Nonfluent Aphasia Research Articles

How about that? Psycholinguistic characteristics of formulaic language that predict fluency in individuals with post-stroke aphasia

ABSTRACT Purpose Formulaic language is an under-explored area of research in the field of acquired language disorders as compared to propositional language. The primary purpose of this study was to explore the utility of a proposed theoretical formulaic language model (Van Lancker Sidtis, 2022) for individuals with post-stroke aphasia to inform research and clinical practice. Method The dataset included previously described formulaic language extracted from Aphasiabank speech samples produced by 144 individuals with fluent and non-fluent aphasias. Formulaic language items were coded according to six psycholinguistic characteristics from the theoretical model. Between-group comparisons and regression analyses were run to determine whether particular psycholinguistic characteristics of produced formulaic items could predict speaker fluency. Results Findings revealed formulaic language differences between fluent and nonfluent aphasias based on the theoretical model. Importantly, psycholinguistic characteristics of frequency and syntactic completeness along with presence of apraxia of speech predicted fluency status with high accuracy (88.4% of individuals with fluent and 70.3% with nonfluent aphasia). Conclusions Findings in this study illustrate how theoretically-driven analyses of formulaic language production may enhance diagnostic and intervention practices in post-stroke aphasia.

Syntactic Scrambling in Broca's Aphasia: Turkish Sample.

Broca's Aphasia (BA) is a language disorder that causes grammatical errors in the language production skills of patients. Contemporary studies revealed the fact that BA patients also have difficulty in analyzing the meaning of phrases and sentences and comprehending the real meaning of the discourse produced by the speaker. The purpose of this study is to investigate possible effect of syntactic movement by changing the word positions in the sentence with morphological markers in order to produce clauses without changing the meaning on the phrasal comprehension skills of Turkish speaking patients with BA. A total of 300 participants were divided as study (n= 150) and control (n= 150) groups between ages of 27 - 89. A test that included 20 relative clauses and 9 noun clauses (in total 29 phrases) was assigned to the BA patients and control group. Relative clause phrases originated from simple sentences by adding suffixes to the verb as a function of Turkish morphology. Each suffix indicated a specific noun, object or subject, and each figure in the test was related to one of them. A researcher asked participants to match the demanded clause with the 6 possiblly related pictures for relative clause and 3 for noun clauses. Findings indicated that BA patients in our study had a lack of comprehending relative clauses due to the syntactic movement of words in the object and subject positions. Compared to the responses of the control group, participants with BA had significantly lower scores when the object and subject positions have moved from their original positions. BA patients also obtained significantly lower scores in object type questions Conclusion: Our findings support the fact that comprehension processing in BA should be investigated profoundly to be able to understand the nature of the disorder in different languages. In Turkish, syntactic movement of words to form a relative clause caused the BA patients to have significant problems to assign the semantic roles to the words in the existance of movement or change in their original positions.

Decoding speech intent from non-frontal cortical areas.

Brain-machine interfaces (BMIs) have advanced greatly in decoding speech signals originating from the speech motor cortices. Primarily, these BMIs target individuals with intact speech motor cortices but who are paralyzed by disrupted connections between frontal cortices and their articulators due to brainstem stroke or motor neuron diseases such as amyotrophic lateral sclerosis. A few studies have shown some information outside the speech motor cortices, such as in parietal and temporal lobes, that also may be useful for BMIs. The ability to use information from outside the frontal lobes could be useful not only for people with locked-in syndrome but also to people with frontal lobe damage, which can cause nonfluent aphasia or apraxia of speech. However, temporal and parietal lobes are predominantly involved in perceptive speech processing and comprehension. Therefore, to be able to use signals from these areas in a speech BMI, it is important to ascertain that they are related to production. Here, using intracranial recordings, we sought evidence for whether, when and where neural information related to speech intention could be found in the temporal and parietal cortices. Causal information enabled us to distinguish speech intent from resting state and other processes involved in language processing or working memory. Information related to speech intent was distributed widely across the temporal and parietal lobes, including superior temporal, medial temporal, angular, and supramarginal gyri. This provides evidence of a decodable production-related signal in these areas. This insight may help in designing speech brain-machine interfaces that could benefit people with locked-in syndrome, aphasia or apraxia of speech.

Transdiagnostic Network Localization of Social, Language, and Motor Symptoms in Patients With Frontotemporal Lobar Degeneration.

Frontotemporal lobar degeneration (FTLD) includes different clinical syndromes with distinct patterns of symptoms and neuroanatomical locations of neurodegeneration. However, FTLD is clinically heterogeneous (with overlapping symptoms across several domains) and neuroanatomically heterogeneous (with brain atrophy in different locations in different patients). Traditional methods struggle to fully account for this heterogeneity. In this study, we use a relatively new neuroimaging approach, atrophy network mapping, to localize clinical symptoms in patients with FTLD to specific brain networks transdiagnostically. Data were obtained from the Frontotemporal Lobar Degeneration Neuroimaging Initiative and 4-Repeat Tauopathy Neuroimaging Initiative. Inclusion required T1-weighted MRI and a diagnosis of behavioral-variant frontotemporal dementia (bvFTD), semantic-variant primary progressive aphasia (svPPA), nonfluent primary progressive aphasia (nfvPPA), progressive supranuclear palsy Richardson syndrome (PSP-rs), corticobasal syndrome (CBS), or normal cognition. Measures of social cognition (Interpersonal Reactivity Index, Revised Self-Monitoring Scale), language (Boston Naming Test, Animal Fluency), and motor function (Unified Parkinson Disease Rating Scale Part III, PSP Rating Scale) were correlated with neuroimaging measures, including cortical thickness, volume, and atrophy network mapping, a newer method that localizes regions connected to brain atrophy using a functional connectome from cognitively normal persons (n = 1,000). Fifty-seven patients with bvFTD (age 61.2 ± 6.8 years, 35% female), 41 PSP-rs (age 69.7 ± 7.4 years, 54% female), 39 CBS (age 66.2 ± 6.2 years, 51% female), 37 svPPA (age 63.0 ± 6.0 years, 46% female), and 36 nfvPPA (age 68.3 ± 7.3 years, 53% female) and 135 healthy age-matched controls (age 63.3 ± 7.4 years, 58% female) were included. Compared with atrophy alone, atrophy network mapping showed more consistent neuroimaging results across patients with the same clinical syndrome (Dice index mean 0.68 vs 0.11, paired t = 263.1, df = 4,452, p < 0.001), more strongly explained social cognition (F(1, 84) = 10.2, p = 0.002) and motor symptoms (F(1, 185) = 91.3, p < 0.001) across different syndromes, and showed novel neuroanatomical associations, with the temporal parietal junction relating to social cognition; Wernicke area relating to language symptoms; and association sensorimotor cortex, thalamus, and cerebellum relating to motor symptoms. Atrophy network mapping can improve understanding of brain-behavior relationships in clinically and neuroanatomically heterogeneous disorders such as FTLD.

Progressively complex neurorehabilitation: from a severe coma to a vegetative state, minimal consciousness ... and the Phoenix bird survives and is reborn from its ashes

Romania has the highest rate of car accidents and deaths per million inhabitants in the European Union, primarily due to poor driving and substandard road conditions. Victims of car accidents often present with complex medical cases involving multiple injuries across various organs, frequently leading to severe complications. Case report. With the approval of the patient's family and the Ethics Committee (no. 19348/25.04.2024) at the Neuromuscular Rehabilitation Clinic, Emergency Hospital "Bagdasar-Arseni," a case study was conducted. A 22-year-old man without a previous medical history suffered severe polytrauma as a result of a road accident. He was transferred to the Neuromuscular Rehabilitation Clinic in a vegetative state (after multiple fractures of the skull base and visceral cranium, with 3 points GCS), atlantoaxial subluxation (requiring cervical collar immobilization), rib fractures, drained hemothorax, near-complete atelectasis of the left lung, status post-pericardial effusion. The medical intervention involved a multifaceted pharmacological approach. Focal intramuscular injections of botulinum toxin targeted specific muscles significantly alleviated spasticity. Special robotic orthoses were used to correct postural abnormalities and maintain the favorable effects of the botulinum toxin. The patient received a personalized and complex nursing rehabilitation program including tracheal stoma management, nutritional support through IV infusions and percutanous gtrostomy (PEG) feeding, re-education of deglutition, intermittent urinary catheterization, and positioning on a special mattress to prevent pressure ulcers. The kinesiotherapy was progressively adapted to the neurologic and general condition. The patient had slight improvements in motor and cognitive abilities, resulting in simple voluntary gestures and affective response schemes. In time, he progressed to a minimally conscious state; he responded to verbal stimuli through blinking and reactive adequate affective mimic in the context of persistent expressive aphasia. He was safely discharged at home. Our main functional objective is the patient’s reinsertion into his family. Ad vitam prognosis and ad functionem outcomes are guarded. Ad laborem prognosis is nil. The patient was periodically reassessed for further rehabilitative care. This case emphasizes the importance of a complex multidisciplinary and patient-centered approach in managing post-traumatic vegetative status following a road traffic accident. The Phoenix symbolically takes steps toward fulfilling its destiny - to survive and gradually rise from its ashes.

Self-Improved Language Production in Nonfluent Aphasia Through Automated Recursive Self-Feedback.

Persons with nonfluent aphasia (PWNA) use feedback from external agents (e.g., speech-language pathologists) and self-feedback to improve their language production. The extent to which PWNA can improve their language production using their self-feedback alone is underexplored. In a proof-of-concept study, we developed an automated recursive self-feedback procedure to demonstrate the extent to which two PWNA who used self-feedback alone improved their production of sentences from trained and untrained scripts. In the current study, we use the Rehabilitation Response Specification System as a framework to replicate our initial findings. We tested the effects of two treatments: script production with recursive self-feedback and script production with external feedback in four persons with chronic nonfluent aphasia. We compared the effects of treatment by measuring percent script produced, speaking rate, and speech initiation latency of trained and untrained scripts. The participants received the treatments remotely through mini tablets using two versions of a mobile app we developed. All the participants received each treatment intensively for 14 sessions across 2-3 weeks. We estimated clinical improvements of production of sentences from trained and untrained scripts through nonoverlap of all pairs analysis of performance pretreatment and posttreatment. Both treatments improved PWNA's language production. Recursive self-feedback improved speaking rate and speech initiation latency, which generalized to untrained scripts in all participants. External feedback treatment did not generalize to improvement in speaking rate in two participants. Our findings confirm our initial evidence that PWNA can self-improve their sentence production from scripts through recursive self-feedback. This novel procedure enables PWNA to autonomously enhance their language production over time. Given the evidence and the mechanics of the procedure, we propose that its utility is not constrained by linguistic idiosyncrasies across cultures. Consequently, it has the potential to bypass linguistic barriers to aphasia care. https://doi.org/10.23641/asha.27007060.

Features of therapy of localized scleroderma in a severe comorbid patient

Localized scleroderma is an autoimmune chronic connective tissue disease characterized by the appearance of foci of local inflammation in various areas of the skin, followed by the formation of sclerosis and/or atrophy of the skin and underlying tissues in them. Among systemic connective tissue diseases, scleroderma occupies the second place in terms of frequency, mainly female patients. The authors observed a severe comorbid patient S., 75 years old, who was hospitalized at the Federal Center of Brain Research and Neurotechnologies of the FMBA of Russia in the department of medical rehabilitation for patients with impaired central nervous system function № 1 from 02.11.2022 to 03.01.2022 with a diagnosis of the underlying disease: the consequences of an ischemic stroke in the basin of the left middle cerebral artery from 02.23.2021, cardioembolic pathogenetic variant. Right-sided hemiparesis. Complex motor aphasia. After consulting a dermatovenerologist, a diagnosis was added to the concomitant diseases: localized scleroderma. Limited plaque shape. Patient S. external treatment was carried out (fluticasone ointment 0.005 % applied to the affected areas of the skin 1 time a day in a thin layer for 4 weeks), upon discharge, a course of physiotherapy at the place of residence was recommended.

Kissing balloon treatment for stenosis of the internal and external carotid artery orifice associated with moyamoya disease: illustrative case.

Moyamoya disease (MMD) is a cerebrovascular disorder that is characterized by progressive stenosis in the terminal portions of the internal carotid artery (ICA). Although a substantial number of patients with MMD exhibit stenosis of the ICA orifice (ICAO), it infrequently occurs in patients with MMD with external carotid artery orifice (ECAO) stenosis. A 48-year-old female with no past medical history presented to the authors' hospital with right hemiparesis and motor aphasia. Head magnetic resonance imaging revealed bilateral acute cerebral infarctions in the left frontal lobe, and magnetic resonance angiography demonstrated bilateral ICA terminal stenosis. Digital subtraction angiography revealed severe stenosis in the right ICAO and left ICAO and ECAO, as well as bilateral ICA terminal stenosis; therefore, the authors diagnosed this case as MMD. They first performed percutaneous transluminal angioplasty (PTA) using the kissing balloon technique (KBT) for the stenosis in the left ICAO and ECAO, followed by PTA for the right ICAO stenosis. After that, they performed bilateral direct and indirect revascularization. The authors present a rare case of MMD with stenosis of the ICAO and ECAO, which was treated with PTA using the KBT, followed by direct and indirect revascularization. Although the strategy is controversial in terms of which treatment should be performed first, this method of anterograde revascularization was a promising strategy. https://thejns.org/doi/10.3171/CASE24425.

Transient cerebral ischemia in pituitary apoplexy-induced internal carotid artery occlusion: illustrative case.

Cerebral ischemia secondary to occlusion or vasospasm of adjacent large vessels is a rare but significant complication of pituitary apoplexy. Misdiagnosis can lead to delays in management and devastating neurological outcomes. This case is the first reported instance of an initial presentation with transient cerebral ischemic symptoms, in addition to a classic pituitary apoplexy syndrome, for this clinical entity of pituitary apoplexy with adjacent large vessel occlusion. A 49-year-old man presented with a classic pituitary apoplexy syndrome of headache, vomiting, and hemianopia, with transient preceding expressive dysphasia and right-hand numbness. Computed tomography (CT) and CT angiography of the brain demonstrated a large apoplectic pituitary tumor and associated occlusion of the left internal carotid artery. Subsequent CT perfusion studies revealed a threatening large ischemic penumbra in the left middle cerebral artery territory. He underwent urgent transsphenoidal resection of the pituitary tumor, resulting in symptom resolution and the prevention of cerebral infarction. The recognition of transient cerebral ischemic symptoms in pituitary apoplexy should encourage the exclusion of any large-vessel complications and resultant cerebral ischemia. Early assessment, particularly with angiography and perfusion studies, can assist in guiding management, which is usually surgical decompression, distinct from traditional treatment for cerebrovascular events. https://thejns.org/doi/10.3171/CASE24566.

Neurological Manifestations of Aortic Dissection: A Scoping Review.

Aortic dissection (AD) is the most prevalent aortic pathology, with an incidence of 2.6-3.5 cases per 100,000 inhabitants per year with mortality rates as high as 90% at 3 months without proper management. Despite the presence of typical symptoms, it has been reported that up to 38% of cases go unnoticed in the initial evaluation, either due to additional symptomatology or the absence of classic symptoms. In 28% of cases the diagnosis is made post-mortem, highlighting the severity and importance of timely diagnosis. The main goals of this study were to identify the primary neurological manifestations of acute AD and the frequency of these manifestations in type A and B AD according to the Stanford classification. A total of 2,734 records were retrieved from two databases, of which 2,611 were excluded. Therefore, 123 articles were obtained and 88 were evaluated for eligibility. Consequently, 79 articles were included in the review. The abstracts identified in the search were screened by seven blinded independent authors and excluded those who lacked relevance. The authors read the full texts independently to determine inclusion. A third reviewer adjudicated discrepancies when opinions were at odds. There were 169 patients diagnosed with Stanford type A, of which 43.8% displayed quantitative impairment of consciousness. Within this group, transient loss of consciousness was observed in 34.3% of cases. Motor syndrome was present in 54.5%, with 23.7% of patients presenting with hemiparesis or hemiplegia. 3.6% had facial paresis or paralysis and less frequently monoparesis, paraparesis, hyperreflexia, spasticity, and muscle spasms. 7.6% presented with language impairments including Broca's aphasia and dysarthria. Seizures were present in 3.6%. Neuro-ophthalmological symptoms were 2.9%, cortical or cognitive symptoms and headache were 2.3%, cerebellar syndrome was 1.8%, and sensory syndrome was 1.2%. Of 86 patients diagnosed with Stanford type B, 57.0% displayed motor syndrome, with 50.0% being paraparesis or paraplegia, 4.7% monoplegia, and 2.3% hemiplegia or hemiparesis. Additionally, impairment of consciousness was present in 26.7%, sensory syndrome in 12.8%, and language impairments in 3.5%. In the emergency department, understanding the neurological manifestations in both Stanford type A and B dissections emerges as a pivotal cornerstone for conducting precise assessments and efficient patient management. Given the wide spectrum of manifestations, we emphasize the importance of suspecting AD when neurological disorders are associated with the classic symptoms. In these cases, we encourage a complete neurological examination to be performed and a multidisciplinary group assembled to tackle this entity.

Investigating the Effectiveness of Neuropsychological Rehabilitation on Stroke Patients

Objectives: This study aimed to investigate neuropsychological rehabilitation’s effectiveness on stroke patients’ cognitive status. Methods: This quasi-experimental study examined 22 adults with ischemic stroke of the left hemisphere (with an average age of 64.31 years) before and after the intervention. The patients had fluent aphasia (10 people) and non-fluent aphasia (12 people), along with cognitive disorders such as memory or attention disorder. Medical examination and para-clinical diagnosis of magnetic resonance imaging (MRI) with different causes, along with the Persian diagnostic aphasia battery bedside version (P-DAB-AQ1, 2016), were conducted. The severity of language disorder and type of aphasia were investigated using the Persian diagnostic aphasia battery (P-DAB-1) and Persian picture naming battery tests. Also, the mini-mental state examination (MMSE) test checked the cognitive dimensions. Verb network strengthening therapy, treatment of underlying forms, Persian verb, and sentence production protocol, and semantic feature analysis (SFA) for patients were also used. Results: Findings show that the participants’ average aphasia quotient (AQ1) score increased from 74.80 to 80.12, and the average MMSE score increased from 17 to 22.59. The main variables do not follow a normal distribution (P&lt;0.05), but the difference between scores before and after the intervention follows a normal distribution (P&lt;0.05). Both the AQ1 and MMSE variables significantly differ before and after the intervention, according to the Wilcoxon test. The non-fluent aphasia group has a higher increase in MMSE scores than the fluent aphasia group. Discussion: Neuropsychological rehabilitation interventions can effectively improve AQ1 and MMSE. In addition, further research on neuropsychological rehabilitation interventions with two intervention and control groups and the treatment methods used during this study can be suggested for the treatment of stroke patients.

Delayed Deep White Matter Ischemia After Resection of Gliomas by Awake Surgery

BACKGROUND AND OBJECTIVES: Deep white matter (DWM) is perfused by the medullary arteries from the cortex, and ischemia sometimes occurs after glioma resection. However, the clinical significance of postoperative medullary artery–related ischemia has not been well studied. We retrospectively reviewed cases of delayed DWM ischemia after awake craniotomy to elucidate the clinical characteristics, mechanisms, and management of delayed ischemia. METHODS: We identified 4 cases of intra-axial brain tumors, mainly gliomas, that underwent tumor resection by awake craniotomy at our hospital and developed DWM ischemic symptoms after surgery, despite no worsening of neurological symptoms at the end of surgery. RESULTS: Four patients (3 men and 1 woman) presented with glioblastoma, oligodendroglioma, astrocytoma, and brain metastasis. The median age at surgery was 47.5 years (41-73 years). The tumors were located in the watershed area in the frontal lobe (n = 2) and the parietal lobe (n = 2), all of which were left-sided (n = 4). DWM ischemic symptoms, such as motor dysfunction, aphasia, dysarthria, and dysgraphia, developed at an average of 24 hours (14-48 hours) after resection by awake craniotomy. All 4 patients showed symptom improvement within a week after surgery and completely recovered within a month. CONCLUSION: DWM ischemia is caused by sacrifice of the medullary artery, which feeds the tumor and adjacent brain tissue during tumor resection, and should be considered when delayed aphasia or paralysis occurs postoperatively. These symptoms are often transient and recovery usually occurs. Tumors located in the frontal or parietal lobes, particularly in the watershed area, should be carefully monitored for postoperative ischemia.

Isolated expressive aphasia caused by acute subdural hematoma: case report and literature review

The occurrence of aphasia as an isolated and dominant clinical feature of acute subdural hematoma (aSDH) has been rarely mentioned in the available literature. Being the most common focal intracranial lesion, subdural hematomas (SDH) pose a clinical challenge, especially when presented with unorthodox clinical features. We report a case of a patient with a traumatic aSDH, presenting with intense frontal headaches and normal neurological examination. On the 3rd postadmission day, he developed expressive dysphasia which progressed to aphasia, with neurological examination findings of an upper motor neuron lesion (UMNL), without hematoma expansion, verified via head CT (computed tomography). The patient underwent decompressive craniotomy and hematoma evacuation. Early speech improvements were noted immediately postoperatively, and at hospital discharge the patient had no evident clinical features of speech disorder and neurological deficits or tests suggesting UMNL. Speech disorders in the setting of an aSDH need to be further investigated and potentially considered as an indication for surgical management, especially in rare instances where they present as an isolated clinical feature and conservative treatment is initially considered.

Recursive self-feedback improves spontaneous speech in chronic aphasia within real-world settings

ABSTRACT Background Spontaneous speech generation, often impaired in chronic nonfluent aphasia, is essential for natural communication. Treatments aiming to optimize spontaneous speech in real-world settings are critical for improving the quality of life for persons with nonfluent aphasia (PWNA). Traditional treatments frequently rely on models and feedback from external agents, which may not be sustainable in the long-term. Preliminary evidence suggests that PWNA can use self-feedback alone, through recursive self-feedback, to improve their production of scripted sentences. This study developed and examined the impact of spontaneous speech with recursive self-feedback on enabling PWNA to self-improve their spontaneous speech in real-world settings. Method Using a cross-over design, 3 participants received 2 treatments at their homes: spontaneous speech with recursive self-feedback and spontaneous speech with speech model. Recursive self-feedback treatment involved iterative self-monitoring and minimization/correction of errors during spontaneous speech response to narrative prompts. The speech model treatment provided corrective model responses to prompts from an external source which served as reference frames to help improve the participants’ responses. Participants utilized a mobile app to practice the treatments intensively at home for 2 hours each day over a period of 12 to 14 days, spanning 2 to 3 weeks. Direct and generalized treatment effects on microlinguistic measures of spontaneous speech were determined using general linear mixed effects model and standardized mean difference. Results Both treatments led to significant improvements in microlinguistic measures of spontaneous speech, with recursive self-feedback treatment showing broader post-treatment effects on treated prompts and generalization effects. to untreated prompts. Conclusion Recursive self-feedback is a promising procedure for enhancing spontaneous speech in PWNA, providing a simple and flexible self-directed treatment option. This procedure relies primarily on speech-auditory stimulations and self-feedback loops to improve spontaneous speech, suggesting its potential applicability across various spoken language cultures. To validate these findings and assess their broader relevance, further research is recommended.

Caregiver perspectives enable accurate diagnosis of neurodegenerative disease.

The history from a relative or caregiver is an important tool for differentiating neurodegenerative disease. We characterized patterns of caregiver questionnaire responses, at diagnosis and follow-up, on the Cambridge Behavioural Inventory (CBI). Data-driven multivariate analysis (n=4952 questionnaires) was undertaken for participants (n=2481) with Alzheimer's disease (typical/amnestic n=543, language n=50, and posterior cortical n=50 presentations), Parkinson's disease (n =740), dementia with Lewy bodies (n=55), multiple system atrophy (n=55), progressive supranuclear palsy (n=422), corticobasal syndrome (n =176), behavioral variant frontotemporal dementia (n=218), semantic (n=125) and non-fluent variant progressive aphasia (n=88), and motor neuron disease (n=12). Item-level support vector machine learning gave high diagnostic accuracy between diseases (area under the curve mean 0.83), despite transdiagnostic changes in memory, behavior, and everyday function. There was progression in CBI subscores over time, which varied by diagnosis. Our results highlight the differential diagnostic information for a wide range of neurodegenerative diseases contained in a simple, structured collateral history. We analyzed 4952 questionnaires from caregivers of 2481 participants with neurodegenerative disease. Behavioral and neuropsychiatric manifestations of neurodegenerative disease had overlapping diagnostic boundaries. Simple questionnaire response patterns were sufficient for accurate diagnosis of each disease. We reinforce the value of a collateral history to support a diagnosis of dementia. The Cambridge Behavioural Inventory is sensitive to change over time and suitable as an outcome measure in clinical trials.

Comprehensive Approach to Speech and Language Assessment in Recurrent Meningioma: A Case Study

Meningioma is a tumor that arises from the meninges - the membranes that surround the brain and spinal cord. It compresses the adjacent brain tissues, nerves and vessels, leading to changes in vision, loss of smell, headaches, hearing loss or ringing in the ears, memory loss, seizure and most importantly communication difficulty. It affects mainly the elderly above the age of 60, at a female: male ratio of 3:2. Recurrence and progression are well known and are frequent characteristics of meningiomas. The present study aimed to perform a comprehensive approach to speech and language assessment in a case with recurrent meningioma. A case reported following postsurgical recurrent meningioma in the left parietal temporal area, exhibiting symptoms of language, speech and swallowing difficulty associated with a weakness in the left upper and lower limb. The evaluation process from a speech and language perspective involved perceptual and instrumental assessment of cognition, communication and swallowing using tests and tools. The case was found to have comorbid disorders of nonfluent aphasia associated with neuro cognitive deficit, mild dysphagia, mild dementia and dysarthria of speech. Though the presence of language and speech disorders in case of recurrent meningioma is not common, the severity of the disorder may lead to severe communication deficit. Assessing and interpreting an individual's communication ability involves the integration of a variety of information collected in the evaluation process. Keywords: Recurrent meningioma, dysphagia, aphasia, dysarthria

Time is brain: detection of nonconvulsive seizures and status epilepticus during acute stroke evaluation using point-of-care electroencephalography

ObjectivesSeizures are both a common mimic and a potential complication of acute stroke. Although EEG can be helpful to evaluate this differential diagnosis, conventional EEG infrastructure is resource-intensive and unable to provide timely monitoring to match the emergent context of a stroke code. We aimed to evaluate the real-world use and utility of a point-of-care EEG device as an adjunct to acute stroke evaluation. Materials and MethodsWe performed a retrospective observational cohort study at a tertiary care community teaching hospital by identifying patients who underwent point-of-care EEG monitoring using Rapid Response EEG system (Ceribell Inc., Sunnyvale, CA) during stroke code evaluation of acute neurological deficits during the study period from January 1, 2020 to December 31, 2020. We assessed the frequency of seizures and highly epileptiform patterns among patients with either confirmed strokes or stroke mimics. ResultsPoint-of-care EEG monitoring was used in the wake of a stroke code in 70 patients. Of these, neuroimaging and clinical information resulted in a diagnosis of stroke in 38 patients (28 ischemic, 6 hemorrhagic, 4 transient ischemic attack; median NIHSS score of 6.5 [IQR 2.0-12.0]) and absence of any stroke in 32 patients. Point-of-care EEG detected seizures and highly epileptiform patterns in 6 (15.8 %) stroke patients and 11 (34.4 %) stroke-mimic patients, including 2 patients with persistent expressive aphasia due to repeated focal seizures. ConclusionsPoint-of-care EEG has utility for detecting nonconvulsive seizures in patients undergoing acute stroke evaluations.

A Patient With Incomplete Motor Aphasia Due to Frontoparietal Bone Metastasis From Prostate Cancer

Prostate cancer has a strong tendency to metastasize to bone, and cranial metastasis to the frontoparietal bone is rare, and its clinical symptoms vary according to the location of the lesion. In this paper, the authors report a case of frontoparietal bone metastasis from prostate cancer with incomplete motor aphasia symptoms and briefly summarize the available literature.

Abstract 250: Early Revascularization in Cervical Artery Dissection: Case Studies of Improved Neurological Outcomes

Introduction Cervical artery dissection (CAD) involves a tear in the inner lining of the carotid or vertebral artery, contributing to up to 25% of ischemic strokes in individuals under 50 years of age. This condition can lead to the formation of a false lumen within the vessel wall, potentially causing intraluminal thrombus, vessel stenosis, or pseudoaneurysm, ultimately leading to cerebral ischemia. Endovascular therapy is an option for recurrent cerebrovascular events, dissecting aneurysms, and severe stenosis, as well as in cases where anticoagulation is not tolerated. Here, we describe two cases of left internal carotid artery dissections that required revascularization due to recurrent episodes of reduced blood supply or distal embolism. Methods Electronical medical records review. Results Case 1: A 39‐year‐old man with a history of hypertension, hyperlipidemia, and migraine presented with traumatic bilateral carotid stenosis due to dissection after a fall. Initially discharged on antiplatelet agents and returned with TIA symptoms of left hemispheric hypoperfusion followed by a small left MCA stroke. Catheter angiography revealed cervical ICA dissection with a false and true lumen, along with a 99% distal cervical carotid stenosis and trace distal flow. Revascularization was performed by crossing the stenosis with an Aristotle 14 wire for good distal access. Subsequently, the Spider device was deployed in the petrous internal carotid, and Xact stents (8times6x40mm and 9times7x40mm) were placed across the distal and proximal portion of the stenosis. Post‐intervention, the patient was started on Eptifibatide infusion for 4 hours, followed by DAPT and Apixaban upon discharge. At the 30‐day follow‐up, the patient had a modified Rankin Scale (mRS) score of 0 and repeated carotid Doppler ultrasonography (CDUS) showed a patent stent. Case 2 A 36‐year‐old female with a history of hyperlipidemia, depression, and hypertension presented as a level 1 code stroke for aphasia and right hemiplegia. On arrival, her NIHSS was 9. CTA head and neck revealed a left ICA occlusion caused by dissection with reconstitution and occlusion of the left MCA inferior division. Catheter angiography revealed a left ICA occlusion due to dissection with a true and false lumen and distal reconstitution of the vessel. The diagnostic catheter and base catheter were advanced past the dissection, and a thrombectomy was performed using an Aristotle 14 wire catheter with aspiration and a stent retriever with TICI 2b reperfusion. Following this, the catheter was retracted to the cervical carotid, and the Walrus balloon was inflated, followed by the deployment of Xact stents (8times6x40mm and 9times7x40mm). Post‐intervention, the patient was started on Aspirin and Ticagrelor. Subsequent MRI of the brain and MRA showed a left MCA stroke with occlusion of the stent, which CDUS confirmed. Despite this, on discharge, the patient had mixed aphasia and RSW (3/5 strength). At 30 days, the patient had mild expressive aphasia with a mRS of 2, which improved to a mRS of 1 at 90 days. Conclusion These cases illustrate examples of select situations where early revascularization intervention can improve neurological outcomes under specific conditions. Additional studies are required.

Abstract 405: Severe “Crescendo” Recurrent TIAs In Moderate Carotid Artery Stenosis Without High‐risk Features

Introduction Symptomatic internal carotid artery stenosis (ICA) is defined as focal neurologic deficits ipsilateral to carotid artery pathology presenting as a transient ischemic attack (TIA) or stroke, frequently seen with moderate to severe (50‐99%) ICA stenosis. Stroke warning syndrome (SWS) is a rare form of TIA presenting as recurrent, or “crescendo”, TIAs with a high stroke risk typically seen in the absence of cortical signs and related to small vessel disease or hypoperfusion. Our case describes a patient with recurrent stereotypic crescendo TIAs with near complete cortical left middle cerebral artery (MCA) syndrome secondary to moderate (50‐69%) ICA stenosis without high‐risk features (intraplaque hemorrhage, large lipid‐rich necrotic core, thin or ruptured fibrous cap), with complete resolution of symptoms after carotid endarterectomy (CEA). Case We report a 66‐year‐old female smoker without significant medical history presenting with complete left MCA syndrome‐ left gaze, dysarthria, complete expressive aphasia, and right sided hemiplegia, with last known well approximately 12 hours prior to presentation. CT angiography (CTA) of the head and neck demonstrated an estimated 60‐65% stenosis of the left carotid bifurcation with mixed hard and soft plaque without ulceration or unstable thrombi; no intracranial occlusions were noted. The patient had spontaneous resolution of symptoms with NIHSS 0, so thrombolysis was deferred. Within a few hours of presentation, she experienced three additional episodes of varying severity, each lasting approximately five minutes, with complete resolution between episodes. This raised concern for an unstable plaque; therefore, she was started on aspirin and intravenous (IV) heparin drip with plan for urgent carotid revascularization. After heparin was paused pre‐operatively, she had two additional witnessed similar events lasting less than ten minutes each. Following endarterectomy, she had complete resolution of symptoms without recurrence. MRI brain showed no infarction, additional stroke workup was otherwise unrevealing, and she was discharged on daily aspirin. On three‐month post‐operative follow up, the patient reported no further symptom recurrence. Discussion The incidence of TIAs presenting as SWS is as high as 4.5%, yet there are no clear guidelines for SWS management. SWS is typically observed in small vessel pathology and hypoperfusion, and less commonly in carotid artery pathology. Our patient presented with episodes consistent with cortical L MCA symptoms, typically seen with a proximal MCA occlusion. However, the frequency of these episodes exceeded what is expected from moderate carotid artery stenosis, especially in the absence of many known high‐risk plaque markers. While stereotypic symptoms raise concern for alternative diagnosis, such as seizures, the cessation of symptoms with IV heparin and subsequent complete resolution following revascularization confirmed the diagnosis of symptomatic carotid disease. In symptomatic moderate ICA stenosis, the benefit of urgent carotid revascularization over medical treatment of anti‐thrombotic or stroke prevention is modest, with the greatest effect observed in cases with severe stenosis. In patients with crescendo TIA with moderate ICA stenosis, even without high‐risk features, carotid revascularization may be beneficial. While there is no strong evidence supporting anticoagulation over anti‐platelet therapy in symptomatic ICA stenosis, anticoagulation may be considered in patients presenting with SWS.