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DISORDERS OF SPEECH AND LANGUAGE
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Anomic aphasia has been associated with lesions in different parts of the language area, classically in the left temporal lobe In these cases the lesion has been deep in the basal portion of the posterior temporal lobe or in the middle temporal convolution, in position to interrupt connections between sensory language areas and the hippocampal regions concerned with learning and memory Mass lesions such as a tumor, herpes encephalitis, or an abscess are the most frequent causes; as these lesions enlarge, a contralateral upper quadrantic visual eld defect or a Wernicke s aphasia is added Occasionally, anomia appears with lesions due to occlusion of the temporal branches of the posterior cerebral artery, and it s in these instances that we have seen the most dramatic cases, usually associated with a right hemianopia and alexia but normal writing ability Anomia may be a prominent manifestation of transcortical motor aphasia (see below) and may be associated with the Gerstmann syndrome, in which case the lesions are found in the frontal lobe and angular gyrus, respectively An anomic type of aphasia is often an early sign of Alzheimer and Pick disease (minor degrees of it are common in old age) and is a principal feature of a number of the degenerative lobar cerebral atrophies (see Chap 39) Finally, anomic aphasia may be the only residual abnormality after partial recovery from Wernicke s, conduction, transcorticosensory, or (rarely) Broca s aphasia (Benson) Isolation of the Language Areas (Transcortical Aphasias) The identifying feature of these language disturbances is a preservation of the ability to repeat Destruction of the vascular border zones between anterior, middle, and posterior cerebral arteries usually as a result of prolonged hypotension, carbon monoxide poisoning, or other forms of anoxic-ischemic injury may effectively isolate the intact motor and sensory language areas, all or in part, from the rest of the cortex of the same hemisphere In the case reported by Assal and colleagues, for example, multiple infarcts had isolated all of the language area In transcortical sensory aphasia, so named by Lichtheim and further de ned by Goldstein, the patient suffers a de cit of auditory and visual word comprehension, making writing and reading impossible Speech remains uent, with marked paraphasia, anomia, and empty circumlocutions; however, unlike the de cit in Wernicke s and conduction aphasia, the ability to repeat the spoken word is preserved Facility in repetition, in extreme degree, takes the form of echoing, parrot-like, word phrases and songs that are heard (echolalia) In a series of 15 such patients, CT and isotope scans have uniformly disclosed a lesion in the posterior parieto-occipital region (Kertesz et al) This locale explains the frequent concurrence of transient visual agnosia and hemianopia In general, this disorder has a good prognosis Presumably, in transcortical sensory aphasia, information from the nonlanguage areas of the cerebrum cannot be transferred to Wernicke s area for conversion into verbal form The paraphasia is thought to result from the weakened control of the motor language areas by the auditory and visual areas, though the direct connection between them, presumably the arcuate fasciculus, is preserved Preservation of this direct connection is said to account for the ability to repeat Reading and auditory comprehension suffer because the sensory information does not reach the central integrative centers In transcortical motor aphasia ( anterior isolation syndrome, dynamic aphasia of Luria) the patient is unable to initiate conversational speech, producing only a few grunts or syllables Comprehension is relatively preserved, but repetition is strikingly intact,
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distinguishing this syndrome from pure word mutism (see above) Transcortical motor aphasia occurs in two clinical contexts: (1) in a mild or partially recovered Broca s aphasia in which repetition remains superior to conversational speech (repeating and reading aloud are generally easier than self-generated speech) and (2) in states of abulia and akinetic mutism with frontal lobe damage, for the same reason Several of our cases have resulted from infarctions in the watershed zone between the anterior and middle cerebral arteries, after cardiac arrest or shock These transcortical syndromes are of great theoretical interest and are probably more common than is currently appreciated Foreign Accent Syndrome This rare but peculiar (and somewhat amusing) condition de es classi cation but is worthy of comment because it may be mistaken for hysteria or psychosis An accent that is vague but distinctly foreign replaces the patient s native language The syndrome arises after a left-sided lesion, most often a stroke; and a mild Broca s aphasia is usually associated Although the accent may be interpreted by the listener as compatible with German, Spanish, French, Asian, or another nationality, authoritative analysis of the speech pattern indicates that the alterations are not speci c to any genuine language and are simply attributed by the listener to a known foreign accent Usually this aberration is encountered as a transient phenomenon during recovery from stroke The relation to disorders of prosody is unclear An extensive analysis of one case and references can be found in the article by Kurowski and colleagues
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