Great progress has been made in the study of aphasia for more than a century. With the gradual deepening of aphasia research, many scholars have put forward dozens of classification methods according to their different viewpoints and research purposes, some of which overlap each other, and some methods have a lot of confusion in the names of aphasia classification. So far, there is no recognized method. Although there are many classification methods, all classifications are relative. A classification often reflects the understanding of aphasia mechanism through the combination of different language symptoms after brain injury.

1979, Benson began to use the word "aphasia syndrome" in "Aphasia, agraphia and alexia", that is, the concept that the focus is in a certain part and the patient has a set of complete or incomplete clinical symptoms at high frequency, which was widely used in later aphasia research and rehabilitation, and was considered to show commonness in all major languages in the world, reflecting the structural and functional characteristics of the human brain.

(2) Classification of Chinese aphasia.

The classification of aphasia in China is based on Benson classification. The main types of Chinese aphasia are as follows.

The main types of Chinese aphasia

(3) Classification of typical and atypical aphasia.

Recent studies have confirmed that more limited cortical language center injuries often show typical aphasia symptoms; Extensive cortical and subcortical injuries often manifest as atypical aphasia. Therefore, the classification methods of typical aphasia and atypical aphasia are proposed, as shown in the following figure.

Because of different lesion sites and different course of disease, the clinical manifestations of patients are very different, and typical aphasia is relative, and some aphasia is difficult to classify. According to the research data of foreign countries in 1990s and the observation of domestic scholars, about 30% aphasia can't be clearly classified. At the end of 1970s, there appeared a dichotomy of aphasia into non-fluent aphasia and fluent aphasia. Generally, when the lesion is slightly in front of the central sulcus, it is not fluent.

Typical aphasia and atypical aphasia

Clinical characteristics and damage of four types of aphasia

1. broca aphasia or expressive aphasia, motor aphasia.

(1) Main clinical features

The main manifestations are: the expression disorder is obviously more serious than the comprehension disorder. Spontaneous speech is not fluent, the amount of speech is small, laborious, the language is poor, and there are no grammatical words. Telegraph speech is silent when it is serious, so it is difficult to name and find words. However, giving initial voice prompts often leads to correct response and repetition obstacles, especially when repeating long sentences, there are many errors, especially prosodic errors, and the understanding obstacles are light, so you can understand simple words. It is often difficult to master long sentences and execute oral instructions, and the ability to understand and read words may be difficult to varying degrees. The writing of more complicated sentences is also damaged and the grammar is seriously wrong. In addition, Broca's aphasia is often accompanied by oral and facial apraxia. When the patient only has oral disorders, but his understanding, writing, intelligence and calculation are normal, it is called pure verbal sign language, also known as pure motor aphasia or speech apraxia.

(2) pathological changes

In Broca area, which is located in the posterior third of the inferior frontal gyrus of the dominant hemisphere, most patients are accompanied by right hemiplegia. Generally speaking, the prognosis of aphasia in broca is better than other types, but there are great differences among individuals due to different degrees.

(3) Examples of cases

Male, 58 years old, university degree, cadre, right-handed speech disorder with poor right limb movement. Patients admitted to the hospital in June of 5438+0 found that their right limbs could not move or speak when they got up at noon before June of 5438+0, and were immediately sent to a nearby hospital for treatment. He was diagnosed with cerebral infarction. After treatment, he was transferred to the rehabilitation center for rehabilitation. Physical examination showed that the patient was conscious and cooperative, with shallow nasolabial groove on the right side and protruding right tongue. The muscle strength of the right upper limb is grade 2, the muscle strength of the right lower limb is grade 3, the right tendon reflex is hyperactive, and the right Babinsky sign is positive. Aphasia examination: the patient has little spontaneous speech, and can only answer his name and address in Beijing, and can answer the date of birth with some numbers, but the date is incorrect. There are many pauses in the conversation, and I can't speak fluently, and my pronunciation is unclear and my expression is difficult to understand. The correct rate of nouns, verbs and sentences is 70%, 60% and 40% respectively. The naming accuracy is 40%, the action description is 30%, and the prefix sound and gesture prompt are acceptable. The correct rate of noun repetition is 50%, the correct rate of verb is 40%, and sentences with 3-5 words can be repeated. The correct rate of reading comprehension is 40% for noun verbs, 70% for noun verbs and 20% for sentences. The correct rate of writing and naming is 30%, the correct rate of copying is 80% for nouns, 60% for verbs, 40% for nouns, 20% for verbs and 0 for sentences. Calculate 6 points (6 questions are correct). MRI showed "low-density focus in Bullokar area of left frontal lobe". Diagnosis: broca aphasia caused by cerebral infarction.

2. Transcortical motor aphasia.

(1) Main clinical features

Oral English is not fluent, there are few spontaneous words, and they often respond simply to stimuli. There are individual differences in pronunciation, reading and naming ability, and retelling is better in understanding. Some patients have difficulty in writing. The main difference with broca's aphasia is that this kind of patients can repeat longer sentences, and the prognosis of this kind of aphasia is better as a whole.

(2) pathological changes

Most diseases in front of and above Bullokar District are due to middle cerebral artery infarction and brain injury.

(3) Examples of cases

Male, 52 years old, right-handed, driver, junior high school education, poor speech due to poor physical activity on the right side. 1 May, the patient suddenly fell unconscious when washing his face in the morning. On the same day, CT examination showed "a large area of left frontal cerebral infarction" and drug treatment such as dehydration was carried out. 1 week later, the consciousness turned clear, but after 1 month, he still could not speak. I have never received systematic speech training. In order to improve my speaking ability, I was admitted to the hospital for rehabilitation. After admission, I had a standard aphasia examination in Chinese: I was not fluent in spoken English and could express it with some words and gestures. For example, I use the steering wheel to mean "driver". The correct rate of some four-tone errors in spoken English is 90% for nouns and verbs, 70% for sentences and 0 for oral instructions. The correct repetition rate of nouns is 90% and that of verbs is 70%. Sentence naming 40%, action description 90%, picture description 0, reading accuracy noun 40%, verb and sentence 0, reading comprehension accuracy noun 90%, verb 80%, sentence 40%, written explanation 0. All kinds of endless calculations. 17 speech diagnosis: transcortical aphasia.

3. wernicke's aphasia.

Or sensory aphasia, sensory aphasia.

(1) Main clinical features

Wernicke's aphasia is a typical fluent aphasia, and its main feature is that the understanding disorder is obviously more serious than the expression disorder. Wernicke's aphasia is characterized by fluent speech, and a large number of misspelled words and new words are mixed together, resulting in disordered sentences, which are called random words or strange words. There is a persistent phenomenon of words, and there are obvious obstacles in naming and finding words. Patients can speak fluently, but they don't know what they are talking about and lack the core content of expression. In terms of understanding, language holes are manifested as speech comprehension obstacles, often manifested as impaired pronunciation and semantic understanding. Due to different severity, people's ability to understand written language is also impaired to varying degrees. People can read words, but most of them are misspelled and often have glyphs. However, patients with aphasia in wernicke often lack self-awareness of the disease, and the prognosis of this aphasia is often poor as a whole.

(2) pathological changes

It is mainly located in the Wernicke area 1/3 at the posterior part of the superior temporal gyrus or the posterior edge of the lateral fissure of the brain, with the posterior part of the middle temporal gyrus of the superior temporal gyrus as the central area. Most patients with cerebral infarction (cortical branch of middle cerebral artery) are often accompanied by hemianopia.

(3) Examples of cases

Male, 59 years old, You Li, college degree, suffering from rheumatic heart disease for more than 30 years, atrial fibrillation 10 years. After dinner two months ago, in a quiet state, he suddenly felt that his right limb was not moving well and he could not speak clearly. Later, I went to a local hospital for treatment. CT examination showed that after left temporal lobe cerebral embolism treatment, the limb movement basically recovered, but the speech still did not improve. In order to recover from speech, he was transferred to hospital for treatment. Listening test is the normal threshold. Chinese standard aphasia test: fluent in spoken English, with obvious confusion. In conversation, he lacks the ability to restrain himself. For example, when answering his name question, he said, "Li La thought suddenly, suddenly ..." The correct answer rate of listening comprehension is: noun and verb 10%, sentence and verb instruction is 0, repetition or confusion. The score is 0 and the reading comprehension is 0. Verb 60%, sentence 50%, written instruction execution 0, transcription 50% correct, address writing and description writing are messy words, writing too much, score 0, 20% correct. Language diagnosis: wernicke aphasia

4. Transcortical sensory aphasia.

(1) Main clinical features

In terms of expression, spontaneous speech is fluent, but there are many mistakes, naming has serious obstacles, and retelling ability is good. However, there is a phenomenon of learning a language, that is, although you don't know what the other party is saying, you repeat what the other party said repeatedly, which shows that there are obstacles in language understanding and written language understanding. You can read words aloud, but you often don't understand their meaning. In the process of recovering from wernicke's aphasia, you often become this type. The biggest difference between wernicke's aphasia and repetition is that.

(2) pathological changes

Generally speaking, it is a widespread lesion around the speech center of the dominant hemisphere fissure of the brain, but the injury confined to the back will also have the same symptoms.

5. Conductive aphasia.

(1) Main clinical features

In terms of expression, spontaneous speech is fluent, but most of them are accompanied by phoneme errors. Conductive aphasia is characterized by repetition disorder, which is manifested by spontaneous language naming, repetition and errors in word reading. In terms of understanding, words and sounds are good, and most conductive aphasia with dysgraphia generally has a good prognosis.

(2) pathological changes

At present, the focus of conductive aphasia is still controversial. It is generally believed that the focus is mainly located in the arcuate tract connecting Wernicke's area and broca's area, which makes the speech information in Wernicke's area not well transmitted to broca's area, resulting in serious repetition disorder. However, some scholars have questioned this. They believe that the lesion is not limited to a specific site, and is often caused by scattered injuries in the upper and lower parts of the lateral fissure of the dominant hemisphere.

(3) Examples of cases

Male, 56 years old, from Youli, with college education, was injured in the left head by a club when he was learning to play golf in September. 1997. He had a bad headache and was taken to the local hospital immediately. On the way to the hospital, the patient was unconscious. The CT examination of the local hospital showed "intracranial hematoma in the left temporal lobe". After the operation, the patient woke up the next day, and after waking up, he had speech difficulties and mild movement disorder of his right limb. After 1 month, the body movements basically recovered, but there were still obvious expression obstacles and articulation. Please don't seek medical treatment for speech rehabilitation. Do a standard aphasia examination after admission: the patient is fluent in oral English, and there are a lot of phonetic errors in answering and asking questions, and there are also many mistakes in naming. It is impossible to repeat words. Sometimes individual tones can be repeated, and most of them can be understood under visual cues. Nouns and verbs are better. Only at the sentence level, the accuracy of reading comprehension is slightly impaired: nouns 80%, verbs 70% and sentences 50%. There are many phonetic errors in reading aloud: naming writing and descriptive writing are better, and sentence description is difficult to write. MRI showed "left temporal lobe encephalomalacia". Language diagnosis: conductive aphasia.

6. Named aphasia (Named Aphasia)

(1) Main clinical features

Naming disorder fluent aphasia, also known as nominalization aphasia and amnesia, is characterized by spontaneous difficulty in finding words and saying people's names. If there are mistakes, they often detour the language, but others, such as understanding, retelling and writing, are reserved. Named aphasia has a good prognosis.

(2) pathological changes

It is generally believed that the lesions are located in the angular gyrus and the posterior part of the middle temporal gyrus of the left cerebral hemisphere, but it is difficult to find a single lesion at present, and most of these aphasia are caused by scattered injuries.

(3) Examples of cases

Male, 36 years old, from Youli, with a university education, was admitted to a local hospital in June 2000 due to craniocerebral injury, and was transferred to the hospital for further rehabilitation three months later. After admission, the standard aphasia was checked in Chinese: fluency in spoken English, characterized by lack of substantive words, such as nouns. When the patient answered his profession, he said, "I want to sell everything that others can use." When the patient named the fruit, he said, "I don't know what to say now ... what's the name of that sand?" It slipped my mind. I can call it out by reading words ... they didn't give me anything I knew. As soon as I said it, they gave it to me and stuffed it in my mouth. I didn't want to eat it. They forced me to eat. "We don't even have this thing there." When talking about another picture (banana), we said: "This man and woman can eat it, and everyone can eat it as long as they like, but some people can't eat it, so they have to slip away." The correct rate of listening comprehension test: nouns 70%, verbs 60%, sentences 40%, and oral instructions 20%. When 80% of the sentences are named, only 20% are correct, and voice prompts can answer the correct actions. The correct reading rate is 100%: nouns and verbs are 60% and 70% respectively, and sentences are 0. The correct rate of reading comprehension is 70%, verbs and sentences are 70%, 60% and 40% respectively, writing is 0, copying is 40%, and dictation is 20%.

7. Complete aphasia (complete aphasia)

(1) Main clinical features

Complete aphasia belongs to non-fluent aphasia, which is a kind of aphasia in which listening, speaking, reading and writing are seriously damaged. The main performance is that there are few spontaneous words, only a few words or meaningless syllables are repeatedly named and repeated, and words are not understood, even if they can understand them. The biggest feature of this kind of patients is that they can speak a series of languages, such as taking a breath and singing some songs and lyrics. Complete aphasia is difficult to recover. It is difficult for patients to recover to the point where they can communicate with each other in words. At first, they were completely aphasia. With the progress of treatment and the passage of time, when the symptoms are relieved, they may have the characteristics of Broca and Wernicke aphasia. Some scholars call it mixed non-fluent aphasia. Some cases have a good understanding in the rehabilitation period, but the oral expression is seriously impaired, which is characterized by Broca aphasia and is a common transformation form of complete aphasia.

(2) pathological changes

Most scholars believe that the language area around the lateral fissure of the dominant hemisphere of the brain has been extensively damaged. Most of these patients are accompanied by right hemiplegia, hemianopia and hemiplegia.

(3) Examples of cases

Male, 62 years old, You Li, engineer, college degree199810125 October, he fell down when he got up and went to the toilet, then he found that his right upper and lower limbs were weak and he gradually could not speak. 654381October 27th, CT showed "low density lesion of left frontotemporal lobe". He was treated in a local hospital for 2 weeks, and his condition was stable. He was transferred to a hospital for aphasia examination and further recovered. "Man, man, man ……" is a serious obstacle to oral comprehension. Only individual words and simple gestures can be understood. Reading, reading, understanding and writing should not be neglected. Mouth shape and facial movements cannot be imitated in vowel order. There is an exploratory behavioral diagnosis: cerebral infarction complete aphasia, facial apraxia.

8. Mixed transcortical aphasia.

(1) Main clinical features

Also known as isolation of speech areas.

Mixed transcortical aphasia is the coexistence of transcortical motor aphasia and transcortical sensory aphasia. This kind of aphasia is not very common in oral expression, and it is impossible to form a language that can express meaning, or even it is just a rigid repetition, or it is limited to imitating all or part of what the examiner said. For example, when a doctor asks a patient "What's your name", the patient immediately answers "What's your name"; When asked "How many people are there in the family", the patient immediately answers "How many people are there", which is called echo or imitation. It is one of the characteristics of mixed transcortical aphasia. Some patients will also have the phenomenon of completion, that is, after hearing the other side say part of the commonly used sentence, they can complete the second half sentence. For example, if the examiner says "the mountains cover the day", the patient can say "the ocean drains the golden river" later, or even finish the rest, which seriously hinders oral understanding.

(2) pathological changes

It is generally believed that the lesion site is a large lesion in the watershed area of the dominant hemisphere, but Wernicke area in Broca area and the area connecting them are not damaged

(3) Examples of cases

Female, 6 1 year-old, You Li, retired worker, college education, was admitted to the hospital in 200 1 year for "inability to move her right limb 1 month, and her speech was unclear". The patient had chills during intravenous infusion due to dizziness in that year 10 month, and his body temperature was as high as 39℃. When his blood pressure dropped, he was transferred to a local superior hospital for treatment. At that time, he didn't respond. After 8 days of treatment, his consciousness became clear, but he could not speak. After half a month, he can say a few words, but he can't take the initiative to express it. The cough has eased. CT reexamination showed that "the parietal lobe and basal ganglia of the left frontotemporal lobe were low-density lesions". After further recovery after admission, the hearing test is the normal threshold. Examination of Chinese standard aphasia: spontaneous spoken language is not fluent, and there are echoes. If you ask "What's your name", the patient will answer "What's your name" and ask "How old are you this year", and the patient will answer "Age", which is incomplete. The correct answer rate is 20% for nouns and verbs, 70% for repeated nouns, and 10% for short sentences that can repeat 3-4 words.

9. Pure text deafness

(1) Main clinical features

Clinical manifestation is a serious obstacle to listening comprehension, and it can't be completed even by listening to word finger graphs. Patients often take the initiative to say that they can't understand what others say. If patients can write, they often take the initiative to ask for fluent written answers and express their ideas. There were no or occasional phonetic errors at the beginning of the disease. With the prolongation of the course of the disease, patients' mistakes increase obviously, which makes it difficult for the other party to distinguish its meaning and repeat serious obstacles. Often even words or monosyllables can't repeat the patient's spontaneous writing. Naming writing descriptions is normal, and you can even write diaries and articles. However, dictation disorder or inability to be completely deaf will lead to the separation of word sounds from social natural sounds. Patients don't know the meaning of words, but they can distinguish non-word sounds, such as thunder, running water, cat barking, clapping, baby crying, train whistle and so on. Even patients can distinguish the sound of "old-fashioned" steam locomotives. Most of the hearing is at the normal threshold, and some may be mild high-frequency hearing loss. Pure word deafness is rare in clinic, and it is still controversial whether its disorder belongs to aphasia or auditory aphasia. But at present, most people think that pure word deafness is not a real language barrier, but a problem of sensory transmission, which has defects in the ability to transmit verbal stimuli to the cortex to explain its meaning. The causes of pure word deafness are mostly cerebrovascular accident, brain tumor and brain injury, and cerebrovascular accident is unilateral temporal lobe injury.

(2) pathological changes

Located in unilateral temporal lobe or bilateral temporal lobe, almost all lesions in bilateral temporal lobe can cause pure word deafness. At present, it is considered that Wernicke's area is complete when unilateral or bilateral temporal lobe lesions cause pure word deafness. Unilateral temporal lobe injury is located in the deep part of the main temporal lobe, affecting the transverse temporal gyrus or fibers projecting to the primary auditory pathway, and bilateral temporal lobe lesions involve the middle part of bilateral superior temporal gyrus.

(3) Examples of cases

Male, 28 years old, Li Heren, was admitted to the hospital on June 3rd because of "language comprehension disorder and expression disorder 12", 1995. He was diagnosed as "encephalitis sequela". Physical examination: conscious, free expression, no abnormality in nervous system examination, normal limb function, V-level muscle strength and bilateral symmetry of muscle tension. Examination of standard aphasia in daily life: spontaneous speech is few and fluent. A large number of pronunciation errors seriously hinder listening comprehension. The correct rate of nouns is only 30%, and verbs and sentences are understood as 0. Reading aloud is relatively good, with an average correct rate of 70%~80%. The correct rate of common social environment sounds (including thunder, streams, running water, hens laying eggs, trains, birds singing and clapping, etc.). ) It is 80%. Pure tone hearing test and auditory evoked potential.

10. Subcortical aphasia

The types of aphasia mentioned above are closely related to the damage of cortical language center or conduction bundle interruption connecting cortical areas, and most of them are typical aphasia. In recent 30 years, with the development of clinical diagnostic techniques, such as the application of CT and CT-MRI to measure regional cerebral blood flow, it has been found that aphasia can also be caused by subcortical lesions alone, but the pathogenesis of aphasia is still controversial. Common aphasia types, such as basal ganglia aphasia and thalamic aphasia, are atypical compared with the above aphasia types, so some scholars call them atypical aphasia.

(1) Basal ganglion aphasia

① Main clinical features: The basal ganglia includes caudate nucleus of putamen and globus pallidus, which is anatomically close to the internal capsule, so it is often involved at the same time. Domestic aphasia research found that this kind of aphasia is the most common. Patients with basal ganglia aphasia in Peking University Affiliated Hospital account for 22% of all aphasia patients, and cases studied by China Rehabilitation Research Center account for 26%. The conversational speech of basal ganglia aphasia is between fluent aphasia and non-fluent aphasia, which is called intermediate type. Foreign data showed that the lesion was located in broca. When the focus is on the back, it is similar to wernicke's aphasia. The lesion is large, affecting the whole basal ganglia, and its clinical manifestations are similar to complete aphasia. Domestic research shows that when the lesion is in front, it is similar to non-fluent aphasia. When the lesion is in the back, it is similar to fluent aphasia. Generally speaking, it is better in retelling, but it may not be good in the early stage of the disease, especially when the injury area is large, but with the recovery of the disease, the retelling ability can be recovered quickly. Generally, short sentences can be repeated, but for longer sentences, nouns are better named and there are obvious obstacles in enumerating them. The description of scenes is difficult in oral comprehension. I have a good understanding of noun verbs and short sentences, but I have obvious obstacles to the understanding of longer sentences and the execution of oral instructions. In reading, most patients perform well in reading, but their reading comprehension ability is poor, which is similar to oral comprehension disorder. In writing, except for a few patients who can write names, most patients have outstanding obstacles in action description.

② Lesions: Mainly in the capsule area of basal ganglia.

(2) thalamic aphasia.

Thalamic aphasia is aphasia caused by thalamic lesions. Thalamic aphasia collected by the Language Department of China Rehabilitation Research Center 10 accounted for 4% of the total aphasia, including 3 cases of cerebral hemorrhage and 1 case of brain tumor 1 case.

① Main clinical features: Intermediate thalamic aphasia has smooth conversation, low tone and volume, and sometimes even sounds like a whisper, but the voice is still clear. Individual expressions are indifferent and do not take the initiative to speak. Generally, you can simply answer questions and describe your medical history. Some patients have normal or mild semantic spelling disorder, and most thalamic aphasia can repeat sentences with obvious naming disorder. In naming, there are serious semantic errors in naming words and enumerations. It is better to name nouns, verbs and short sentences with colors, but reading comprehension is better, but reading comprehension is relatively poor. Thalamic aphasia mostly has different degrees of word formation and grammatical structure obstacles, and the prognosis of thalamic aphasia is better. Most of them can recover within a few weeks, but they often leave different degrees of naming obstacles, but some data confirm that individual patients leave obvious language obstacles.

② focus: thalamus

1 1. Cross aphasia

Clinically, most aphasia is caused by left hemisphere injury, but there are some exceptions. Braimwell( 1899) introduced the term "cross aphasia" to describe the right hemiplegia and aphasia caused by the left hemisphere injury of left-handed brain. Or left hemiplegia and aphasia caused by right-handed people's right hemisphere injury. At present, cross aphasia is used to describe aphasia caused by right-handed people's right hemisphere damage. This kind of patient is rare, its incidence is less than 1%~2% of aphasia, and its etiology is different from typical aphasia and non-crossed aphasia. Boller( 1973) estimated that only 23% of the patients with crossed aphasia were caused by vascular diseases, and most of them were caused by tumors and craniocerebral trauma. This conclusion is obviously different from the traditional right-handed aphasia caused by left hemisphere damage, mainly because of vascular diseases. Cross aphasia is difficult to be classified according to the traditional aphasia, so it is also called atypical aphasia. In terms of symptoms, most patients have grammar and writing disorders, and listening comprehension and naming have a slight impact, but they also have an impact.

12. Acquired aphasia in children

Aphasia refers to aphasia after children have partially acquired or already acquired oral English. Foreign data show that the onset age is after 3 years old, but some people think that acquired aphasia in children after 1 year old is rare. In the Language Department of China Rehabilitation Research Center, the disease accounts for 4.7% of the total number of aphasia diagnosed and treated. Etiologically speaking, the main cause of adult aphasia is cerebrovascular disease. The main cause of acquired aphasia in children is brain trauma in language performance, which is rare in adult patients. After the silence disappears, it is characterized by slow speech, few words, weak voice and abnormal rhythm. In addition, almost all aphasia children are not fluent in oral expression, which is obviously different from adult aphasia. Adult frontal lobe injury is characterized by non-fluent aphasia, while temporal lobe injury is characterized by fluent aphasia and disorder.