A patient presents with sudden onset aphasia—what is the appropriate emergent workup and acute management?

Emergent Workup and Acute Management of Sudden Onset Aphasia

A patient presenting with sudden onset aphasia requires immediate stroke protocol activation with emergent non-contrast head CT to rule out hemorrhage, followed by vascular imaging (CTA or MRA) to identify large vessel occlusion, and urgent neurology consultation to determine thrombolytic or thrombectomy eligibility within the critical time window. 1

Immediate Emergency Department Actions

Initial Stabilization and Stroke Protocol

• Activate stroke code immediately upon recognition of aphasia, as this represents a potential acute ischemic stroke requiring time-sensitive intervention to reduce mortality and permanent disability 1
• Obtain vital signs and establish IV access while simultaneously ordering emergent neuroimaging 1
• Document exact time of symptom onset or last known normal, as this determines eligibility for reperfusion therapies 1

Emergent Neuroimaging

• Order non-contrast head CT as the first-line imaging study to exclude intracranial hemorrhage before considering thrombolytic therapy 1
• Obtain CT angiography (CTA) of head and neck or MR angiography to identify large vessel occlusion amenable to mechanical thrombectomy 1
• Consider MRI with diffusion-weighted imaging if available and does not delay treatment, as it provides superior sensitivity for acute ischemia 2

Neurological Assessment

• Screen for communication disorders using a simple, reliable, validated tool to document baseline aphasia severity 3, 1
• Distinguish aphasia from dysarthria (motor speech disorder) and apraxia of speech (motor planning disorder), as these require different management approaches 3
• Evaluate for associated neurological deficits including hemiparesis, visual field defects, and neglect that suggest specific vascular territories 4

Acute Stroke Management Considerations

Reperfusion Therapy Window

• If presenting within 4.5 hours of symptom onset and no contraindications on CT, consider IV thrombolysis per stroke protocols 1
• If large vessel occlusion identified on CTA within 6-24 hours (depending on specific criteria), consider mechanical thrombectomy 1
• Do not delay imaging or treatment to perform detailed language assessment, as time is brain tissue 1

Alternative Diagnoses to Consider

• Rule out hypoglycemia with immediate point-of-care glucose testing, as this can mimic stroke and is rapidly reversible 1
• Consider seizure with postictal aphasia (Todd's paralysis), particularly if witnessed rhythmic movements or altered consciousness 4
• Evaluate for intracranial mass, abscess, or encephalitis if subacute presentation or atypical features 4

Early Post-Acute Management (First 24-48 Hours)

Speech-Language Pathology Consultation

• Refer all patients with suspected aphasia to a speech-language pathologist for comprehensive assessment within 24-48 hours of admission 3, 1
• The assessment must evaluate comprehension, speaking, reading, writing, gesturing, use of technology, and functional communication impact 3, 1
• Document the specific aphasia type (Broca's, Wernicke's, global, anomic, conduction, transcortical) based on fluency, comprehension, and repetition patterns 4

Communication Strategies During Acute Hospitalization

• Train all healthcare providers caring for the patient in alternative communication methods including gesture, drawing, writing, and yes/no questions 3
• Use augmentative and alternative communication devices as appropriate, evaluated by an experienced clinician 3
• Explain the nature and implications of aphasia to the patient, family, and entire treatment team to ensure appropriate communication accommodations 1, 5

Early Therapy Initiation

• Begin speech and language therapy as early as tolerated, ideally within the first 4 weeks post-stroke to maximize language recovery and reduce long-term disability 3, 1
• Provide 30-45 minute therapy sessions, 2-3 days per week during the acute phase (first 6 weeks) 3
• Intensive therapy of at least 45 minutes of direct language therapy five days per week should be implemented during the first few months after stroke 3, 1

Psychosocial Assessment and Support

Mental Health Screening

• Screen all patients with aphasia for anxiety and depression, as these are common complications that significantly impact quality of life and rehabilitation outcomes 1
• Assess the impact on functional activities, participation, relationships, vocation, and leisure from early post-onset 3, 1

Family and Caregiver Education

• Provide aphasia-friendly information about the condition, prognosis, and communication strategies in formats accessible to patients with language impairment 3
• Train family members and communication partners in supported conversation techniques to improve functional communication 3

Critical Pitfalls to Avoid

• Do not assume the patient cannot understand simply because they cannot speak—many aphasia types (particularly Broca's aphasia) have relatively preserved comprehension despite severe expressive deficits 4
• Do not delay stroke workup to perform detailed language testing—the priority is identifying treatable causes within the therapeutic window 1
• Do not discharge without speech-language pathology evaluation and outpatient therapy arrangements, as early intensive therapy maximizes recovery 3, 1
• Do not use standard cognitive assessment tools without speech-language pathologist input, as most cognitive tests have significant language demands that invalidate results in aphasic patients 1, 6