Factors Affecting Recovery Following Vascular Aphasia

Mervat Mostafa et al
Factors Affecting Recovery Following Vascular
Aphasia
Mervat Mostafa1, Hosna Mostafa2, Ibtesam Fahmy1, Manal Fahmy1, Kamel Hamouda1,
Yahia Zakaria1, Nervana El-Faioumy1, Noha Abo-Krysha1
Departments of Neurology1, Nuclear Medicine2, Cairo University
ABSTRACT
Objective: To study the influence of some demographic, clinical and neuroimaging variables on
recovery of vascular aphasia. Subjects and Methods: The study included 47 aphasic patients (27 females
and 20 males), who were subjected to thorough clinical assessment, scoring of aphasia using modified
Chesher test and Achen aphasia test (AAT), laboratory work-up and SPECT scan of the brain. Results: A
significant negative correlation was obtained between age and the scores of the different aspects of the
aphasia scales, though no significant correlation was found between age and regional cerebral blood
flow (rCBF). Female patients with aphasia of more than 3 months duration showed significant higher
mean scores of aphasia tests compared to males, moreover, females had a higher mean left hemispheric
CBF compared to males. Literate patients had significantly higher mean scores of aphasia tests
compared to illiterates, however, no significant difference was observed between literates and illiterates
regarding CBF. Patients with multiple risk factors for stroke had lower mean scores of aphasia scales
and lower rCBF compared to those with a single risk factor. Patients with nominal and transcortical
(TCM) aphasia had significantly higher mean scores of aphasia scales compared to global and Broca’s
aphasics, though no significant difference was detected between different types of aphasia regarding
CBF. Patients with large sized hypoperfusion and those with cerebellar diaschesis had lower mean
scores in the used aphasia tests compared to those with small sized hypoperfusion and those without
diaschesis. Conclusion: Factors predicting good recovery following vascular aphasia include: young
age, female gender, education, absence of risk factors for stroke, localized forms of aphasia, higher
grade of motor power on the paretic side, small sized hypoperfusions and absence of cerebellar
diaschesis on SPECT study. . (Egypt J. Neurol. Psychiat. Neurosurg., 2004, 41(1): 183-194).
INTRODUCTION
It is known that the greatest spontaneous
recovery in vascular aphasia takes place
within the first 6 months following stroke
onset,1,2 however, other authors use a 3months as a cut off point of spontaneous
recovery.3,4
Many variables tend to affect recovery of
aphasia as: etiology of aphasia, type of
aphasia, age and sex of the patient,
handedness, intellectual and educational level
of the patient and certain behavioral and
social factors.5
The prognosis of aphasia is significantly
different according to etiological varieties;
aphasias caused by trauma have better
prognosis than aphasias caused by
progressive disorders and strokes.6 Moreover,
patients with aphasia caused by strokes, who
have had prior infarcts, show limited
recovery.7
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Egypt J. Neurol. Psychiat. Neurosurg.
Mild Broca’s aphasia, transcortical motor
aphasia (TCMA), and conduction aphasia
usually show good recovery compared to
global aphasia.8 However, severe Broca’s and
Wernicke’s aphasias tend to recover along
several pathways.9
Recovery from aphasia may be agerelated. Some authors documented that
improvement appeared to favor younger
patients.10.11 However, others found that age
had a minor effect as regard recovery in
aphasics.2,4
Several studies showed that gender
difference had no significant effect in
recovery in aphasics.6,12,13 However, other
studies concluded that females recover
significantly better than males in oral
expression, but not in auditory verbal
comprehension.14,15
Aphasia in left handers is usually milder
than in right handers, regardless of the
hemisphere damaged. Moreover, left handers
generally recovery more quickly and more
thoroughly from aphasia than do right
handers.6
Intellectual and educational level
influences the limits of what the patient and
his environment will consider normal.6 In
addition several behavioral and psychological
factors were found to have significant effect
on the course of recovery from aphasia.16
Studies using CBF during recovery from
aphasia have produced conflicting results.
Some studies found that good recovery form
aphasia was associated with an increase in
regional CBF in the right hemisphere.17,18
Other studies suggested that the activation of
the left hemisphere was the best indictor of
good recovery from aphasia.19
In addition, other researchers suggested
that the initial language recovery within the
first year post-stroke may be linked primarily
to functional recovery in the dominant
hemisphere, whereas, long-term recovery in
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aphasia may be related to slow and gradual
compensatory functions in the contralateral
hemisphere.20
So, this study was designed to study the
influence of some demographic, clinical and
neuroimaging variables on the rate of
recovery following vascular aphasia.
PATIENTS AND METHODS
This study was conducted on 47 righthanded Egyptian aphasic patients due to
cerebral infarction in the domain of middle
cerebral artery. Patients were recruited from
the Internal Medicine and Neurology
Departments, Kasr El-Aini Hospitals.
Excluded from this work were: Patients with
aphasia due to causes other than stroke,
patients with disturbed conscious level or
comatosed patients and patients with other
concomitant neurologic or psychiatric
diseases.
Patients were submitted to the following
battery of assessment:
1. Thorough clinical evaluation.
2. Clinical testing of aphasia using:
a. The Arabic translated form of the
modified Chesher test.
b. Aachen aphasia test (AAT).
3. Laboratory test including: Complete
blood picture, fasting and postprandial
blood sugar, urea and creatinine levels,
liver function, lipid profile, and serum
uric acid.
4. Non-contrast CT and or MRI of the
brain: To confirm that aphasia is due to
vascular occlusion in the domain of
MCA.
5. Single photon Emission computerized
tomography (SPECT):
SPECT scans of the brain were
performed using Tc99m Hexamethyl
Mervat Mostafa et al
propylenamine
(HMPAO).
SPECT
images were acquired 60 minutes postinjection of the radiopharmaceutical by a
dual head gamma camera equipped with
high-resolution collimators interfaced to
a dedicated computer.
Statistical Methods:
Individual data were expressed in mean
and standard deviation (SD). The Student ttest was used to test the significance of
differences between the two means. The
Mann-Whitney U test was used to compare
the means of two independent groups. The
correlation coefficient and the Chi-squared
tests were used to measure the relationship
between two quantitative and qualitative
variables respectively.
RESULTS
Forty-seven
right-handed
aphasic
patients (27 females and 20 males) were
included in this study. Their ages ranged from
17 to 81 years with a mean of 46.45±12.71
years. Fourteen patients were literate
(29.79%), mostly males, whereas, 33 patients
were illiterate (70.21%).
Forty-two patients (89.36%) were found
to have multiple risk factors for
cerebrovascular stroke (CVS) detected either
clinically or by investigations, while 5
patients (10.64%) had only a single risk
factor. The clinical risk factors for CVS
encountered in our patients included:
hypertension in 21 patients (44.68%),
smoking in 12 patients (25.53%) and Diabetes
Mellitus in 8 patients (17.02%). History of
rheumatic fever was recorded in 11 patients
(23.4%) and cardiac arrhythmias were found
in 8 patients. Previous transient ischemic
attacks (TIAs) in the domain of the carotid
system were reported in 8 patients (17.02%)
and pulseless disease was encountered in one
patient (2.13 %). Contraceptive pill intake
was reported in 4 female patients.
Risk factors detected by laboratory workup are shown in table (1).
Carotid duplex studies revealed diffuse
atherosclerosis in both carotid arteries in 7
cases (14.9%), atheromatous plaques in 5
cases (10.6%), left internal carotid artery
stenosis in 3 cases (6.4%), complete
occlusion of left common carotid artery in 2
cases (4.3%), tortousity of left common
carotid artery (CCA) and internal carotid
artery (ICA) in one case (2.13%) and
complete occlusion of left and right common
carotid arteries, both subclavian arteries and
both axillary arteries in one case (2.13%).
Echocardiography studies revealed
concentric left ventricular hypertrophy in 8
cases (17.02%), mitral regurge and left atrial
dilatation in 7 cases (14.9%), aortic regurge in
5 cases (10.6%), diastolic dysfunction in 4
cases (8.5%), mitral valve prolapse, dilated
cardiomyopathy and sclerosed aortic valve,
each detected in 2 cases (4.3%) and
pulmonary hypertension, interventricular
hypertrophy and dilatation of right atrium and
ventricle, each detected in one case (2.1%).
Age:
A significant negative correlation was
found between the age of the patient with the
repetition subtest of modified Chesher test
(p=0.02); total score of spontaneous speech
ratings, repetition and token subtests of AAT
(p= 0.009, 0.01 and 0.02 respectively).
However, no significant correlation was
found between age and the CBF of the left or
right
hemispheres
(p=
0.91,
0.63
respectively).
Sex:
No significant difference was found
between male and female patients as regards
the mean scores of aphasia subtests.
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Egypt J. Neurol. Psychiat. Neurosurg.
However, comparison between male and
female patients with aphasia of more than 3
months duration showed that female patients
had significantly higher total score of
modified Chesher test and higher articulation
score of AAT, (p= 0.02, 0.01 respectively).
As regard CBF, there was a trendwise
higher mean left hemispheric CBF in female
patients compared to males (p= 0.07).
Moreover, the mean left temporal and left
parietal CBF were significantly higher in
female patients compared to males, (p= 0.001,
0.04 respectively). Table (2)
Literacy State:
Literate patients showed significantly
higher mean scores in nearly all subtests of
the used aphasia scales. Table (3).
However, comparison between literate
and illiterate patients as regard CBF revealed
no significant difference between both
groups. Table (4).
Grade of motor power on the hemiparetic
side:
The grade of motor power in upper limb
showed significant positive correlation with
comprehension score and the total score of
modified Chesher test (p= 0.04, 0.03
respectively); and with articulation and
comprehension scores of AAT (p= 0.04,
0.006 respectively).
The grade of motor power in lower limb
was also positively correlated with repetition;
comprehension, and the total scores of
modified Chesher test (p= 0.007, 0.003 and
0.002 respectively), and with total
spontaneous speech rating score; naming,
repetition; comprehension and token test
scores of AAT (p= 0.005, 0.05, 0.02, 0.000
and 0.020 respectively).
A significant positive correlation was
also found between the grade of motor power
of upper limb and the rCBF of both right and
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Vol. 41 (1) – Jan 2004
left frontal lobes (p= 0.01,0.003 respectively).
Moreover, the grade of motor power of upper
and lower limbs showed significant negative
correlation with the size of hypoperfusion
lesion (p= 0.004, 0.02, respectively).
Clinical type of aphasia:
The types of aphasia found in our
patients are shown in table (5).
Global and Broca's aphasics showed
significantly lower mean scores in almost all
subtests of the used aphasia scales compared
to TCM aphasics and anomics. Table (6).
However, comparison between different
clinical types of aphasia as regard CBF;
revealed no significant difference. Table (7)
Comparison between patients with a single
risk factor and those with multiple risk
factors:
The mean scores of aphasia scales were
compared between patients with a single risk
factor and those with multiple risk factors,
those with multiple risk factors had lower
mean scores. Moreover, patients with multiple
risk factors showed lower mean CBF in the
left hemisphere compared to those with a
single risk factor. However, as there is a big
difference in the number of patients between
the two groups (42 versus 5), the significance
of these differences could not be tested.
Size of cerebral infarction causing aphasia:
The mean scores of aphasia tests were
compared among patients with small, medium
and large infarcts. Statistically significant
differences in the mean scores of naming and
comprehension subtests of AAT were found
between the three groups (p= 0.02, 0.03
respectively), being higher in patients with
small sized lesions followed by medium sized
then large sized lesions.
The mean CBF in different lobes of both
brain hemispheres was also compared
Mervat Mostafa et al
between patients with small, medium and
large infarcts. The means of CBF were
significantly better in the left frontal, parietal
and temporal lobes in the small sized lesions.
Small sized infarcts also showed significantly
higher CBF in the right frontal lobe. Table (8)
Comparison between patient with and
without cerebellar diaschesis:
Patients with cerebellar diaschesis
showed significantly lower mean scores in the
comprehension, articulation subtests and the
Token test of AAT (p=0.01, 0.05, 0.04
respectively). They also had lower mean
scores in the other subtests of AAT and
modified Chesher test, as compared to
patients without diaschesis, however, the
differences were not statistically significant
(p> 0.05).
Comparison between patients with
cerebellar diaschesis and those without as
regard CBF was biased by the presence of
hyperperfusion lesions in a considerable
number of patients with cerebellar diaschesis,
which led to a false impression of being of
better perfusion than those without diaschesis,
hence, this comparison was omitted.
Table 1. Laboratory risk factors detected in 47 stroke patients.
Laboratory risk factors
Hyperuricemia
Hypercholesterolemia
Hypertriglyceridemia
Low HDL
High LDL
Positive Rheumatoid factor
No.
(%)
21
9
7
12
6
1
44.68
19.15
14.89
22.53
12.77
2.13
Table 2. Comparison between male and female patients as regard mean CBF in different lobes of
both hemispheres.
Lobe
Side
Male (n=20)
Female (n=27)
Mean ± SD
Mean ± SD
Frontal
Left
93.77 ± 18.69
88.57 ± 16.92
Right
96.7 ± 9.04
93.66 ± 11.49
Parietal
Left
71.73 ± 12.93
87.69 ± 13.72
Right
84.36 ± 7.41
87.48 ± 8.59
Temporal
Left
73.9 ± 15.22
83.63 ± 10.75
Right
86.22 ± 7.32
88.93 ± 7.49
Occipital
Left
84.22 ± 12.56
86.03 ± 9.35
Right
87.86 ± 7
88.57 ± 5.88
Hemispheres
Left
69.3 ± 12.27
75.84 ± 13.45
Right
83.49 ± 7.88
87.3 ± 9
*Statistically significant. ** Highly significant ~ Trendwise higher
P value
0.2
0.15
0.04*
0.17
0.001**
0.19
0.50
0.68
0.07~
0.1
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Egypt J. Neurol. Psychiat. Neurosurg.
Table 3. Comparison between literate and illiterate patients as regard the mean scores of aphasia scales.
Aphasia scales
I. Modified Chesher test
1) Naming
2) Repetition
3) Comprehension
a) Spoken words
b) Pantomime
4) Total
II. AAT
1- Spontaneous speech
- Articulation
- Automatic
- Communication
- Phonology
- Semantic
- Syntactic
- Total
2-Naming
3-Repetition
4-Comprehension
5-Token test
*Statistically significant.
Literate patient
N= 14
Illiterate patients
N= 33
P-value
78.10 ± 25.99
88.04 ± 28.39
36.62 ± 40.36
52.61 ± 46.44
0.001**
0.01*
93.53 ± 13.07
98.3 ± 4.13
84.21 ± 20.88
83.69 ± 32.82
85.02 ± 32.34
63.75 ± 30.44
0.2
0.01*
0.02*
4.46 ± 0.877
4.77 ± 0.83
3.85 ± 1.21
4.38 ± 1.19
4 ± 1.22
3.69 ± 1.38
25.15 ± 5.92
94.23 ± 30.68
116.15 ± 43.11
104.61 ± 32.56
43.07 ± 11.64
** Highly significant.
2.95 ± 2.12
2.69 ± 2.28
1.67 ± 1.86
2.26 ± 2.23
2.11 ± 2.05
1.83 ± 1.95
13.52 ± 11.49
40.36 ± 45.74
61.9 ± 58.36
91.42 ± 37.26
23.23 ± 17.22
0.016*
0.002**
0.000**
0.002**
0.003**
0.002**
0.001**
0.001**
0.003**
0.26
0.001**
Table 4. Comparison between literate and illiterate patients as regard CBF of different lobes of both
brain hemispheres.
Site
Frontal
Parietal
Temporal
Occipital
Hemisphere
188
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Literate
N=14
94.23 ± 17.16
98 ± 11.3
73 ± 12.33
83.61 ± 9.19
76.61 ± 14.23
85.69 ± 8.03
85 ± 12.24
89.92 ± 2.66
71.89 ± 11.29
82.98 ± 8.92
Illiterate
N=33
89.54 ± 17.87
95.5 ± 10.85
76.02 ± 14.04
87.04 ± 7.82
80.71 ± 13.26
88.52 ± 7.26
85.4 ± 10.31
87.78 ± 7.01
73.58 ± 13.94
86.63 ± 8.54
P value
0.4
0.47
0.48
0.19
0.34
0.23
0.9
0.29
0.69
0.18
Mervat Mostafa et al
Table 5. Clinical types of aphasia in our patients.
Clinical type of aphasia
*Aphasia with repetitive disorder:
- Broca’s
- Global
- Conduction
- Wernicke’s
*Aphasia without repetitive disorder:
- TCM
- Mixed TC
- Nominal
* Alexia with agraphia
No.
Percent
12
7
2
2
25.5
14.7
4.2
4.2
14
2
7
1
29.4
4.2
14.7
2.1
Table 6. Comparison between different types of aphasia as regards the mean scores of aphasia
scales.
Subtests
I. Modified chesher test
1) Naming
2) Repetition
3) Comprehension
- Spoken words
- Pantomime
Total
II. AAT
1) Spontaneous speech
- Articulation
- Automatic
- Communication
- Phonology
- Semantic
- Syntactic
- Total
2) Naming
3) Repetition
4) Comprehension
5) Token test
Global
N=7
Broca’s
N=12
TCM
N=14
Nominal
N=7
P
17.6±32.5
15.1 ± 37.5
13.4 ± 24.4
22.13 ± 35.7
71.08 ± 35.9
94.81 ± 20.75
71.3 ± 32.7
99.2 ± 2.1
0.001**
0.001**
34.85 ± 44.5
38.85 ± 49.4
24.15 ± 37.2
96 ± 7.43
94.06 ± 7.6
56.7 ± 14.25
93.06 ± 24.96
93.75 ± 25
86.7 ± 24.2
100 ± 0
100 ± 0
91.3 ± 8.4
0.002**
0.007**
0.001**
1.4 ± 1.9
1.7 ± 2.4
0.86 ± 1.46
0.86 ± 1.5
0.86 ± 1.5
0.43 ± 0.8
6.1 ± 9.1
21.42 ± 36.3
17.14 ± 41.1
34.3 ± 41.2
8.6 ± 16.5
1.9 ± 2.2
1.4 ± 2.03
0.59 ± 0.94
1.29 ± 1.96
0.94 ± 1.51
0.64 ± 0.79
6.8 ± 8.47
14.11 ± 24.25
22.35 ± 35.79
102.35 ± 22.22
23.3 ± 14.9
4.5 ± 0.73
4.3 ± 1.6
3 ± 1.8
3.8 ± 1.93
3.75 ± 1.65
3.18 ± 1.79
22.56 ± 8.39
85 ± 43.32
120.63 ± 36.6
106.25 ± 31.6
34.7 ± 16.5
4.5 ± 0.5
4.7 ± 0.5
4.43 ± 0.9
4.7 ± 0.5
4.6 ± 0.5
4.6 ± 0.5
27.57 ± 2.9
75.7 ± 46.1
132.9 ± 26.3
114.3 ± 15.1
40.29 ± 16.6
0.001**
0.001**
0.001**
0.001**
0.001**
0.001**
0.001**
0.001**
0.001**
0.002**
0.001**
** Highly significant.
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Egypt J. Neurol. Psychiat. Neurosurg.
Table 7. Comparison between clinical types of aphasia as regard CBF.
Site
1-Left hemisphere
2- Left frontal
3- Left parietal
4- Left Temporal
5- Left occipital
6-Right hemisphere
7- Right frontal
8- Right parietal
9- Right Temporal
10- Right occipital
Global
N=7
Mean±SD
69.6 ± 5.3
90.4 ± 18.4
69.5 ± 5.7
73.3 ± 8.9
86.3 ± 9.8
82.9 ± 9.4
97.1 ± 10.5
82.9 ± 9.5
84.1 ± 9.8
88.7 ± 3.4
Mean CBF in different types of aphasia
Broca’
TCM
Nominal
N=12
N=14
N=7
Mean±SD
Mean±SD
Mean±SD
75.4 ± 17.07
77.87 ± 12.3
67±10.1
91.7 ± 17.19
86 ± 17.9
94 ± 19.3
77.94 ± 16.33
78.68 ± 11.8
69.1 ± 13.22
79.7 ± 15.5
83.12 ±12.8
84.14 ± 11.4
83.05 ± 12.9
90 ±0
82.6 ± 12.9
88.53 ± 7.5
87.9 ± 8.2
83.4 ± 8.9
96.9 ± 9.16
92.9 ± 11.01
99.14 ± 10.33
88.5 ± 6.2
88.2 ± 7.9
85.3 ± 8.7
90.5 ± 6.3
88.8 ± 6.06
89.4 ± 5.5
85.7 ± 10.12
90 ± 0
89.1 ± 5.4
P
0.2
0.7
0.2
0.4
0.1
0.3
0.5
0.3
0.2
0.3
Table 8. Comparison between patients with small, medium and large infarcts as regard means of CBF.
Left frontal
Left parietal
Left temporal
Left occipital
Left hemisphere
Right frontal
Right parietal
Small infarct
Mean ± SD
105 ± 0
81.63 ± 11.8
83.72 ± 12.4
87.54 ± 7.2
72.96 ± 12.27
105 ± 0
87.09 ± 8.65
Medium infarct
Mean ± SD
94.1 ± 15.55
72.94 ± 12.47
81.47 ± 12.49
82.42 ± 13.09
72.2 ± 11.62
98 ± 9.97
86.57 ± 8.28
Large infarct
Mean ± SD
76.35 ± 16.10
68.6 ± 9.19
72.25 ± 12.48
85.65 ± 10.83
68.61 ± 9.18
90.35 ± 11.23
85.55 ± 9.09
0.00**
0.012*
0.025*
0.44
0.46
0.006**
0.87
Right temporal
Right occipital
Right hemisphere
87.9 ± 4.78
90.09 ± 2.02
83.96 ± 9.5
89.47 ± 7.91
86.26 ± 9.57
87.37 ± 8.86
86.6 ± 8.93
88.8 ± 4.11
85.56 ± 9.08
0.522
0.26
0.6
Site
**Highly significant
*Statistically significant
DISCUSSION
This study was conducted on 47 aphasic
patients in an attempt to throw light on the
factors which may affect recovery following
vascular aphasia including: age, sex, literacy
state, risk factors, type of aphasia and size of
the vascular lesions.
In our study, no significant correlation
was observed between age of the patient and
190
P value
the rCBF. However, a significant negative
correlation was obtained between age and the
scores of the different aspects of the used
aphasia scales, i.e. the younger the patient, the
higher the score of aphasia scales. This
observation
agreed
with
previous
studies,6,21,22,23,24 that reported that age and
rate of recovery from aphasia showed a trend
of negative correlation; but there were
exceptions, depending on other factors; as the
initial severity of aphasia. However,
Mervat Mostafa et al
Ogrezeanu et al.4, and Pedreson et al.25,
reported that the influence of age was
minimal on the recovery of aphasia.
Comparison between male and female
patients in the scores of the used aphasia
scales revealed no significant difference.
However, female patients with aphasia of
more than 3 months duration had significant
higher mean scores of aphasia scales
compared to males. This finding suggests that
during the recovery period (i.e. 3 months
following the onset of aphasia), female
patients achieve better performance than
males. The same conclusion was documented
by Basso et al.12, Schehter et al.14, and Elias et
al.23, who reported that females recovered
significantly better than males in oral
expression. It was suggested that the bilateral
or diffuse representation of language function
in the female brain may account for the
greater improvement of aphasia in females.15
However, other studies reported no
significant sex difference in the recovery of
aphasia.4,6,13,25,26
In our study, female patients showed a
higher left hemispheric mean CBF compared
to males, especially the mean left temporal
and parietal CBF. Our results confirmed with
that of Hatazawa et al.27, who reported that
women have higher rates of CBF than men,
however, after the sixth decade, men and
women have similar flow rates. Regland et
al.28, also reported that women have better
verbal memory and higher rates of resting
regional CBF compared to men.
Intellectual
and
educational levels
influence the limit of what the aphasic and his
environment will consider normal; as those
with premorbid superior IQ and high
environment expectations may score within
the normal range of aphasia scales.6
In our study, literate patients have
significantly higher mean scores in the used
aphasic tests than illiterate patients. This is in
agreement with Elias et al.23, who reported
that patients who had the fewest years of
formal education had the lowest performance
levels, with lower levels of performance for
men than women among the least educated
patients. Moreover, Connor et al.29, also
found that early severity of aphasia to be
significantly greater for subjects in the lower
educational and occupational groups,
however, rate of recovery was the same
regardless of educational and occupational
status.
To our knowledge there is no published
data studying the effect of literacy on CBF. In
our study, no significant difference was found
between literate and illiterate patients as
regard CBF.
Different risk factors for CVS were
detected among our studied patients. Most of
our patients, 42, had multiple risk factors
(89.36%), those with a single risk factors
were only 5 patients (10.64%). patients with
multiple risk factors were found to have lower
scores in aphasia scales and lower rCBF
compared to patients with a single risk factor,
however, the significance of these findings
could not be tested due to the big difference
in number of patients. Moreover, we could
not be able to correlate between a certain risk
factor as hypertension or DM and rCBF as the
majority of our patients had multiple risk
factors, so the effect of each risk factor per se
on CBF could not be assessed.
In our study, a statistically significant
difference was observed between the mean
scores of the used aphasia scales in the
different clinical types of aphasia. Generally
speaking, patients with nominal and TCM
aphasia had significantly higher mean scores
as compared to global and Broca’s aphasics.
Our finding confirmed the previous
impressions of Kertesz and McCabe6 and
Hojo et al.22, who concluded that global
aphasics usually have poor recovery, while
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Egypt J. Neurol. Psychiat. Neurosurg.
anomics, conduction and TCM aphasics have
a uniformly good prognosis whereas Broca’s
and Wernicke’s aphasia usually have
heterogeneous outcome depending on the
initial severity.
A significant negative correlation was
observed between the size of cerebral infarcts
and mean scores of aphasia tests and this is
reflected on the significant positive
correlation between grade of motor power on
the hemiparetic side and the scores of aphasia
tests (i.e. patients with smaller lesions had
better motor power and scored better than
those with larger ones). This is in agreement
with Hojo et al.22, who studied the relation
between the size of lesions detected by CT
brain in 127 aphasic patients and recovery
rates depending on the Standard Language
Test of Aphasia (SLTA) scores (initial and 3
months later). They found a negative
correlation between the size of lesions and the
initial SLTA score, i.e., the larger the lesions,
the more severe the aphasia. They also found
a negative correlation between the size of
lesions and the recovery rate. Moreover,
Goldenberg and Spatt30, found that the size of
lesion had a negative influence on recovery of
aphasia in all phases.
In our study, a significant negative
correlation was also detected between the size
of infarcts and rCBF i.e., patients with large
sized infarcts had the lowest rCBF compared
to those with medium and small sized
infarcts.
Crossed cerebellar diaschesis (CCD) is a
SPECT finding that may be seen following
stroke, it is one of the most important
functional derangements that represent a
disconnection or deafferentation phenomenon
that occur following stroke.31
In our study, patients with cerebellar
diaschesis (14 patients) were found to have
lower mean scores in the used aphasia scales
as compared to those without diaschesis,
192
especially the mean scores of the articulation,
comprehension and Token test of AAT.
Moreover, we observed that cerebellar
diaschesis is more frequent in patients having
large sized lesions involving mainly the
frontal and parietal lobes. This also explains
the observation that patients with CCD had
lower grades of motor power on the paretic
side, especially the power in the upper limb,
which was significantly lower in those with
CCD as compared to those without CCD.
This may lead us to consider that the presence
of CCD may be a predictor of poor recovery
in aphasic patients.32
In our study, the association of CCD with
the large sized lesion involving the left frontal
and parietal lobes conformed with Marien et
al.33, who said that the occurrence of a CCD
in
aphasic
syndromes
support
the
pathophysiological hypothesis for the
deactivation of the left hemispheric language
areas (especially the left frontal area) due to
the loss of excitatory impulses through
cerebello-ponto-thalamo cortical pathways.
The findings emerged from this study
suggested that the prognostic factors for good
recovery following vascular aphasia include:
young age, female gender, education, absence
of risk factors for stroke, localized forms of
aphasia as nominal and conduction aphasia,
higher grade of motor power on the paretic
side, small sized hypoperfusions and absence
of cerebellar diaschesis on SPECT study.
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