Case Report

How Long Is the Recovery
of Global Aphasia? Twenty-Five Years
of Follow-up in a Patient With Left
Hemisphere Stroke

Neurorehabilitation and
Neural Repair
24(9) 871­–875
© The Author(s) 2010
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1545968310368962
http://nnr.sagepub.com

Nicola Smania, MD1, Marialuisa Gandolfi, MD1,
Salvatore Maria Aglioti, MD2, Paolo Girardi, PhD1,
Antonio Fiaschi, MD1, and Flavia Girardi, SP3

Abstract
Background. Current knowledge regarding the time course of aphasia recovery is based on observations limited to the first
years after stroke. Objective. The authors studied long-term outcome (25 years) of language in a patient with global aphasia.
Methods. A 37-year-old man with global aphasia from a large ischemic lesion in the left middle cerebral artery territory was
tested 9 times between 3 weeks and 25 years poststroke by means of the Milan Language Examination, Token Test, Raven
Test, and apraxia tests. Results. Three main periods of recovery were identified. The first year after stroke was characterized
by recovery of verbal comprehension and word repetition. From 1 to 3 years, naming and reading improved. From 3 to
25 years, progressive improvement of previously emerged functions was found, as well as the appearance of spontaneous
speech. Conclusions. This unique long-term follow-up shows that the time span for recovery of language functions in global
aphasia after stroke may be much longer than previously documented.
Keywords
language, outcome, rehabilitation, cerebrovascular disorders

Introduction
Studies on aphasia recovery report that the greatest degree of
language recovery takes place in the first months after stroke.1
Although the rate of recovery drops after 3 to 6 months,
evidence of language improvement even 1 or 2 years after
stroke have been reported in the literature.2,3 Only a small
number of studies have followed patients with aphasia longer
than 2 years poststroke.1,4-6 Therefore, current knowledge on
the potential recovery of chronic aphasia is not sufficient.
In this article, we report the case study of a patient with
global aphasia who was tested in a wide range of language,
intelligence, and praxic abilities for 25 years after stroke.
Information drawn from this study may have important implications for aphasia therapy.

Hospital, Verona, Italy. The computed tomography scan of his
brain revealed a large ischemic cortical and subcortical lesion
in the left middle cerebral artery territory. The patient had no
risk factors for cerebrovascular disease and no previous history
of cerebrovascular attacks. He was right handed and had 13
years of education. He underwent language rehabilitation for
2 years, 5 times per week in the first 6 months and then 3 times
per week until the end of the second year. For many years, his
only speech production was the nonsense word “musi.” Details
of his brain lesion are presented in Figure 1. He was tested
with the Milan Language Examination (MLE), the Token Test,8
the Raven Test,9 and tests for oral, ideational, and ideomotor
apraxia10 at 3 weeks, 2 and 6 months, and 1, 2, 3, 10, 21, and
1

CRRNC, University of Verona, Italy
Fondazione Santa Lucia IRCCS and Sapienza, Università di Roma, Italy
3
“C Santi” Rehabilitation Centre, Verona, Italy
2

Case Report
In 1983, a 37-year-old man presented with acute onset of right
hemiplegia, hemianesthesia, and language disturbances. He
was admitted to the Neurology Unit of the GB Rossi University

Corresponding Author:
Nicola Smania, MD, Rehabilitation Unit, “GB Rossi” University Hospital,
Via LA Scuro, 10, 37134 Verona, Italy
Email: nicola.smania@univr.it

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Neurorehabilitation and Neural Repair 24(9)
description 15%). Significant correlations were found between
time changes in these language functions: Comprehension–
Repetition (r = .928, P < .001), Naming–Reading (r = .994,
P < .001), Repetition–Naming (r = .867, P < .001), and
Repetition–Reading (r = .874, P < .001).

Discussion

Figure 1. Brain magnetic resonance imaging performed 21 years
after stroke. Lesion mapping showed involvement of Brodmann’s
areas 22, 21, 20, 37, 44, 6, 6s, 4, 40, 39, 3, 1, 2, 5, and 7 (MRIcron
software, see http://www.mricro.com/mricron)

25 years poststroke. An additional examination performed 3
years after stroke showed that spatial memory (Corsi BlockTapping test,11 span = 5, supraspan = 8) and selective attention
(Attentional Matrices Test,12 total score = 42/60) were within
normal ranges. Verbal memory was not testable because of
the severity of his aphasia.
MLE data were analyzed by means of descriptive analysis
and a linear regression model (score = a + β log(time)) to
estimate the trend of the MLE data over time. Spearman’s
test between the main language functions (comprehension,
repetition, naming, event description, reading) was performed
by computing the raw scores of speech naming and event
description and the mean scores of comprehension, repetition,
and reading items of the MLE (P < .05). Statistical analysis
was performed with R Package 2.8.1.

Results
MLE and other neuropsychological test data are given in Table
1. The MLE linear regression model showed a significant
improvement in each language function (Comprehension R2
= 81.85, Repetition R2 = 96.67, Naming R2 = 79.13, Reading
R2 = 78.68, Event description R2 = 60.36) over time. The rate
of improvement was estimated at 1 year (Comprehension 70%,
Repetition 50%, Naming 0%, Reading 0%, Event description
0%), 3 years (Comprehension 84%, Repetition 62%, Naming
24%, Reading 25%), and 25 years after stroke (Comprehension
100%, Repetition 85%, Naming 45%, Reading 46%, Event

Results showed that recovery of global aphasia after stroke
is not limited to just the first years following onset but can
extend for even more than 1 decade. Overall, 3 main periods
of recovery could be identified (Figure 2). The first period
(first year after stroke) was characterized by recovery of verbal
comprehension and word repetition, the second (1-3 years)
by emergence of naming and reading, and the third (3-25
years) by a progressive improvement of previously emerged
functions, as well as the appearance of spontaneous speech
(event description).
To illustrate the time course of recovery found in our
patient, we will discuss each main language function tested
by the MLE separately (Figure 2).
Auditory comprehension was the first function to show
recovery, in particular in the first years.2 However, different
patterns of comprehension recovery were evident, depending
on the contextual content of the tasks used. In the MLE
comprehension subtests, in which the patient was challenged
with simple and contextualized tasks (eg, to indicate which
figure represents the everyday object verbalized by the
speech therapist), the patient showed a rapid recovery,
approaching normal performance in a 1-year time frame. On
the contrary, a slower and more progressive recovery of performance occurred in the Token Test,3,13 which consists of
very decontextualized and unusual verbal comprehension
tasks (eg, to touch 1 or more tokens of different sizes and/
or colors; Table 1).
Repetition also had its greatest rate of recovery in the first
year, paralleling the trend of comprehension improvement.
After the first year, repetition continued to slowly improve,
reaching its highest level after 10 years.
Naming of a visual item, which implies the ability to
autonomously transform a visual–structural representation
into a phonological output,14 emerged between 1 and 3 years
after stroke and progressively improved, reaching 45% of
performance in 25 years. It should be noted that reading had
a trend of recovery equivalent to that of naming (Figure 2),
suggesting that reading and naming may share elements of
their neural substrates.15 Spontaneous speech (“Event description” in Table 1) emerged many years after stroke, first documented at 10 years, and then slightly improved over time.
Although spontaneous speech production was limited to a
few high-frequency words (house, bread, beard, etc), this
complex language task implies that the patient reached the
skill of autonomously selecting a lexical representation from

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Smania et al
Table 1. Results of Neuropsychological Examination
Time From Stroke
Milan Language
Examination

3 Weeks

2 Months

6 Months

1 Year

2 Years

3 Years

10 Years

21 Years

Speech									
Event description
0
0
0
0
0
0
1
2
0
0
0
0
10
20
35
55
Naming
Comprehension									
Words
40
55
80
95
100
100
100
100
WSR
10
40
80
80
90
90
100
100
Sentences
10
10
45
90
75
100
100
100
Repetition									
Letters
0
80
90
100
100
100
100
100
80
80
70
90
100
100
100
100
Syllable
Words
0
0
35
35
50
70
80
95
Neologism
0
0
20
50
30
30
50
80
0
0
0
20
0
0
30
60
Sentences
Writing									
Text (letter)
Unable
Unable
Unable
Unable
Unable
Unable
Unable
Unable
Naming
0
0
10
15
25
25
25
30
Reading comprehension									
Words
0
75
100
100
100
100
100
100
SWR
0
70
70
75
90
95
100
100
Sentences
0
0
80
80
80
80
80
80
Reading									
Letters
0
0
10
20
20
20
40
75
Syllable
0
0
0
0
15
50
50
70
Words
0
0
0
0
0
15
50
70
Neologism
0
0
0
0
0
0
20
20
Sentences
0
0
0
0
0
0
20
40
Dictation									
Letters
0
90
80
100
100
80
90
100
Syllable
0
20
0
70
90
60
80
100
Words
0
0
0
10
10
10
30
50
Neologism
0
0
0
0
0
10
10
10
Sentences
0
0
0
0
0
0
10
10
Copying									
Words
0
70
100
100
100
100
100
100
M-m
0
10
50
95
100
95
100
100
Other neuropsychological									
tests
7
7
10
14
18
22
26
29,5
Token Test
Raven’s Test
ND
ND
ND
17
ND
18
ND
26
Oral apraxia
ND
15
15
20
16
20
20
20
Ideational apraxia
ND
6
12
14
14
14
14
14
Ideomotor apraxia
ND
63
60
69
65
52
ND
70

25 Years
2
50
100
100
100
100
100
95
80
40
Unable
40
100
100
100
60
70
70
30
40
100
100
35
10
10
100
100
30
28
20
14
72

Abbreviations: SRW, semantically related word; ND, no data.

semantics, accessing the phonological word form, motor
programming, and planning of articulation to say the word.14
The most challenging question is to understand why this
patient demonstrated such improvements in the long-term. In
the first years after stroke, we hypothesize that improvements
may have been influenced by language rehabilitation, which

took place 5 days per week in the first 6 months and then 3
times per week until the end of the second year.16 With regard
to the progressive recovery seen in the long term, other factors,
such as the patient’s strong motivation and active social participation,17 may also have played an important role. Indeed,
motivation may have continuously stimulated the patient to

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Neurorehabilitation and Neural Repair 24(9)

Figure 2. Time course of recovery of language function over 25 years. MLE indicates Milan Language Examination

express himself and to practice his linguistic abilities outside
of a rehabilitative context.17 Further important factors possibly
contributing to the recovery process may be the patient’s young
age1,18 and the presence of relatively spared residual cognitive
functions, such as memory and attention.19,20 This condition
may have produced a favorable foundation for continued acquisition of new language abilities.
Evidence emerging from the present case report may have
implications for rehabilitation of language disorders after
stroke. First, the results suggest that the time window for
possible improvement in global aphasia may be much wider
than previously believed. Based on this, it could be hypothesized that patients may benefit from language stimulation
over the long term. Moreover, the behavioral changes seen
in our patient suggest that possible care programs in chronic
aphasia should take into account not only conventional aphasia
training approaches but also other kinds of stimulation such
as the stimulation of various nonlinguistic cognitive abilities19,20 and the creation of a context within a person’s everyday life that provides a sense of motivation and permits social
interaction.17 The main limit of the present case report is that
because this study was based only on clinical examination, it
is not possible to identify how functional brain changes were
involved in the process of long-term language recovery.

In conclusion, the present study highlights that in patients
with global aphasia there may be some potential for the emergence and improvement of linguistic functions even many
years after stroke.
Declaration of Conflicting Interests
The author(s) declared no conflicts of interest with respect to the
authorship and/or publication of this.

Funding
The author(s) disclosed receipt of the following financial support
for the research and/or authorship of this article: This work was
supported by a grant from the CariVerona Foundation, Italy.

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