Behavior Neurology Series

Language, Aphasia, and

Brain-hemisphere

Bagian Ilmu Penyakit Saraf

RS Bayukarta
Karawang
Bambang Hartono

“ Terus terang, kemampuan bahasa kita kurang, sehingga sulit

berkomunikasi. Mungkin perlu bagi perwira kita untuk meng-upgrade-
diri di bidang bahasa. Karena kejadian seperti ini bisa terjadi lagi.
Sekarang memang jamannya borderless crime, terorisme, narkoba,
people smuggling, itu yang namanya borderless crime, transnational
crime. Orang kita sudah lumayan ada, tidak banyak.
Tapi perlu kaderisasi. “

( I Made Mangku Pastika, Kompas, hal. 4, 24 November 2002 )

Bambang Hartono

DISORDERS OF SPEECH AND LANGUAGE

Language is a complex, multifaceted skill that encompasses

the formation of sounds, the development of sophisticated
rule systems, and the existence of vast quantity of meaning
and significant information.

Four major component of language:

1. Phonology: dealing with producing and processing speech
sounds
2. Syntax: involving the rules of word order and form, or grammar
3. Semantics: the processing of meaning
4. Pragmatics: involving intonation in speech, practical significance,
and context.
Bambang Hartono

The Aphasias

The 2 major categories of aphasia are:

- Expressive (motor) aphasia  Broca’s aphasia
speaks very little, when speech is attempted, it is halting-
the patient has difficulty getting the words out – telegraphic
or agrammatic speech.
Patients seem to be aware of most their errors.

- Receptive (sensory) aphasia  Wernicke’s aphasia

a disturbance in which the patients has great difficulty
comprehending speech.
The speech is fluent, but it may vary from being slightly odd –
completely meaningless.
Patients often use paraphasias or neologisms.
They unaware that their speech is defective / meaningless
 op
44 R
45
op

op

op = operculum, R= rolandic operculum

Bambang Hartono

The division of aphasia into these 2 categories implies

clear-cut distinction, that is not enough to explains:
- patients show symptoms attributed to the both types
- not truly representing how language is organized in the brain

Investigators have labeled other forms of aphasia, according

to both patterns of brain damage and of language deficits.

Conduction aphasia (firstly was predicted by Wernicke):

A lesion interrupting the neural pathways connecting the Broca’s
And Wernicke’s area (arcuate fasciculus) (Geschswind, 1965)
- patient’s inability to repeat aloud what is heard
- spontaneous speech may be meaningless
- fluent jargon
- comprehension of spoken and written material remain intact
Bambang Hartono

Transcortical aphasias (Geschwind, 1965; 1970):

Involve lesions that spare the speech areas and their main
interconnecting pathways. When brain damage isolates:
- Wernicke’s area  transcortical sensory aphasia
- Broca’s area  transcortical motor aphasia
- both  transcortical mixed aphasia

Word deafness
A lesion disconnecting Wernicke’s area from auditory inputs.

Anomic aphasia
A damage to the cortical area at the junction of the temporal,
parietal, and occipital lobes (the angular gyrus)

Global aphasia
A widespread damage to the left hemisphere involving
most of the areas thought to play a role in language
Bambang Hartono

Subcortical aphasia
Lesions to brain structures deep within the brain, especially the
thalamus, can result in language disturbances.
Damage to the left thalamus:
- affect verbal fluency
- creating word-finding hesitation as well as perseveration
 The thalamus is an integrating center between frontal and
posterior cortical language areas

The thalamus has 2 general functions in speech (Ojemann, 1976):

(1) to serve as an alerting mechanism to direct attention to verbal
information in the environment as well as to retrieve verbal
information properly from verbal memory
(2) to control (at least in part) some of the physical substrates of
speech, such as respiration and the speech musculature
Bambang Hartono

Language Symptomatology in Aphasia

Type of aphasia Spontaneous Paraphasia Comprehension Repetition Naming

Broca nonfluent uncommon good poor poor

Wernicke fluent common poor poor poor

(verbal)
Conduction fluent common good poor poor
(literal)
Global nonfluent variable poor poor poor

Mixed transcortical nonfluent uncommon poor good poor

(echolalia)
Transcortical motor nonfluent uncommon good good poor
(echolalia)
Transcortical fluent common poor good poor
sensory (echolalia)
Anomic fluent absent good good poor

Subcortical fluent / common variable good variable

nonfluent
Bambang Hartono

Right hemisphere and language

Intonation
Patients with right-hemisphere damage:
- speak with flattened intonation (aprosody)
- difficulty judging the emotional tone of the speech produced
by others
Melodic intonation therapy is good for patients with Broca’s aphasia
 word sequences first incorporated in a song  the melody then
de-emphasized gradually  speak the phrase without singing.

Metaphor and humor

Patients with right-hemisphere damage:
- Literal in their interpretation of words, stories, and cartoons.
- They lose of emotional intonation, aspects of metaphor and
humor
Bambang Hartono

Right hemisphere in recovery of aphasia

Most improvement of aphasia occurs during the first 6 – 12 months,

depend on number of many factors.

One of them is by involving right-hemisphere in language processing

Evidences in clinic:
- In 3 patients recovering from aphasia due to left-hemisphere
lesions. Injection of the Wada procedure into the left carotid
artery did not worsen speech, but in the right side: arrest of
speech in 2 of the 3 patients.
- Recovery of language from the infants after left-hemispherectomy
- Supported by evoked-potential and cerebral blood-flow data
that the activity of the right-hemisphere showed greater in
patients recovery from aphasia than in normal condition.