Pearls of Wisdom: Stroke-Induced Aphasia

Martha sustained an ischemic stroke 3 years ago. According to her caregiver, her primary complication is expressive aphasia. She is currently taking a statin and clopidogrel. After 1 year of speech therapy, she is considered at maximum benefit for that modality. Her blood pressure is controlled at 125/75 mm Hg with hydrochlorothiazide.

What treatment would you consider at this point?

A. Olanzapine
B. Duloxetine
C. Zolpidem
D. Ibandronate
E. None. Aphasia is not amenable to medication at this point.

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.

Answer: Zolpidem

Expressive aphasia is a devastating consequence of ischemic stroke. The scope of impairment ranges from modest disruption to complete abolition of meaningful communication. Speech therapy and speech-assistive tools can provide some degree of recovery or compensatory communication progress, but insufficient recovery may leave patients feeling frustrated. In addition to the impairment of sensible communication, people with expressive aphasia may end up blurting out expletives and more primitive language components at the inability to express their thoughts, which further increases their frustration.

The Research

The New England Journal of Medicine reported an interesting case of a 52-year-old right-handed woman who sustained an inschemic stroke 3 years prior.¹ The areas of infarction included the left insula, putamen, and superior temporal gyrus. Her stroke resulted in expressive aphasia, leaving her with no intelligible words. Nonetheless, the patient’s full language comprehension had remained intact.

Expressive Aphasia: A Case Report¹

Because of difficulties with occasional insomnia, the patient received treatment with zolpidem, 10 mg. (Note: Dosing recommendations for zolpidem have changed since this report was published in 2004). Although the patient did subsequently fall asleep, in the interval between taking the zolpidem and onset of sleep, the patient experienced a dramatic improvement in speech. Full expressive aphasia returned upon awakening. This process was repeated several times with the same result.

Subsequent single-photon-emission computed tomography scanning of this patient indicated that zolpidem increases flow in the Broca area of the brain, an area intimately involved with speech. From these observations, the authors concluded that “A selected subgroup of patients with aphasia, perhaps with subcortical lesions and spared but hypometabolic cortical structures, might benefit from this treatment.”¹

Expressive Aphasia: Clinical Course¹

What’s the Take Home?

Just because a patient has crossed an established threshold to be labeled maximum potential clinical improvement does not mean that such status needs to be etched in stone. When scientific evolutions provide new insights, sometimes it’s worth trying. Considering that there is nothing to lose, and that the risk is minimal, why not? It may be worth trying zolpidem in patients who have been labeled with otherwise refractory chronic expressive aphasia. Could this help patients earlier in the course, patients with milder disease, or patients with other ischemic central nervous system syndromes? Results from a single patient trial such as this one cannot predict whether other applications could be valuable or not.

Reference:

1. Cohen L, Chaaban B, Habert M-O. Transient improvement of aphasia with zolpidem. N Engl J Med. 2004;350(9):949-950.