Sudden loss of speech: causes, symptoms, diagnosis

In case of sudden speech loss, first of all it is necessary to determine whether anarthria is (that is, the impossibility of pronouncing words due to a violation of the coordinated activity of the respiratory, voice-forming and articulatory apparatus due to their paresis, ataxia, etc.) or - aphasia there is a violation of speech praxis).

This task is not easy, even when the patient is conscious and able to follow instructions, which rarely happens in acute pathology. On simple questions, it is possible to get answers like "yes" / "no", which with a probability of 50% are answers at random. Moreover, even with aphasia, patients can very well grasp the meaning of what they heard, using the "keyword" strategy, by which they understand the general meaning of the phrase due to the available situational ("pragmatic") skills that do not suffer from speech impairment.

Research through simple commands is difficult if the patient has hemiplegia and (or) it is immobilized. In addition, concomitant apraxia also may limit the ability of the physician. In the case of oral apraxia, the patient will not be able to perform even simple instructions (for example, "open your mouth" or "stick your tongue out").

The ability to read is difficult to study, because reading requires the preservation of the response to oral gesticulation and motor skills, but studying the written language can help make the right decision. With right-side hemiplegia, a test is used: the patient is offered to arrange in the correct order the words of the completed sentence, which he receives in written form on separate sheets of paper, interspersed. However, in some cases, even an experienced aphasia specialist can not immediately make the right decision (for example, when the patient does not even attempt to make at least a sound). It should be remembered that over time, the picture can change rapidly, and instead of the aphasia that the patient had at the time of admission, dysarthria can quickly come to the fore, that is, a purely articulatory speech disorder. When the diagnosis is made, the age of the patient plays an important role.

The main causes of sudden loss of speech:

1. Migraine with aura (aphasic migraine)
2. Stroke in the left hemisphere
3. Postictal condition
4. Tumor or abscess of the brain
5. Thrombosis of intracerebral sagittal sinus
6. Encephalitis caused by herpes simplex virus
7. Psychogenic mutism
8. Psychotic mutism

Migraine with aura

In patients of a young age, you can first suspect a migraine with an aura. In these cases, there is the following typical combination of symptoms: acute or subacute speech loss (often without hemiplegia), accompanied by a headache that has repeatedly occurred in the patient in the past and which could both be accompanied and not accompanied by changes in the neurological status. If a migraine attack occurs for the first time in a given patient, useful information can be given by studying a family history (if there is such an opportunity), since in 60% of cases this disease is of a family nature.

The EEG is most likely the detection of a focus of slow-wave activity in the left temporal parietal region, which can persist for 3 weeks, while in neuroimaging no pathology is detected. Expressed focal changes on the EEG in the absence of abnormalities based on the results of neuroimaging imaging on the 2nd day of the disease in principle make it possible to correctly diagnose, with the exception of cases of herpetic encephalitis (see below). The patient should not have cardiac murmurs, which may indicate the possibility of cardiogenic embolism, which can be observed at any age. A possible source of embolism is detected (or eliminated) by echocardiography. Listening to vascular noises above the vessels of the neck is less reliable than ultrasound dopplerography. If possible, transcranial ultrasound dopplerhophy should be performed. A patient suffering from migraine and belonging to the age group of 40 to 50 years may have asymptomatic stenotic vascular disease, but the typical character of the headache, the rapid reverse development of symptoms and the absence of structural changes in the brain from the results of neurovisualizational methods of investigation in conjunction with the changes described above on EEG allow to put the correct diagnosis. If the symptoms do not progress, there is no need to study the cerebrospinal fluid.

Left hemisphere stroke

If speech is impaired in an elderly patient, the most likely diagnosis is a stroke. In most cases of speech disorders in stroke, the patient is diagnosed with right-side hemiparesis or hemiplegia, hemi-hemesthesia, sometimes hemianopsia or a defect of the right-hand visual field. In such cases, neuroimaging is the only way to reliably differentiate intracerebral hemorrhage and ischemic stroke.

Loss of speech almost always occurs with left hemisphere stroke. It can also be observed in right hemisphere stroke (i.e. - in the defeat of the non-dominant hemisphere), but in these cases speech is restored much faster, and the probability of complete recovery is very high.

Mutism may precede the appearance of aphasia in the defeat of the Broca region, it is also described in patients with damage to the additional motor area, with severe pseudobulbar paralysis. In general, mutism is more likely to develop with bilateral brain lesions: the thalamus, the anterior regions of the cingulate gyrus, damage to putamen from both sides, the cerebellum (cerebellar mutism in acute bilateral damage to the cerebellar hemispheres).

A gross violation of articulation can occur with circulatory disturbances in the vertebrobasilar basin, but a complete absence of speech is observed only with occlusion of the basilar artery, when an akinetic mutism develops, which is a rather rare phenomenon (bilateral lesion of the mesencephalon). Mutism as the absence of vocalization is possible even with bilateral paralysis of the muscles of the pharynx or vocal cords ("peripheral" mutism).

Postictal state (condition after convulsive seizure)

In all age groups, except for infants, loss of speech can be a postictal phenomenon. The epileptic seizure itself can go unnoticed, and a bite of the tongue or lips may be absent; indicating a seizure may be an increase in the level of creatine phosphokinase, but this finding in terms of diagnosis is unreliable.

It is often satisfied with the diagnosis of EEG: generalized or local slow and acute activity is recorded. Speech is quickly restored, and the doctor is faced with the task of determining the cause of an epileptic fit.

Tumor or abscess of the brain

In a history of patients with a tumor or brain abscess, any valuable information may be missing: there was no headache, no behavioral changes (aspontaneity, flattening of affect, apathy). An obvious inflammatory process of ENT organs can also be absent. Sudden loss of speech can occur: due to rupture of the vessel, blood supply to the tumor, and the resulting hemorrhage into the tumor; due to the rapid build-up of perifocal edema; or - in the case of left-hemispheric tumor or abscess localization - due to partial or generalized epileptic seizure. Establishing the correct diagnosis is possible only with a systematic examination of the patient. It is necessary to conduct an EEG-study, in which it is possible to detect a focus of slow-wave activity, the presence of which can not be unequivocally interpreted. However, the presence of very slow delta-band waves combined with a general slowdown in brain electrical activity may indicate an abscess of the brain or a tumor of hemispheric localization.

In computed tomography, both in the case of a tumor and in the case of an abscess, it is possible to detect a volumetric intracerebral process in the form of a low-density focus with or without contrast absorption. With abscesses, there is more pronounced perifocal edema.

Thrombosis of intracerebral sagittal sinus

There is the following typical triad of symptoms, which may indicate thrombosis of the intracerebral sinus: partial or generalized epileptic seizures, hemispheric focal symptomatology, decreased wakefulness. On the EEG, a generalized low-amplitude slow-wave activity is recorded over the entire hemisphere, which also extends to the opposite hemisphere. In neuroimaging, sinus thrombosis is indicated by cerebral edema (predominantly in the parasagital area) with diapedesis hemorrhages, hyperintensity of the signal in the sinus region (s), and a deltoid zone that does not accumulate the introduced contrast and corresponding to the affected sinus.

Encephalitis caused by the herpes simplex virus (HSV)

Since herpetic encephalitis caused by HSV is predominantly affected by the temporal lobe, aphasia (or paraphasia) is often the first symptom. On the EEG, focal slow-wave activity is detected, which upon repeated registration of the EEG is transformed into periodically arising three-phase complexes (triplets). Gradually these complexes extend to the frontal and contralateral leads. In neuroimaging, a low-density zone is identified, which soon acquires the characteristics of the volumetric process and spreads from the deep sections of the temporal lobe to the frontal lobe, and then contralateral, involving primarily the zones related to the limbic system. In the cerebrospinal fluid, signs of an inflammatory process are found. Unfortunately, the verification of HSV infection by direct visualization of virus particles or by immunofluorescence analysis is possible only with a significant time delay, whereas antiviral therapy should begin immediately when the first suspicion of the presence of viral encephalitis occurs (given that the mortality in HSV- encephalitis reaches 85%).

Psychogenic mutism

Psychogenic mutism manifests itself in the absence of reciprocal and spontaneous speech with a safe ability to talk and understand the speech addressed to the patient. This syndrome can be observed in the picture of conversion disorders. Another form of neurotic mutism in children is an elective (selective, emerging when communicating with only one person) mutism.

Psychotic mutism - mutism in the picture of the syndrome of negativism in schizophrenia.

Diagnosis of sudden loss of speech

General and biochemical blood test; ESR; ocular fundus; investigation of cerebrospinal fluid; CT or MRI; UZDG the main arteries of the head; invaluable help can be provided by a neuropsychologist.

[1], [2], [3], [4], [5], [6], [7], [8], [9]