Alexia is an acquired disorder resulting in the inability to read or comprehend written language. The affected individuals remain capable of spelling and writing words and sentences but are unable to comprehend what was written by themselves. This is differentiated from the mechanical inability to read, such as visual impairment and educational factors resulting in illiteracy. Alexia is usually a result of brain injury/damage, most often from cerebral vascular accidents affecting the dominant hemisphere. It is often associated with other comprehension deficits such as agraphia (inability to write), acalculia (inability to do arithmetics), and aphasia (spoken language and language recognition deficit). Alexia is also known as "word blindness" or "agnosic alexia" and is a rare condition, first described by Dejerine in 1887. This condition involves the inability to read with retention of writing skills, speech production, and comprehension.
Alexia ranges on a spectrum from very mild reading deficit to a complete inability to comprehend written language often associated with agraphia, the inability to write. The most common cause of alexia is a stroke (embolic or ischemic cerebral vascular accident) affecting the dominant cerebral hemisphere, although it may be caused by other etiologies resulting in a disruption to that area such as lesions, injury, or trauma. The specific area of the brain affected results in three distinct types of alexia: frontal or anterior alexia, central or parietal-temporal alexia, and posterior or occipital alexia. Each type is characterized by specific deficits in reading comprehension with or without other neurocognitive deficits.
Isolated alexia without agraphia is uncommon, and statistics are limited. However, it is often associated with other types of strokes and neurological deficits caused by cerebral vascular accidents. Strokes cause a significant amount of morbidity and mortality worldwide in both women and men. Statistics from 2017 show an incidence rate of stroke at 140.3 to 161.8 per 100,000 in 2017.
There are varying degrees of comprehension deficit resulting in different types of alexia, including occipital or posterior alexia, central or parietal-temporal alexia, and frontal or anterior alexia. The neuroanatomical area that controls visual perception and interpretation is known as the visual word form area (VWFA) located in the occipitotemporal gyrus. Most of the language processing occurs around the angular gyrus of the left hemisphere, the dominant hemisphere for most of the population. Damage to these areas can result in multiple language-related deficits such as Broca's aphasia, Wernicke's aphasia, global aphasia, alexia, and others. In each form of alexia, a different area of the brain is found to be damaged. There are three major classifications of alexia with different alexia syndromes associated with each.
The first presentation is known as alexia without agraphia, pure alexia, posterior alexia, or occipital alexia and is associated with damage to the occipital region. The visual word form area is affected, and visual input cannot be relayed to the language comprehension areas of the brain. The communicating area between the auditory centers and the language centers is maintained, resulting in the retained ability to interpret words spelled out to or by the individual.
The second presentation known as central or parietal-temporal alexia is associated with damage to the angular gyrus. Central alexia involves damage to the pathways connecting the visual word form area and the auditory area to the language centers of the brain, resulting in word blindness as well as the inability to spell out or recognize spelled out words.
The third presentation, known as frontal or anterior alexia, is associated with an anterior lesion to the left hemisphere. The visual word form area is spared, resulting in the ability to interpret written language through verbal working memory. The individual is able to recover word identity by recognition of common or content words.
Alexia without agraphia, pure alexia, posterior alexia, or occipital alexia is associated with damage to the occipital region.
Central or parietal-temporal alexia is associated with damage to the angular gyrus.
Frontal or anterior alexia is associated with an anterior lesion to the left hemisphere.
Evaluation of a patient with alexia includes a thorough physical examination to assess for reading fluency as well as comprehension. A baseline reading level prior to the insulting injury would be beneficial to the evaluation of the patient. Patients should be asked to read short stories and evaluated on comprehension of the material and the speed at which the material was read. Patients should also be evaluated on their ability to spell out words, comprehend spelled words, and writing. A comprehensive neurological examination should be completed to assess for other neurocognitive disfunction. Neuroimaging with a computed tomography (CT) scan or magnetic resonance imaging (MRI) may be done to help localize the affected area, severity, and acuity of the condition. A stat head CT scan should be done on anyone presenting with new-onset alexia to assess for acute cerebral vascular accidents. MRI brain has a higher sensitivity than a head CT and must be considered if the head CT is nondiagnostic.
Treatment and management of alexia are focused on rehabilitation strategies to improve reading. The treatment modality for alexia depends on the neuroanatomical area affected, as described above. For individuals with intact letter recognition, a letter by letter approach to reading is used in which each letter is sounded out individually. For patients with intact writing skills, a kinesthetic approach is used. In this approach, the patient will trace or outline the letters and sound them out by the tactile input provided from writing the letter. These tactics can be used regularly to increase reading speed over time. Although this may improve symptoms, a definite cure for the disorder has not been found.
Alexia is the inability to comprehend written language due to focal brain injury in the temporal lobe. It is important to distinguish alexia from other disease processes that impair reading. These may include visual impairment, eye trauma or injury, cataracts or blindness, other neurocognitive disorders such as global aphasia, dementia, intoxication, mutism, and psychiatric conditions such as catatonia, depression, or schizophrenia.
The prognosis for patients suffering from alexia is variable and highly dependant on multiple variables. The type of alexia, cause of injury, and amount of rehabilitation done after the insulting injury play a critical role in determining prognosis. Although individuals may improve their reading comprehension, complete resolution is rare.
Complications of alexia encompass a spectrum of reading disabilities that range from permanent loss of comprehension to mild reading impairment. Alexia almost always accompanies other neurocognitive deficits associated with the inciting insult. These conditions include but are not limited to complete aphasia, hemineglect, visual field deficits, and death.
Alexia itself has less association with increased morbidity in affected individuals however, combined with other communication issues, it can significantly contribute to disability. Individuals suffering from strokes and subsequent neurocognitive dysfunction can become withdrawn, depressed, and feel secluded. Removing a form of communication such as interpretation of written language can add to depression and isolation. Patient education should be emphasized to the individual and surrounding family and caretakers. Education should be provided in multiple forms rather than the traditional written discharge instructions, which will be incomprehensible to the patient. Education should focus on how to interpret repeat stroke symptoms for patients, patient's families, and caretakers.
Individuals living with alexia may never recover, and emphasis should be placed on rehabilitation. New reading techniques such as letter-by-letter reading, word recognition, and kinesthetic approach, mentioned above, should be implemented. An interprofessional team approach should be taken between the patient's neurologist, primary care provider, rehabilitation team, family, and caregivers to maximize recovery. Patients should also be provided with emotional support for the possible development of depression commonly seen in individuals suffering from strokes with neurocognitive deficits.
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