Final Exam Cumulative
If you had a patient that presented with a (L) MCA CVA what type of deficits would you expect to observe.
A (L) MCA CVA translates to a left middle cerebral artery cerebrovascular accident, or a stroke in the middle cerebral artery in the left hemisphere of the brain. The first things I would focus on would be that the stroke occurred in the left hemisphere, where most people are language-dominant, and that it occurred in the middle cerebral artery branch of the Circle of Willis. The middle cerebral artery is the largest cerebral artery of the Circle of Willis that feeds the language areas of the brain. If this is where the stroke occurred, and on the left hemisphere, I would expect to see major language deficits. These would include possible symptoms of different types of aphasia, including fluent and nonfluent, or global aphasia. There may also be some difficulty in language comprehension depending on the display of the aphasia.
Explain the importance of the Circle of Willis in the cerebrovascular system. What types of obstructions might occur? What area if obstructed would have the most impact on speech and language?
The Circle of Willis is very important in the cerebrovascular system. The function of the Circle of Willis is to feed the brain oxygenated blood through three branches: the anterior cerebral artery, the middle cerebral artery, and the posterior cerebral artery. The Circle of Willis acts almost as a traffic circle, redirecting the oxygenated blood if there is a blockage. The types of obstructions that can occur are Ischemic CVAs, a Thrombotic Ischemic CVA, an Embolic Ischemic CVA, a Transient Ischemic CVA, or a Hemorrhagic CVA. An Ischemic CVA is a blood clot, thrombotic is where the blockage is in place, embolic is a travelling blood clot, and transient is a small warning sign for a larger Ischemic CVA. A Hemorrhagic CVA is a bleed caused by weakening or bursting of a blood vessel. The area that would have the most impact on speech and language if it were obstructed would be the Middle Cerebral Artery, because it feeds all the language areas in the brain.
Describe the functions of the basal ganglia (what is it responsible for). If you had a patient with damage to this area what type of symptoms/diseases might you observe?
The basal ganglia regulates complex motor functions such as posture, locomotion, balance, and arm swinging. It helps inhibit some functions and coordinates motor behavior. It also produces dopamine and can play a role in the development of Parkinson's disease. In terms of speech, the basal ganglia can play a role in dysarthria, dysphonia, comprehension, naming, and repetition problems. If a patient had damage to the basal ganglia, I would expect a variety of deficits. It is most often associated with Parkinson's disease, due to the decreased production of dopamine. Problems with the basal ganglia often produce dyskinesias such as: tremors in movement or in speech, rigidity due to increased muscle tone, bradykinesia, tics, gait issues, dystonia, chorea, and athetosis.
Describe the functions of each of the lobes of the brain. Which lobes & the specific areas within them are most important to speech and language?
The frontal lobe controls reasoning, planning, motor movement, and executive functions. The parietal lobe controls sensory perception and interpretation. The occipital lobe controls vision, and the temporal lobe controls memory and receptive language. The frontal lobe contains many important areas for language. One of the most important is Broca's area, which is responsible for language planning and production. The frontal lobe also contains the primary motor cortex, or the motor strip, which sends motor plans to the muscles for them to act and is very important for speech muscles and speech production. The parietal lobe is mainly responsible for sensory perception, but contains areas that are also important for speech and language. This area is the primary sensory cortex which processes somatosensory information such as vibration, proprioception, and touch. It also contains the somatosensory cortex which is involved in the fine motor movements associated with speech. The occipital lobe contains areas that are important for the visual aspects of language. These include the visual cortices, where information from the eyes is received and processed into two streams, the dorsal and ventral streams. The dorsal stream analyzes motion and spatial relationships and the ventral stream analyzes forms, colors, and faces. Lastly, the temporal lobe contains very important areas to speech and language. One of the most important areas in the temporal lobe is Wernicke's area, which is responsible for language comprehension, or attaching meaning to auditory information. The inferior temporal area is also involved in the processing of auditory and language information, as well as reading facial emotions. Lastly, the temporal lobe contains the primary auditory cortex, which receives auditory information from the auditory pathway and processes sound intensity and frequency
Please name and describe the function of the 3 cranial nerves that would be most relevant to you as a speech language pathologist. If your patient had damage to these Cranial Nerves what type of damage would you expect to see?
The three cranial nerves that I would expect to be most relevant to a Speech Language Pathologist are CN V- Trigeminal Nerve, CN VII- Facial Nerve, CN X- Vagus Nerve. The Trigeminal Nerve controls sensory information, touch, pain, temperature, and senses in the mouth and anterior 2/3 of the tongue. It also controls chewing muscles, jaw-jerk reflex, and provides sensation to soft palate and tensor tympani. If a patient had damage to the Trigeminal Nerve, they would experience difficulty with mastication, possible swallowing difficulties, and also difficulty with articulation involving the soft palate. The Facial Nerve is another cranial nerve that is very important for speech language pathologists. It controls the muscles of the face, sensation near the ears, taste in the anterior 1/3 of the tongue, and salivary glands. If a patient had damage to this cranial nerve, they would experience facial paralysis or paresis, and possible taste loss. If a patient has paralysis or paresis to the face, speech becomes immensely more difficult. The third cranial nerve that is important to speech language pathologists is the Vagus Nerve. This cranial nerve controls the pharyngeal and laryngeal muscles, the heart, lungs, digestive tract, sensory information for the pharynx, blood pressure, and taste. If a patient had damage to the Vagus Nerve, they would present with an absent gag and swallow reflex, a loss of velar movement, and a loss of voice.
What is aphasia? How would the symptoms of a patient with Broca's aphasia differ from one with Wernicke's aphasia?
o Aphasia is an acquired multimodality language disorder. Broca's aphasia is characterized by difficulty with language programming/planning and execution, whereas Wernicke's aphasia is characterized by deficits in language/auditory comprehension, verbal jargon, lack of understanding others' speech.
Compare and contrast aphasia, dysarthria, and apraxia.
o Aphasia is an acquired multimodality language disorder. Dysarthria is an actual impairment (weakness/paralysis/interruption) of the muscles. Apraxia is a motor planning and programming disorder. There are many different types of aphasia, but the main symptoms, depending on the type, include auditory comprehension loss, fluent or nonfluent aphasia, anomia, jargon, paraphasia, and neologisms. There are also many different types of dysarthria, including spastic, flaccid, hypertonic, hypotonic, ataxic, and mixed. The hallmark characteristic of apraxia of speech is searching/groping for articulatory placement, along with random substitutions and errors in articulatory placement.
A recently certified SLP read the report of a patient with impaired speech, language, cognitive, and sensorimotor functions following traumatic brain injury caused by a four wheeler accident. The neurological report identifies many sites of injury including Brodmann's areas 3,1, 2, 4, 10, &11. What sensorimotor and behavioral symptoms are you most likely to see in this patient? Use the back of this paper.
o Broadmann areas 1, 2, and 3: Primary Sensory Cortex; processes somatosensory information such as vibration, proprioception, touch, and asterogenosis o Broadmann area 4: Primary Motor Cortex, motor strip; sends motor plans to muscles, helps speech muscles o Broadmann areas 10 and 11: Prefrontal Cortex; selecting and planning of motor movements, involved in turning on motor plans o Along with the areas previously outlined, I would expect pragmatic deficits in areas of social communication, as that is often a concurrent deficit with TBI. I would also expect problems in attention, orientation, memory, new learning, thought organization, reasoning, problem solving, executive functions, along with dysphagia, dysarthria, aphasia, apraxia of speech, and hearing loss.
List the components of a typical neurologic examination and briefly describe how you might assess each area.
o Step 1: The Interview: get a report of what the patient is experiencing during the illness, elicit patients' chief complain, history of the present illness, past medical history, family history, social history, environmental history, and review of systems, which is more for a doctor and not a speech language pathologist. o Step 2: The Physical Exam: the speech pathologist examines awakeness, alterness, and responsiveness of the patient. Personal hygiene and dress are also looked at, then an examination of the head, eyes, nose, and throat is conducted. Body posture and motor activity is also looked at. o Step 3: The Neurological Exam Proper: mental status is looked at, informally assessing patients expressive and receptive language abilities, patient's orientation to time, place, and person, memory is assessed, cranial nerve evaluation takes place Step 4: Laboratory Tests: speech pathologists will often see the results of lab tests such as MRI or CAT scan in the chart, so interpretation ability is important
Describe the functions of the cerebellum (what is it responsible for). If you had a patient with cerebellar disease what type of symptoms might you observe?
o The cerebellum helps in planning, monitoring, and correction of motor movements using sensory feedback. It also coordinates fine motor activity, monitors head and body position, and participates in the learning of new motor skills. The cerebellum functions as an error control device that coordinates all relevant input and output systems during movement. The cerebellum is most involved in rapid, alternating, and sequential movements. If there is damage to the cerebellum, a variety of deficits can be observed. Most commonly, balance and coordination/gait issues are to be expected with damage to the cerebellum, as it also controls equilibrium. Lesions to the cerebellum often result in tremors and decreased muscle tone. In terms of disorders, damage to the cerebellum is called Friedreich's Ataxia, which is a more common degenerative disorder affecting the cerebellum.
Explain how the direct (primary motor strip) & indirect motor pathway systems (include basal ganglia and cerebellum in discussion) contribute to the production of speech. Compare and contrast UMN lesions vs. LMN lesions within your discussion.
o The direct motor pathway (pyramidal system) involves the lateral motor system, makes few stops, crosses over at medulla/spinal cord juncture, main center is the primary motor cortex. Lateral corticobulbar and corticospinal tracts control voluntary motor movement of speech muscles. The direct motor pathway also includes the upper and lower motor neurons. It can result in either spastic of flaccid dysarthria. The indirect motor system (extrapyramidal) includes the basal ganglia and cerebellar circuits and medial motor systems. Its function is to aid in posture and muscle tone, it has many different stops, and does not have a decussation point. When the indirect motor system is damaged, dyskinesias, tremors, rest tremors, action tremors, chorea, athetosis, dystonia, and myoclonus can occur. Can also cause hyperkinetic or hypokinetic dysarthria. o UMN damage: Spastic muscles Hypertonia Hyperreflexia (+reflexes) Clonus (+) Babinski sign No atrophy No fasciculations LMN damage: Flaccid muscles Hypotonic Hyporeflexia (-reflexes) No clonus No Babinski sign Marked atrophy Fasciculations
If you had a patient that presented with a "brainstem" stroke what type of deficits would you expect to observe.
o The functions of the brainstem are mainly life functions, such as breathing, heart rate, blood pressure, and digestion. It also plays a role in sensory and motor functions, such as speech, voice, articulation, swallowing, and hearing. The brainstem is where all the cranial nerves are stored. Injury to the brainstem can cause a variety of deficits. any disorder that can occur with damage to a cranial nerve (ex: anosmia, visual loss, ptosis, diplopia, nystagmus, facial paresis, sensation loss, chewing difficulties, hearing loss, taste loss, balance issues, absent gag and swallow reflex, loss of velar mvmt, loss of voice, droopy shoulder, loss of tongue mvmt) specific disorders associated with brainstem stroke are: o Wallenberg syndrome: contralateral loss of pain and temp in body, ipsilateral loss of pain and temp in face, paralysis of palate and vocal cord, o coma and/or locked-in-syndrome, o Weber's syndrome: contralateral hemiplegia and ipsilateral oculomotor paralysis with ptosis Benekidt's syndrome: contralateral hemiparesis and ataxic tremor