Patient with repetitive speech

1. AN INTERESTING OF
IRRELEVANT SPEECH
Dr.ARUL SELVAN Unit
Presenter: Dr.M.RAMESH BABU

2. Brief History
• Mr. X 72 yrs old gentleman, businessman,
Hypertensive, smoker presented with chief ℅
• Sudden onset of repetitive speech
• Irrelevent talk
• Restlessness -
30minutes.

3. • HOPI: Pt. was apparently normal before at 5
pm he went to wash room, came out and told
that he is not feeling well and lyed on the bed.
• from 5:40pm he started keep on repeating
kids..kids…kids.. (they went to school not at
reached home)
• family members try to talk to him but they came
to know that he is not in a communicative
state.

4. • Immediately brought to ER at 6:15pm.
• No h/o headache / LOC/nausea/vomiting/ limb
weakness/deviation angle of mouth/ vision
disturbance/ TIA in the past.
• no h/o fever/ night sweat/ loss of appetite/ loss of
weight loss.
• no h/o hallucinations / abnormal behaviour before
/ no psychiatric illness
• H/o Hypertensive on Rx T.Concor 2.5mg OD , Not
a Diabetic, CAD
• H/o retinal detachment - 10yrs back.

5. • no travel history
• no other drug usage (ayurvedic or
homeopathic)
• no toxin exposure
• no h/o any recent vaccination

6. History Summary
• 72yrs old gentleman, businessman,
hypertensive, smoker came with ℅ sudden
onset of Sudden onset of repetitive speech,
irrelevant talk and restlessness
- 30minutes without dysarthria, headache,
fever, nausea, vomiting, visual disturbance,
limb weakness, imbalance while walking.
• Probable diagnosis: Wernickes’s aphasia
• encephalitis /
encephalopathy

7. On Clinical Examination
• No pallor/cyanosis/clubbing/pedal
oedema/lymphadenopathy/thyroid swelling
• Vitals - PR-78/min, B.P - 190/100mm of hg
• CNS Examination:
• Pt. is conscious, irritable, agitated

8. Speech
• Speech:
• Spontaneous speech - Fluency is good (
Repetitive talks, neologism +)
• Repetition - impaired,
• Comprehension - impaired
• Naming - impaired
• Reading & writing - not cooperative.

9. • Pupils- B/L 3mm Reactive, fundus- normal.
• EOM- Full,No ptosis,
• No facial lag
• Other Cranial nerves examination - normal
• Motor system: tone -normal, power 5/5 all 4 limbs,
DTR’S - 2+, plantar - flexors
• Sensory - Not able to check
• no cerebellar signs
• no meningeal signs / no neckstiffness
• other systemic examination - normal.

10. • CT brain - Normal and angiography -
thrombosis of Lt. parietal branches of M2.

11. • Patient was within the window period -
Thrombolysed immediately within 40 minutes
with IV Tenectaplase dosage of 25mg (double
dose) and started on antiplatelets and statins
after 24 hours of thrombolysis.
• Patient status - Post Thrombolysis - Not much
beneficial.

12. MRI

13. MRI & MRA

16. Investigations• Hb% - 14.3gm%
• PCV- 43%
• WBC- 7810 cells
• Platelets - 2.3lakhs
• Blood glucose - 109 mg/dl
• B.urea - 33mg/dl
• S.Cretinine - 1.05 mg/dl
• S. Na - 139 , K+ - 3.8 , LFT - normal
• PT - 12/12, INR - 1.0, PTT - 30 /27
• ECG - RSR, ECHO Heart - Normal LV fun. EF- 65%, no
RWMA

17. Final diagnosis
• Acute ischemic infarct - MCA territory - inferior
divison or its branches
• Wernickes’ apahsia

18. • Which may be beneficial Tenectapalse vs
alteplase ?
• Low dose vs high dose Tenectaplase ?

24. Approach to a case of Speech
disorder
• Aphasia- is true language disturbance in which
patient demonstrates an impaired production or
comprehension of spoken language.
• Dysarthria- a specific disorder of articulation in
which basic language intact.
• Alexia – is loss of reading ability
• Agraphia- loss of writing ability.
• Dysprosody- is an interruption of speech melody.

25. Neuroanatomy
• Auditory cortex-reception of spoken language.
• Wernicke’s - area-decoding of sounds into
linguistic information.
• Brocas area- spontaneous speech and repetition
• SMG-phoneme processing in comprehensionand
phoneme production for repetition and speech
• AG-processing of visual language into
auditory language information

26. • Arcuate fasciculus- connects sensory and
motor language areas.
• Role of subcortical structures :
• Thalamus - a relay station for RAS, appears to
alert the language system
• Basal ganglia-involved in expressive speech

27. Evaluation
• Spontaneous speech
• Comprehension
• Repetition
• Naming
• Reading
• Writing

29. Approach

38. THANK YOU