Improved language in a chronic nonfluent aphasia patient after treatment with CPAP and TMS

Abstract

Objective: To present pretreatment and post-treatment language data for a nonfluent aphasia patient who received 2 treatment modalities: (1) continuous positive airway pressure (CPAP) for his sleep apnea, starting 1-year poststroke; and (2) repetitive transcranial magnetic brain stimulation (TMS), starting 2 years poststroke.

Background: Language data were acquired beyond the spontaneous recovery period of 3 to 6 months poststroke onset. CPAP restores adequate oxygen flow throughout all stages of sleep, and may improve cognition. A series of slow, 1 Hz repetitive TMS treatments to suppress a posterior portion of right pars triangularis has been shown to improve phrase length and naming in chronic nonfluent aphasia.

Method: The Boston Diagnostic Aphasia Examination and Boston Naming Test were administered pre-CPAP, and after 2 to 5 months of CPAP. These same tests were administered pre-TMS, and at 3 and 6 months post-TMS, and again 2.4 years later.

Results: Post-CPAP testing showed increased Phrase Length, Auditory Comprehension, and naming Animals and Tools/Implements (Boston Diagnostic Aphasia Examination). Testing at 3 and 6 months post-TMS showed significant increase in Phrase Length, Auditory Comprehension, and Boston Naming Test compared with pre-TMS. These gains were retained at 2.4 years post-TMS. CPAP use continued throughout.

Conclusions: Physiologic treatment interventions may promote language recovery in chronic aphasia.

Figures

Figure 1

a) Structural MRI scan (3-dimensional magnetization prepared rapid gradient echo) obtained at 1 year poststroke. Large cortical lesion was present in the left temporal lobe, including anterior portions of superior and middle temporal gyrus, with posterior extension across most of the middle temporal gyrus (BA 21). Only small lesion was present in the more anterior portion of Wernicke's area. Small cortical lesion was present in only the most inferior portions of Broca's area. The lesion was primarily subcortical, with lesion in the two, deep white matter areas near ventricle, associated with persistent nonfluent speech: 1) medial subcallosal fasciculus area, deep to Broca's area and adjacent to frontal horn (vertical white arrows); and 2) periventricular white matter area adjacent to body of lateral ventricle, deep to sensori-motor mouth area (horizontal white arrow). b) Diagrams showing location, and some pathways within each of these two white matter areas adjacent to ventricle: 1) medial subcallosal fasciculus area adjacent to frontal horn, showing pathways from SMA and anterior cingulate gyrus to head of caudate (horizontal black arrow); and 2) periventricular white matter (PVWM) adjacent to body of lateral ventricle (vertical black arrow). See also text, where additional pathways are listed.

Figure 2

Location of the five frontal ROIs that were each suppressed with 1 Hz rTMS for 10 min during Phase 1 TMS, to determine the best-response ROI. These five ROIs included R M1, mouth (orbicularis oris muscle, as verified with MEP), and four subregions within R Broca's area as defined in the text, using sulcal boundaries (arrows). The gyral location for each ROI that was suppressed with rTMS is marked in color, see legend box. The legend box also shows the number of Snodgrass & Vanderwart (S&V) pictures (Max.=20) named immediately after rTMS suppression of each ROI. The PTr posterior ROI (green symbol), was the best-response ROI - e.g., the area associated with a naming score that reached at least 2 SD above baseline S&V naming ability (e.g., 15). Note that the number of pictures named correctly immediately post-rTMS decreased for any given ROI as the distance from the best-response ROI increased by 1 or 2 cm, in a rostral or caudal direction. The PTr posterior ROI (green symbol) was used as the target for suppression with 1 Hz rTMS for ten, 20-min treatments during Phase 2 TMS. PTr, pars triangularis; POp, pars opercularis.

Figure 3

a) Bar graph showing the percent change from baseline, for S&V pictures named correctly following 10 min of rTMS to suppress each of the five RH ROIs during Phase 1 TMS. b) Bar graph showing the percent change from baseline, for RT to name the pictures, for each of the five RH ROIs. Note, the PTr posterior ROI was associated with the greatest improvement in number of pictures named, on two occasions.