What is the appropriate evaluation and management for a 54-year-old patient presenting with an hour of aphasia?

Acute Evaluation of One-Hour Aphasia in a 54-Year-Old

This patient requires immediate stroke protocol activation with urgent neuroimaging (preferably MRI with diffusion-weighted sequences) within 24 hours, though isolated aphasia without motor/sensory deficits is most commonly a stroke mimic rather than ischemic stroke.

Immediate Risk Stratification

This presentation demands urgent evaluation because:

• Isolated aphasia represents only 3% of acute stroke presentations, and in one emergency department study, none of the 21 patients with isolated aphasia had infarcts on neuroimaging 1
• However, true ischemic stroke with isolated aphasia can occur, particularly in patients with prior stroke/TIA history (p=0.023 for association with ischemia) 1
• A recent 2025 case report confirmed acute left parietotemporal infarction presenting solely as aphasia in a 41-year-old, emphasizing this remains a real diagnostic possibility 2

Essential Diagnostic Workup

Neuroimaging (Priority #1)

• Obtain MRI with diffusion-weighted imaging within 24 hours of symptom onset as the preferred modality 3
• If MRI unavailable, perform CT scan immediately to rule out hemorrhage and assess for early ischemic changes 3
• The one-hour timeframe still permits consideration of thrombolytic therapy if ischemic stroke is confirmed 3

Vascular Imaging

• Perform noninvasive imaging of cervical vessels (carotid ultrasound or CTA) urgently 3
• Consider intracranial vessel imaging, as this is reasonable in the acute setting 3

Cardiac Evaluation

• Obtain electrocardiography immediately 3
• Arrange prolonged cardiac monitoring and echocardiography with bubble study, particularly given the association between isolated aphasia and cardioembolic sources like patent foramen ovale 2, 3

Laboratory Assessment

• Check blood glucose immediately to exclude hypoglycemia as a stroke mimic 1
• Obtain routine blood tests including complete metabolic panel, as toxic/metabolic disturbances account for 39% of isolated aphasia mimics 1

Critical History Elements

Focus specifically on:

• Prior history of stroke or TIA (strongest predictor of true ischemia in isolated aphasia presentations) 1
• Age >55 years, hypertension, diabetes, tobacco use, hyperlipidemia 4, 2
• Sudden versus gradual onset (true stroke is sudden) 3
• Fluctuating symptoms suggesting metabolic cause versus persistent deficit 1

Physical Examination Priorities

Document precisely:

• NIHSS score to quantify deficit severity 1, 2
• Presence or absence of any motor weakness, sensory loss, visual field deficits, or cranial nerve abnormalities 1, 2
• Detailed language assessment: comprehension, speech production, reading, writing, repetition 5
• Level of consciousness and attention (to distinguish from delirium/encephalopathy) 1

Disposition Decision

Hospitalize this patient if:

• Presenting within 72 hours AND cannot rapidly complete outpatient evaluation 3
• Any concern for true ischemic etiology based on risk factors or imaging findings 3

The most likely diagnoses in order of probability are:

1. Toxic/metabolic disturbance (39% of isolated aphasia cases) 1
2. Transient ischemic attack (14% in one series) 1
3. Acute ischemic stroke (rare but documented, especially with cardioembolic sources) 2
4. Other mimics: dementia exacerbation, seizure, psychiatric disorder 1

Common Pitfalls to Avoid

• Do not dismiss isolated aphasia as "just confusion" without comprehensive stroke workup 2
• Do not delay neuroimaging beyond 24 hours 3
• Do not overlook cardioembolic sources, particularly in younger patients without traditional vascular risk factors 2
• Do not assume stroke mimic without documenting negative MRI and alternative explanation 1, 2

If Stroke Confirmed: Immediate Speech-Language Pathology Referral

Should ischemic stroke be confirmed:

• Refer immediately to speech-language pathologist for comprehensive assessment of comprehension, speech, reading, writing, and functional communication impact 5
• Begin therapy as early as tolerated, ideally within first 4 weeks, with sessions of 30-45 minutes, 2-3 days per week during acute phase 6, 5
• Initiate dual antiplatelet therapy and statin if ischemic stroke confirmed 2