What is the management for a 60-year-old patient with sudden speech loss after a fall, who is able to follow instructions with intact range of motion (ROM) and muscle strength?

Acute Stroke Management

This patient requires immediate emergency evaluation for acute stroke with urgent brain imaging (CT or MRI) and activation of stroke protocols, as the sudden onset of speech loss following a fall with preserved ability to follow commands and intact motor function strongly suggests an acute ischemic stroke affecting language centers.

Immediate Recognition and Action

This clinical presentation is a stroke emergency requiring time-sensitive intervention:

• Sudden speech loss (aphasia) with preserved comprehension (able to follow instructions) indicates a focal brain lesion, most likely affecting Broca's area or surrounding language networks 1
• The fall may have been the initial manifestation of the stroke rather than the cause of neurological symptoms, as falls are commonly reported as the presenting problem in acute stroke even when the primary issue is cerebrovascular 2
• Motor strength and ROM being intact does not rule out stroke—isolated aphasia without hemiparesis occurs in approximately 30% of stroke patients 1

Critical Diagnostic Steps

Immediate Emergency Department Transfer

• Activate Emergency Medical Services immediately for rapid transport to a stroke-capable facility 2
• Time of symptom onset is critical for determining thrombolytic eligibility (within 4.5 hours for IV tPA)
• The "fall this morning" provides the time window for intervention

Urgent Neuroimaging

• Non-contrast CT head is the first-line imaging to exclude hemorrhage before considering thrombolysis
• MRI with diffusion-weighted imaging is more sensitive for acute ischemic stroke, particularly in the hyperacute phase
• Do not delay imaging for extensive workup—brain imaging must occur within 25 minutes of ED arrival per stroke protocols

Focused Neurological Assessment

• Document specific aphasia characteristics: Can the patient speak at all (aphasia vs. mutism)? Can they write? Can they name objects? 1
• Distinguish aphasia type: Nonfluent aphasia (Broca's) with preserved comprehension vs. fluent aphasia (Wernicke's) with impaired comprehension 1
• This patient's ability to follow commands with inability to speak suggests Broca's (expressive) aphasia, typically from left frontal lesions 1
• Assess for subtle motor deficits: Pronator drift, facial asymmetry, and coordination testing may reveal findings not apparent on gross strength testing

Differential Considerations (Lower Priority but Consider)

Head Trauma from Fall

• CT head will simultaneously evaluate for traumatic injury (subdural hematoma, epidural hematoma, contusion)
• However, the speech loss pattern is more consistent with stroke than diffuse traumatic brain injury 3
• Traumatic brain injury typically presents with altered consciousness, which this patient does not have 3

Post-Fall Syncope Evaluation (Secondary Priority)

• Once stroke is ruled in or out, evaluate for syncope as cause of fall 4, 5
• Comprehensive fall assessment should include orthostatic vital signs, medication review, ECG, and gait evaluation 4, 5
• However, this evaluation is secondary to acute stroke management and should not delay imaging

Why This is NOT a Primary Fall or Functional Speech Disorder

• Functional speech disorders have gradual onset, variability across contexts, and often co-occur with psychological stressors 4, 6
• This patient has sudden, fixed speech loss—the hallmark of structural brain injury 1
• The temporal relationship (speech loss immediately after fall) suggests either stroke causing the fall or traumatic injury, not functional etiology
• Functional aphonia/dysphonia would not impair language production while preserving comprehension—this patient cannot talk but can understand, indicating true aphasia 4

Post-Acute Management (After Stroke Confirmed)

Speech-Language Pathology Referral

• Early speech therapy consultation (within 24-48 hours) for aphasia assessment and swallowing evaluation 1
• Spontaneous recovery is most intensive in the first 2 weeks for ischemic stroke 1
• Treatment should begin as soon as medically stable 1

Secondary Stroke Prevention

• Comprehensive stroke workup including vascular imaging, cardiac monitoring, and risk factor modification
• Antiplatelet or anticoagulation therapy as indicated by stroke etiology

Fall Prevention

• Once neurologically stable, implement multifaceted fall prevention including physical therapy, medication review, and home safety assessment 5
• Address any orthostatic hypotension, gait impairment, or environmental hazards 4, 5

Critical Pitfall to Avoid

Do not attribute sudden speech loss to a "functional" or "psychogenic" cause without first excluding stroke with urgent imaging. The consequences of missing acute stroke are catastrophic (permanent disability, death), while the consequences of over-investigating for stroke are minimal 1, 2. The time-sensitive nature of stroke treatment demands immediate action.