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cerebrum (The term operculum refers to the cortex that borders the sylvian ssure and covers or forms a lid over the insula, or island of Reil) In other words, the lesion in the usual form of Broca s aphasia extends well beyond the so-called Broca s area (Brodmann s areas 44 and 45) Furthermore, persistence of Broca s aphasia is associated with the larger type of lesion, illustrated in Fig 23-2 It is noteworthy that in one of Broca s original patients, whose expressive language had been limited to a few verbal stereotypes for 10 years before his death, inspection of the surface of the brain (the brain was never cut, although CT scans have since been made) disclosed an extensive lesion encompassing the left insula; the frontal, central, and parietal operculum; and even part of the inferior parietal lobe posterior to the sylvian ssure The Wernicke s area was spared, refuting the prediction at the time of Marie Inexplicably, Broca attributed the aphasic disorder to the lesion of the frontal operculum alone Broca ignored the rest of the lesion, which he considered to be a later spreading effect of the stroke Perhaps he was in uenced by the prevailing opinion of the time (1861) that articulation was a function of the inferior parts of the frontal lobes The fact that Broca s name later became attached to a discrete part of the inferior frontal cortex helped to entrench the idea that Broca s aphasia equated with a lesion in the Broca s area However, as pointed out above, a lesion con ned only to this area gives rise to a relatively modest and transient motor speech disorder (Mohr et al) or to no disorder of speech at all (Goldstein) Motor speech disorders, both severe Broca s aphasia and the more restricted and transient types, are most often due to a vascular lesion Embolic infarction in the territory of the upper (rolandic, superior) division of the middle cerebral artery is the most frequent type of stroke and results in the most abrupt onset and sometimes the most rapid regression of aphasia (hours or days), depending on whether the ischemia proceeds to tissue necrosis Even with the latter, however, ischemia around the zone of infarction causes a more extensive syndrome than one might expect from the infarct itself, ie, the physiologic impairment initially exceeds the pathologic Because of the distribution of the superior branch of the middle cerebral artery, there are a frequently associated right-sided faciobrachial paresis and a left-sided manual-brachial apraxia (socalled sympathetic apraxia), due probably to interruption of the bers that connect the left and right motor cortices Atherosclerotic thrombosis, primary or metastatic tumor, subcortical hypertensive, traumatic or anticoagulant-induced hemorrhage, and seizure, should they involve the appropriate parts of the motor cortex, may also declare themselves by a Broca s aphasia A closely related syndrome, pure word mutism (aphemia), causes the patient to be wordless (mute) but leaves inner speech intact and writing undisturbed Anatomically, this is believed to be in the nature of a disconnection of the motor cortex for speech from lower centers and is described with the dissociative speech syndromes discussed further on in this chapter Wernicke s Aphasia This syndrome comprises two main elements: (1) an impairment in the comprehension of speech, basically an inability to differentiate word elements or phonemes, both spoken and written, and (2) a relatively uent but paraphasic speech (further de ned below) The location of the lesion in cases of Wernicke s aphasia is the left superior lateral temporal lobe near the primary auditory cortex reveals the major role of the auditory region in the regulation of language The defect in language is manifest further by a varying inability to repeat spoken and written. barcode font for word 2010 code 128 Install Code 128 Fonts Add-In in Word - BarCodeWiz
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