Speech and Higher Mental Function Examination Viva

Short Case Viva Defence — Case A: Acute Wernicke Aphasia

Candidate's opening statement (model answer)

"I examined Mrs Kaur, a 72-year-old woman, brought in forty minutes after the sudden onset of strange speech. She is alert and afebrile. On examination of the speech, spontaneous speech is fluent — long phrases, normal melody, effortless — but the content is empty, with frequent phonemic and verbal paraphasias and several neologisms. She does not appear frustrated by her speech. Comprehension is impaired: she manages an occasional one-step command but cannot follow a two-step command. Repetition is impaired — she cannot repeat 'no ifs, ands, or buts.' Naming is impaired for a watch, a pen and the fingers. Hearing is intact to a whispered number in each ear, so this is not a peripheral auditory problem. Attention, tested by digit span and months backwards, is preserved. ^[1]

'In summary, this patient has a fluent aphasia with impaired comprehension and impaired repetition — a Wernicke aphasia. The sudden onset in a vasculopathic patient localises to the dominant superior temporal gyrus in the inferior division of the left middle cerebral artery, and this is an acute stroke. The emergency registrar has labelled her confused, but her preserved alertness and attention, her focal language-specific deficit, and the discrete sudden onset confirm a focal aphasia, not delirium. My immediate priority is to activate the acute stroke pathway for urgent CT to exclude haemorrhage, then assess for thrombolysis and thrombectomy.'" ^[1]

Examiner probing questions and model answers

Q1: "How do you know this is aphasia and not delirium?" ^[1]

"Because the core features of delirium are absent. Delirium is defined by an acute, fluctuating impairment of attention with altered consciousness, and this patient has preserved alertness and attention — she is fully awake, she manages one-step commands, and her digit span is preserved. In delirium the speech is globally disorganised — rambling, tangential, off the point — whereas here the fluency and melody are normal and only the content is disordered, with specific language errors: phonemic paraphasias, verbal paraphasias and neologisms. Those are language errors of a focal type, not the jumbled thinking of an acute confusional state. The onset is sudden and discrete, consistent with a vascular event, rather than the fluctuating, precipitant-driven course of delirium. The danger of the confusion label is that a patient with an acute dominant-hemisphere stroke is worked up for sepsis while the thrombolysis clock runs out, so I would confirm attention formally with digit span and months backwards, and then activate the stroke pathway." ^[1]

Q2: "Walk me through your classification of this aphasia." ^[1]

"I classify on three axes — fluency, comprehension and repetition — because no single axis is sufficient. First, fluency: she speaks in long phrases with normal melody and rate, so she is fluent. That puts the lesion posteriorly, in the temporal or parietal language area rather than the frontal Broca area. Second, comprehension: she cannot follow a two-step command, so comprehension is impaired. A fluent aphasia with impaired comprehension narrows it to Wernicke or transcortical sensory. Third, repetition: she cannot repeat 'no ifs, ands, or buts,' so repetition is impaired. That distinguishes Wernicke from transcortical sensory, because the transcortical aphasias — by definition — preserve repetition. So fluent plus impaired comprehension plus impaired repetition is Wernicke aphasia, from a left superior temporal gyrus lesion. The preserved repetition of a transcortical aphasia tells me the perisylvian language loop is intact and the lesion is in the watershed territory; the impaired repetition here tells me the perisylvian cortex itself is involved, which is the MCA territory." ^[1]

Q3: "What is your evidence base for speech therapy once she stabilises?" ^[1]

"The Brady 2016 Cochrane review of speech and language therapy for aphasia following stroke, which pooled 57 randomised trials and about 3000 participants. It found that speech and language therapy improves functional communication, receptive language and expressive language compared with no therapy, with a suggestion that higher intensity and dose are more effective ^[4]. It did not find enough evidence to favour one therapeutic approach over another, or to settle group versus individual therapy. So the practical position is to refer early to a speech and language therapist, deliver therapy at a clinically meaningful intensity — not a token weekly session — and set functional communication goals. I would also involve the family in supported communication strategies from the outset, because the social impact of aphasia is substantial and is often under-recognised."