APHASIA, APRAXIA, AND AGNOSIA
APHASIA, APRAXIA, AND AGNOSIA: Excerpt from Differential Diagnosis in Primary Care
These disorders signify a dysfunction of the cerebrum. Aphasia must be
distinguished from dysarthria, which could also be due to involvement of the
brain stem or cerebellum. Patients with dysarthria have no difficulty
recognizing or interpreting words or phrases, but speech is garbled and
difficult to understand by the clinician. The mnemonic VINDICATE would
be useful in developing the differential diagnosis of these symptoms and
signs.
V—Vascular should bring to mind TIA, cerebral thrombosis, embolism,
hemorrhage. Cerebral or arteriosclerosis should also be considered.
I—Inflammation. Conditions include viral encephalitis,
brain abscess, and human immunodeficiency virus (HIV) infections.
N—Neoplasm brings to mind primary and metastatic tumors.
D—Degenerative disorders include Alzheimer disease, Pick disease,
Huntington chorea, and dementia with Lewy bodies. There is also a condition
known as progressive aphasia without dementia.
I—Intoxication should suggest the possibility of alcohol or drug
intoxication and Korsakoff psychosis.
C—Congenital disorders include cerebral palsy, the leukodystrophies,
and congenital abnormalities of the brain such as hydrocephalus and
microcephaly. Cerebral aneurysm and atrioventricular (A-V) anomalies might
also be brought to mind in this category.
A—Autoimmune disorders include multiple sclerosis, lupus
erythematosus, thrombotic thrombocytopenic purpura, and other collagen
disorders.
T—Trauma should bring to mind epidural, subdural, and intracerebral
hematomas related to trauma.
E—Endocrine disorders are not particularly suggestive of cerebral
pathology, but an amniotic fluid embolism may rarely be responsible for
aphasia, apraxia, or agnosia. Hypoparathyroidism may bring about seizures
which could cause transient aphasia in the postictal phase.
Approach to the Diagnosis
A thorough neurologic examination may disclose hemiparesis suggesting a
cerebrovascular accident or papilledema, suggesting a space-occupying
lesion. The history would be very important in ruling out alcohol or drug
intoxication, trauma, or autoimmune disorders. A CT scan would be useful in
acute cases, whereas an MRI would be best for cases with a gradual onset.
These studies would be most definitive for an infarct, space-occupying
lesion, or degenerative disorders. A VDRL test, ANA, CBC, and sedimentation
rate would be helpful to rule out systemic causes. A urine drug screen may
be necessary. For cases of intermittent symptoms, an EEG should be done to
rule out epilepsy, and a carotid scan should be done to rule out carotid
stenosis or plaque formation. A neurologist should be consulted if
four-vessel angiography is contemplated.
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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