Type of Bleed in Speech Area
Intracerebral hemorrhage (ICH) in the speech area is typically a lobar hemorrhage, most commonly occurring in the left frontal (Broca's area) or left temporal-parietal regions (Wernicke's area), and is frequently associated with cerebral amyloid angiopathy rather than hypertensive vasculopathy. 1
Hemorrhage Classification by Location
The speech areas of the brain are located in cortical (lobar) regions, specifically:
- Broca's area: Left inferior frontal gyrus (expressive speech)
- Wernicke's area: Left superior temporal gyrus (receptive speech)
- Arcuate fasciculus: White matter connection between these regions
When hemorrhage occurs in these locations, it is classified as lobar ICH rather than deep ICH. 2, 3
Underlying Pathophysiology
Lobar hemorrhages in speech areas have distinct risk factors compared to deep hemorrhages:
- Cerebral amyloid angiopathy (CAA) is the primary underlying microangiopathy for lobar ICH, including speech areas 1, 4
- APOE ε2 or ε4 genotype is specifically associated with lobar ICH, not deep hemorrhages 1
- Hypertension is specifically associated with deep (nonlobar) ICH, not lobar hemorrhages 1
This distinction is critical because lobar hemorrhages behave differently than deep hemorrhages in terms of expansion patterns and outcomes.
Clinical Presentation
Hemorrhage in speech areas presents with:
- Aphasia (expressive, receptive, or mixed depending on location)
- Focal neurological deficits referable to the specific cortical region 5
- Symptoms developing over seconds to minutes 5
Hemorrhage Expansion Characteristics
Deep ICH expands more frequently than lobar ICH (adjusted OR 1.57,95% CI 1.08-2.29), but the threshold for poor outcomes differs by location. 6
- Deep ICH: 30% expansion threshold associated with poor outcomes
- Lobar ICH: 50% expansion threshold associated with poor outcomes 6
This means that while lobar hemorrhages (including speech areas) expand less frequently, they still require urgent imaging and management.
Diagnostic Approach
Non-contrast head CT is the standard diagnostic tool for identifying ICH in speech areas. 2, 3
- CT should be performed within 1 week of symptom onset to reliably demonstrate acute hemorrhage 5
- MRI with gradient recalled echo (GRE) sequences can identify small hemorrhages and cerebral microbleeds that suggest underlying CAA 5, 4
- Strictly lobar cerebral microbleeds on MRI are pathologically proven markers of cerebral amyloid angiopathy 4
Common Pitfall
Do not assume all ICH has the same underlying cause. Lobar hemorrhages in speech areas are NOT typically hypertensive bleeds—they are more commonly related to cerebral amyloid angiopathy, especially in older patients. 1, 4 This distinction affects both acute management and secondary prevention strategies.