Vision, Aphasia, Neglect Assessment for Large Vessel Occlusion Stroke.

BACKGROUND AND PURPOSE: Vision, Aphasia, Neglect (VAN) is a large vessel occlusion (LVO) screening tool that was initially tested in a small study where emergency department (ED) nurses were trained to perform VAN assessment on stroke code patients. We aimed to validate the VAN assessment in a larger inpatient dataset. METHODS: We utilized a large dataset and used National Institute of Health Stroke Scale (NIHSS) performed by physicians to extrapolate VAN. VAN was compared to NIHSS greater than or equal to 6 and established prehospital LVO screening tools including Rapid Arterial Occlusion Evaluation scale (RACE), Field Assessment Stroke Triage for Emergency Destination (FAST-ED), and Cincinnati Pre-hospital Stroke Scale (CPSS). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and area under receiver operating characteristics curve was calculated to estimate the predictive value of LVO. RESULTS: VAN was comparable in sensitivity (79% versus 80%) and NPV (88% versus 87%) to NIHSS greater than or equal to 6. It was superior in specificity (69% versus 57%), PPV (53% versus 46%) and accuracy to NIHSS greater than or equal to 6 (72% versus 64%) with significant receiver operating curve (.74 versus .69, P = .02). VAN also had comparable area under the curve when compared to RACE, FAST-ED, and CPSS however slightly lower accuracy (69%-73%) compared to RACE (76%), FAST-ED (77%), and CPSS (75%). VAN had the highest NPV among all screening assessments (88%). CONCLUSIONS: VAN is a simple screening tool that can identify LVOs with adequate accuracy in hospital setting. Future studies need to be conducted in prehospital setting to validate its utility to detect LVOs in the field.

Communicative Accessibility in Aphasia: An Investigation of the Interactional Context of Long-Term Care Facilities.

Purpose: The purpose of this study was to examine the ability of persons with aphasia to access interaction and be included in social encounters in long-term care facilities (LTCFs). Method: Four persons with aphasia were the focus of this investigation. A qualitative research approach using ethnographic methods was used to conduct participant observation, semistructured interviews, and artifact analysis. Expanded field notes from observations, transcribed interviews, and artifacts were then coded to identify patterns in the data. Results: The interactional context of LTCFs negatively influenced the ability of persons with aphasia to communicate with others and develop meaningful relationships. Three major themes emerged from the data detailing the contextual elements leading to communication accessibility and inclusion: (a) lack of support, (b) social hierarchy, and (c) focus on performance. Conclusions: Findings highlighted several barriers in LTCFs that worked to discourage persons with aphasia from living social and expressive lives. Specific obstacles included a misunderstanding of aphasia and its influence on communicative exchanges and performance-oriented environment that overlooked psychosocial needs. Speech-language pathologists have an important role for advocacy in LTCFs. Clinical implications for assessment and treatment in institutions are discussed.

A cognitive psychometric model for assessment of picture naming abilities in aphasia.

Picture naming impairments are a typical feature of stroke-induced aphasia. Overall accuracy and rates of different error types are used to make inferences about the severity and nature of damage to the brain's language network. Currently available assessment tools for picture naming accuracy treat it as a unidimensional measure, while assessment tools for error types treat items homogenously, contrary to findings from psycholinguistic investigations of word production. We created and tested a new cognitive psychometric model for assessment of picture naming responses, using cognitive theory to specify latent processing decisions during the production of a naming attempt, and using item response theory to separate the effects of item difficulty and participant ability on these internal processing decisions. The model enables multidimensional assessment of latent picture naming abilities on a common scale, with a relatively large cohort for normative reference. We present the results of 4 experiments testing our interpretation of the model's parameters, as they apply to picture naming predictions, lexical properties of the items, statistical properties of the lexicon, and participants' scores on other tests. We also created a website for researchers and clinicians to analyze item-level data using our model, providing estimates of latent abilities and percentile scores, as well as credible intervals to help gauge the reliability of the estimated model parameters and identify meaningful changes. To the extent that the model is successful, the estimated parameter values may aid in treatment decisions and progress monitoring, or they may help elucidate the functional properties of brain networks. (PsycINFO Database Record

A quick aphasia battery for efficient, reliable, and multidimensional assessment of language function.

This paper describes a quick aphasia battery (QAB) that aims to provide a reliable and multidimensional assessment of language function in about a quarter of an hour, bridging the gap between comprehensive batteries that are time-consuming to administer, and rapid screening instruments that provide limited detail regarding individual profiles of deficits. The QAB is made up of eight subtests, each comprising sets of items that probe different language domains, vary in difficulty, and are scored with a graded system to maximize the informativeness of each item. From the eight subtests, eight summary measures are derived, which constitute a multidimensional profile of language function, quantifying strengths and weaknesses across core language domains. The QAB was administered to 28 individuals with acute stroke and aphasia, 25 individuals with acute stroke but no aphasia, 16 individuals with chronic post-stroke aphasia, and 14 healthy controls. The patients with chronic post-stroke aphasia were tested 3 times each and scored independently by 2 raters to establish test-retest and inter-rater reliability. The Western Aphasia Battery (WAB) was also administered to these patients to assess concurrent validity. We found that all QAB summary measures were sensitive to aphasic deficits in the two groups with aphasia. All measures showed good or excellent test-retest reliability (overall summary measure: intraclass correlation coefficient (ICC) = 0.98), and excellent inter-rater reliability (overall summary measure: ICC = 0.99). Sensitivity and specificity for diagnosis of aphasia (relative to clinical impression) were 0.91 and 0.95 respectively. All QAB measures were highly correlated with corresponding WAB measures where available. Individual patients showed distinct profiles of spared and impaired function across different language domains. In sum, the QAB efficiently and reliably characterized individual profiles of language deficits.

Development and Standardization of a New Cognitive Assessment Test Battery for Chinese Aphasic Patients: A Preliminary Study.

BACKGROUND: Nonlinguistic cognitive impairment has become an important issue for aphasic patients, but currently there are few neuropsychological cognitive assessment tests for it. To get more information on cognitive impairment of aphasic patients, this study aimed to develop a new cognitive assessment test battery for aphasic patients, the Non-language-based Cognitive Assessment (NLCA), and evaluate its utility in Chinese-speaking patients with aphasia. METHODS: The NLCA consists of five nonverbal tests, which could assess five nonlinguistic cognitive domains such as visuospatial functions, attention test, memory, reasoning, and executive functions of aphasic patients. All tests are modified from the nonverbal items of the current existed tests with some changes to the characteristics of Chinese culture. The NLCA was tested in 157 participants (including 57 aphasic patients, 50 mild cognitive impairment (MCI) patients, and 50 normal controls), and was compared with other well-established relative neuropsychological tests on the reliability, validity, and utility. RESULTS: The NLCA was fully applicable in the MCI patients and the normal controls, almost working in the aphasic patients (57/62 patients, 91.9%). The NLCA scores were 66.70 ± 6.30, 48.67 ± 15.04, and 77.58 ± 2.56 for the MCI group, the aphasic group, and the control group, respectively , and a significant difference was found among three groups (F = 118.446, P < 0.001). The Cronbach's alpha of the NLCA as an index of internal consistency was 0.805, and the test-retest and interrater reliability was adequate (r=0.977 and r= 0.970, respectively). The correlations of the cognitive subtests and their validation instruments were between 0.540 and 0.670 (all P < 0.05). Spearman's correlation analysis indicated that the coefficient of internal consistency of each subtest itself was higher than other subtests. When choosing the Montreal Cognitive Assessment score of <26 as the diagnostic criteria of cognitive impairment, the area under the curve for all participants in the control and MCI groups was 0.942 (95% confidence interval: 0.895-0.989), and an optimal cutoff point of 75.00 seemed to provide the best balance between sensitivity and specificity. Age (r = -0.406, P < 0.001) was the main influence factor for the NLCA. CONCLUSIONS: The NLCA could efficiently differentiate the cognitive impairment patients from the normal controls and is a reliable and valid cognitive assessment test battery to specially find nonlinguistic cognitive function for aphasic patients.

Neuroscientific Implications in Assessment and Intervention for Aphasia.

Within an overarching theme of generational change in aphasiology, the aims of this paper are to (a) unify the neuroscience of the language impairment of aphasia with the psychosocial science of aphasia, (b) consider the implications of technology and (c) address the global challenge of translational research in this field. To achieve the first two aims, 10 principles of neuroplasticity will be interpreted within the World Health Organization's International Classification of Functioning, Disability and Health (ICF). Two novel treatment approaches to aphasia (UQ Aphasia LIFT and CommFit™) will be described that illustrate how the neuroplasticity principles can be interpreted more broadly within the ICF. The global challenge of translational research will bring the perspective of clinicians and consumers through to aphasia research via 3 recent sets of best practice statements for aphasia. Each demonstrates how the field of aphasiology is undertaking a knowledge synthesis within its broader remit of knowledge transfer and exchange. The Australian Aphasia Rehabilitation Pathway is described as a way of creating living clinical guidelines that are helpful to all stakeholders in aphasia research.

Assessment practices of speech-language pathologists for cognitive communication disorders following traumatic brain injury in adults: an international survey.

PRIMARY OBJECTIVE: This study's objective was to examine the current assessment practices of SLPs working with adults with acquired cognitive communication impairments following a TBI. METHODS AND PROCEDURES: Two hundred and sixty-five SLPs from the UK, the US, Canada, Australia and New Zealand responded to the online survey stating the areas of communication frequently assessed and the assessment tools they use. MAIN OUTCOMES AND RESULTS: SLPs reported that they routinely assessed functional communication (78.8%), whereas domains such as discourse were routinely assessed by less than half of the group (44.3%). Clinicians used aphasia and cognitive communication/high level language tools and tools assessing functional performance, discourse, pragmatic skills or informal assessments were used by less than 10% of the group. The country and setting of service delivery influenced choice of assessment tools used in clinical practice. CONCLUSIONS: These findings have implications for training of SLPs in a more diverse range of assessment tools for this clinical group. The findings raise questions regarding the statistical validity and reliability of assessments currently used in clinical practice. It highlights the need for further research into how SLPs can be supported in translating current evidence about the use of assessment tools into clinical practice.

Lesion correlates of patholinguistic profiles in chronic aphasia: comparisons of syndrome-, modality- and symptom-level assessment.

One way to investigate the neuronal underpinnings of language competence is to correlate patholinguistic profiles of aphasic patients to corresponding lesion sites. Constituting the beginnings of aphasiology and neurolinguistics over a century ago, this approach has been revived and refined in the past decade by statistical approaches mapping continuous variables (providing metrics that are not simply categorical) on voxel-wise lesion information (voxel-based lesion-symptom mapping). Here we investigate whether and how voxel-based lesion-symptom mapping allows us to delineate specific lesion patterns for differentially fine-grained clinical classifications. The latter encompass 'classical' syndrome-based approaches (e.g. Broca's aphasia), more symptom-oriented descriptions (e.g. agrammatism) and further refinement to linguistic sub-functions (e.g. lexico-semantic deficits for inanimate versus animate items). From a large database of patients treated for aphasia of different aetiologies (n = 1167) a carefully selected group of 102 first ever ischaemic stroke patients with chronic aphasia (∅ 12 months) were included in a VLSM analysis. Specifically, we investigated how performance in the Aachen Aphasia Test-the standard clinical test battery for chronic aphasia in German-relates to distinct brain lesions. The Aachen Aphasia Test evaluates aphasia on different levels: a non-parametric discriminant procedure yields probabilities for the allocation to one of the four 'standard' syndromes (Broca, Wernicke, global and amnestic aphasia), whereas standardized subtests target linguistic modalities (e.g. repetition), or even more specific symptoms (e.g. phoneme repetition). Because some subtests of the Aachen Aphasia Test (e.g. for the linguistic level of lexico-semantics) rely on rather coarse and heterogeneous test items we complemented the analysis with a number of more detailed clinically used tests in selected mostly mildly affected subgroups of patients. Our results indicate that: (i) Aachen Aphasia Test-based syndrome allocation allows for an unexpectedly concise differentiation between 'Broca's' and 'Wernicke's' aphasia corresponding to non-overlapping anterior and posterior lesion sites; whereas (ii) analyses for modalities and specific symptoms yielded more circumscribed but partially overlapping lesion foci, often cutting across the above syndrome territories; and (iii) especially for lexico-semantic capacities more specialized clinical test-batteries are required to delineate precise lesion patterns at this linguistic level. In sum this is the first report on a successful lesion-delineation of syndrome-based aphasia classification highlighting the relevance of vascular distribution for the syndrome level while confirming and extending a number of more linguistically motivated differentiations, based on clinically used tests. We consider such a comprehensive view reaching from the syndrome to a fine-grained symptom-oriented assessment mandatory to converge neurolinguistic, patholinguistic and clinical-therapeutic knowledge on language-competence and impairment.

Clinical application of Loewenstein Occupational Therapy Cognitive Assessment Battery-Second Edition in evaluating of cognitive function of Chinese patients with post-stroke aphasia.

OBJECTIVE: To investigate the clinical application value of Loewenstein Occupational Therapy Cognitive Assessment battery in Chinese patients with post-stroke aphasia. METHODS: Cognitive functions of 59 Chinese patients with aphasia following a stroke were assessed with the Chinese version of the second edition of LOTCA battery and their linguistic functions were tested with the Western Aphasia Battery (WAB) Scale, respectively. The Results of LOTCA were analyzed and compared across different groups, in the light of gender, age, educational background, the length of illness, and the degree of aphasia. RESULTS: Neither the score of subtests of the LOTCA nor the overall scores of LOTCA of aphasia patients with different gender and educational background differed (all P>0.05). In different age groups, apart from thinking operation (F=3.373, P=0.016), visuomotor organization (F=3.124, P=0.022), attention (F=3.729, P=0.009) and the total score (F=2.683, P=0.041), there was no difference in terms of the other subtest scores of LOTCA (all P>0.05). In the groups of different length of time with illness, apart from orientation (F=2.982, P=0.039) and attention (F=3.485, P=0.022), the score of other subtests and the total score of LOTCA were not different (all P>0.05). In the groups of different degree of aphasia, apart from attention (F=2.061, P=0.074), both the score of other subtests and the total score of LOTCA differed (all P<0.05). CONCLUSION: LOTCA might be suitable to assessing the cognitive ability of post-stroke Chinese patients with aphasia.

Impairment only on the fluency subtest of the Frontal Assessment Battery after prefrontal lesions.

The Frontal Assessment Battery is a set of six subtests that is used widely to assess frontal cortical executive dysfunction. Performance on the Frontal Assessment Battery has been shown to be sensitive to various neurodegenerative diseases, but it has never been shown to be sensitive to damage restricted to the frontal cortex. Thus, despite its wide use, it has never been validated on an appropriate population of patients with frontal lesions. The present study shows that, of the six subtests that comprise the Frontal Assessment Battery, only performance on the verbal fluency subtest (mental flexibility) was specifically sensitive to injury restricted to the frontal cortex. Performance of patients with damage to the dorsal part of the medial frontal region in the language-dominant left hemisphere was impaired. None of these patients was aphasic at the time of testing. The critical region in the dorsomedial frontal cortex includes the supplementary speech zone but is not restricted to it: it extends into the cingulate motor region and the paracingulate cortex as well as the medial prefrontal areas 8 and 9. The results indicate that the Frontal Assessment Battery is not a sensitive measure of prefrontal cortical dysfunction, except for the verbal fluency subtest.

Toward a quantitative basis for assessment and diagnosis of apraxia of speech.

PURPOSE: We explored the reliability and validity of 2 quantitative approaches to document presence and severity of speech properties associated with apraxia of speech (AOS). METHOD: A motor speech evaluation was administered to 39 individuals with aphasia. Audio-recordings of the evaluation were presented to 3 experienced clinicians to determine AOS diagnosis and to rate severity of 11 speech dimensions. Additionally, research assistants coded 11 operationalized metrics of articulation, fluency, and prosody in the same speech samples and in recordings from 20 neurologically healthy participants. RESULTS: Agreement among the 3 clinicians was limited for both AOS diagnosis and perceptual scaling, but inter-observer reliability for the operationalized metrics was strong. The relationships between most operationalized metrics and mean severity ratings for corresponding perceptual dimensions were moderately strong and statistically significant. Both perceptual scaling and operationalized quantification approaches were sensitive to the presence or absence of AOS. CONCLUSIONS: Perceptual scaling and operationalized metrics are promising quantification techniques that can help establish diagnostic transparency for AOS. However, because satisfactory reliability cannot be assumed for scaling techniques, effective training and calibration procedures should be implemented. Operationalized metrics show strong potential for enhancing diagnostic objectivity and sensitivity.

Living with aphasia: three Indigenous Australian stories.

The incidence of cardiovascular disorders and stroke in Australian Aboriginal communities is more than twice as high as non-Indigenous Australians. Approximately 30% of people who survive stroke are left with some level of aphasia, and yet Indigenous Australians appear to be infrequent users of speech-language pathology services, and there is virtually no research literature about the experiences of aphasia for this group of people. This paper presents the stories of living with aphasia for three Indigenous Australian men living in Perth, Western Australia. Their narratives were collected by an Indigenous researcher through in-depth, supported interviews, and were explored using both within-case and cross-case analyses for common and recurring themes. It is argued that there is value for speech-language pathologists, and other health professionals, to be aware of the broad experiences of living with aphasia for Indigenous Australians because their stories are rarely heard and because, as with people with aphasia generally, they are at risk of social isolation and tend to lack visibility in the community. This study explores the key issues which emerge for these three men and highlights the need for further research in this area.

The dignity of struggle.

The theme of this article focuses on the survivors' ability to participate in life as fully as they choose and the way in which individuals in those persons' lives can support this objective. A description of how the adult onset of communication disorders can affect self-image and self-identity is provided. Persons with aphasia are encouraged to consider various issues: What do individuals have control over at each level of their recovery versus what choices are made for them? What communicative power do individuals have and what environmental barriers are at play? Variables that define dignity along each stage of recovery are outlined. This thematic impression is supported by my recent experience with my mother who suffered a stroke with aphasia. It can be a challenge to translate the philosophical basis for professional work into a personal relationship. However, many lessons about dignity and empathy are gleaned from the experience.

Language tasks used for the presurgical assessment of epileptic patients with MEG.

Determining the language dominant hemisphere and the intrahemispheric localization of this function are imperative in the planning of neurosurgical procedures in epileptic patients. New noninvasive diagnostic techniques are being developed to reduce the risks associated with more invasive techniques. The aim of this paper is to review the different protocols for lateralizing and/or localizing language functions using magnetoencephalography (MEG), a noninvasive technique. The reviewed studies include control and patient populations using various protocols which employ different expressive and receptive language tasks. The overall findings reveal high concordance between MEG and the intracarotid amobarbital test (IAT). Moreover, MEG allows intrahemispheric localization of receptive and expressive language functions. However, the different language tasks used with MEG, whether receptive or expressive, appear to activate the left temporal more than frontal areas. The best task to assess language comprehension in both adults and children appears to be a word recognition task. A verbal fluency task could be used to test language production in children and a verb generation task in adults.

Comparison of alternatives to multidimensional scoring in the assessment of language comprehension in aphasia.

PURPOSE: Multidimensional scoring methods yield valuable information about communication abilities. However, issues of training demands for valid and reliable scoring, especially in current service delivery contexts, may preclude common usage. Alternatives to multidimensional scoring were investigated in a sample of adults with aphasia. METHOD: One alternative method involved modified multidimensional scoring; the others incorporated correct/incorrect scoring. The scores for the 3 alternative methods were derived from the scores obtained using the traditional multidimensional method. Revised Token Test scores obtained using the traditional multidimensional method were collected from 10 participants with aphasia. These scores were manipulated to yield 3 additional sets of scores corresponding to the alternative methods. RESULTS: There were no significant differences between the traditional multidimensional method and 1 of the correct/incorrect methods. Significant differences were found between traditional multidimensional scoring and each of the other 2 methods. CONCLUSIONS: The study findings suggest that simpler scoring systems might yield similar data to traditional multidimensional scoring. If simpler alternative methods yield similar results, using alternative scoring methods with published tests based on multidimensional scoring will help expand their use in everyday clinical practice.

Neurobehavioral assessment of mood and affect in patients with neurological disorders.

Patients with neurological disorders are particularly susceptible to a variety of affective and mood disorders. Unfortunately, several factors confound the analysis of the individual case. These factors include the fact that neurological deficits may limit the capacity of the individual to communicate mood and feelings. In some cases, the deficits might mimic affective disorders. In this article we will review the traditional presentation of affective disorders in the normal patient. We offer a discussion of specific aspects of the neurobehavioral assessment that might confound the analysis of the individual case. The confounding factors include frontal lobe deficits, aspects of impairments in language, and memory disorders. We also direct attention to motor system deficits and other problems such as sleep disorders that might contribute to a better diagnosis of affective and mood disorders. Finally, we summarize this information and present a general approach for the analysis of the individual.

Attention deficits in aphasia: presence, nature, assessment, and treatment.

Recently, there has been growing interest in understanding how nonlinguistic cognitive problems such as impaired attention might negatively affect the linguistic abilities of adults with aphasia. This article begins with a summary of research focused on the relationship between attention and language impairments in aphasia and a discussion of why it might be important for clinicians to address the attention abilities of their aphasic patients. Also discussed are formal and informal measures for quantifying and qualifying attention problems, treatment strategies for directly or indirectly remediating attention problems in patients with aphasia, and empirical support for such treatment.

Impaired speech perception in aphasic patients: event-related potential and neuropsychological assessment.

The mismatch negativity component (MMN) of auditory event-related potentials (ERP) was recorded in four aphasic patients and in age, gender and education matched controls. The MMN changes elicited by tone, vowel, voicing stop consonant and place-of articulation contrasts were recorded over both hemispheres. The results of MMN amplitude, latency and distribution differences between aphasics and controls were analyzed in detail. An extensive neuropsychological investigation was performed in order to highlight the assumed dissociation and possible interactions between the impaired acoustic/phonetic perception and deficient comprehension in aphasic patients. Our principal finding was that MMN elicited by pitch deviations is not enough sensitive to distinguish between patients and age-matched controls. The MMN elicited by consonant contrasts was found to be the most vulnerable in aphasic patients investigated. The MMN elicited by voicing ([ba:] vs. [pa:]) and place-of-articulation ([ba:] vs. [ga:]) could be characterized by total lack, distorted or very limited distribution and correlated with the patients' performance shown in the behavioral phoneme discrimination task. The magnitude of the deficient phoneme (vowel and consonant contrasts) processing shown by MMN anomalies was proportionally related to the non-word discrimination and did not interact with the word discrimination performance. The impact of deficient speech sound processing on higher level processes may depend on the type of aphasia, while the presence of perceptual deficits in processing acoustic/phonetic contrasts seems to be independent of the type of aphasia.

Magnetic resonance assessment of acute and chronic stroke.

This article describes the important role of magnetic resonance imaging (MRI) in noninvasively assessing human focal ischemic stroke. Conventional MRI, diffusion-weighted and/or perfusion-weighted imaging have been used to facilitate both the qualitative and quantitative evaluation of heterogeneity of ischemic brain tissue. Further, by combining 2 or more magnetic resonance parameters, tissue-signature models have been developed that may be used as surrogate markers of tissue histopathology to characterize ischemic tissue as salvageable, necrotic, or tissue in transition to necrosis. Magnetic resonance tissue-signature models and results are presented. Dynamic changes in the evolution of ischemic tissue to infarction are also discussed. Recovery from acute stroke was studied with blood oxygenation level-dependent functional MRI to investigate the neural mechanisms for recovery from aphasia after stroke.

Please pass the cauliflower: a recipe for introducing undergraduate students to brain structure and function.

Neurophysiology/pathophysiology content is a frequent source of anxiety for undergraduate students and their instructors. This learning module supplements traditional lecture and overhead presentations to offer a novel, nonthreatening, and entertaining introduction to neuropathology. The module is based on a ridiculous analogy between the human brain and the cauliflower. This module has been used with both underclassmen and more advanced health science undergraduate students and has produced enthusiastic student responses while deescalating both student and instructor anxiety.