for stroke outcomes. Stroke 1994; 25:1721.
- Davidson B, Howe T, Worrall L, et al. Social participation for older people with aphasia: the impact of communication disability on friendships. Top Stroke Rehabil 2008; 15:325.
- Isaki E, Turkstra L. Communication abilities and work re-entry following traumatic brain injury. Brain Inj 2000; 14:441.
- Hilari K, Byng S. Health-related quality of life in people with severe aphasia. Int J Lang Commun Disord 2009; 44:193.
- Bakas T, Kroenke K, Plue LD, et al. Outcomes among family caregivers of aphasic versus nonaphasic stroke survivors. Rehabil Nurs 2006; 31:33.
- Choi-Kwon S, Kim HS, Kwon SU, Kim JS. Factors affecting the burden on caregivers of stroke survivors in South Korea. Arch Phys Med Rehabil 2005; 86:1043.
- Demir SO, Altinok N, Aydin G, Köseoğlu F. Functional and cognitive progress in aphasic patients with traumatic brain injury during post-acute phase. Brain Inj 2006; 20:1383.
- Paolucci S, Matano A, Bragoni M, et al. Rehabilitation of left brain-damaged ischemic stroke patients: the role of comprehension language deficits. A matched comparison. Cerebrovasc Dis 2005; 20:400.
- Ellis C, Simpson AN, Bonilha H, et al. The one-year attributable cost of poststroke aphasia. Stroke 2012; 43:1429.
- Ashtary F, Janghorbani M, Chitsaz A, et al. A randomized, double-blind trial of bromocriptine efficacy in nonfluent aphasia after stroke. Neurology 2006; 66:914.
- Laska AC, Hellblom A, Murray V, et al. Aphasia in acute stroke and relation to outcome. J Intern Med 2001; 249:413.
- Pedersen PM, Vinter K, Olsen TS. Aphasia after stroke: type, severity and prognosis. The Copenhagen aphasia study. Cerebrovasc Dis 2004; 17:35.
- Bakheit AM, Shaw S, Carrington S, Griffiths S. The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke. Clin Rehabil 2007; 21:941.
- Lazar RM, Minzer B, Antoniello D, et al. Improvement in aphasia scores after stroke is well predicted by initial severity. Stroke 2010; 41:1485.
- El Hachioui H, Lingsma HF, van de Sandt-Koenderman MW, et al. Long-term prognosis of aphasia after stroke. J Neurol Neurosurg Psychiatry 2013; 84:310.
- Poeck K, Huber W, Willmes K. Outcome of intensive language treatment in aphasia. J Speech Hear Disord 1989; 54:471.
- Moss A, Nicholas M. Language rehabilitation in chronic aphasia and time postonset: a review of single-subject data. Stroke 2006; 37:3043.
- Jordan LC, Hillis AE. Disorders of speech and language: aphasia, apraxia and dysarthria. Curr Opin Neurol 2006; 19:580.
- Richter M, Miltner WH, Straube T. Association between therapy outcome and right-hemispheric activation in chronic aphasia. Brain 2008; 131:1391.
- Saur D, Lange R, Baumgaertner A, et al. Dynamics of language reorganization after stroke. Brain 2006; 129:1371.
- de Boissezon X, Démonet JF, Puel M, et al. Subcortical aphasia: a longitudinal PET study. Stroke 2005; 36:1467.
- Price CJ, Crinion J. The latest on functional imaging studies of aphasic stroke. Curr Opin Neurol 2005; 18:429.
- Warren JE, Crinion JT, Lambon Ralph MA, Wise RJ. Anterior temporal lobe connectivity correlates with functional outcome after aphasic stroke. Brain 2009; 132:3428.
- Turkeltaub PE, Messing S, Norise C, Hamilton RH. Are networks for residual language function and recovery consistent across aphasic patients? Neurology 2011; 76:1726.
- Lidzba K, Staudt M, Zieske F, et al. Prestroke/poststroke fMRI in aphasia: perilesional hemodynamic activation and language recovery. Neurology 2012; 78:289.
- Mattioli F, Ambrosi C, Mascaro L, et al. Early aphasia rehabilitation is associated with functional reactivation of the left inferior frontal gyrus: a pilot study. Stroke 2014; 45:545.
- Forkel SJ, Thiebaut de Schotten M, Dell'Acqua F, et al. Anatomical predictors of aphasia recovery: a tractography study of bilateral perisylvian language networks. Brain 2014; 137:2027.
- Robson H, Zahn R, Keidel JL, et al. The anterior temporal lobes support residual comprehension in Wernicke's aphasia. Brain 2014; 137:931.
- Hagmann P, Cammoun L, Martuzzi R, et al. Hand preference and sex shape the architecture of language networks. Hum Brain Mapp 2006; 27:828.
- Nieuwenhuis L, Nicolai J. The pathophysiological mechanisms of cognitive and behavioral disturbances in children with Landau-Kleffner syndrome or epilepsy with continuous spike-and-waves during slow-wave sleep. Seizure 2006; 15:249.
- Kelly H, Brady MC, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Database Syst Rev 2010; :CD000425.
- de Jong-Hagelstein M, van de Sandt-Koenderman WM, Prins ND, et al. Efficacy of early cognitive-linguistic treatment and communicative treatment in aphasia after stroke: a randomised controlled trial (RATS-2). J Neurol Neurosurg Psychiatry 2011; 82:399.
- Robey RR. A meta-analysis of clinical outcomes in the treatment of aphasia. J Speech Lang Hear Res 1998; 41:172.
- Bhogal SK, Teasell R, Speechley M. Intensity of aphasia therapy, impact on recovery. Stroke 2003; 34:987.
- Bakheit AM, Shaw S, Barrett L, et al. A prospective, randomized, parallel group, controlled study of the effect of intensity of speech and language therapy on early recovery from poststroke aphasia. Clin Rehabil 2007; 21:885.
- Meinzer M, Streiftau S, Rockstroh B. Intensive language training in the rehabilitation of chronic aphasia: efficient training by laypersons. J Int Neuropsychol Soc 2007; 13:846.
- Aftonomos LB, Appelbaum JS, Steele RD. Improving outcomes for persons with aphasia in advanced community-based treatment programs. Stroke 1999; 30:1370.
- Cherney LR, Erickson RK, Small SL. Epidural cortical stimulation as adjunctive treatment for non-fluent aphasia: preliminary findings. J Neurol Neurosurg Psychiatry 2010; 81:1014.
- Szaflarski JP, Ball A, Grether S, et al. Constraint-induced aphasia therapy stimulates language recovery in patients with chronic aphasia after ischemic stroke. Med Sci Monit 2008; 14:CR243.
- Cherney LR, Patterson JP, Raymer A, et al. Evidence-based systematic review: effects of intensity of treatment and constraint-induced language therapy for individuals with stroke-induced aphasia. J Speech Lang Hear Res 2008; 51:1282.
- Meinzer M, Djundja D, Barthel G, et al. Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke 2005; 36:1462.
- Palmer R, Enderby P, Cooper C, et al. Computer therapy compared with usual care for people with long-standing aphasia poststroke: a pilot randomized controlled trial. Stroke 2012; 43:1904.
- Berthier ML, Green C, Lara JP, et al. Memantine and constraint-induced aphasia therapy in chronic poststroke aphasia. Ann Neurol 2009; 65:577.
- Greener J, Enderby P, Whurr R. Pharmacological treatment for aphasia following stroke. Cochrane Database Syst Rev 2001; :CD000424.
- Sabe L, Salvarezza F, García Cuerva A, et al. A randomized, double-blind, placebo-controlled study of bromocriptine in nonfluent aphasia. Neurology 1995; 45:2272.
- Walker-Batson D, Curtis S, Natarajan R, et al. A double-blind, placebo-controlled study of the use of amphetamine in the treatment of aphasia. Stroke 2001; 32:2093.
- Martinsson L, Hårdemark HG, Wahlgren NG. Amphetamines for improving stroke recovery: a systematic cochrane review. Stroke 2003; 34:2766.
- Kessler J, Thiel A, Karbe H, Heiss WD. Piracetam improves activated blood flow and facilitates rehabilitation of poststroke aphasic patients. Stroke 2000; 31:2112.
- Berthier ML, Hinojosa J, Martín Mdel C, Fernández I. Open-label study of donepezil in chronic poststroke aphasia. Neurology 2003; 60:1218.
- Hong JM, Shin DH, Lim TS, et al. Galantamine administration in chronic post-stroke aphasia. J Neurol Neurosurg Psychiatry 2012; 83:675.
- Code C, Hemsley G, Herrmann M. The emotional impact of aphasia. Semin Speech Lang 1999; 20:19.
- Kauhanen ML, Korpelainen JT, Hiltunen P, et al. Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke. Cerebrovasc Dis 2000; 10:455.
- Thomas SA, Lincoln NB. Factors relating to depression after stroke. Br J Clin Psychol 2006; 45:49.
- Laska AC, von Arbin M, Kahan T, et al. Long-term antidepressant treatment with moclobemide for aphasia in acute stroke patients: a randomised, double-blind, placebo-controlled study. Cerebrovasc Dis 2005; 19:125.
- Martin PI, Naeser MA, Theoret H, et al. Transcranial magnetic stimulation as a complementary treatment for aphasia. Semin Speech Lang 2004; 25:181.
- Naeser MA, Martin PI, Nicholas M, et al. Improved picture naming in chronic aphasia after TMS to part of right Broca's area: an open-protocol study. Brain Lang 2005; 93:95.
- Mottaghy FM, Sparing R, Töpper R. Enhancing picture naming with transcranial magnetic stimulation. Behav Neurol 2006; 17:177.
- Elsner B, Kugler J, Pohl M, Mehrholz J. Transcranial direct current stimulation (tDCS) for improving aphasia in patients with aphasia after stroke. Cochrane Database Syst Rev 2015; 5:CD009760.
- Cotelli M, Calabria M, Manenti R, et al. Improved language performance in Alzheimer disease following brain stimulation. J Neurol Neurosurg Psychiatry 2011; 82:794.
- Thiel A, Hartmann A, Rubi-Fessen I, et al. Effects of noninvasive brain stimulation on language networks and recovery in early poststroke aphasia. Stroke 2013; 44:2240.
- Wang CP, Hsieh CY, Tsai PY, et al. Efficacy of synchronous verbal training during repetitive transcranial magnetic stimulation in patients with chronic aphasia. Stroke 2014; 45:3656.
- Monti A, Ferrucci R, Fumagalli M, et al. Transcranial direct current stimulation (tDCS) and language. J Neurol Neurosurg Psychiatry 2013; 84:832.
- Baker JM, Rorden C, Fridriksson J. Using transcranial direct-current stimulation to treat stroke patients with aphasia. Stroke 2010; 41:1229.
- Tsapkini K, Frangakis C, Gomez Y, et al. Augmentation of spelling therapy with transcranial direct current stimulation in primary progressive aphasia: Preliminary results and challenges. Aphasiology 2014; 28:1112.
- Tippett DC, Hillis AE, Tsapkini K. Treatment of Primary Progressive Aphasia. Curr Treat Options Neurol 2015; 17:362.