Key-words:
Aphasia - aphasia - brain tumors - cerebrovascular accident - head injury - language
- memory - speech - traumatic brain injury
Introduction
Damage to the brain tissue impairs a person's ability to perform certain functions
and communication based on the damaged area and extent of damage. Traumatic brain
injury (TBI), neurosurgical intervention for tumors, cerebrovascular accident (CVA),
etc., are known to cause postsurgical complications such as communication difficulties
when the areas corresponding to speech and language comprehension and expression are
involved. Based on the area and extent of brain tissue damage, a person's ability
to communicate can be impaired from mild-to-severe degree. Based on the cortical or
subcortical structures damaged, speech and language disturbances vary among neurosurgical
patients. Aphasia is a common communication disorder seen in these patients. Aphasia
is defined as the impairment of comprehension or production of language in written
or spoken forms due to an acquired lesion of the dominant cerebral hemisphere.[[1]] There are many types of aphasia and they are broadly classified as nonfluent and
fluent types. In nonfluent aphasias, comprehension is preserved to some extent, but
expression is severely affected. In fluent aphasias, expression is preserved to some
extent, but comprehension is more affected. The knowledge on speech and communication
abnormality from our state is limited. The present study from a tertiary care hospital
discusses its experience among neurosurgical patients visited with speech and communication
impairment.
Materials and Methods
The present study was carried out at Narayana Medical College Hospital in Nellore,
AP, India. A total of 38 adult patients (12 female and 26 male) with various etiologies
were taken for the study. Among them, 28 were head injury (HI) cases, 2 postoperative
CVA (1 ischemic and 1 hemorrhagic), and 8 postoperative tumor patients were included
in this study. The study was approved by institutional ethical committee and informed
consent was obtained from the patients and or their relatives. All the patients were
assessed for speech and language disturbances in the acute stage. A pro forma was
made to evaluate speech and language disturbances based on Western Aphasia Battery
bedside evaluation.[[2]] The pro forma includes demographic details, medical history, radiological findings,
and surgical intervention details. Detailed pro forma is attached in appendix.
Results
The age range of patients was 17 years being minimum and 87 years being maximum (mean
age was 45.6 years with standard deviation 16 years). Education levels of the patients
were as follows: illiterates 16 and literates 22. Most of the patients were monolinguals
with Telugu as their mother language only four patients were bilinguals. All patients
were right-handed dominance individuals. Of 28 TBI patients, 10 patients had loss
of consciousness. Brain parenchyma contusion was seen among 20 patients, subdural
hemorrhage among 13 patients, subarachnoid hemorrhage, and extradural hemorrhage among
one patient. Twenty patients had left cerebral hemisphere injury, 6 patients had right
cerebral hemisphere and 2 patients had bilateral cerebral hemisphere injury. Eight
patients had brain tumor, of them four had in right and four had in left cerebral
hemispheres. Two patients had CVA, of them one patient right and one patient had left
cerebral hemisphere affected. Details of speech and communication abnormality with
side of cerebral hemispheres involved are mentioned in [[Table 1]].
Table 1: Details of speech and communication abnormality among neurosurgical patients
Discussion
One of the major causes, which impair communication in adult population, is sudden
damage to the brain tissue. This damage could be due to trauma to head, CVA, postsurgical
complications, etc., This damage can lead to communication disorders such as aphasia
(common classification used for aphasia is as follows: Global, Broca's, Wernicke's,
transcortical motor, transcortical sensory, mixed transcortical, conduction, anomic,
crossed, subcortical, and primary progressive aphasia),[[3]] dysarthria, and apraxia of speech. CHI cases may exhibit some linguistic difficulties
for first few months which can be identified by aphasia battery. These difficulties
may not be seen later. Focal lesions cause aphasia, dysarthria, apraxia, dysphagia,
amnesia, etc., and may also result in attention, pragmatic, and perceptual disturbances.
Diffuse brain injury causes difficulties in attention, long-term memory, perception,
problem solving, and pragmatic aspects (poor comprehension and expression of abstract
items).[[4]] Difficulties in attention was seen in the present study also as some of the patients
were not assessed properly due to lack of attention. The present study reports that
irrespective of cause of brain damage left hemisphere damage manifest with conduction
aphasia, anomic aphasias, mild dysarthria, transcortical sensory aphasia (TSA), Wernicke's
aphasia, global, and subcortical aphasia. Damage to the right side cerebral hemisphere
manifest with mild dysarthria, anomic aphasia, and TSA [[4]] reported that in RHD cases there will be deficits in confrontation naming, comprehension
of complex information, word fluency, reading, and writing.
Some patients do have auditory perception problems when the auditory cortex is involved.
Studies have reported that acute stage of HI patients' exhibit anomic aphasia and
verbal paraphasias frequently, along with reading and writing difficulties. In the
present study, most of the cases had anomic aphasia than other types. Confused language,
irrelevance, confabulation, verbal paraphasias, and memory disturbances were major
difficulties reported in majority studies which were done on HI patients. Initial
and long-term communication difficulties in TBI are as follows:[[5]] confused language, dysarthria, auditory comprehension difficulties, reading and
writing difficulties, word-finding difficulty, and poor pragmatics of language (turn-taking,
topic maintenance, selection of topic, being relevant while communicating, etc.).
TBI cases exhibit more pragmatic deficits than a typical aphasic patient (CVA). Many
TBI cases recover language functions in 1 or 2 months after injury. However, difficulties
in naming, reading, and writing persist for longer time in many cases. Excerpts of
various studies mentioned in [[6]] revealed acute stage of HI patients exhibit anomic aphasia and verbal paraphasias
frequently, along with reading and writing difficulties. Most of the cases with anomic
aphasia resolved completely in <2 years. Language and memory disturbances which were
present following CHI were resolved to major extent in 4 months. Most of the studies
mentioned anomic aphasia in majority cases.[[6]]
Diffuse upper motor neuron damage causes spastic dysarthria and damage to cranial
nerves due to HI causes flaccid dysarthria. Other cognitive and communication deficits
seen in TBI are deficits in concentration, attention, memory, nonverbal problem solving,
part/whole analysis and synthesis, discourse comprehension and expression, abstract
thinking, and speed of processing.[[6]],[[7]] Identifying these disturbances helps us to frame therapy based on individual needs.
Providing rehabilitation at the earliest gives opportunity to utilize the trauma-induced
plasticity to maximum and also improves the quality of life of the patients. The present
study results replicate the literature; however, this series contains a large mixture
of different pathologies and a larger study is needed to further understand the impact
of cortical pathologies on speech and language dysfunctions.
Conclusions
The present study reports that regardless of brain tissue damage, patients' manifest
with speech and communication disturbances. This data add additional knowledge on
speech and communication abnormality among neurosurgical patients from AP, India.
Financial support and sponsorship
The present study was partly funded by a research grant from Association for Helping
Neurosurgical Sick Patients, Valencia (Spain).
