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The National Institutes of Health Stroke Scale (NIHSS). Note: NIHSS is a systematic assessment tool that provides a quantitative measure of stroke-related neurological impairments.
Source publication
Background: Data on the early course of stroke-related aphasia after thrombolysis are scant.Aims: The aim of this study was to describe recovery patterns of aphasia after thrombolysis in a large sample of stroke patients.Methods & Procedures: Clinical and radiological data of consecutive stroke patients treated with thrombolysis over a 5-year perio...
Context in source publication
Context 1
... each patient, the following characteristics were recorded prospectively: age, gender; handedness; first language; history of hypertension, diabetes mellitus, dementia, and/or stroke; smoking history; time from symptom onset to thrombolysis initiation; stroke signs and clinical severity based on the NIHSS (Figure 1); involved vascular territories; and aetiology. The NIHSS is used in acute stroke to objectively quantify the stroke-related impairments. ...
Citations
... Reperfusion therapies are medical treatments in acute stroke that restore blood flow either by surgical removal of a blood clot or with medications that dissolve clots. Reperfusion therapies, particularly intravenous thrombolysis with recombinant tissue plasminogen activator (rTPA), have been shown to be effective in improving language after acute ischemic stroke in the left hemisphere (163)(164)(165)(166). For example, a recent study in patients with ischemic stroke showed significantly higher percentage of resolved aphasia in patients treated with rTPA compared to the non-treated group, and a higher percentage of global aphasia was observed in the non-treated group compared to treated patients (167). ...
Introduction: Aphasia is a debilitating language disorder and even mild forms of aphasia can negatively affect functional outcomes, mood, quality of life, social participation, and the ability to return to work. Language deficits after post-stroke aphasia are heterogeneous.
Areas covered: The first part of this manuscript reviews the traditional syndrome-based classification approach as well as recent advances in aphasia classification that incorporate automatic speech recognition for aphasia classification. The second part of this manuscript reviews the behavioral approaches to aphasia treatment and recent advances such as noninvasive brain stimulation techniques and pharmacotherapy options to augment the effectiveness of behavioral therapy.
Expert opinion: Aphasia diagnosis has largely evolved beyond the traditional approach of classifying patients into specific syndromes and instead focuses on individualized patient profiles. In the future, there is a great need for more large scale randomized, double-blind, placebo-controlled clinical trials of behavioral treatments, noninvasive brain stimulation, and medications to boost aphasia recovery.
... 16 On the other hand, in another study, similar improvement of aphasia and limb motor deficit was found at 24 hours and 1 week after stroke in 109 patients who were mainly treated with IV thrombolysis. 10 This last study is difficult to compare with the other studies because of the use of composite NIHSS scores by combining the language item with items for cognitive functioning, which were not specifically designed to test language. ...
... It is remarkable that 58% of the AIS patients in MR CLEAN (288 out of 500) had aphasia, compared to 15%-40% in earlier studies. [6][7][8][9][10][11] A likely explanation is that only patients with a proven proximal occlusion were included in the present study, while in other studies imaging of intracranial vessels was not routinely performed, resulting in inclusion of patients with more distal occlusions. It is known that the more proximal the occlusion, the higher the risk of aphasia, especially in case of an occlusion of the MCA. 10 While other studies have reported left lateralized language functioning in at least 96% of the individuals, in the present study only 91% of the aphasic patients had a stroke in the left hemisphere. ...
... It is known that the more proximal the occlusion, the higher the risk of aphasia, especially in case of an occlusion of the MCA. 10 While other studies have reported left lateralized language functioning in at least 96% of the individuals, in the present study only 91% of the aphasic patients had a stroke in the left hemisphere. 23,30 This implies an uncommonly high proportion of patients with crossed aphasia in our study. ...
Objective:
To investigate the effect of intra-arterial treatment (IAT) on early recovery from aphasia in acute ischemic stroke. We hypothesized that the early effect of IAT on aphasia is smaller than the effect on motor deficits.
Methods:
We included patients with aphasia from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), in which 500 patients with a proximal anterior circulation stroke were randomized to usual care plus IAT (<6 hours after stroke, mainly stent retrievers) or usual care alone. We estimated the effect of IAT on the shift on the NIH Stroke Scale (NIHSS) item language and the NIHSS item motor arm at 24 hours and 1 week after stroke with multivariable ordinal logistic regression as a common odds ratio, adjusted for prognostic variables (acOR). Differences between the effect of IAT on aphasia and on motor deficits were tested in a multilevel model with a multiplicative interaction term.
Results:
Of the 288 patients with aphasia, 126 were assigned to IAT and 162 to usual care alone. The acOR for improvement of language score at 24 hours was 1.65 (95% confidence interval [CI] 1.05-2.60), and at 1 week 1.86 (95% CI 1.18-2.94). The acOR for improvement of motor deficit at 24 hours was 2.44 (95% CI 1.54-3.88), and at 1 week 2.32 (95% CI 1.43-3.77). The effect of IAT on language deficits was significantly different from the effect on motor deficits at 24 hours and 1 week (p = 0.005 and p = 0.011).
Conclusions:
IAT results in better early recovery from aphasia than usual care alone. The early effect of IAT on aphasia is smaller than the effect on motor deficits.
Classification of evidence:
This study provides Class II evidence that for patients with acute ischemic stroke IAT increases early recovery from aphasia and that the early effect on aphasia, as measured by the NIHSS, is smaller than the effect on motor deficits.
... The NIHSS (National Institute of Health and Stroke Scale) is the gold standard assessment tool to evaluate neurological deficits in acute stroke patients. Nonetheless, the language item of the scale has been criticized due to its inability to differentiate between aphasic symptoms, its poor evaluation of comprehension, and its failure to identify mild symptoms (11,12). A factor analysis of the NIHSS (13) identified two items that are loaded in the same factor as language: the request to answer some questions (item 1b) and the response to verbal commands (1c). ...
... Although not tackling language specifically, these items can be considered indirect measures of aphasia. In two recent studies (12,14), they were used in a compound measure to evaluate language improvement, but so far they have not been validated as such. ...
... This score can be particularly relevant for aphasia assessment given the widespread use of the NIHSS scale, allowing direct comparisons between different series of stroke patients. Two previous studies with CVS (12,14) including 129 left MCA cases and 100 cases with isolated aphasia, produced similar degrees of improvement, but did not take lesion size into account. ...
Objectives:
Language recovery following acute stroke is difficult to predict due to several evaluation factors and time constraints. We aimed to investigate the predictors of aphasia recovery and to identify the National Institute of Health and Stroke Scale (NIHSS) items that best reflect linguistic performance, 1 week after thrombolysis.
Materials and methods:
We retrieved data from a prospective registry of patients with aphasia secondary to left middle cerebral artery (MCA) stroke treated with intravenous thrombolysis. Complete recovery at day 7 (D7) was measured in a composite verbal score (CVS) (Σ Language+Questions+Commands NIHSS scores). Lesion size was categorized by the Alberta Stroke Program Early CT score (ASPECTS) and vascular patency by ultrasound. CVS was correlated with standardized aphasia testing if both were performed within a two-day interval.
Results:
Of 228 patients included (age average 67.32 years, 131 men), 72% presented some language improvement that was complete in 31%. Total recovery was predicted by ASPECTS (OR=1.65; 95% CI, 1.295-2.108; P < 0.00) and baseline aphasia severity (OR=0.439; 95% CI, 0.242-0.796; P < 0.007). CVS correlated better with standardized aphasia measures (aphasia quotient, severity, comprehension) than NIHSS_Language item.
Conclusions:
Lesion size and initial aphasia severity are the main predictors of aphasia recovery one week after thrombolysis. A NIHSS composite verbal score seems to capture the global linguistic performance better than the language item alone.
Purpose
Recovery from aphasia after stroke has a decelerating trajectory, with the greatest gains taking place early and the slope of change decreasing over time. Despite its importance, little is known regarding evolution of language function in the early postonset period. The goal of this study was to characterize the dynamics and nature of recovery of language function in the acute and early subacute phases of stroke.
Method
Twenty-one patients with aphasia were evaluated every 2–3 days for the first 15 days after onset of acute ischemic or hemorrhagic stroke. Language function was assessed at each time point with the Quick Aphasia Battery (Wilson, Eriksson, Schneck, & Lucanie, 2018), which yields an overall summary score and a multidimensional profile of 7 different language domains.
Results
On a 10-point scale, overall language function improved by a mean of 1.07 points per week, confidence interval [0.46, 1.71], with 19 of 21 patients showing positive changes. The trajectory of recovery was approximately linear over this time period. There was significant variability across patients, and patients with more impaired language function at Day 2 poststroke experienced greater improvements over the subsequent 2 weeks. Patterns of recovery differed across language domains, with consistent improvements in word finding, grammatical construction, repetition, and reading, but less consistent improvements in word comprehension and sentence comprehension.
Conclusion
Overall language function typically improves substantially and steadily during the first 2 weeks after stroke, driven mostly by recovery of expressive language. Information on the trajectory of early recovery will increase the accuracy of prognoses and establish baseline expectations against which to evaluate the efficacy of interventions.
Supplemental Material
https://doi.org/10.23641/asha.7811876
Aphasia is a devastating brain disorder, detrimental for medical care and social interaction. The early diagnosis of language disorders and accurate identification of patient-specific deficits are crucial for patients’ care, as aphasia rehabilitation is more effective when focused on patient-specific language deficits. We developed the Core Assessment of Language Processing (CALAP), a new scale combining screening and detailed evaluation to rapidly diagnose and identify patient-specific language deficits. This scale is based on a model of language processing distinguishing between the comprehension, production, and repetition modalities, and their different components: phonology (set of speech-sounds), morphology (how the sounds combine to form words), lexicon (words), syntax (how words combine to form sentences), and concept (semantic knowledge). This scale was validated by 189 participants who underwent the CALAP, and patients not unequivocally classified as without aphasia by a speech-language pathologist underwent the Boston Diagnosis Aphasia Evaluation as the gold standard. CALAP-screening classified patients with and without aphasia with a sensitivity of 1 and a specificity of 0.72, in 3.14 ± 1.23 min. CALAP-detailed evaluation specifically assessed the language components in 8.25 ± 5.1 min. Psychometric properties including concurrent validity, internal validity, internal consistency and interrater reliability showed that the CALAP is a valid and reliable scale. The CALAP provides an aphasia diagnosis along with the identification of patient-specific impairment making it possible to improve clinical follow up and deficit-based rehabilitation. It is a short and easy-to-use scale that can be scored and interpreted by clinicians nonexpert in language, in patients with fatigue and concentration deficits.
Purpose:
Reperfusion therapies are medical treatments that restore blood flow either by surgical removal of a blood clot or with medications that dissolve clots. The introduction of reperfusion therapies has the potential to change the presentation of aphasia following acute ischaemic stroke (AIS). This scoping study will explore the relationship between aphasia and reperfusion therapies from a speech-language pathology perspective.
Method:
A systematic literature search was performed on studies published up until October 2016. Relevant studies that reported on aphasia and reperfusion therapy were assessed for quality and the relationship between the two.
Results:
Overall, 27 studies were identified, these studies were heterogeneous in nature. Despite speech-language pathologists filling a central role in management of aphasia, only seven of these studies mentioned involvement of speech-language pathologists, with minimal information about the precise nature of the involvement of speech-language pathology services.
Conclusion:
Based on this scoping review, reperfusion therapy appears to be impacting on the presentation of aphasia. A prospective study into reperfusion therapy and aphasia is required to inform speech-language pathologists on this patient population.
Introduction
One third of patients with acute stroke have aphasia. The majority receive speech and language therapy. There is evidence for a beneficial effect of speech and language therapy on restoring communication, but it is unknown whether and how efficacy of speech and language therapy is influenced by timing of treatment. We studied whether speech and language therapy early after stroke by way of intensive cognitive-linguistic treatment is more effective than no speech and language therapy in the Rotterdam Aphasia Therapy Study-3, a multicentre randomised single-blind trial.
Methods and patients
Stroke patients with first-ever aphasia were randomised within 2 weeks of onset to either 4 weeks of early intensive cognitive-linguistic treatment (1 h/day) or no language treatment. Hereafter, both groups received regular speech and language therapy. Primary outcome was the score on the Amsterdam-Nijmegen Everyday Language Test, measuring everyday verbal communication, 4 weeks after randomisation. Secondary outcomes were Amsterdam-Nijmegen Everyday Language Test at 3 and 6 months. The study was powered to detect a clinically relevant difference of four points on the Amsterdam-Nijmegen Everyday Language Test.
Results
Of the 152 included patients, 80 patients were allocated to intervention. Median treatment intensity in the intervention-group was 24.5 h. The adjusted difference between groups in mean Amsterdam-Nijmegen Everyday Language Test-scores 4 weeks after randomisation was 0.39, 95% confidence interval: [−2.70 to 3.47], p = 0.805. No statistically significant differences were found at 3 and 6 months after randomisation either.
Conclusion
Four weeks of intensive cognitive-linguistic treatment initiated within 2 weeks of stroke is not more effective than no language treatment for the recovery of post-stroke aphasia. Our results exclude a clinically relevant effect of very early cognitive-linguistic treatment on everyday language.
Background:
Data about evolution of aphasia following stroke are rare and controversial especially following fibrinolysis. The aim of this study was to describe the early clinical patterns of isolated aphasia in consecutive stroke patients with or without thrombolysis.
Methods:
Clinical and radiological data of consecutive stroke patients were routinely entered in prospective registry. Patients were considered aphasic when NIHSS (National Institutes of Health Stroke Scale) item 9 >0. 'Isolated aphasia' was defined by aphasic patients without motor limb deficit. We created a 'composite language score' obtained by summing the NIHSS items 1b, 1c and 9, which reflects language-processing ability. Recovery of functions was evaluated as measured by global NIHSS, composite language score and language screening test (LAST) at baseline, H24 and day 7 (D7). 'Mild deficit' was defined as global NIHSS <5.
Results:
A total of 100 consecutive patients met study criteria for isolated aphasia. Twenty-five underwent thrombolysis and 75 did not. There was no difference between the 2 groups concerning demographic characteristics, involved territories and presence of arterial occlusion, initial median NIHSS, composite language and LAST scores at entrance. Evolution was significantly better in thrombolysed patient for the 3 testings: NIHSS, composite language score and LAST at D7 (respective p = 0.0002; p = 0.01 and p = 0.004). Similar results were found when we focused on the subgroups of patients with initial 'mild' deficits (p = 0.01; p = 0.0003 and p = 0.007). No symptomatic hemorrhagic transformation occurred following thrombolysis.
Conclusion:
These data strongly suggest that thrombolysis is safe and effective in patients with 'isolated aphasia,' even if the global NIHSS score is <5.
