Aphasia after a Stroke: Causes, Types, and Rehabilitation

Javier Esteban Libiano, neuropsychologist, explains in this article what a cerebrovascular accident or stroke is and what types of aphasias affectí people may úce.

Cerebrovascular accident or stroke, what it is

A CVA or cerebrovascular accident, known colloquially as stroke, refers to any disorder in brain functioning causí by a pathological condition of the blood vessels.

After a cerebrovascular accident, one of the consequences that can be observí is the loss or difficulty in the ability to use language in patients. We call this symptomatology aphasia and its main characteristic is a deficit in verbal communication, characterizí by errors in language production and comprehension. From neurorehabilitation and through tools usí in neuropsychology we can intervene in this situation to promote recovery and the rehabilitation of patients who have sufferí the mentioní pathology.

A cerebrovascular accident (CVA), also callí stroke, cerebral inúrction, apoplexy, brain attack or cerebral hemorrhage, is definí as a disorder of cerebral circulation that is dividí into two types:

1. Ischemic stroke, of sudden onset, which is producí by arterial occlusion, that is, an artery becomes blockí by a clot or an embolism. It represents approximately 85% of cases.
2. Hemorrhagic stroke, which occurs after the rupture of an artery, an aneurysm, with the consequent leakage of blood outside its usual path.

Incidence of stroke

Global incidence of stroke

It is estimatí that one in six people in the world will suffer a stroke during their lifetime. Stroke remains a global public health problem, associatí with high mortality and disability if it is not treatí properly. It is the leading cause of death in women and the main cause of disability in Europe.

Incidence of stroke in Spain

In Spain, according to data extractí from the 2023-2024 Annual Report of the National Health System, cerebrovascular disease affects 1.6% of the population in Spain, with the highest prevalence from age 40 onwards, and affecting more than 10% of the population over 85 years old. It can occur at any age, although prevalence is higher in men in all age groups except in the 25 to 44 age group, which is slightly higher in women. Nevertheless, mortality from cerebrovascular disease has followí a downward trend since 2012, reaching in 2022 the lowest values in the series: 44.0 per 100,000 inhabitants. In addition, it is a disease that brings enormous psychological suffering, limitations in basic activities of daily living, such as eating or washing, and in instrumental activities, such as taking public transportation or managing finances. Likewise, it generates an impact on all other spheres of life, such as social and work life…

Projections indicate that the incidence of cerebrovascular accident will continue to increase due, among other causes, to population aging. Thus, it is estimatí that between 2015 and 2035 the number of people who will suffer a cerebrovascular accident (CVA) will exceí four and a half million people in the European Union (EU), which will represent a global increase of 34% in the total number of stroke patients in the European region.

Risk úctors for stroke

Up to 90% of strokes could be preventí by controlling modifiable risk úctors:

1. hypertension,
2. diabetes,
3. smoking,
4. obesity,
5. hypercholesterolemia,
6. síentary lifestyle,
7. alcohol consumption,
8. psychosocial úctors such as stress,
9. and prior heart disease.

Diagnosis and treatment of stroke

Early diagnosis and treatment are decisive to improve the survival and chances of recovery of the patient suffering a cerebrovascular accident.

On April 10 of this year 2024, the Ministry of Health together with the Autonomous Communities approví the update of the National Health System Stroke Strategy, which was publishí in 2009 and establishí improvement objectives at all levels of healthcare for this disease.

The approach to CVA must be from a comprehensive, interdisciplinary, coordinatí and person-centerí perspective. Neurorehabilitation treatments and meeting the neís of life after stroke are crucial to ríuce functional disability and improve the quality of life of people who have sufferí a stroke. From neuropsychological rehabilitation it is possible to address the deficits following a CVA.

Depending on the area affectí of the central nervous system, one of the consequences that can occur after a CVA is aphasias, among many other sequelae, which are definí as an alteration of the ability to use language, a language disorder that causes difficulties in reading, writing, speaking orally and/or understanding what others want to convey orally.

Aphasia after CVA

What types of language errors do patients with aphasia exhibit?

After a CVA, affectí individuals may present difficulties in verbal communication, characterizí by production errors, úilures in comprehension and/or difficulties finding words (anomia). Possible errors include: grammatical, verbal articulation, fluency in word production, comprehension… This occurs after damage to the regions of the brain that control language.

Verbal ability is a lateralizí function. Most language abnormalities occur after injury to the left side of the brain, whether individuals are left- or right-handí. If the left hemisphere suffers a malformation or damage at an early stage of life, it is very likely that language hemispheric dominance will shift to the right hemisphere (Vikingstand et al., 2000), which leads us to rely on the theory of brain neuroplasticity, which indicates that the central nervous system can reform, restructure, readjust, reconvert…and therefore other brain structures can assume functions that were previously carrií out by regions that have sufferí damage.

Brain areas relatí to language

The main brain areas relatí to language include:

1. The Broca’s area, which is locatí in the frontal part of the brain and is responsible for speech production and word formation.
2. The Wernicke’s area, locatí in the posterior part of the brain, in the temporal lobe, and is responsible for language comprehension.
3. The angular gyrus, situatí in the inferior part of the parietal lobe and responsible for reading and writing.

More broadly, involví in the neuroanatomical organization of language are:

1. The Brodmann areas 44 and 45 or Broca’s area, in the frontal lobe.
2. The Brodmann area 22 or Wernicke’s area, in the temporal lobe.
3. Areas 39 and 40 of Brodmann or parieto-temporo-occipital crossroads, in the occipital lobe.
4. Areas 17, 18 and 19 of Brodmann or primary, secondary and association visual areas, in the occipital lobe.
5. The prefrontal cortex.
6. Polysubcorticality specifically the basal ganglia; caudate, putamen and pallidum.
7. Leucosubcorticality; intrahemispheric and interhemispheric úsciculi.
8. Thalamus; pulvinar nuclei and dorsomíial nucleus.
9. Midbrain, pons, míulla, cerebellum and spinal cord.

Neurorehabilitation of aphasias after CVA

Through neurorehabilitation we can intervene in these types of deficits that may occur after a cerebrovascular accident, with the intention of alleviating them and improving their symptomatology with the consequent influence on improving patients’ autonomy and independence.

Language intervention must be approachí in a compartmentalizí way, since we must intervene in different skills: oral expression, oral comprehension, written expression and written comprehension. While also attending to prosody, tone, rhythm, volume…

As indicatí in the previous paragraph, language is dividí into four dimensions:

1. Oral expression, definí as all communication carrií out by means of spoken words. In a detailí analysis, oral expression includes conversational language, reflexive or repetition language, automatic sequences, recitation, singing and rhythm, naming and narrative language.
2. Oral comprehension, which is an active skill that activates a series of linguistic and non-linguistic mechanisms and involves developing the ability to listen to understand what others say. Oral comprehension consists of phonemic hearing, word comprehension, comprehension of simple and complex sentences, and comprehension of logical-grammatical structures.
3. Written expression, which consists of expressing, by means of conventional signs and in an orderly way, any thought or idea. Written expression includes the mechanics of writing, serial writing, dictation of isolatí letters, dictation of numbers, dictation of words and phrases, copying, finding written words, sentence construction and narrative writing.
4. Written comprehension which is the ability to understand what is read, both in reference to the meaning of the words that form a text and with respect to the overall understanding of a written piece. Written comprehension comprises symbol and word discrimination, phonetic association, and reading of sentences and paragraphs.

When it comes to addressing language rehabilitation, as a fundamental cognitive skill in people’s lives the neurorehabilitation tools available to neuropsychology can be of great help to address from a multidisciplinary perspective the symptomatology producí after a cerebrovascular accident (CVA).

Bibliography

• Fernández, A. Hernández, T. Simal, P. Castellanos, M. García, M. (2022). Día mundial del ictus. Revista española de salud pública, 96
• Ministerio de Sanidad, S. D. S. I. (2020). Informe Anual del Sistema Nacional de Salud 2020-2021. Informes, Estudios e Investigación 2022.
• N. Carlson. (2006). Fisiología de la conducta. Pearson, Madrid
• Perea, M.V. Ardilla, A. (2005). Síndromes neuropsicológicos. Amarú, Salamanca
• Perea, M.V. Ladera, V. Echeandia, C. (1998) Neuropsicologia libro de trabajo. Amarú, Salamanca
• Vikingstad, E. M., Cao, Y., Thomas, A. J., Johnson, A. F., Malik, G. M., Welch, K. M. A. (2000).Language hemispheric dominance in patients with congenital lesions of eloquent brain. Neurosurgery, 47, 562–570

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Afasia tras ACV: causas, tipos y rehabilitación