Severe Comprehension Deficit Research Articles

Communication deficits in a case of a deletion in 7q31.1-q31.33 encompassing FOXP2

ABSTRACT Copy number variants (CNVs) found in individuals with communication deficits provide a valuable window to the genetic causes of problems with language and, more generally, to the genetic foundation of the human-specific ability to learn and use languages. This paper reports on the language and communication problems of a patient with a microduplication in 22q11.23 and a microdeletion in 7q31.1-q1.33 encompassing FOXP2. The proband exhibits severe speech problems and moderate comprehension deficits, whereas her pragmatic abilities are a relative strength, as she uses gestures quite competently to compensate for her expressive issues. This profile is compatible with the deficiencies found in patients with similar CNVs, particularly with people bearing microdeletions in 7q31.1-q31.33.

Neural correlates of syntactic comprehension: A longitudinal study

Broca’s area is frequently implicated in sentence comprehension but its specific role is debated. Most lesion studies have investigated deficits at the chronic stage. We aimed (1) to use acute imaging to predict which left hemisphere stroke patients will recover sentence comprehension; and (2) to better understand the role of Broca’s area in sentence comprehension by investigating acute deficits prior to functional reorganization. We assessed comprehension of canonical and noncanonical sentences in 15 patients with left hemisphere stroke at acute and chronic stages. LASSO regression was used to conduct lesion symptom mapping analyses. Patients with more severe word-level comprehension deficits and a greater proportion of damage to supramarginal gyrus and superior longitudinal fasciculus were likely to experience acute deficits prior to functional reorganization. Broca’s area was only implicated in chronic deficits. We propose that when temporoparietal regions are damaged, intact Broca’s area can support syntactic processing after functional reorganization occurs.

Intellectual awareness of naming abilities in people with chronic post-stroke aphasia

Anosognosia, or lack of self-awareness, is often present following neurological injury and can result in poor functional outcomes. The specific phenomenon of intellectual awareness, the knowledge that a function is impaired in oneself, has not been widely studied in post-stroke aphasia. We aim to identify behavioral and neural correlates of intellectual awareness by comparing stroke survivors’ self-reports of anomia to objective naming performance and examining lesion sites. Fifty-three participants with chronic aphasia without severe comprehension deficits rated their naming ability and completed a battery of behavioral tests. We calculated the reliability and accuracy of participant self-ratings, then examined the relationship of poor intellectual awareness to speech, language, and cognitive measures. We used support vector regression lesion-symptom mapping (SVR-LSM) to determine lesion locations associated with impaired and preserved intellectual awareness. Reliability and accuracy of self-ratings varied across the participants. Poor intellectual awareness was associated with reduced performance on tasks that rely on semantics. Our SVR-LSM results demonstrated that anterior inferior frontal lesions were associated with poor awareness, while mid-superior temporal lesions were associated with preserved awareness. An anterior-posterior gradient was evident in the unthresholded lesion-symptom maps. While many people with chronic aphasia and relatively intact comprehension can accurately and reliably report the severity of their anomia, others overestimate, underestimate, or inconsistently estimate their naming abilities. Clinicians should consider this when administering self-rating scales, particularly when semantic deficits or anterior inferior frontal lesions are present. Administering self-ratings on multiple days may be useful to check the reliability of patient perceptions.

Post-stroke Depression Increases Disability More Than 15% in Ischemic Stroke Survivors: A Case-Control Study.

We performed a retrospective, case-control study in consecutive ischemic stroke patients admitted to our stroke rehabilitation unit. Patients were matched for severity of neurological impairment (evaluated with the Canadian Neurological Scale, CNS), age (difference within 1 year), and onset admission interval (difference within 3 days). Participants were divided into two subgroups according to the presence or absence of PSD. Aim was to assess the specific influence of post-stroke depression (PSD) and antidepressant treatment on both basal functional status and rehabilitation outcomes. All PSD patients were treated primarily with serotoninergic antidepressants (AD). The final sample included 280 patients with depression (out of 320 found in a whole case series of 993 ischemic patients, i.e., 32.25%) and 280 without depression. Forty patients with depression were excluded because they had a history of severe psychiatric illness or aphasia, with a severe comprehension deficit. On one hand, PSD patients obtained lower Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at both admission and discharge, with minor effectiveness of rehabilitative treatment and longer length of stay; on the other hand, this group had a lower percentage of dropouts. Lastly, PSD patients showed a different functional outcome, based on their response to antidepressant therapy, that was significantly better in responders than in non-responders (13.13%). Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.

Profile of hyperlexia: Reconciling conflicts through a systematic review and meta-analysis

Abstract It is believed that children with poor decoding skills and adequate listening comprehension skills exhibit a dyslexia-type syndrome. However, there is no consensus relating to the other problem that arises: children who have exceptional decoding but poor listening comprehension. Sometimes, these children have been labeled as “individuals exhibiting hyperlexia.” There is no clear understanding of the following aspects of hyperlexia: a) population criteria (e.g., typically vs. atypically developing children), b) specific criteria (e.g., precocity, definition of “good decoding”) on their associations with reading, and c) the applicability of reading theories to hyperlexia (e.g., phonemic awareness is critical in decoding; both decoding and listening comprehension contribute to reading comprehension). Therefore, we conducted a systematic and meta-analytic review to explore these questions. We found that despite good decoding and verbal short-term memory skills, individuals with hyperlexia exhibit poor listening, verbal working memory, and reading comprehension skills. Also, all but three studies identified hyperlexics from atypical developing populations; however, criteria to define “good decoding” varied and the onset of precocious decoding behavior was not consistently reported. Our meta-regression analysis suggests that decoding still predicted the performance of reading comprehension after controlling for listening comprehension, suggesting that the variations of defining “good decoding” led to different reading comprehension profiles (e.g., mild vs. severe reading comprehension deficit). Further, listening comprehension but not decoding is related to phonemic awareness, which may be due to the difficulty of understanding phonemic awareness tasks. However, it may also suggest that the current decoding theory is not applied to hyperlexia. Future suggestions for hyperlexia research are provided.

Intensive Auditory Comprehension Treatment for Severe Aphasia: A Feasibility Study.

Severe auditory comprehension impairments secondary to aphasia can adversely influence rehabilitative outcomes and quality of life. Studies examining intensive rehabilitative treatments for severe single-word auditory comprehension impairments are needed. Our purpose was to examine the feasibility and influence of a high-intensity word-picture verification treatment on high-frequency, word response accuracy. Research questions: (a) Can people with severe aphasia tolerate an intensive comprehension treatment? (b) Does an intensive intervention increase auditory comprehension response accuracy of spoken high-frequency words? This single-case ABA design study included 2 participants with chronic, severe auditory comprehension deficits secondary to stroke. A high-frequency, word-picture verification treatment was administered 2 hr/day, 5 days/week for 4 weeks and required participants to match the spoken word of the examiner to a picture representing an object. Preliminary results suggest that some people with severe chronic aphasia can tolerate an intensive auditory comprehension treatment and demonstrate improvements in high-frequency, word-level response accuracy with large effect sizes suggesting generalization to untrained stimuli. An intensive auditory comprehension treatment protocol can contribute to improvements in response accuracy for some people with severe aphasia. Larger sample size studies are needed to further examine the influence of intensity on improvements in auditory comprehension.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting

BackgroundApproximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients’ access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke.MethodsWe enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability.ResultsOver 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most “convenient”.ConclusionsIndividualized speech-language therapy delivered by mobile tablet technology is feasible in acute care.

The relationship between post-stroke depression and physical recovery

BackgroundPost-stroke depression (PSD) is a serious and common complication of stroke. In this prospective study on the relationship between clinical PSD and physical recovery, we focused on (1) distinguishing between depression and apathy, (2) issues in assessment of PSD, and (3) timing of assessment. MethodsJapanese stroke patients (n=117) were studied. We used self-rating scales [Zung Self-Rating Depression Scale (SDS) for depression; Apathy Scale (AS) for apathy] and observer-rating scales [Montgomery–Åsberg Depression Rating Scale (MADRS) for depression; Neuropsychiatric Inventory-Nursing Home (NPI-NH) for apathy] to assess psychological state. We assessed physical disability using the Functional Independence Measurement (FIM). Two-way analysis of covariance was used to determine effects of depression and apathy on functional outcome. We evaluated PSD twice, within 10 days after hospitalization and four weeks later. ResultsObjective scales gave higher prevalence than subjective scales for both depression and apathy. A significant effect of apathy on FIM recovery was seen with objective scale assessment during hospitalization; there was a marginal effect of depression at the same time. LimitationsWe did not consider the stroke size and location. In addition, we excluded patients with severe comprehension deficits or with a history of stroke. ConclusionsOur findings indicate that depression and apathy could occur independently after stroke and could individually influence functional recovery. We obtained more accurate estimates of functional recovery using objective measures. Furthermore, our findings suggest that depression and apathy should be assessed not only at admission but also during hospitalization to estimate and enhance the functional recovery of stroke patients.

A Cognitive Neuropsychological Examination of the Das-Naglieri Cognitive Assessment System Subtests: A Report of Three Stroke Cases Studied Longitudinally During Recovery

In this study three patients with unilateral focalized stroke lesions were examined longitudinally on the CAS subtests at 1 month and 6 months postinfarct such that each patient functioned as baseline. Patient 1 with a left temporal pole lesion had a severe syntactic comprehension deficit on Sentence Questions. Patient 2 had a rare right anterior cerebral artery (ACA) aneurysm culminating in a classical orbitofrontal syndrome and impairments on Expressive Attention, Word Series as well as a previously undescribed praxis-based figure ground reversal phenomenon on Figure Memory. Patient 3 suffered a right frontoparietal lesion with resulting representational as well as elements of motor neglect and impairments on Matching Numbers, Number Detection, and Receptive Attention. The three patient's lesions were all entirely consistent with the nature of cognitive neuropsychological symptoms suggesting that the CAS subtests are not only unique but also sensitive and specific to focalized cortical lesions.

T'ai chi

Post-stroke depression (PSD) is a serious and common complication of stroke. In this prospective study on the relationship between clinical PSD and physical recovery, we focused on (1) distinguishing between depression and apathy, (2) issues in assessment of PSD, and (3) timing of assessment.Japanese stroke patients (n=117) were studied. We used self-rating scales [Zung Self-Rating Depression Scale (SDS) for depression; Apathy Scale (AS) for apathy] and observer-rating scales [Montgomery–Åsberg Depression Rating Scale (MADRS) for depression; Neuropsychiatric Inventory-Nursing Home (NPI-NH) for apathy] to assess psychological state. We assessed physical disability using the Functional Independence Measurement (FIM). Two-way analysis of covariance was used to determine effects of depression and apathy on functional outcome. We evaluated PSD twice, within 10 days after hospitalization and four weeks later.Objective scales gave higher prevalence than subjective scales for both depression and apathy. A significant effect of apathy on FIM recovery was seen with objective scale assessment during hospitalization; there was a marginal effect of depression at the same time.We did not consider the stroke size and location. In addition, we excluded patients with severe comprehension deficits or with a history of stroke.Our findings indicate that depression and apathy could occur independently after stroke and could individually influence functional recovery. We obtained more accurate estimates of functional recovery using objective measures. Furthermore, our findings suggest that depression and apathy should be assessed not only at admission but also during hospitalization to estimate and enhance the functional recovery of stroke patients.

A Receptive Language Deficit in Schizophrenic Thought Disorder: Evidence for Impaired Semantic Access and Monitoring

Introduction: Two issues have been overlooked in the literature describing the language abilities of schizophrenic patients with formal thought disorder. The first concerns whether such patients have a comprehension deficit in addition to their obvious expressive problems. The second concerns the extent to which any expressive and receptive deficits vary across time. The examination of these issues has important consequences for the likely focus of any underlying cognitive deficit in thought disorder. Method : The current study used a cognitive neuropsychological case-study approach to examine the expressive and receptive language abilities in a schizophrenic patient (TC) with severe formal thought disorder. Results : Expressive (naming) and receptive (word and sentence comprehension) language abilities were tested across time. TC's naming ability was inconsistent across both time and modality (i.e. to-picture and to-description). He also showed a severe comprehension deficit that was highly variable across time. Further testing revealed that the comprehension deficit did not reflect a disorder of working memory, but stemmed directly from impaired access to word meaning. Conclusion : It is suggested that a central semantic memory deficit would most parsimoniously account both for TC's expressive and receptive language problems. Moreover, this deficit appears to affect semantic access rather than a degradation of the semantic knowledge base itself.

Primary progressive semantic aphasia: A case study

A longitudinal case study of a patient with a progressive loss of meaning of objects with preserved phonology and syntax is presented. Repeated measures of language, praxis, visual cognition, and semantic processing were carried out. The patient still has preserved conversational speech, social skills, and orientation in her 8th year of her illness, but shows severe anomia and comprehension deficit in all modalities of stimulus presentation. In addition to standardized tests of language, cognition, and memory, specific experiments of categorization, modalities of word access, item consistency, category specificity, and definition of words were carried out. Results indicate a frequency dependent loss of meaning that was consistent in all modalities and throughout all object categories. However, the relative preservation of visual categorization of all categories tested and the language based categorization of animals suggested some fractionation of semantic memory. Relative preservation of autobiographical and personal memories versus semantic memory was a striking observation. Evidence for selective impairment of central semantic processing was obtained from experiments indicating item consistency of loss and the lack of semantic cuing. Neuroimaging evidence of left temporal lobe atrophy and the classical picture is compatible with similar cases published under the term semantic dementia or "transcortical sensory aphasia with visual agnosia" and suggest the diagnosis of Pick's disease.

Spoken Sentence Comprehension in Aphasia: Event-related Potential Evidence for a Lexical Integration Deficit

In this study the N400 component of the event-related potential was used to investigate spoken sentence understanding in Broca's and Wernicke's aphasics. The aim of the study was to determine whether spoken sentence comprehension problems in these patients might result from a deficit in the on-line integration of lexical information. Subjects listened to sentences spoken at a normal rate. In half of these sentences, the meaning of the final word of the sentence matched the semantic specifications of the preceding sentence context. In the other half of the sentences, the sentence-final word was anomalous with respect to the preceding sentence context. The N400 was measured to the sentence-final words in both conditions. The results for the aphasic patients (n = 14) were analyzed according to the severity of their comprehension deficit and compared to a group of 12 neurologically unimpaired age-matched controls, as well as a group of 6 nonaphasic patients with a lesion in the right hemisphere. The nonaphasic brain damaged patients and the aphasic patients with a light comprehension deficit (high comprehenders, n = 7) showed an N400 effect that was comparable to that of the neurologically unimpaired subjects. In the aphasic patients with a moderate to severe comprehension deficit (low comprehenders, n = 7), a reduction and delay of the N400 effect was obtained. In addition, the P300 component was measured in a classical oddball paradigm, in which subjects were asked to count infrequent low tones in a random series of high and low tones. No correlation was found between the occurrence of N400 and P300 effects, indicating that changes in the N400 results were related to the patients' language deficit. Overall, the pattern of results was compatible with the idea that aphasic patients with moderate to severe comprehension problems are impaired in the integration of lexical information into a higher order representation of the preceding sentence context.

Lexical-semantic event-related potential effects in patients with left hemisphere lesions and aphasia, and patients with right hemisphere lesions without aphasia.

Lexical-semantic processing impairments in aphasic patients with left hemisphere lesions and non-aphasic patients with right hemisphere lesions were investigated by recording event-related brain potentials (ERPs) while subjects listened to auditorily presented word pairs. The word pairs consisted of unrelated words, or words that were related in meaning. The related words were either associatively related, e.g. "bread-butter', or were members of the same semantic category without being associatively related, e.g. "church-villa'. The latter relationships are assumed to be more distant than the former ones. The most relevant ERP component in this study is the N400. In elderly control subjects, the N400 amplitude to associatively and semantically related word targets is reduced relative to the N400 elicited by unrelated targets. Compared with this normal N400 effect, the different patient groups showed the following pattern of results: aphasic patients with only minor comprehension deficits (high comprehenders) showed N400 effects of a similar size as the control subjects. In aphasic patients with more severe comprehension deficits (low comprehenders) a clear reduction in the N400 effects was obtained, both for the associative and the semantic word pairs. The patients with right hemisphere lesions showed a normal N400 effect for the associatively related targets, but a trend towards a reduced N400 effect for the semantically related word pairs. A dissociation between the N400 results in the word pair paradigm and P300 results in a classical tone oddball task indicated that the N400 effects were not an aspecific consequence of brain lesion, but were related to the nature of the language comprehension impairment. The conclusions drawn from the ERP results are that comprehension deficits in the aphasic patients are due to an impairment in integrating individual word meanings into an overall meaning representation. Right hemisphere patients are more specifically impaired in the processing of semantically more distant relationships, suggesting the involvement of the right hemisphere in semantically coarse coding.

A case of ‘sign blindness’ following left occipital damage in a deaf signer

We report on a right-handed, deaf, life long signer who suffered a left posterior cerebral artery (PCA) stroke. The patient presented with right homonymous hemianopia, alexia and a severe sign comprehension deficit. Her production of sign language was, however, virtually normal. We suggest that her syndrome can be characterized as a case of ‘sign blindness’, a disconnection of the intact right hemisphere visual areas from intact left hemisphere language areas. This case provides strong evidence that the neural systems supporting sign language processing are predominantly in the left hemisphere, but also suggests that there are some differences in the neural organization of signed vs spoken language within the left hemisphere.

Positive and negative neuropsychiatric features in Alzheimer's disease.

Positive neuropsychiatric features (paranoia, delusions, hallucinations) and negative features (disinterest/withdrawal, apathy, reduced speech output, reduced physical activity) occur in Alzheimer's disease (AD), although most studies have focused on positive features alone. Positive features may be associated with a more severe and rapidly progressive subtype of AD. A retrospective analysis of prospectively obtained research data (101 probable AD patients) revealed that patients with positive features had been ill longer but were otherwise similar to patients with negative features. Patients with any neuropsychiatric features had more rapid progression and more severe cognitive and comprehension deficits than patients without such features. Neuropsychiatric features in AD likely reflect variations in mesocortical and mesolimbic degeneration rather than an etiologic or prognostic subtype.

Factors complicating the diagnosis of depression in cerebrovascular disease, Part II--Neurological deficits and various assessment methods.

Neurological deficits associated with cerebrovascular disease such as aphasia, dementia, anosognosia and aprosodia may impair the ability to express or experience depressive symptoms. Identification of depression in the absence of verbal report on subjective mood state is a difficult task. The value of various diagnostic methods including depressive rating scales, standard psychiatric interviews and biological variables in the diagnosis of depression in cerebrovascular disease is considered. This review concludes by focusing on the deficiencies of existing approaches in the diagnostic assessment of depression in patients with severe communication and comprehension deficits and emphasizes the importance of devising a standard diagnostic method with less reliance on verbal responses.

Treatment of Wernicke's aphasia with jargon: A case study

This case study concerns an adult with Wernicke's aphasia characterized by neologistic jargon and a severe auditory comprehension deficit. No communicative or linguistic improvements had been observed after eight months poststroke. Up until this time, therapeutic intervention was aimed at managing the patient's rambling communicative style and improving auditory comprehension skills. A therapeutic regimen was introduced that focused on visual/written information and included a hierarchy of visual word and sentence comprehension tasks. All auditory/verbal stimulus presentation was eliminated. After two months on the program, improvement was noted in naming abilities and general ability to communicate in conservation, including a reduction of neologistic jargon and an increase in semantic jargon. No improvement was noted in auditory comprehension. The visual program may have facilitated the patient's general attentional set, thereby possibly contributing to her improvement in communicative style and sensitivity to conversational interactions with others.

Evoked potential measures of auditory cortical function and auditory comprehension in aphasia

This study investigated the relation between severity of auditory comprehension impairment in aphasia and the functional integrity of the posterior superior temporal region as evaluated by middle- and long-latency auditory evoked potentials and dipole source analysis. AEPs were studied in 20 stroke patients and in age-matched controls. AEPs and language data were collected 1 year or more post onset, and were compared to performance early after onset. Patients were differentiated in a group with severe and a group with moderate to recovered auditory comprehension impairment. Significant asymmetries of auditory evoked dipole source potentials were more frequent in the severely impaired group. However, a severe auditory comprehension deficit was not incompatible with normal AEPs. The results confirm the importance of the posterior superior temporal region for auditory language comprehension, but the correlation between AEP asymmetry and auditory comprehension seems due to the close spatial relation of AEP generating substrate and posterior language area rather than to partial overlap. Dipole source analysis of AEPs proved to be a valuable method for the assessment of interhemispheric asymmetries, enhancing the sensitivity of AEPs to unilateral damage of auditory cortex.

Development and Testing of a Computerized Language Intervention for Acute Global Aphasia

There is a need for effective language therapy interventions appropriate for patients with global aphasia in the acute stage of recovery from stroke. This paper reports a feasibility study of a therapy designed for this population. The therapy program, E-VIC, is presented with the aid of a Macintosh computer. Stimuli and performance are automatically computer-monitored. Results of training with seven globally aphasic patients show that all learned to use the mouse to carry out the task, despite their severe comprehension deficit. Five of the seven patients learned to select correctly from two alternative responses by session 5, and four patients were reliably selecting the correct picture from a response field of at least 3 and as many as 12 items by the time training was terminated (5–18 sessions). A study of the efficacy of E-VIC for recovery of language function is in progress.