Broca Aphasia


Article Author:
Aninda Acharya


Article Editor:
Michael Wroten


Editors In Chief:
Rodrigo Kuljis
Oleg Chernyshev
Aninda Acharya


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
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Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/29/2019 12:27:55 PM

Introduction

Aphasia is a term used to describe a disturbance in the ability to use symbols (written or spoken) to communicate information and is categorized into two types: expressive aphasia or receptive aphasia. These two types of aphasia can occur together. This article discusses Broca’s aphasia (also called expressive aphasia). Broca's aphasia was first described by the French physician Pierre Paul Broca in 1861. A mild form of this condition is termed dysphasia. Aphasia/dysphasia should be distinguished from dysarthria which results from impaired articulation. Dysarthria, as opposed to aphasia, is a motor dysfunction due to disrupted innervation to the face, tongue or soft palate that results in slurred speech but intact fluency and comprehension. Aphasia is typically considered a cortical sign. Its presence suggests dysfunction of the dominant cerebral cortex.  [1][2][3]

Etiology

The most common cause of Broca’s aphasia is a stroke involving the dominant inferior frontal lobe or Broca's area. A stroke in Broca's area is usually due to thrombus or emboli in the middle cerebellar artery or internal carotid artery. Other causes of Broca’s aphasia include traumatic brain injury, tumors, and brain infections. Aphasia is a symptom of degenerative dementing illnesses such as Alzheimer disease. With dementing illness, patients develop gradual progressive language deficits as opposed to a sudden onset of loss of language function that is seen in an ischemic stroke.[4]

Epidemiology

Data on the incidence of Broca’s aphasia are limited. In the United States, approximately 170,000 new cases of aphasia related to stroke occur annually.[5]

Pathophysiology

Broca’s area is a region in the inferior frontal lobe of the dominant hemisphere of the brain made up of Brodmann area 44 and 45. Language function lateralized to the left hemisphere in 96% to 99% of right-handed people and 60% of left-handed people. Various pathways connect Broca's area to the frontal lobe, basal ganglia, cerebellum, and contralateral hemisphere.

As a result of a lesion in Broca's area, there is a breakdown between one's thoughts and one's language abilities. Thus, patients often feel that they know what they wish to say but are unable to produce the words. That is, they are unable to translate their mental images and representations to words. This affects the normal fluency of speech. The loss of language function may be because Broca's area serves a role in ordering sounds into words, and words into sentences, and thus creates relationships between linguistic elements.

History and Physical

Broca’s aphasia is non-fluent aphasia. The output of spontaneous speech is markedly diminished. There is a loss of normal grammatical structure (agrammatic speech). Specifically, small linking words, conjunctions (and, or, but) and the use of prepositions are lost. As an example, a sentence like "I took the dog for a walk." may become "I walk dog." Patients can exhibit interjectional speech where there is a long latency, and the words that are expressed are produced as if under pressure. The ability to repeat phrases is also impaired. Despite these impairments, the words that are produced are often intelligible and contextually correct. In pure Broca's aphasia, comprehension is intact. 

Patients with Broca's aphasia are often very upset about their difficulty communicating. This may be due to the deficit itself or may be due to damage to adjacent frontal lobe structures which control the inhibition of negative emotions. Broca's aphasia can accompany other neurological deficits such as right facial weakness, hemiparesis or hemiplegia, and apraxia.

Evaluation

Bedside examination of a patient with suspected aphasia includes assessments of fluency, the ability to name objects, repeat short phrases, follow simple and complex commands, read, and write. Formal neuropsychological testing may be helpful in determining the type and severity of the language deficit. Neuroimaging (CT, MRI, fMRI, PET or SPECT) may be required to localize and diagnose the cause of aphasia. Patients should also be screened for depression as this is also common in Broca's aphasia. [6]

Treatment / Management

Broca's aphasia often has a devastating effect on the ability of individuals to carry out their normal activities. It affects the patient's ability to communicate and often leads to loss of productivity and vocation and can also lead to social isolation.[7][8][9]

Currently, there is no standard treatment for Broca’s aphasia. Treatments should be tailored to each patient's needs. Speech and language therapy is the mainstay of care for patients with aphasia. It is essential to provide aphasic patients a means to communicate their wants and needs, so these may be addressed. Often this is done by providing a board with various objects so that the patient can point to the object that they want. Involvement of a speech therapist, neuropsychologist, and neurologist in the development of a care plan for the patient with Broca's aphasia is very helpful in obtaining a good outcome.  One innovative treatment option for patients with Broca's aphasia is melodic intonation. Melodic intonation relies on the fact that musical ability is often spared in Broca's aphasia. Thus, the speech therapist encourages the patient with poor speech production to try to express their words with musical tones. This approach has shown promise in clinical trials.

Medical treatment of aphasia is currently under investigation in clinical trials. Drug therapies have included catecholaminergic agents (bromocriptine, levodopa, amantadine, dexamphetamine), piracetam and related compounds, acetylcholine esterase inhibitors, and neurotrophic factors. Previous studies have been small, and further studies are needed to determine the efficacy of these pharmacological agents. Also, transcranial magnetic stimulation and transcranial direct stimulation trials for aphasia are currently underway.

When the cause of Broca’s aphasia is a stroke, recovery of language function peaks within two to six months, after which time further progress is limited. However, patients should be encouraged to work on speech production, because cases of improvement have been seen long after a stroke. There are commercial software products available that claim to improve language function, but for the most part, these have not been rigorously tested in randomized clinical trials. 

It is important to address issues of post-stroke depression and post-stroke cognitive impairment, as well as disorders of executive function, awareness, neglect, and hemiparesis during the rehabilitation process to optimize the outcome for an individual patient. Family and social support are extremely important to keep patients with language deficits engaged in social and leisure activities which can greatly influence the aphasic patient’s quality of life.

Pearls and Other Issues

When speaking to a patient with aphasia, it is important to maintain a normal rate and volume. Questions should be simple. It is preferable to ask yes or no questions rather than open-ended questions that require a lengthy answer.

Enhancing Healthcare Team Outcomes

Broca's aphasia is often seen in patient's with head trauma or a stroke. While the individual has preserved comprehension, they have trouble speaking fluently. These patients often undergo speech therapy but because of their other illnesses are often looked after by nurses. Hence, nurses need to be aware of this speech disorder. Individuals with this disorder may be able to read, but their writing ability may be limited. However, it is important to appreciate the fact that in Broca's aphasia, there is a preservation of intellectual and cognitive functions. [10][6]

Some patients may recover functionally and be able to lead an independent life as long as they do not have other comorbidities or neurological deficits. The recovery after Broca's aphasia is often many months or even years, especially if the cause was a stroke. Most people see mild improvement within the first six months, but full recovery can take years. The key is to educate the family members of caregivers who will be looking after the patients.[11]


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Broca Aphasia - Questions

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Which of the following is associated with trauma to the frontal lobe?



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Which of the following facts is not correct concerning Broca aphasia?



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A 60-year-old female has non-fluent aphasia characterized by good comprehension but poor repetition. What is the best description of this condition?



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A 75-year-old patient undergoes coronary artery bypass grafting (CABG). Upon awakening from anesthesia, he is not able to speak. He can only say a few words. He also has weakness on his right side. What type of aphasia is the patient experiencing?



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An 89-year-old right-handed female is brought in with acute symptoms of inability to produce words. There are no other findings. CT head is negative. The physician orders a brain MRI. Where would one expect to find a lesion causing her symptoms?



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Which of the following aphasia is characterized by non-fluent aphasia with poor repetition but good comprehension?



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A patient is noted to have difficulty with verbal expression and answering questions. There seems to be no problem understanding written material. What is the term for this condition?



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Broca Aphasia - References

References

Ripamonti E,Frustaci M,Zonca G,Aggujaro S,Molteni F,Luzzatti C, Disentangling phonological and articulatory processing: A neuroanatomical study in aphasia. Neuropsychologia. 2018 Oct 24     [PubMed]
Friedrich P,Anderson C,Schmitz J,Schlüter C,Lor S,Stacho M,Ströckens F,Grimshaw G,Ocklenburg S, Fundamental or forgotten? Is Pierre Paul Broca still relevant in modern neuroscience? Laterality. 2018 Jun 22     [PubMed]
Grossman M,Irwin DJ, Primary Progressive Aphasia and Stroke Aphasia. Continuum (Minneapolis, Minn.). 2018 Jun     [PubMed]
Fridriksson J,Fillmore P,Guo D,Rorden C, Chronic Broca's Aphasia Is Caused by Damage to Broca's and Wernicke's Areas. Cerebral cortex (New York, N.Y. : 1991). 2015 Dec     [PubMed]
Ochfeld E,Newhart M,Molitoris J,Leigh R,Cloutman L,Davis C,Crinion J,Hillis AE, Ischemia in broca area is associated with broca aphasia more reliably in acute than in chronic stroke. Stroke. 2010 Feb     [PubMed]
Des Roches CA,Vallila-Rohter S,Villard S,Tripodis Y,Caplan D,Kiran S, Evaluating Treatment and Generalization Patterns of Two Theoretically Motivated Sentence Comprehension Therapies. American journal of speech-language pathology. 2016 Dec 1     [PubMed]
Ali N,Rafi MS,Ghayas Khan MS,Mahfooz U, The effectiveness of script training to restore lost communication in a patient with Broca's aphasia. JPMA. The Journal of the Pakistan Medical Association. 2018 Jul     [PubMed]
Silva FRD,Mac-Kay APMG,Chao JC,Santos MDD,Gagliadi RJ, Transcranial direct current stimulation: a study on naming performance in aphasic individuals. CoDAS. 2018 Aug 30     [PubMed]
Hartwigsen G,Saur D, Neuroimaging of stroke recovery from aphasia - Insights into plasticity of the human language network. NeuroImage. 2017 Nov 23     [PubMed]
Fridriksson J,Rorden C,Elm J,Sen S,George MS,Bonilha L, Transcranial Direct Current Stimulation vs Sham Stimulation to Treat Aphasia After Stroke: A Randomized Clinical Trial. JAMA neurology. 2018 Aug 20     [PubMed]
Silverman ME, Community: the key to building and extending engagement for individuals with aphasia. Seminars in speech and language. 2011 Aug     [PubMed]

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