J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

Journal ofNeurology, Neurosurgery, and Psychiatry, 1976, 39, 1062-1070

Aphasic disorder in patients with closed

H. S. LEVIN, R. G. GROSSMAN', AND P. J. KELLY From the Division ofNeurosurgery, Department ofSurgery, UJniversity of Texas Medical Branch, Galveston, Texas, USA

SYNOPSIS Quantitative assessment of 50 patients with closed head injury disclosed that anomic errors and word finding difficulty were prominent sequelae as nearly half of the series had defective scores on tests of naming and/or word association. Aphasic disturbance was associated with severity of brain injury as reflected by prolonged coma and injury of the brain stem.

The majority of traumatic brain injuries in civilian dardised language tests were studied in relation to

life are due to closed head injuries. Although closed neurological indices of severity of head injury. The by guest. Protected copyright. head injury (CHI) poses a major medical problem, association between and perceptual disorder relatively few studies have investigated the range of and persistent temporal disorientation was also residual linguistic defects. While it is commonly re- investigated. cognised that head-injured patients often exhibit decreased verbal productivity, aphasia is not generally regarded as one of the important sequelae of CHI. METHODS Detailed evaluation of patients with CHI by Heilman et al. (1971) disclosed that anomic aphasia was the SUBJECTS most frequent type of linguistic impairment. The Fifty patients, including four women, who had sus- possibility that Wernicke's and Broca's tained blunt trauma to the head were studied. The occur only infrequently after CHI was suggested by majority of the patients had been injured in moving the series of patients described by de Morsier (1973). vehicle accidents; about one-third of the patients had Although these studies suggest that a distinctive sustained trauma of multiple organ systems. We em- pattern of linguistic deficits may follow CHI, neither ployed the term CHI to denote that the primary investigation employed quantitative analysis of find- mechanism of injury at the time of impact was one of ingsobtained through standardised assessment. More- blunt trauma, rather than a penetrating injury. In- over, correlation of aphasia with neurological indices cluded in this group were two patients who had sus- of injury in the study by Heilman et al. (1971) was tained shallow depressed right frontal and parietal complicated by the widespread alcoholism in their skull fractures, respectively, who developed under- patients. Aphasia resulting from CHI has been ob- lying intracerebral haematoma, one patient who served to occur frequently with concomitant higher developed a right frontal intracerebral haematoma, level disturbances. Akbarova (1972) reported that and one patient who developed a right frontal epidural http://jnnp.bmj.com/ aphasic disturbance in CHI was accompanied by haematoma. impairment in storage of new information. We have Criteria for including patients in the study were an recently found that defective short-term recognition age limit of 50 years and a negative history for memory for essentially nonverbal material was alcoholism and previous cerebral disease or injury. closely associated with linguistic defects (Levin et al., An age limit was employed to minimise the possibility 1976). of confounding the effects of CHI with age-related The present study was undertaken to characterise degenerative changes. Of the head-injured group, 47 the pattern ofaphasia after CHI in young and middle- patients were right handed and three were left handed. on September 28, 2021 aged adults. Defective scores on quantitative, stan- Head-injured patients were included in the study ir- respective of handedness because of the diffuse nature of their injuries. Forty-one patients were tested while I Address for reprint requests: Dr Robert G. Grossman, Chief, on the and Division of Neurosurgery, The University of Texas, Medical Branch, hospitalised Neurosurgery Neurology Galveston, Texas 77550, USA. Services, University of Texas Medical Branch, (Accepted 28 May 1976.) Galveston, Texas. Nine previously hospitalised 1062 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

Aphasic disorder in patients with closed head injury 1063 patients were tested as outpatients after an extended namingpicturesofboth familiar objects-for example, period ofconvalescence. piano-and details-for example, keys-with a 15 Patients with CHI were classified into subgroups second time limit for each of 30 items; (2) Sentence according to the severity of injury determined by Repetition-oral repetition of 14 progressively longer serial neurological examinations. The grade of injury sentences read by the examiner; (3) Controlled Word assigned was based upon the duration of coma and Association-a test of verbal associative fluency presence of neurological impairment. The term coma, wherein the patient is asked to recite as many words as used here, was defined as a failure of the patient to as possible (excluding proper nouns) beginning with a exhibit vocal responses or carry out purposeful specific letter within a minute and repeated for three motor activity after verbal or somatic stimulation by letters, the score corresponding to the total number of the examiner. Stupor was defined as an uncommuni- words given by the patient; (4) Token Test-manipu- cative state of the patient from which he could be lation of metal tokens varying in shape and colour aroused to vocalisation or purposeful motor activity. according to 22 non-redundant oral commands Transient loss of consciousness immediately after varying in complexity and structure-for example, impact was not considered in assigning a grade be- 'pick up the large white square and small green cause it was not always possible to have independent circle'; (5) Auditory Comprehension of Words and verification of brief loss of consciousness in accident Phrases-selection of the appropriate drawing from a victims. The criteria for grade I (n = 19) were con- multiple-choice array corresponding to each of 21 sciousness on admission, and throughout the period words or phrases given aurally by the examiner; (6) of hospitalisation, and absence of neurological Reading Comprehension-this test was essentially deficits. Grade II patients (n = 17) were comatose for similar to Auditory Comprehension of Words and by guest. Protected copyright. not more than a single day, although they may have Phrases with the exception that the stimuli were been stuporous for a longer interval and may have silently presented on flash cards rather than given developed neurological deficits. Patients whose injury orally. Scores were adjusted for latency of response in was rated as grade III (n = 14) were comatose for at Visual Naming and Controlled Word Association. least 24 hours and may have manifested specific Empirically derived corrections for age, education, neurological deficits. The presence of injury to the and sex as provided in the test manual were frequently brain stem was inferred from the presence of at least unnecessary because of the restricted age range in the one of the following signs of disturbance of oculo- CHI patients. Previous research (Benton, 1967) and vestibular systems: pupillary abnormalities and our preliminary analysis have established that age oculomotor palsies, not due to intraocular injury; correction is unnecessary on any subtest for adults skew deviation; markedly abnormal responses to ice below 55 years of age. Supplementary data were water caloric stimulation of the vestibular system. It is available for head-injured patients given selected sub- recognised that the presence of an oculomotor palsy tests of the Neurosensory Center Comprehensive does not unambiguously demonstrate the presence of Examination for Aphasia (Spreen and Benton, 1966). brain stem injury but may indicate injury to the third, These tests included Writing to Dictation-writing fourth, or sixth cranial nerves along their course from sentences dictated by the examiner, and Copying- the brain stem to the orbit. However, within the con- writing sentences presented on flash cards. text of the study of severely head-injured patients, the authors believe that it is reasonable to use the presence of oculomotor palsies as an indicator of the PROCEDURE occurrence of traumatic forces in the area of the brain Hospitalised patients with CHI were tested after http://jnnp.bmj.com/ stem. Thirty patients with diverse somatic disease periodic monitoring of orientation to surroundings without evidence or history of cerebral disease or and time (Benton et al., 1964) had disclosed an injury served as a control group. absence or at least marked reduction of confusion. Despite these precautions, certain patients manifested APHASIA EXAMINATION persistent disorientation long after regaining con- The Multilingual Aphasia Examination (MAE) of sciousness. Scheduling difficulties precluded testing Benton (1967) was the primary instrument used to the entire of and control samples head-injured on September 28, 2021 assess linguistic disturbance. Expressive language was patients on the full MAE protocol. Consequently, evaluated in terms of naming objects, repetition of minor variation in sample size was tolerated (Table 2). sentences, and verbal associative fluency. Assessment Normative data on the MAE were available for 228 of receptive language referred to both comprehension medical patients without evidence or history of brain of aural language and reading comprehension. damage who were previously studied at the Univer- Writing was also considered. Subtests of the MAE sity of Iowa Hospitals, Iowa City. The distributions given in the study included: (1) Visual Naming- of scores obtained on the Iowa standardisation J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

1064 H. S. Levin, R. G. Grossman, and P. J. Kelly sample were used to define a defective level of per- subtest was defined as a score falling below the second formance on each subtest ofthe MAE. percentile of the Iowa normative distribution. The Temporal orientation was assessed concurrently proportion of patients with defective scores in each with the aphasia examination as the former measure group and in the present control group was compared was felt to reflect persistent post-traumatic amnesic on the MAE subtests utilising a two-tailed test. effects. Perceptual performance was considered on tests of facial recognition (Benton and Van Allen, 1968), reproduction of geometric designs (Bender, TABLE 2 1938), and finger localisation (Benton, 1959). CORRECTED SUBTEST SCORES ON MULTILINGUAL APHASIA EXAMINATION RESULTS Head-injured The mean age and years of education for the three Performance measure Control group subgroups of head-injured patients and control patients who completed the Visual Naming Test are Visual Naming n 30 19 17 14 shown in Table 1, as is the mean coma duration for 3z 53.9 48.4 40.2 35.8 patients with grade II or grade III injuries. As sug- SD 6.9 9.3 9.0 15.8 gested by Table 1, application of the t test confirmed Sentence Repetition n 30 17 16 13 that grade I and control patients were significantly 3z 12.7 11.9 11.1 10.8 older than patients with grade II or grade III injuries. SD 1.8 1.9 1.9 2.6 Word Association by guest. Protected copyright. This finding did not contraindicate further analysis n 27 16 16 14 because previous research did not disclose develop- 3Z 40.5 32.7 29.5 21.7 in performance within the age range SD 10.6 8.3 12.8 13.2 mental changes Token Test considered in the present study. The head-injured and n 26 18 16 13 control groups did not differ significantly in educa- 3z 43.0 40.3 38.1 34.2 SD 1.6 4.8 6.2 10.8 tion. By definition, the upper limnit of coma duration Aural Comprehension in grade II patients was 24 hours, whereas the range n 29 19 17 14 Xz 39.1 37.0 36.1 34.0 was one to 25 days in patients with grade III injuries. SD 3.9 3.8 4.2 5.8 Reading Comprehension n 29 18 16 14 x 19.6 19.7 18.1 16.9 TABLE 1 SD 1.2 0.7 2.6 4.2 AGE, EDUCATION, AND COMA DURATION IN HEAD INJURED AND CONTROL GROUPS* EXPRESSIVE LANGUAGE Head-injured Variable Control group Correct responses within the time limit on Visual (n=30) (n= 19) (n= 17) (n=14) Naming were awarded two points, a perfect perform- ance corresponding to a score of 60. A score below Age to less than the second percentile of 3z 32.1 31.3 24.0 24.0 40 corresponded SD 11.4 10.3 6.8 9.3 the Iowa distribution. Table 2 shows that our control Education patients achieved scores above those of head-injured 3Z 11.4 10.3 10.5 10.1 http://jnnp.bmj.com/ SD 2.6 3.6 2.0 2.9 patients; the percentage of deficient naming of Coma R - - 0.4 12.4 objects was only slightly greater in our control group Duration SD - - 0.4 6.6 as compared with the Iowa norms (Figure). In con- (days) trast, 20 of the head-injured patients (40 %) had * Based upon the patients completing the Visual Naming subtests. anomic disturbance; this proportion was far greater There was variation in sample size on the other subtests. than in the control group, X2= 11.20, P<0.001. In comparison with the control group, a greater propor- tion of grade II (X2 = 8.49, p<0.005) and grade III Mean scores on the subtests of the MAE are given (X2=13.8, P<0.001) patients manifested defective on September 28, 2021 in Table 2. It may be seen that the level ofperformance naming. Relatively mild CHI (grade I) was associated generally decreased in the more severely injured with an increase in risk of anomia which approached patients, whereas the variability of scores showed a significance (X2 = 3.8, p < 0.10). As suggested by the corresponding increase particularly on the Visual Figure, the subgroups ofpatients with CHI of varying Naming, Token Test, and Reading Comprehension severity did not differ significantly with respect to the subtests. Clinically significant impairment on each proportion ofdefective scores. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

Aphasic disorder in patients with closed head injury 1065

(U)n LU w cc0 C-) U) LL FIGURE Percentage ofhead-injured LU and controlpatients with defective LLIL scores in the Multilingual Aphasia C) Examination (VN = Visual Naming; H SR = Sentence Repetition; 01 = D COWA Controlled Word 0 It Association; TT = Token Test; ACWP = Auiditory Comprehension 0 of Words and Phrases; z RC = Reading Comprehension; C-) SE = LU) WD Writing to Dictation; (I WC = Writing-Copying). by guest. Protected copyright.

Expressive Tests Receptive Tests

Repetition without error of each sentence given by Examination were available for 40 head-injured the examiner was awarded a point, a perfect total patients. The suggestion in the Figure of a dispropor- score being 14. Table 2 shows that inability to repeat tionate number of defective writing-to-dictation sentences was found infrequently in both control and scores in patients with grade II or grade III injuries as head-injured patients. Consonant with this impres- compared with grade I cases was confirmed by sion, the proportion of the total CHI sample or of any Fisher's Exact Method (p = 0.04), whereas the former CHI subgroup with the impaired repetition (Figure) groups were comparable. Dysgraphic copying was did not differ significantly from that of the control relatively infrequent and did not serve to differentiate group (X2 = 0.18) nor were differences among the the groups. subgroups ofthe head-injured patients significant. The score on Controlled Word Association was the total number of words produced by the patient across RECEPTIVE LANGUAGE the three trials, adjusted for sex and education. An Correct execution of each of 22 commands on the adjusted score of 17 or less fell below the second per- Token Test earned two points, a perfect score corre*- centile of the Iowa normative distribution. According ponding to 44 points. If a patient responded success- http://jnnp.bmj.com/ to this criterion, 10 head-injured patients and no con- fully to a command on a second trial after an initial trol patients exhibited defective verbal-associative failure, he was credited with one point. A score of less fluency (X2 = 5.09, p < 0.025). In comparison with the than 36 fell below the second percentile of the Iowa control group, impairment of verbal fluency was norms. According to this criterion, 16 head-injured above expectation in the grade It (X2 = 6.75, P < 0.01) patients (34%) and no control patients manifested and grade III (X2 = 7.90, p <0.005) groups, whereas impaired comprehension of oral language. These patients with less severe injuries were not measurably proportions of defective scores were clearly different, affected on this variable. As indicated by the Figure, X2 = 9.43, p < 0.005. Impairment of performance on on September 28, 2021 Fisher's Exact Method disclosed that dysfluency was the Token Test was proportionately greater in the more frequent in patients with grade II (p = 0.02) or grade II (p<0.05) and grade III (p <0.005) CHI grade III (P=0.01) injuries as compared with the groups than in the control group, whereas grade I grade I group. Relative frequency of verbal- injury did not produce a significant increase in risk of associative deficit was comparable in the grade II and receptive language deficit. As shown in the Figure, grade III subgroups. Data for the writing subtests receptive language deficit on the Token Test was (dictation, copying) of the Neurosensory Center more frequent in patients with grade III injuries as J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

1066 H. S. Levin, R. G. Grossman, and P. J. Kelly compared with the grade I group (p <0.03); other CLASSIFICATION OF APHASIC DISORDER comparisons between the CHI groups did not reach Configuration of scores and qualitative aspects of significance. performance were considered in the classification of Each selection of the picture depicting the word or aphasic disorder shown in Table 3. It may be seen phrase given on Aural Comprehension of Words and that and specific anomic defect Phrases was awarded two points, a perfect perform- predominated in patients with CHI of mild or mod- ance corresponding to a score of 42. Fewer than 2 % erate severity as judged by duration of coma and the of the Iowa normative sample had scores below 31; presence of neurological deficit. Anomic disturbance this score was adopted as a defective level of per- was often characterised by stereotyped descriptive formance. A single control patient (3.5 %) as com- statements and semantic approximations and was pared with eight head-injured patients (16%) had generally free of jargon. Table 3 indicates that both defective scores on this test, though the proportions expressive and receptive deficits were more common in of impairment were not significantly different cases with severe CHI. (X2= 1.83). Contrary to the impression given by the Multiple stepwise discriminant analysis was under- Figure of greater deficit in patients with grade III taken to determine the relative contribution of the injuries, pairwise comparisons between the CHI aphasia tests toward a function which yielded 81 % subgroups and the control group were not substan- correct classification of injury severity on the basis of tiated by Fisher's Exact Method. test scores. Naming pictures of objects and controlled Correct selection of the appropriate picture for the word association were the greatest contributors to word or phrase shown on the cue card was credited the discrimination of the three groups of patients. Of by guest. Protected copyright. with a point on Reading Comprehension, a perfect the receptive language measures, the token test was performance corresponding to a score of 20. A score the most predictive ofgrade ofinjury. of less than 16 fell below the second percentile of the normative distribution. Given this criterion, six head-injured patients (13%) and a single control CONCOMITANT NEUROPSYCHOLOGICAL DEFICITS patient (3%) had defective reading comprehension. Further analysis was undertaken to investigate the The proportion of head-injured patients with de- relationship between the presence of aphasic disorder ficient reading comprehension did not significantly and temporal disorientation, impairment of facial differ from that of control patients (X2 = 0.86). Com- recognition, defective reproduction, and finger parison of each subgroup of CHI with the control agnosia. In the case of serial examinations, the scores group revealed that the increase in proportion of on these tests which were obtained closest in time to patients with defective reading comprehension ap- the aphasia examination were used. Of the 21 patients proached significance only in the grade III group with aphasic disorder classified in Table 3, 20 com- (P<0.10); other differences were clearly non- pleted the protocol for temporal orientation, while 28 significant. As suggested by the Figure, deficient of the 29 non-aphasic patients were tested. Of the reading comprehension was more characteristic of total group of patients with CHI tested for dis- patients with grade III injuries as compared with the orientation, 18 (38%) were defective as defined by a grade I group (P=0.03); scores by grade II patients score below that of 97 % of a previously studied con- did not differ significantly from those of the other trol population (Benton et al., 1964). Eleven (55 %) of head-injured groups. the aphasics were disoriented for time according to http://jnnp.bmj.com/

TABLE 3 CLASSIFICATION OF APHASIC DISORDER

Type ofaphasic disorder on September 28, 2021 Grade oJ Expressive Specific anomia Receptive Mixed injury - - Mild Severe Mild Severe Mild Sever-e Mild Severe

I (n= 19) 1 0 0 0 1 0 0 0 ll (n= 17) 1 1 4 1 0 0 3 1 III (n= 14) 2 0 0 0 0 0 1 5 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

Aphasic disorder in patients with closed head injury 1067

this criterion. By comparison, seven (25 %) ofthe non- that is, adequacy of performance was inversely re- aphasic patients were disoriented. The positive as- lated to persistence of coma. It should be noted that sociation between aphasia and temporal disorienta- persistent coma was neither a necessary nor sufficient tion approached a statistically significant level condition for anomic disturbance as the previous (X2 = 3.29, p < 0.10). Impairment of facial recognition analysis had failed to differentiate subgroups of CHI was also defined as a score exceeded by 970% of a with respect to proportion of defective scores. Several control group (Levin et al., 1975). Although 270% of patients who lost consciousness for several minutes or the total group had defective facial recognition scores, less manifested impairment of naming, though spon- aphasic disorder had no demonstrable relationship taneous was not grossly dysphasic. Significant with impaired facial recognition. Of the 19 aphasics correlations between duration of coma and test scores who completed the facial recognition test, five (26 %) were also found on word association (rs = -0.42, performed at a defective level as compared with p < 0.005), comprehension of aural language seven of the 25 non-aphasic patients (28 %). Seven of (rs= -0.35, P<0.02), and reading comprehension the 13 aphasics (540%) who completed the Bender (rs= -0.44, p<0.002). In contrast, sentence rep- Gestalt figures had more than two errors scored ac- etition (rs= -0.21) and performance on the token test cording to the Koppitz method, a score clearly defec- (rs = -0.27) were not significantly correlated with tive for the normal adult population. In contrast, six duration of coma. Scatter-plots revealed numerous of the 22 non-aphasic patients (27 %) performed at a examples of defective scores in patients who lost con- defective level. However, the association between sciousness for brief periods. Although writing-to- aphasic disorder and visuomotor impairment on the dictation did not yield a significant correlation Bender test did not reach significance, X2 = 1.46. A (rs= -0.29), copying performance was related to by guest. Protected copyright. similar pattern was observed for finger localisation duration ofcoma (rs = -0.37, P < 0.02). which was defective in 16 of the 43 patients (37 %) Correlates of linguistic disturbances in head- studied. Of the 20 aphasics tested, 10 performed at a injured patients were investigated by comparing the level below 970% of a control population (Benton, proportions of patients with defective scores ac- 1959). Six of the 23 non-aphasics (26%) showed cording to the presence or absence of hemispheric finger agnosia, a proportion which did not differ from deficit, signs of brain stem injury, and skull fracture. that ofthe aphasics (X2 = 1.69). Preliminary analysis was first undertaken to exclude the possibility that patients who had defective scores on at least one of the linguistic measures were tested CORRELATION WITH NEUROLOGICAL INDICES after a briefer injury-test interval than patients who Consideration of severity of injury as a discrete performed above a defective level on all tests. The variable by comparing the grades of injury was sup- injury-test interval in patients who manifested im- plemented by correlating the corrected score on each pairment on at least a single test (XZ= 112 days, test with duration of coma for the total sample of SD= 213) was not discrepant from the interval in patients with CHI. The Spearman rank order correla- patients whose language was apparently unaffected by tion coefficient between the adjusted score on Visual CHI (Z=111 days, SD= 176). Naming and duration of coma was -0.33 (p < 0.02)- As shown in Table 4, the presence of hemispheric

BLE 4 http://jnnp.bmj.com/ PERCENT OF PATIENTS WITH DEFECTIVE LINGUISTIC SCORES ACCORDING TO PRESENCE OF INJURY COMPLICATIONS

Hemispheric deficit* Brain stem involvementt Skullfracture

+ ~~~++ (no.) ( ,) (no.) (%) (no.) (%O) (no.) (%) (no.) ( ) (no.) ( %) on September 28, 2021 Visual Naming 3 0 47 45 7 86 43 35 31 32 19 58 Sentence Repetition 3 0 43 5 7 14 39 3 28 4 18 6 Word Association 3 0 43 23 7 57 39 15 27 1 t 19 37 Token Test 3 0 44 36 7 71 40 28 29 21 18 56 Aural Comprehension 3 0 46 17 7 57 42 9 31 10 19 26 Reading Comprehension 3 0 45 13 7 57 41 5 29 7 19 21

* Exclusive of signs of brain stem injury. t Concomitant hemispheric injury may have been present. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

1068 H. S. Levin, R. G. Grossman, and P. J. Kelly motor or sensory deficit apart from brain stem injury whose loss of consciousness was limited to a few was not associated with aphasic disturbance on any minutes. In other respects, the pattern of test findings variable tested. Nor was the presence of a skull frac- in cases with haematoma was not distinguishable ture contributory. By contrast, signs of brain stem from other patients in the series. injury were associated with defective visual naming Neurological findings were reviewed in an attempt (X2 = 5.05, p < 0.025), dysfluent word associations to ascertain lateralised injury of either cerebral (X2 = 3.88, P < 0.05), and impaired comprehension of hemisphere. This analysis was frequently compli- aural language when selection of a corresponding cated by evidence of widespread injury, particularly picture was employed (X2= 10.54, P<0.005). Al- in patients classified as grade III with brain stem in- though Table 4 suggests an association between volvement. Notwithstanding this limitation, Table 5 brain stem injury and impaired comprehension on includes the results for 25 patients who had lateral- the token test, this trend only approached significance ising findings on the neurological examination, EEG, (X2 = 3.35, p < 0.10). Inability to repeat sentences was arteriography, computerised axial tomography not related to brain stem injury. (CAT), or depressed skull fracture which required Intracerebral haematoma was evacuated before surgical elevation. Of the 15 patients with pre- testing in two patients (right frontal) with grade II dominant involvement of the left hemisphere, seven injuries and in a single case of grade I injury (right (47 %) were impaired on at least one aphasia subtest, posterior parietal); epidural haematoma in this series whereas six of the 10 patients with greater injury of was limited to a single patient (right frontal) who had a the right hemisphere satisfied this criterion of grade I injury. In all cases the haematoma was con- linguistic disturbance. The proportion of impaired fined to the right hemisphere and associated with patients in the lateralised injury groups did not differ by guest. Protected copyright. impairment on at least one linguistic measure. The according to Fisher's Exact Method. Table 5 suggests grade I patient with an intracerebral haematoma had that a right hemiparesis was closely though not more widespread linguistic deficit than other patients exclusively associated with aphasic defect. However,

TABLE 5 NEUROLOGICAL FINDINGS OF LATERALISING SIGNIFICANCE IN RELATION TO LINGUISTIC DEFECT*

Initials Hemisphere Linguistic Contralateral EEG Arteriogram Depressedfracture primarily defect hemiparesis abnormal and/or CAT requiring surgery damaged abnormal

R.J. L C.M. L + L.R. L + + W.G. L + + R.R. L + + C.L. L + + M.A. L + +

J.S. L + http://jnnp.bmj.com/ S.K. L M.D. L D.M. L + R.O. L N.L. L L +1 G.G. + G.M. L R.D. R + K.O. R + +, E W.F. R + +. I R.P. R + +, I +,I R.A. R + on September 28, 2021 J.N. R + M.D. R D.W. R R E J.P. + + +, A.P. R

* I = intracerebral haematoma, E =epidural haematoma. Positive findings on arteriogram, CAT other than haematoma included swelling, con- tusion, or porencephalic cyst. Linguistic defect based upon at least one test failure. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

Aphasic disorder in patients with closed head injury 1069 interpretation of this association is complicated by assessment of residual deficits after CHI is that evidence of brain stem injury in all but one of these sensitive measures of anomic disturbance and patients. deficient verbal fluency should be employed. Con- fining the linguistic examination to a brief sample of conversational speech may obscure these subtle DISCUSSION defects, whereas 10 minutes of testing could identify The present study sought to elucidate the profile of cases in which speech therapy is indicated. linguistic deficits after closed head injury and to Classification of patients according to severity of correlate complications of injury with aphasia. injury demonstrated that the risk of aphasic disturb- Quantitative assessment disclosed that anomic errors ance was significantly greater in patients with and verbal associative difficulty were prominent persistent coma and evidence of concomitant sequelae of CHI, as nearly half of the patients in our hemispheric and brain stem involvement. However, series performed at a defective level on visual naming elucidation of the specific contribution of brain stem and/or word association. Moreover, naming ability injury as distinct from more pervasive hemispheric and verbal associative fluency proved to be the most injury awaits further investigation. Grade II and efficient predictors of grade of injury. These findings grade III injuries were frequently associated with confirm the report of Heilman et al. (1971) which anomia, dysfluent word finding, and impaired implicated anomic aphasia in patients with CHI. In comprehension of both oral and written language. contrast with the study by Heilman et al., the effects Writing to dictation was also compromised in severely injured patients. The association between of CHI in our patients were not complicated by by guest. Protected copyright. alcoholism and age-related changes were minimised. severity of injury and degree of neuropsychological Impaired comprehension of aural language on the deficit confirms previous studies of mnemonic deficit token test was found in a third of the patients. (Brooks, 1974; Levin et al., 1976). Although the However, injuries which produced prolonged coma adequacy of linguistic performance was negatively frequently resulted in linguistic disturbance of a correlated with duration of coma, an extended period rather general, nonspecific character. Whether this of unconsciousness was neither a necessary nor global decline is attributable to generalised cerebral sufficient condition for aphasic disorder. Despite dysfunction or to dysfunction of the dominant apparent preservation of speech in mildly injured hemisphere alone remains to be determined. patients, standardised testing revealed deficits that Several cases of relatively isolated anomia or were frequently undetected on gross examination. general disturbance in word finding were observed, Consonant with the diffuse anatomical effects of though configurations of findings characteristic of CHI, the linguistic defects described herein might be Broca's or Wernicke's aphasia were absent. In accord viewed as instances of general mental impairment. with previous observations (de Morsier, 1973), slow, Quite to the contrary, aural repetition of lengthy halting, and effortful speech with agrammatism and sentences was generally preserved in our patients. phonemic paraphasia were not marked in our Although aphasia appeared to be associated with patients, nor were literal paraphasias, jargon, and temporal disorientation and perceptual deficits, this circumlocutions frequently present. Although an trend was not confirmed by statistical analysis. attempt to identify patients with lateralised hemi- In view of the concomitant aphasic and mnemonic spheric injury did not demonstrate an association defects observed in patients with CHI (Akbarova, 1972), it is tempting to infer that an impairment of between linguistic defect and left hemisphere involve- http://jnnp.bmj.com/ ment, it is likely that diffuse effects of CHI were verbal coding underlies both disorders and to present in most patients. However, the vulnerability postulate that training in imagery would improve of naming and verbal-associative processes and memory. Contrary to this view, Levin et al. (1976) comprehension of nonredundant commands suggests found that short-term recognition memory for involvement of the temporoparietal areas. This random geometric forms was deficient in patients inference is supported by previous necropsy findings with severe CHI. Moreover, recognition of relatively (Heilman et al., 1971) in two aphasic patients with nonverbal memoranda was unrelated to association value of the stimuli. Consequently, it is unlikely that CHI which indicated that contusion of the dorso- on September 28, 2021 lateral surface of the temporal lobe and temporo- a specific verbal coding deficit can account for the parietal junction were the predominant features. It full range of neuropsychological sequelae of CHR. may be inferred that the posterior speech generating process is affected by CHI, whereas the preserved This investigation was supported by USPHS Grant 2 repetition suggests that connections between PO1 NS 07377-06 Center for the Study of Nervous Wernicke's area and Broca's region are intact. An System Injury. The authors are indebted to Professor implication of our findings for routine clinical A. L. Benton for his careful reading of the manuscript J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.39.11.1062 on 1 November 1976. Downloaded from

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