For more than a century, the study of aphasia has made great progress. With the gradual deepening of aphasia research, many scholars have put forward dozens of classification methods according to their different viewpoints and research purposes, some of which overlap, and some of them have a lot of confusion in the names of aphasia classification. So far, there is no recognized method. Although there are many classification methods, all classifications are relative. A classification often reflects the understanding of aphasia mechanism through the combination of different language symptoms after brain injury

1979 Benson began to use the word "aphasia syndrome" in "aphasia, agraphia and alexia", that is, the concept that the focus is in a certain part and the patient has a group of complete or incomplete clinical symptoms at a high frequency has been widely used in the later aphasia research and rehabilitation, and it is considered to be * * * in the major languages all over the world, reflecting the human brain.

(2) Classification of Chinese aphasia

The classification of aphasia in China is based on Benson classification. The main types of aphasia in Chinese are as follows.

Main types of Chinese aphasia

(3) Classification of typical and atypical aphasia

Studies in recent years have confirmed that more limited cortical language center injuries often show typical aphasia symptoms; Extensive cortical injury and subcortical injury often show atypical aphasia. Therefore, a classification method of typical aphasia and atypical aphasia is proposed, as shown in the figure below.

Because patients' clinical manifestations vary greatly due to different lesion sites and different course of disease, typical aphasia is also relative, and some aphasia is difficult to be classified. According to the research data of foreign countries in the 1990s and the observation of domestic scholars, about 30% aphasia cannot be clearly classified. At the end of 1970s, there was a dichotomy that aphasia was divided into non-fluent aphasia and fluent aphasia. Generally, when the lesion site was slightly in front of the central sulcus, the speech was not fluent.

Typical aphasia and atypical aphasia

Clinical characteristics and lesions of four types of aphasia

1.Broca aphasia or expressive aphasia, motor aphasia.

(1) Main clinical features

The main manifestations are as follows: the expression obstacle is obviously worse than the comprehension obstacle. Spontaneous speech is not fluent, the amount of speech is small, laborious, the language is poor and lacks grammatical words. When telegraphic speech is serious, it is silent, and it is difficult to name and find words. However, giving the initial sound prompt can often lead to correct response and repetition obstacles, especially when repeating long sentences, there are more mistakes, especially prosodic errors, and the understanding obstacle is light, so you can understand simple words. It is often difficult to grasp long sentences and perform oral instructions, and the ability to understand and read words may also be difficult to varying degrees. The writing of more complicated sentences is also damaged, and the grammar is seriously wrong. In addition, Broca's aphasia is often accompanied by oral and facial apraxia. When patients only have oral disorders, but their understanding, writing, intelligence and calculation are normal, they are called pure words dumb, which is also called pure motor aphasia or speech apraxia.

(2) Lesions

In Broca area, which is located in the posterior third of the inferior frontal gyrus of the dominant hemisphere, most of these patients are accompanied by right hemiplegia. On the whole, the prognosis of Broca aphasia is better than other types, but there are great differences among individuals due to different degrees.

(3) Examples of cases

Male, 58 years old, college education, cadre, right-handed speech disorder with poor right limb movement 1 month ago, the patient admitted to the hospital found that his right limb could not move and could not speak at noon, and was immediately sent to a nearby hospital for treatment. After treatment, his condition was stable and he was transferred to a rehabilitation center for rehabilitation treatment. Physical examination: The patient was conscious and cooperative, and his right nasolabial groove became shallow. The muscle strength of the right upper limb is Grade 2, the muscle strength of the right lower limb is Grade 3, the right tendon reflex is hyperactive, and the right Babinski sign is positive. Aphasia examination: The patient has little spontaneous speech, and can answer his own name and address only in Beijing, and can answer the date of birth with some numbers, but the date is incorrect. There are many pauses in the conversation, the speech is not fluent, and the pronunciation is unclear, and the expression is difficult to understand. The correct rate is 70% for nouns, 60% for verbs and 40 for sentences. The correct rate of naming is 40%, the action description is 30%, and the prefix sound and gesture prompt are acceptable. The correct rate of repeating nouns is 50%, verbs are 40%, and sentences with 3-5 words can be repeated. The correct rate of reading comprehension is 40% for nouns and verbs, 70% for nouns and verbs, and 20% for sentences. The correct rate of writing and naming is 30%, the correct rate of copying is 80% for nouns and 60% for verbs, the correct rate of dictation is 40% for nouns and 20% for verbs, and the sentence is 0. Calculate 6 points (6 questions are correct). MRI shows "low-density focus in Broca area of left frontal lobe". Diagnosis: Broca aphasia due to cerebral infarction.

2. transcortical motor aphasia.

(1) Main clinical features

Oral English is not fluent, and there are few spontaneous words, so they often respond to stimuli simply. There are individual differences in pronunciation, reading and naming ability, and retelling is better in understanding. Some patients have difficulties in writing. The main difference from Broca's aphasia is that such patients can retell longer sentences, and the prognosis of this kind of aphasia is better on the whole.

(2) Lesions

Most diseases in front and above Broca area are due to middle cerebral artery infarction and brain injury.

(3) Examples of cases

Male, 52 years old, you Li, driver, junior high school education level, poor speech due to poor physical activity on the right side/In Kloc-0/year, when the patient was washing his face in the morning in May 1 995, he suddenly lost consciousness. On the same day, CT examination showed that "a large area of cerebral infarction in the left forehead" was treated with drugs such as dehydration. 1 week later, his consciousness turned clear, but he still could not speak/. I have never received systematic speech training. In order to improve my speech ability, I was admitted to hospital for rehabilitation treatment. After I was admitted to hospital, I underwent Chinese standard aphasia examination: my spoken language is not fluent and can be expressed by some words and gestures. For example, I used the steering wheel to indicate "driver". The correct rate of some four-tone errors in spoken language is 90% for nouns and verbs, 70% for sentences, and 0 for verbal instructions. The correct rate of repetition is 90% for nouns and 70% for verbs. Sentence is 40%, naming and action description accuracy is 90%, picture description is 0, reading accuracy is 40% for nouns, 0 for verbs and sentences, reading comprehension accuracy is 90% for nouns, 80% for verbs, 40% for sentences, and 0 for executing written instructions. All kinds of writing can't complete calculation 17 points for language diagnosis: transcortical motor aphasia.

3.Wernicke aphasia.

Or receptive aphasia, sensory aphasia.

(1) Main clinical features

Wernicke's aphasia is a representative fluent aphasia, whose main feature is that the understanding obstacle is obviously more serious than the expression obstacle. Wernicke's aphasia is characterized by fluent speech, and a large number of wrong words and new words are mixed together to make the speech appear messy sentences, called messy words or strange words. There are persistent phenomena of words, and there are obvious obstacles in naming and finding words. Patients can speak fluently themselves, but they don't know what they are saying and lack the core content of expression. In terms of understanding, language hole is characterized by speech comprehension disorder, which is often characterized by impaired pronunciation and semantic understanding. Due to different degrees of severity, the understanding ability of written language is also impaired to varying degrees, and people can read words, but most of them are misspelled and often have glyphs. However, Wernicke aphasia patients often lack self-awareness of the disease, and the prognosis of such aphasia is often poor as a whole.

(2) Lesions

It is mainly located in Wernicke area at the posterior part of superior temporal gyrus 1/3 or at the posterior margin of lateral fissure of the brain, with the posterior part of middle temporal gyrus of superior temporal gyrus as the central area. Most patients with cerebral infarction (cortical branch of middle cerebral artery) are often accompanied by hemianopia.

(3) Examples of cases

Male, 59 years old, you Li, with a college education, suffered from rheumatic heart disease for more than 30 years and atrial fibrillation 10 years after dinner two months ago. In a quiet state, he suddenly felt that his right limb movement was ineffective and his speech was unclear. Later, he went to the local hospital for treatment. CT examination showed that his limb movement was basically restored after treatment of left temporal lobe cerebral embolism, but his speech was still not improved. For speech rehabilitation, I was transferred to the hospital for treatment. The hearing test is the normal threshold. The Chinese standard aphasia test: the spoken language is fluent, obviously cluttered, and there is a lack of self-suppression ability during the conversation. For example, when answering my own name question, I said, "Li La thinks suddenly and suddenly ..." The correct answer rate of listening comprehension is 10% for nouns and verbs, 0 for sentences and oral instructions, and the repetition is still cluttered. Reading comprehension is better with a score of 0. Correct rate: 70% for nouns, 60% for verbs, 50% for sentences, 50% for executing written instructions, 50% correct for addressing writing and descriptive writing, too much writing, and 20% correct for scoring 0, all of which are one-digit addition and subtraction language diagnosis: Wernicke aphasia.

4. transcortical sensory aphasia.

(1) Main clinical features

In terms of expression, spontaneous speech is fluent, but there are many mistakes, naming has serious obstacles, and the ability to repeat is good, but there is a phenomenon of learning language, that is, although you don't know what the other party is saying, you repeat what the other party said repeatedly, which shows that there are obstacles in language understanding and written language understanding, and you can read words aloud, but you often don't understand their meaning. In the recovery process of Wernicke's aphasia, you often change to this type. The biggest difference between Wernicke's aphasia and repetition reservation is that.

(2) Lesions

Generally speaking, it is a widespread lesion around the speech center of the lateral fissure of the dominant hemisphere of the brain, but the injury confined to the back will also have the same symptoms

5. conduction aphasia.

(1) Main clinical features

In terms of expression, spontaneous speech is fluent, but most of them are accompanied by phonemic errors. Conductive aphasia, which is characterized by repetition disorder, is characterized by errors in spontaneous language naming, repetition and word reading. In terms of understanding, both words and sounds are better, and most conductive aphasia with writing disorder generally has a better prognosis.

(2) Lesions

At present, the focus of conductive aphasia is still controversial. It is generally believed that the focus is mainly located in the arcuate bundle connecting Wernicke area and Broca area, which makes the speech information in Wernicke area not well transmitted to Broca area, resulting in serious repetition disorder. However, some scholars have questioned this. They think that the focus is not confined to a specific part, and it is often caused by scattered injuries in the upper and lower parts of the lateral fissure of the dominant hemisphere.

(3) Examples of cases

Male, 56 years old, You Li, college education, cadre patient was injured in the left head by a club while learning to play golf in September 1997. He had a severe headache at that time and was immediately taken to the local hospital. On the way to the hospital, the patient was unconscious in the local hospital, and CT examination showed "intracranial hematoma in the left temporal lobe". After surgery, the patient woke up the next day, and after waking up, he developed speech difficulties and mild mobility problems in the right limb. /kloc-After 0/month, the limb movements have basically recovered, but there are still obvious expression obstacles and enunciation. Please do not make a diagnosis and treatment for speech rehabilitation. After admission, do a standard aphasia examination: the patient's spoken language is fluent, and there are a lot of phonetic mistakes in answering and asking questions, and there are many mistakes in naming. It is impossible to repeat words. Sometimes, individual tones can be repeated, and most of them can be heard and understood under visual prompts. Noun verb examination is better. Only at the sentence level, the reading comprehension accuracy is slightly impaired: nouns are 80%, verbs are 70%, and sentences are 50%. There are many phonetic mistakes in reading aloud: naming writing and description writing are better, and sentence description is dysgraphia. MRI examination shows "left temporal lobe encephalomalacia". Language diagnosis: conductive aphasia.

6. Named aphasia (anomic aphasia)

(1) Main clinical features

Also known as nominalized aphasia and Amnesia, fluent aphasia with naming disorder is characterized by spontaneous difficulty in finding words and naming people's names. There are mistakes, often circuitous language, and other abilities such as understanding, retelling and writing are reserved. The prognosis of named aphasia is better.

(2) Lesions

It is generally believed that the lesions are located in the angular gyrus and the posterior part of the middle temporal gyrus of the left cerebral hemisphere, but it is difficult to find a single lesion at present, and this kind of aphasia is mostly caused by scattered injuries.

(3) Examples of cases

Male, 36 years old, you Li, university culture, cadre patient was admitted to the local hospital in June 2000 for head injury, and was transferred to the hospital for further rehabilitation treatment three months later. After admission, he was examined for standard aphasia in Chinese: his spoken language is fluent, and his spoken language is characterized by lack of substantive words, such as nouns. When the patient answered his profession, he said, "I have to sell everything that others can use. When the patient said the name of the fruit, he said, "I don't know what to say now ... what's the name of that sand? I forgot it. I can call it out by reading the words ... They didn't give me anything I knew. As soon as I said it, they gave it to me, stuffed it in my mouth, and I didn't want to eat it. They forced me to eat it." We don't even have this thing there. "When talking about another picture (banana), we said," This can be eaten by men and women, and everyone can eat it as long as they like, but some people can't get it, so they have to slip their hands. "Listening comprehension checks the correct rate: nouns are 70%, verbs are 60%, sentences are 40%, and oral instructions are 20% correct. Only 20% of the sentences are correct when they are named 80%, and the voice prompts can answer the correct action instructions 100%. The correct reading rate: nouns and verbs are 60% and 70% respectively, and sentences are 0. The correct reading comprehension rate: nouns and verbs are 70%, 60% and sentences are 40% respectively. Writing is 0, copying is 40% correct and dictation is 20%.

7. Complete aphasia (global aphasia)

(1) Main clinical features

Complete aphasia belongs to non-fluent aphasia, which is a kind of aphasia that all language patterns of listening, speaking, reading and writing are seriously damaged. The main manifestations are that there are very few spontaneous words, only repeated naming and retelling of individual words or meaningless syllables can not understand the words, and even if they can understand, there are very few words. The biggest feature of this kind of patients is that they can speak some series of languages, such as counting some parts in one breath and singing some songs and lyrics. It is difficult to recover from complete aphasia. It is difficult for patients to recover to the point where they can communicate with each other by words. At the beginning, they are completely aphasia. With the passage of treatment and time, they may have Broca and Wernicke aphasia characteristics when their symptoms are relieved. Some scholars call it mixed non-fluent aphasia. Some cases have better understanding during recovery, but the oral expression disorder is serious, showing Broca aphasia characteristics, which is a common transformation form of complete aphasia.

(2) Lesions

Most scholars believe that the language area around the lateral fissure of the dominant hemisphere of the brain has been extensively damaged. Most of these patients are accompanied by right hemiplegia, hemianopia and hemiplegia.

(3) Examples of cases

Male, 62 years old, You Li, engineer, college education 19981On October 25th, he fell when he got up and went to the toilet, and then he found that his right upper and lower limbs were weak, and at the same time he gradually could not speak1On October 27th, CT showed that "low-density lesion in the left frontal and temporal lobes" was treated in a local hospital for 2 weeks, and his condition was stable, so for further recovery. As a stereotype, any words are answered with "people, people ……", which is a serious obstacle to oral understanding. Only individual words and simple gestures can be understood. Reading, reading, understanding and writing can't be repeated aloud. It is impossible to calculate the imitation of oral and facial movements, vowel sequence, and there is an exploratory behavior diagnosis: complete aphasia of cerebral infarction, oral and facial apraxia.

8. mixed transcortical aphasia.

(1) Main clinical features

Also known as isolation of the speech area.

Mixed transcortical aphasia is the coexistence of transcortical motor aphasia and transcortical sensory aphasia. This kind of aphasia is less common in oral expression, and it can't form a language that can express meaning at all, or even is only stereotyped repetition, or is limited to imitating all or part of what the examiner said. For example, when the doctor asks a patient "What's your name", the patient immediately answers "What's your name"; When asked "how many people are there in the family", the patient immediately answers "how many people are there", which is called echo language or imitation language. It is one of the characteristics of mixed transcortical aphasia. Some patients also have the phenomenon of completion, that is, after hearing the other party say part of the commonly used sentence, they can complete the second half sentence. For example, if the examiner says "mountains cover the white sun", the patient can say "and oceans drain the golden river" later, or even finish the rest of the words, which seriously hinders oral understanding.

(2) Lesions

It is generally believed that the lesion site is a large lesion in the watershed area of the dominant hemisphere, but Wernicke area in Broca area and the area connecting them are not damaged

(3) Examples of cases

Female, 6 1 year-old, you Li, retired employee, with a college education level, was admitted to the hospital in 200 1 year1month because of "inability to move the right limb with unclear speech1month". The patient was given intravenous infusion due to dizziness in that year1month. When the blood pressure dropped, he was transferred to the local superior hospital for treatment. At that time, he didn't respond. After 8 days of treatment, his consciousness turned clear, but he couldn't speak. After half a month, he could speak a few words, but he couldn't actively express them. The cough was relieved. The reexamination CT showed that "the left frontotemporal parietal lobe and basal ganglia were low-density foci". After admission for further recovery, the hearing was checked as the normal threshold. Examination of Chinese standard aphasia: spontaneous oral English was not fluent and there was echo language. If you ask "What's your name", the patient answers "What's your name" and asks "How old are you this year", and the patient answers "Age", and there is a phenomenon of completion. The correct answer rate of listening comprehension is: 20% for nouns and 70% for verbs, and the correct naming rate of short sentences that can repeat 3-4 words is 10%.

9. pure word deafness

(1) Main clinical features

Clinical manifestations are serious obstacles to listening comprehension, even if listening to the word finger map can't be completed. Patients often take the initiative to say that they can't understand what others say. If patients can write, they often take the initiative to ask for fluency in written answers and can express their thoughts. There are no or occasional phonetic mistakes in the early stage of the disease. With the extension of the course of the disease, patients' mistakes increase obviously, making it difficult for the other party to distinguish their meaning and repeat the serious obstacles. Often, even words or monosyllables can't repeat the patient's spontaneous writing. The naming writing description is normal, and even diaries and articles can be written. However, dictation disorder or inability to be purely deaf can lead to the separation of word sounds from social natural sounds. Patients don't understand the meaning of words, but they can distinguish non-word sounds, such as thunder, running water, cats screaming, clapping, babies crying, trains whistling and so on. Even patients can distinguish the sound of "old-fashioned" steam locomotive. Most of the hearing is at the normal threshold, and some of them may be mild high-frequency hearing loss. Pure word deafness is rare in clinic, and there is still controversy about whether its disorder belongs to aphasia or auditory aphasia. However, at present, most people think that pure word deafness is not a real language disorder, but a sensory transmission problem, and it is defective in the ability to transmit speech stimuli to the cortex to explain its meaning. The causes of pure word deafness are mostly cerebrovascular accidents, brain tumors and brain injuries, and cerebral vascular accidents are unilateral temporal lobe injuries.

(2) Lesions

Located in unilateral temporal lobe or bilateral temporal lobe, almost all lesions in bilateral temporal lobe can cause pure word deafness. At present, it is believed that Wernicke area is intact when pure word deafness is caused by lesions in unilateral temporal lobe or bilateral temporal lobe. Unilateral temporal lobe injury is located in the deep part of the main temporal lobe, affecting the transverse temporal gyrus or fibers projecting to the primary auditory pathway, while bilateral temporal lobe lesions involve the middle part of bilateral superior temporal gyrus.

(3) Examples of cases

Male, 28 years old, He Liyi was admitted to the hospital on June 3rd, 1995 for "language comprehension disorder and expression disorder 12 years". He was admitted to the hospital and diagnosed as "encephalitis sequela". He was admitted to the hospital for physical examination: conscious, free expression, no abnormality in nervous system examination, normal limb function, bilateral symmetry and normal muscle tension. Self-care Chinese standard aphasia examination: spontaneous. With a large number of phonetic mistakes, the listening comprehension is seriously hindered. The correct rate of nouns is only 30%, and the comprehension of verbs and sentences is 0. Reading aloud is relatively good, and the average correct rate is 70%~80%. Reading, copying, describing and calculating skills are normal. The correct answer rate of common social environment sounds (including thunder, streams, running water, hens laying eggs, trains, cars, birds and clapping, etc. 10 sounds) is 80%. Pure tone listening test and listening test.

10. Subcortical aphasia

The types of aphasia mentioned above are closely related to the damage such as the interruption of the conduction bundle in the cortical language center or the connecting cortical area, and most of them have typical aphasia. In recent 30 years, with the development of clinical diagnostic techniques, such as the application of CT and CTMRI local cerebral blood flow measurement, it has been found that aphasia can also be caused by subcortical lesions alone, but the mechanism of aphasia is still controversial. Common types of aphasia, such as basal ganglia aphasia and thalamic aphasia, are atypical compared with the above types of aphasia, so some scholars call them atypical aphasia.

(1) basal ganglion aphasia

① Main clinical features: Basal ganglia, including caudate nucleus of putamen and globus pallidus, is anatomically close to the internal capsule, so it is often involved at the same time when it is diseased. Domestic aphasia studies have found that this kind of aphasia is the most common. The patients with basal ganglia aphasia in Peking University Affiliated Hospital account for 22% of all aphasia patients, and the cases studied by China Rehabilitation Research Center account for 26%. The conversational speech of basal ganglia aphasia is between fluent and non-fluent aphasia, which is called intermediate type. Foreign data show that the lesion site is in the Broca. When the lesion was located in the back, it was similar to Wernicke aphasia. The lesions are large and spread to the whole basal ganglia, and the clinical manifestations are similar to complete aphasia. Domestic studies show that when the lesion is in the front, it is similar to non-fluent aphasia. When the lesion is at the back, it is similar to fluent aphasia. Generally speaking, it is better in retelling, but in the early stage of the disease, especially when the damage area is large, it may not be good, but with the recovery of the disease, the retelling ability can be quickly restored. Generally, short sentences can be retelled, but for longer sentences, the naming of nouns is better, and there are obvious obstacles in listing. The description of scenes is more difficult in oral understanding. The understanding of noun verbs and short sentences is good, but there are obvious obstacles to the understanding of longer sentences and the execution of oral instructions. In reading, most patients perform better in reading aloud, but have poor reading comprehension, which is similar in nature to oral comprehension obstacles. In writing, except for a few patients who can write by name, most patients have outstanding obstacles in action description.

② Lesions: Mainly in the capsule area of basal ganglia.

(2) thalamic aphasia.

Thalamic aphasia is aphasia caused by thalamic lesions. Thalamic aphasia collected by Language Department of China Rehabilitation Research Center 10 years accounts for 4% of the total aphasia, including 3 cases of cerebral hemorrhage and 1 case of brain tumor 1 case.

① Main clinical features: The intermediate type of thalamic aphasia has a smooth conversation, a low tone and a low volume, and sometimes it even sounds like a whisper, but the sound is still clear. Individual expressions are indifferent and do not take the initiative to speak. Generally, they can simply answer questions and describe their medical history. Some patients have normal or mild obstacles in semantic misspelling, and most thalamic aphasia can repeat sentences with obvious naming obstacles. In naming, naming words and enumerating words have serious semantic errors. Naming nouns, verbs and short sentences in colors is better, but reading comprehension is better, but reading comprehension is relatively poor. Most thalamic aphasia has different degrees of word formation and grammatical structure disorders, and the prognosis of thalamic aphasia is better. Most of them can recover in a few weeks, but they often leave different degrees of naming obstacles, but some data confirm that individual patients leave obvious language obstacles.

② focus: thalamus

1 1. crossed aphasia

The vast majority of aphasia in clinic is caused by the left hemisphere injury, but there are some patients with exception. Braimwell( 1899) introduced the term "cross aphasia", which is used to describe the right hemiplegia and aphasia caused by the left hemisphere injury of left-handed people. Or left hemiplegia and aphasia caused by right-handed people's right hemisphere damage. At present, cross aphasia is used to describe aphasia caused by right-handed people's right hemisphere damage. Such patients are rare, and their incidence rate is less than 1%~2% of aphasia, and it is different from those typical aphasia and non-cross aphasia in etiology. Boller( 1973) estimated that only 23% of cross aphasia was caused by vascular diseases, and the cause of most cases was tumor and craniocerebral trauma. This conclusion is obviously different from that of traditional right-handed aphasia caused by left hemisphere damage, mainly because of vascular diseases. It is difficult to classify cross aphasia according to the types of traditional aphasia, so it is also called atypical aphasia. In terms of symptoms, most patients have grammar and writing disorders. Listening comprehension and naming are less affected, but there are also some reports that aphasia symptoms of patients with right frontal lobe injury caused by cerebrovascular disease are similar to Broca aphasia.

12. Acquired aphasia in children

It refers to the aphasia that occurs after children have partially acquired or already acquired oral English. Foreign data show that the onset age is after 3 years old, but some people think that children's acquired aphasia is rare in aphasia after 1 year old. In the Language Department of China Rehabilitation Research Center, the disease accounts for 4.7% of the total aphasia diagnosed and treated. In terms of etiology, the main cause of adult aphasia is cerebrovascular disease. The main cause of children's acquired aphasia is brain trauma in terms of language performance, which is rare in adult patients. After silence disappears, it is characterized by slow speech speed, less speech, weak voice and abnormal rhythm. In addition, almost all children with aphasia are not fluent in oral expression, which is obviously different from adult aphasia. Adult frontal lobe injury is characterized by non-fluent aphasia, while temporal lobe injury is characterized by fluent aphasia and disorder.