Aphasia didactic material. Examination of persons with aphasia. Motor speech research

- a disorder of previously formed speech activity, in which the ability to use one's own speech and / or understand addressed speech is partially or completely lost. Manifestations of aphasia depend on the form of speech impairment; specific speech symptoms of aphasia are speech emboli, paraphasia, perseveration, contamination, logorrhea, alexia, agraphia, acalculia, etc. Patients with aphasia need to be examined for neurological status, mental processes, and speech function. With aphasia, the underlying disease is treated and special rehabilitation training is carried out.

General information

Aphasia is the disintegration, loss of already existing speech, caused by a local organic lesion of the speech areas of the brain. Unlike alalia, in which speech is not formed initially, with aphasia, the possibility of verbal communication is lost after the speech function has already been formed (in children older than 3 years or in adults). Patients with aphasia have a systemic speech disorder, that is, expressive speech (sound pronunciation, vocabulary, grammar), impressive speech (perception and understanding), inner speech, written speech (reading and writing) suffer to one degree or another. In addition to the speech function, the sensory, motor, personal sphere, and mental processes also suffer, so aphasia is one of the most complex disorders studied by neurology, speech therapy and medical psychology.

Causes of aphasia

Aphasia is a consequence of an organic lesion of the cortex of the speech centers of the brain. The action of factors leading to the occurrence of aphasia occurs during the period of speech already formed in the individual. The etiology of aphasic disorder affects its nature, course and prognosis.

Among the causes of aphasia, the greatest specific gravity occupied by vascular diseases of the brain - hemorrhagic and ischemic strokes. At the same time, in patients who have had a hemorrhagic stroke, a total or mixed aphasic syndrome is more often noted; in patients with ischemic disorders of cerebral circulation - total, motor or sensory aphasia.

In addition, traumatic brain injury, inflammatory diseases of the brain (encephalitis, leukoencephalitis, abscess), brain tumors, chronic progressive diseases of the central nervous system (focal variants of Alzheimer's disease and Pick's disease), brain surgery can lead to aphasia.

Risk factors that increase the likelihood of aphasia include elderly age, family history, cerebral atherosclerosis, hypertension, rheumatic heart disease, transient ischemic attacks, head trauma.

The severity of the aphasia syndrome depends on the location and extent of the lesion, the etiology of speech impairment, compensatory capabilities, the patient's age and premorbid background. So, with brain tumors, aphasic disorders increase gradually, and with TBI and stroke, they develop abruptly. Intracerebral hemorrhage is accompanied by more severe speech disorders than thrombosis or atherosclerosis. Speech recovery in young patients with traumatic aphasia is faster and more complete due to greater compensatory potential, etc.

Aphasia classification

Attempts to systematize the forms of aphasia on the basis of anatomical, linguistic, psychological criteria have been repeatedly undertaken by various researchers. However, the classification of aphasia according to A.R. Luria, taking into account the localization of the lesion in dominant hemisphere- on the one hand, and the nature of the resulting speech disorders - on the other. In accordance with this classification, motor (efferent and afferent), acoustic-gnostic, acoustic-mnestic, amnestic-semantic and dynamic aphasia are distinguished.

Aphasia Correction

Corrective action in aphasia consists of medical and speech therapy directions. Treatment of the underlying disease that caused aphasia is carried out under the supervision of a neurologist or neurosurgeon; includes drug therapy, if necessary - surgical intervention, active rehabilitation (exercise therapy, mechanotherapy, physiotherapy, massage).

The restoration of speech function is carried out in speech therapy classes for the correction of aphasia, the structure and content of which depends on the form of the disorder and the stage of rehabilitation training. In all forms of aphasia, it is important to develop in the patient an attitude to restore speech, to develop intact peripheral analyzers, to work on all aspects of speech: expressive, impressive, reading, writing.

With efferent motor aphasia main task speech therapy classes there is a restoration of the dynamic scheme of pronunciation of words; with afferent motor aphasia - differentiation of kinesthetic signs of phonemes. With acoustic-gnostic aphasia, it is necessary to work on the restoration of phonemic hearing and understanding of speech; with acoustic-mnestic - over overcoming defects in auditory and visual memory. The organization of training in amnestic-semantic aphasia is aimed at overcoming impressive agrammatism; with dynamic aphasia - to overcome defects in internal programming and planning of speech, stimulation of speech activity.

Corrective work with aphasia should begin from the first days or weeks after stroke or injury as soon as the doctor decides. The early start of restorative education helps to prevent the fixation of pathological speech symptoms (speech embolus, paraphasia, agrammatism). Speech therapy work to restore speech in aphasia lasts 2-3 years.

Forecast and prevention of aphasia

Speech therapy work to overcome aphasia is very long and laborious, requiring the cooperation of a speech therapist, the attending physician, the patient and his relatives. Restoration of speech in aphasia proceeds the more successfully, the earlier it is started. corrective work. The prognosis for the recovery of speech function in aphasia is determined by the location and size of the affected area, the degree of speech disorders, the start date of rehabilitation training, the age and general health of the patient. The best dynamics is observed in young patients. At the same time, acoustic-gnostic aphasia, which occurs at the age of 5-7 years, can lead to a complete loss of speech or a subsequent gross violation of speech. speech development(ONR). Spontaneous recovery from motor aphasia is sometimes accompanied by the onset of stuttering.

Prevention of aphasia consists, first of all, in the prevention of cerebral vascular accidents and TBI, in the timely detection of tumor lesions of the brain.

A comprehensive (medical-psychological-pedagogical) examination is required with the identification of the main broken link. A feature of aphasics is that a thorough examination can be carried out in parallel with speech therapy work(this is Oppel's opinion).

In the process of rehabilitation training, a dynamic examination is required (during the entire treatment). When working, the content of the examination takes into account the time and character of the influencing cause, the dynamics of changes in speech and general behavior from the moment of the disease, the level of human development (literacy, education, profession - the patient's premorbid level). Activity in an effort to restore speech. The examination is conducted in-but, the duration of a one-time examination depends on the state of health, from 15 minutes. up to 1 hour.

Survey objectives describe big picture emerging changes in mental activity, identify the main defect, determine the secondary symptoms of the disorder, describe the af syndrome. characteristic of this patient.

In the survey scheme, several blocks can be distinguished.

1. Preliminary conversation, the conversation solves a two-sided problem: a) highlighting the state of consciousness of the patient (how adequately to relate to the disease, whether he remembers himself); b) to reveal the range of pathological phenomena in speech.

2. Study of motor function:

a) motor function of the hand (reveal changes in strength, accuracy, violations of tone, the presence of hyperkinesis)

Tests for the kinesthetic organization of movements (show: index - thumb, index - middle, first on one hand, then on the other)

Counting fingers one by one

Head's test (show the right eye with the left hand, the left ear with the left hand)

b). oral praxis (articulatory gymnastics) - a smile, a tube, a shoulder blade, hold the tongue behind the lower lip, behind the upper one (movements are suggested according to the model). According to the speech instruction (show how they click, how they whistle).

c) study of speech regulation of a motor act. Tasks for graphic activity (draw, draw). The complexity of the task is determined by the condition of the patient.

3. study of auditory-motor coordination.

A) tests for the perception of musical melodies and sound-pitch relationships (it is suggested to model what you hear with your hand)

B) study of perception and reproduction of rhythmic structure (tap, slap)

4. study of visual perception of objects and images.

A) subject gnosis (recognition of objects)

B) subject gnosis in complicated situations (contour image, overlay of silhouette images, Raven matrix technique - find the missing part)

5. study of orientation in space.

using the task laying out figures from sticks, drawing figures, trying out correctly or incorrectly superimposed numbers or letters.

6. The study of impressive speech.

a) phonemic hearing (repeat in isolation the sound, a series of sounds, write down the whole series of sounds, lay out the heard series of sounds from the split alphabet)

b) a study of word comprehension (show the named object, show objects - pictures that are laid out in front of the patient on the table). A complex test is used: the patient is called 2-4 words, he must show the objects in the same order. Find the named picture among 3-7 images. Define the concepts: barb - caterpillar.

B) understanding simple sentences(find the picture for the corresponding this proposal). Follow the instruction three actions in one sentence (take a book, put it on the windowsill, give me a plate)

D) study of understanding of logical-grammatical structures (show a pencil with a pen, a pencil with a pen). Understanding comparative constructions (Petya is higher than Misha, who is lower). Determining a logically correct construction (fly more elephant or an elephant bigger than a fly - When I said it right). Logical-grammatical constructions (Olya is lighter than Katya, but darker than Sonya, who is the lightest)

7. study of expressive speech.

A) the study of sound pronunciation (using the repetition of sounds)

B) the study of reflected speech (repetition of words, sentences)

C) the study of the nominative function of speech (naming an object according to its description, naming generalizing concepts, highlighting an extra word from a number of named ones: pond, river, lake)

D) the study of narrative speech (description of the picture, retelling of the text, story on a given topic, tests using the situation writing: fill in the missing part of the sentence - I went to ... ... to buy bread)

8. Study of writing and reading

A) research sound analysis and synthesis of words (determine the number of sounds in a word, determine the sequence of sounds in a word)

B) study of writing: cheating, dictation

C) reading research: reading syllables, words, phrases and the whole text.

To conduct an examination, it is important to understand that all tasks must be offered very carefully, in a confidential conversation, and not in the form of a test, it is important for the patient to fix attention on positive aspects and end each examination situation on a positive note.

Aphasia was dealt with by: Tsvetkova, Luria, Oppel. The classification of aphasia was distinguished by Luria.

Sections: speech therapy

Introduction

Behind last years Intensive work is being carried out in the healthcare system to improve speech therapy assistance to adults suffering from various speech disorders. Special attention focuses on the problems of restoring speech in patients with cerebral infarction (stroke), craniocerebral trauma and other disorders of higher mental functions (HMF). Speech therapists of city polyclinics work in close contact with the Center for Speech Pathology and Neurorehabilitation (TsPRiN), the Institute of Defectology and Medical Psychology, constantly improve their professional level by attending regular conferences and seminars in scientific centers; participate in the analysis of patients on the basis of the methodological department of the TsPRiN. Correction - pedagogical work with aphasia - one of the components of speech therapy work to overcome speech disorders. It is based on the work of leading experts in Russian neuropsychology - A.R. Luria, E.S. Bein, E.D. Khomskoy, L.S. Tsvetkova, V.M. Shklovsky and their students. A.R. Luria - based on the study of the higher cortical functions of a person, developed a classification of aphasias, which allows, when identifying a primary disturbed neuropsychological prerequisite, to qualify the form of aphasia and their compatibility in various diseases of the brain. Using the developed A.R. Luria of the methodology for studying impaired speech functions, as well as a number of other methods built on its basis, in particular, in the method of V.M. Shklovsky and T.G. Wiesel (1995), allows not only to determine the form of aphasia in a patient, but also to draw up a program of restorative education, as well as to choose methods and techniques for restoring speech, writing, reading and counting.

The return of the lost speech function to the patient is, in principle, possible due to the ability of the brain to compensate. In the process of restoring disturbed functions, both direct and bypass compensatory mechanisms are involved, which leads to the presence of two main types of directional effects. The first is associated with the use of direct disinhibitory methods of work. They are mainly used in the initial stage of the disease and are designed to use reserve intrafunctional capabilities. The second type of targeted overcoming of HMF disorders implies compensation based on the restructuring of the method of implementing the impaired function. For this, various functional relationships are involved. Those of them that were not leading before the disease become so on purpose. This “bypass” of the function is needed to attract spare reserves. Direct teaching methods are designed for involuntary emergence of premorbidly strengthened skills in the memory of patients. Bypass methods involve arbitrary mastering of the way of perceiving speech and one's own speaking. This is due to the fact that bypass methods require the patient to implement the affected function in a new way, which differs from the usual one established in premorbid speech practice. The restoration of a number of speech functions requires the connection of non-speech supports. Therefore, the sequence of work on speech and non-speech functions is decided in each specific case, depending on the combination of verbal and non-verbal components of the syndrome.

The didactic material presented as a manual for examination and further correction of speech in patients with cerebral infarction in the initial period. The creation of this manual is caused by practical necessity, because. many patients turn to a speech therapist after an illness, experiencing difficulties in communication, as well as after hospitals where there was no specialist (speech therapist) who gave them the first instructions on speech and social rehabilitation. Such patients need emotional and psychological correction, adapting them to the world around them. The manual also demonstrates the stimulating effect of non-verbal activity on speech function, creates conditions for listening to the speech of a speech therapist; reduces the inactivity of the patient; increases concentration; promotes the development of skills of self-control and control of the ability to purposeful activity. At an early stage of rehabilitation, it is very important for a speech therapist to educate the patient and his family members with a mindset for restoring everyday speech. The constant conduct of psychotherapeutic conversations, encouraging the patient, allow not only to bring him to social adaptation, not, often, and return to work or school.

This guide consists of bound friend with other sections, which allow to reveal as much as possible the speech capabilities of the patient, preserved after the illness, and use them for further rehabilitation. Work with the patient begins with the identification of violations of subject gnosis with the help of subject pictures:

a) analysis of the visual image (real objects and their images);
b) sketching subject images, drawing them from memory;
c) automation of words - the names of the subject by their "semantic playing" in different contexts;
d) recognizing an object by its verbal description- Reception of "mystery".

Identification of violations of facial gnosis:
a) finding out the degree of familiarity of faces famous people shown in the pictures;
b) "revival" of the visual image of a person on the basis of verbal, cultural and other associations associated with him;
c) discussion of faces involving the concepts of “kind - evil, open - gloomy, smart - stupid”, etc.;
d) comparison of faces, identification of similarities and differences.

Identification of disturbed color gnosis:
a) semantic “playing out” of the concept of a particular color, their shades;
b) finding a given color in a series of multi-colored geometric shapes.

Identification of disorders of opto-spatial apractoagnosia according to the dominant type. Restoration of higher generalized levels of spatial-orientational activity.

Clock work:

a) “revival” of the role of numbers, arrows, divisions into minutes;
b) the arrangement of the hands on the clock according to the given time;
c) independent designation of a given time on a clock without hands.

Identification of spatial situations in which various objects participate. Correlation of real spatial situations with their schematic representation.

Overcoming frustrations in constructive activity:
a) "revitalization" of the concepts of shape and size;
b) identification of various objects and geometric shapes that are not the same in size;
c) drawing objects and geometric shapes from memory;
d) independent drawing of given objects and figures.

Identification of violations of the body schema, overcoming violations of the body schema:
a) showing parts of the body in the picture, on yourself;
b) sketching, independent drawing of people and animals.

Identification of elements of affectively colored speech automatisms. Stimulation of understanding of situational and everyday speech (showing objects, answering questions in a situational dialogue).

release pronunciation side speeches:
a) conjugated, reflected and independent pronunciation of automated speech series;
b) singing songs with words;
c) reciting poetry.

Identification of a disorder of phonemic hearing. Stimulation of understanding of everyday passive vocabulary:
a) showing real objects, pictures depicting objects and actions by their names.

Preparation for the restoration of written speech:
a) selection of a given letter or syllable from the presented series by their name.

Reading State Study:
a) recognition and display of given words;
b) finding captions for pictures;
c) reading the sentence with the selection of pictures for it.

Intelligence research. Category Thinking:
a) display of objects, classification by topic (furniture, clothing, dishes, food);
b) "fourth extra" - the exclusion of the fourth "extra" subject.

Analytical-synthetic thinking:
a) understanding the meaning of plot pictures and stories.

Account research:
a) display of numbers having a different bit structure;
b) solving arithmetic examples;
c) determination of the arithmetic sign in the given examples.

This manual is intended for a wide range of specialists involved in the restoration of speech and other HMF in patients with cerebral infarction in the initial period.

The neuropsychological symptom complex depends on the location of the lesion of the head. The location of lesions in the cerebral cortex determines one form or another of aphasia

Scheme of examination of a patient with aphasia (according to Luria A.R.)

1. Study of the general ability of the patient to verbal communication- a conversation to clarify:

a) the completeness of the patient's own speech;

b) understanding of situational, everyday speech;

c) the degree of speech activity;

d) the tempo of speech, its general rhythmic and melodic characteristics, the degree of intelligibility (attention is also drawn to the presence or absence of a nasal tone of speech).

2 .Study of speech comprehension.

3. The study of automatic speech:

a) forward count to 10 and reverse (from 10 to 0);

b) listing the days of the week, months;

c) the end of proverbs and phrases with a “hard” context such as: “I wash my hands with cold ...”, with a “free”, such as: “They brought me a new one ...”, etc .;

d) singing songs with words.

4. The study of repeated speech.

5. Naming function research:

a) real objects and their pictorial images;

b) actions (answers to questions - “what to do?”, “What are they doing?”) - according to plot pictures;

c) flowers;

d) fingers; e) letters;

6. Special studies of the features of phrasal speech:

a) compiling phrases with prepositions and without prepositions according to plot pictures;

b) construction of phrases from given words;

c) filling in gaps in phrases, for example:

"A jet is flying high in the sky..."; "I always wash my face with cold..."; "They brought to the store ..."; "I always look forward to..."

d) a story based on a plot picture.

7. The study of phonemic hearing.

8. The study of auditory memory. It is suggested to repeat:

a) a series of sounds, for example "asu" or "bsh a";

b) a series of words: "house - forest - cat", "house - forest - cat - night";

c) short and long complex phrases.

9. Study of the meaning of words:

a) an explanation of the direct meanings of individual words, for example, answers to the question: “what are glasses, what are they for? "What is joy? ”, what is the difference between the words: “deception” and “mistake”;

b) an explanation of the figurative meanings of words and phrases, for example, answers to the question, what is a “golden field”, “ iron hand!”, how to understand the proverb “What you sow, you will reap!” etc.

10. Study of reading and writing:

a) reading and writing under the dictation of individual letters, syllables, words, phrases, as well as short texts;

b) independent writing of words and phrases from pictures;

c) sound-letter analysis of the composition of a word, i.e., determining the number of letters in a word; enumeration of these letters; folding words from the letters of the split alphabet.

11. Study of oral and spatial praxis. Tasks are given:

a) stick out the tongue, raise it up, lay it behind the cheek, blow, click the tongue, stretch, stretch the lips, etc. (they also pay attention to the range of movements of the tongue and lips, which may be limited due to the presence of paresis, and not due to apraxic difficulties).

b) blow twice and click your tongue twice, alternating these movements several times in a row;

c) repetition of spatial postures of fingers and series of movements (for example: fist, palm, rib).

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Aphasia

Aphasia (aphasia, from the Greek phasis - speech, and - denial) is a speech disorder caused by damage to those parts of the cerebral cortex where the functions of the second signaling system are localized, or the ways in which the cortex is connected with the first signaling system. Within the limits of the latter there is an analysis and synthesis of stimuli entering the body through the sense organs from the external and internal environment. The second signaling system analyzes and synthesizes speech, i.e. words, which, according to I.P. Pavlov, are “signals of signals”.
The concept of aphasia includes: sensory aphasia, motor aphasia, alexia, agraphia, amnestic aphasia.
In the case of speech disorders, one cannot speak of any narrow localization of the lesion in the cortex, but nevertheless, clinical and anatomical parallels indicate the existence of zones within the cortex of the left hemisphere (in right-handed people), the defeat of which leads to the development of predominantly one or another type of speech disorder - sensory aphasia, motor aphasia, etc. Aphasia
most often observed in patients with cerebral circulation disorders or brain tumors.

Sensory aphasia

Sensory aphasia - impaired understanding oral speech- usually combined with a reading disorder, i.e. alexia.
In rare cases, the ability to read is preserved. Sensory aphasia cannot be classified as speech defects caused by deafness due to damage to the sound-conducting and sound-perceiving apparatus (otitis or neuritis of the ear canals).
Sensory aphasia occurs when the left temporal region is damaged (in right-handers) in the area of ​​the cortical branches of the middle cerebral and prop and (a. cerebri media), parietal or posterior temporal artery (a. parietalis, a. temporalis posterior). Anatomically, lesions are more often observed in the posterior sections of the superior temporal gyrus (field 22).
In table. 16 shows methods for studying oral speech in a sensory aphasic. The tests are given in order of increasing difficulty.
If a patient has motor aphasia in addition to sensory aphasia (see below), it is necessary to choose such tests, in which the researcher could be satisfied with the patient's short answer (yes, no) or just a nod of the head.
In cases where the patient has apraxia (impaired functioning; see below), tests that do not require any action from him (manipulation of the hands, etc.), but only a verbal response, are suitable.
The degree of impaired understanding of oral speech can be different. In severe cases, the patient does not understand a single word and treats speech as noise, devoid of any meaning and meaning (total aphasia). In cases of moderate severity, the patient can understand individual words, simple phrases most commonly used since childhood (partial sensory aphasia). In mild cases, difficulties arise only in understanding complex phrases, proverbs, stories, anecdotes (mild sensory aphasia).
At the same time, sensory aphasic is excessively verbose (speech incontinence or logorrhoea). Due to the loss of control over speech (the patient does not fully or partially understand what he is saying), speech becomes defective. First of all, violations in the structure of the word are noted - the replacement or rearrangement of letters in it (literal paraphasia) or, more often, the replacement of words by them according to auditory, and not semantic similarity (verbal). A sensory aphasic often gets stuck on any one word and inserts it completely meaninglessly into subsequent phrases (perseveration). In other cases, sentence structure (agrammatism) may suffer.
Table 16
Sensory aphasia research

All these violations make speech incomprehensible to others, the patient speaks a lot, but it is difficult to understand him, and sometimes impossible (“salad” of words).

motor aphasia

Motor aphasia - a violation of oral speech - is usually combined with a writing disorder - agraphia. In rare cases, the letter may be unaltered. It is necessary to distinguish from motor aphasia violations of oral speech that are associated with defects in the executive speech apparatus (aphonia and dysphonia with paralysis or paresis of the vocal cords, soft palate; anarthria or dysarthria with paralysis or paresis of the muscles of the tongue, lips; scanned speech with lesions of the cerebellum). In a motor aphasic, the executive speech apparatus is not damaged, but the patient “does not know how to say it,” since he has disintegrated the complex speech motor conditioned reflexes necessary to pronounce a letter, syllable, word, and, finally, a phrase.
Motor aphasia occurs when the left frontal region (in right-handers) is damaged in the area of ​​​​the anterior cortical branches of the middle cerebral artery - a. precentralis, vascularizing the inferior frontal gyrus, central operculum, fence, insula, lenticular body. Anatomically, lesions are often found in the gyrus 1>roca-opercular part of the inferior frontal gyrus (fields 44 and 45).
In table. 17 shows methods for studying oral speech in a motor aphasic. The tests are given in order of increasing difficulty.
The degree of impairment of oral speech may be different. In severe cases, speech is generally impossible (total motor aphasia) or is limited to a few familiar words or interjections. In cases of moderate severity, patients have a small margin of the most simple words(mom, dad, give, etc.). In mild cases, speech is preserved, but the patient's unwillingness to speak, the poverty of vocabulary are characteristic. During a conversation, the patient often has difficulty in choosing the right word. Sometimes paraphasia is noted - literal (replacement or rearrangement of letters in a word), less often - verbal (replacement of glop in a sentence), as well as perseveration (getting stuck on a word) and agrammatism. Repetition and ordinary speech are usually less disturbed than spontaneous speech.

Amnestic aphasia

Amnestic aphasia (aphasia amnestica, from the Greek mnesis - memory, a - denial) is a violation of the naming of familiar objects, animals, surrounding things.
Amnestic aphasia is sometimes combined with sensory aphasia, but can often exist as an independent disorder. Anatomically, in patients with amnestic aphasia, lesions are found at the junction of the temporal, parietal and occipital regions on the left (in right-handed people), in the zone of branching of the cortical branches of the middle cerebral artery (posterior temporal artery - a. temporalis posterior) and the cortical branches of the posterior cerebral artery (its posterior external branch, a. cerebri posterior, field 37).
To study amnestic aphasia, the doctor shows
the patient has a number of familiar objects (pencil, pen, watch, glass, etc.) and asks them to name them. The patient often seeks to name the object descriptively (instead of the word "pencil" - this is how to write, instead of the word "glass" - this is what you can drink from). The hint of the first syllable often helps him to name the correct word in full.

Motor speech research

Alexia

Alexia is various forms violations of reading and reading comprehension (alexia, from the Greek lexis - reading, a-negation). Alexia is more often combined with sensory aphasia. In more rare cases, it can be observed as an isolated symptom of speech disorders. These cases of "pure" alexia occur when the parietal region is damaged in the left hemisphere (in right-handers) in the zone of branching of the cortical branches of the middle cerebral artery (mainly the angular artery - a. angularis and the posterior temporal artery - a. temporalis posterior). Anatomically, lesions are found in the posterior sections of the lower parietal lobe (angular gyrus, field 39). Alexia cannot be attributed to impaired reading function due to decreased vision or loss of visual fields (hemianopsia, scotoma).
The degree of reading disorder may vary. In severe cases, the patient cannot read (either aloud or to himself) or a complete or partial misunderstanding of what is read is revealed. In mild cases, defects are detected when reading aloud - literal or verbal paralexia, as well as more or less significant misunderstanding of what is read (Table 18).
Table 18
Study of reading function

Agraphia

Disorder of writing and understanding of what is written - agraphia (agraphia, from the Greek graphis - writing, a - denial) - is more often combined with motor aphasia. In rare cases, agraphia can be observed as an isolated symptom of speech disorders.
Cases of "pure" agraphia are observed with damage to the frontal region in the left hemisphere (in right-handed people) in the area of ​​the cortical branches of the middle cerebral artery (mainly the precentral artery - a. precentralis).
The degree of writing impairment may vary. In severe cases, the patient cannot write at all. In the lighter ones, he can write, but some defects are revealed: omissions or rearrangements of letters - a literal paragraph, omissions or replacement of some words with others - a verbal paragraph, as well as a more or less pronounced misunderstanding of the meaning of a word or sentence written by the patient himself (Table 19 ).
Table 19
Study of the function of writing

Apraxia

Apraxia (apraxia, from the Greek praxis - action, and - denial) is a violation of the purposefulness of movements or, as they say, “action”, which is not associated with paralysis or paresis, ataxia, hyperkinesis, sensory aphasia. There are ideational, motor and constructive apraxia.
Ideator apraxia - apraxia of "intention" - is characterized by a violation of the sequence of movements necessary to complete the task. Patients often make movements that are not necessary to achieve the goal. If movement on an oral or written task fails to the full extent, then a hint, showing how to perform one or another action, as a rule, helps the patient well. Ideatory apraxia is always bilateral (i.e., it concerns both the right and left hands).
Motor apraxia - apraxia of "execution". With motor apraxia, acting on orders and on imitation is upset. Prompt action (show) the patient does not help or helps little. In contrast to ideational apraxia, motor apraxia can be unilateral (i.e., disturbances can be observed in the activity of one hand).
Constructive apraxia consists in the impossibility of constructing a whole from a part, a figure of matches, sticks, cubes.
In cases of apraxia right hand they find lesions mainly in the zone of cortical branches of the left (in right-handers) middle cerebral artery (anterior and posterior parietal arteries - aa. parietalis anterior et posterior), and with apraxia of the left hand - in the zone of branches of the anterior cerebral artery, vascularizing the corpus callosum, (artery corpus callosum - a. corpus callosi).
Table 20
Study of praxis function

Anatomically, in patients with ideational apraxia, against the background of signs of diffuse damage to the cerebral cortex, small foci are usually found in the lower parietal lobe (fields 39 and 40). With motor apraxia, a lesion is found in the supramarginal gyrus (field 40), and in the case of constructive apraxia, in the angular gyrus (field 39). Apraxia is noted more often in patients with vascular diseases and brain tumors.
In table. 20 shows methods for studying the function of praxis. You should first find out if the patient has symptoms of sensory aphasia.

agnosia

Agnosia (agnosia, from the Greek gnosis - knowledge, a - denial) is a violation of the processes of recognizing objects, things, animals, people by their appearance, color, sounds, smells and others characteristics(Table 21). At the same time, in a disorder of the functions of the analyzers - vision, hearing, taste, smell and touch, or they are slightly impaired, and this cannot explain the occurrence of agnosia. The patient does not recognize ordinary objects and things (watches, pencils, books, glasses) when brought to the eyes, although he sees them. Does not understand the meaning of sounds (does not recognize watches by characteristic ticking, water by dripping or murmuring), although his hearing is preserved, does not recognize familiar smells (cologne, etc.), objects by touch, although he does not have sufficiently pronounced violations of the surface and deep sensitivity of patients are absent.

Table 21
Investigation of the function of gnosis

Agnosia is often combined with apraxia, in these cases, with a thorough study, it is also possible to identify certain violations of the action.
One of the special types of visual agnosia is alexia. special kind auditory agnosia is sensory aphasia, as well as amusia.
Although the function of gnosis is largely due to the synthetic activity of the entire cerebral cortex, the appearance of individual syndromes of gnostic disorders is more often associated with damage to well-defined areas of the cortex.
So, visual agnosia occurs when the cortical branches of the posterior cerebral artery (a. cerebri posterior) are damaged. Anatomically, extensive lesions are found in the occipital region (fields 18 and 19), and sometimes in the parietal region (field 39).
Auditory agnosia is associated with the localization of lesions in the temporal region (fields 20, 21, 22, 42, 52), i.e., in the cortical zone; branches of the middle cerebral artery supplying the temple.
Agnosia of smells and taste is observed when the lower sections of the posterior central gyrus and deep sections of the temporal lobe (fields 43, 28, 34) are affected, receiving blood supply from a branch of the middle cerebral artery.
Astereognosis (failure to recognize objects by touch) is caused by damage to the anterior parts of the parietal lobe (fields 1, 2, 3, 5, 7, and sometimes -.40), i.e., in the area of ​​the cortical branches of the middle cerebral artery.
Agnosia of parts of one's own body is called a violation of the body schema. This syndrome includes autopagnosia (the patient does not recognize parts of his own body, confuses the right side with the left, etc.), pseudomelia (the patient claims that he has six fingers on his hand, three arms, four legs, etc.), anosagnosia (the patient is not aware of his defect - he assures that he walks, moves his paralyzed arm, etc.). A frequent case of violation of the body scheme is agnosia of the fingers (the patient does not recognize and cannot distinguish his fingers). Violation of the body scheme usually occurs when the interparietal sulcus (the lower sections of fields 5 and 7 and the upper sections of fields 39 and 40) of the right hemisphere is affected. Especially characteristic is the defeat of the right hemisphere in the case of pseudomelia. Agnosia is observed more often in vascular lesions and brain tumors.