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// ═══════════════════════════════════════════════════════════════════
//  SLIDE CONTENT
// ═══════════════════════════════════════════════════════════════════

// 1. Title slide
titleSlide("Disorders of Speech\nand Language", "Neurology | Communication Sciences | Clinical Practice");

// 2. Outline
contentSlide("Lecture Outline", [
  "Section 1 — Foundations: Anatomy & Physiology of Speech",
  "Section 2 — Normal Language Development",
  "Section 3 — Dysarthria & Anarthria",
  "Section 4 — Dysphonia & Voice Disorders",
  "Section 5 — Aphasia: Overview & Classification",
  "Section 6 — Individual Aphasic Syndromes",
  "Section 7 — Transcortical & Subcortical Aphasias",
  "Section 8 — Reading, Writing & Related Disorders",
  "Section 9 — Developmental Speech/Language Disorders",
  "Section 10 — Assessment & Management",
], { fontSize: 15 });

// ─── SECTION 1: FOUNDATIONS ───────────────────────────────────────
// 3
sectionBanner("Section 1\nAnatomy & Physiology of Speech");

// 4
contentSlide("Speech: A Complex Motor Act", [
  "Speech requires highly coordinated action of multiple structures:",
  { text: "Respiratory musculature — regulated expired air bursts", sub: true },
  { text: "Larynx & vocal cords — phonation and pitch control", sub: true },
  { text: "Pharynx & palate — resonance modulation", sub: true },
  { text: "Tongue & lips — articulation of consonants and vowels", sub: true },
  "Innervation: Vagal (CN X), Hypoglossal (CN XII), Facial (CN VII), and Phrenic nerves",
  "Motor cortices control nuclei via corticobulbar tracts (bilateral)",
  "Extrapyramidal modulation: cerebellum (coordination) and basal ganglia (smoothness)",
]);

// 5
twoColSlide(
  "Phonation vs. Articulation",
  "Phonation",
  [
    "Production of vocal sounds via the larynx",
    "Vocal cord length & tension determine pitch",
    "Intrinsic laryngeal muscles vary tension",
    "Intratracheal pressure forces air past glottis",
    "Creates vibration series — voice",
    "Vowels are primarily laryngeal in origin",
  ],
  "Articulation",
  [
    "Modification of laryngeal sounds",
    "Involves pharynx, palate, tongue, lips",
    "Consonant types:",
    "  • Labial: /m/, /b/, /p/",
    "  • Lingual: /l/, /t/",
    "  • Guttural: /ng/, /nk/",
    "Nasopharynx & oral cavity act as resonators",
  ]
);

// 6
contentSlide("Neural Pathways for Language", [
  "Language is a dominant hemisphere function (left in ~95% of right-handers)",
  "Broca's Area (Inferior Frontal Gyrus, BA 44/45) — speech production, syntax",
  "Wernicke's Area (Posterior Superior Temporal Gyrus, BA 22) — language comprehension",
  "Arcuate Fasciculus — white-matter bundle connecting Broca & Wernicke areas",
  "Angular Gyrus (BA 39) — reading, writing, cross-modal association",
  "Supramarginal Gyrus (BA 40) — phonological processing",
  "Perisylvian language circuit: Broca → Arcuate Fasciculus → Wernicke",
  "Lesions outside perisylvian zone → Transcortical aphasias (repetition spared)",
]);

// 7
contentSlide("The Perisylvian Language Network", [
  "The Sylvian fissure is the anatomical anchor of core language regions",
  "Anterior: Broca area — production and grammatical processing",
  "Posterior: Wernicke area — comprehension and phonemic decoding",
  "Superior: Arcuate/Superior Longitudinal Fasciculus — repetition pathway",
  "Insula: Adjacent to Broca area — implicated in conduction aphasia",
  "Disruption of any node → specific language syndrome",
  "Vascular supply: predominantly middle cerebral artery (MCA) territory",
  "Watershed zones (ACA-MCA / MCA-PCA) → transcortical aphasias",
]);

// 8
contentSlide("Testing Speech & Language at Bedside", [
  "Six domains to evaluate in every aphasic patient:",
  { text: "1. Spontaneous speech — fluency, phrase length, effort, paraphasias", sub: true },
  { text: "2. Naming — confrontation naming of objects/body parts", sub: true },
  { text: "3. Comprehension — yes/no questions, pointing, complex commands", sub: true },
  { text: "4. Repetition — simple words → complex sentences", sub: true },
  { text: "5. Reading — comprehension (silent) and reading aloud", sub: true },
  { text: "6. Writing — spontaneous, dictation, copying", sub: true },
  "Contrived test phrases: 'Methodist Episcopal'; rapid repetition la-la-la, me-me-me, k-k-k",
  "Associated signs: hemiparesis, hemisensory loss, apraxia, visual field defects",
]);

// ─── SECTION 2: LANGUAGE DEVELOPMENT ─────────────────────────────
// 9
sectionBanner("Section 2\nNormal Language Development");

// 10
contentSlide("Milestones of Speech & Language Development", [
  "Birth–3 months: Cooing, reflexive vocalization, response to voice",
  "4–6 months: Babbling begins; reduplicated syllables (ba-ba)",
  "9–12 months: First words; jargon; response to name",
  "12–18 months: 10–50 single words; points to pictures",
  "18–24 months: Two-word combinations; 200+ word vocabulary",
  "2–3 years: Simple sentences; 900+ words; intelligible to strangers ~75%",
  "3–4 years: Complex sentences; narrative; ~1500 words",
  "4–5 years: Adult-like grammar; 2000+ words; fully intelligible",
  "Phonological accuracy: most sounds mastered by age 7–8",
]);

// 11
contentSlide("Language Dominance & Hemispheric Lateralization", [
  "~95% of right-handers: left hemisphere dominant for language",
  "~70% of left-handers: left hemisphere dominant",
  "~15% of left-handers: right hemisphere dominant",
  "~15% of left-handers: bilateral representation",
  "Dichotic listening and sodium amytal (Wada) testing can assess lateralization",
  "Early lesions (< 2 years) may allow right hemisphere to take over language",
  "This plasticity decreases with age — critical period concept",
  "Gender differences: women show more bilateral language representation",
]);

// ─── SECTION 3: DYSARTHRIA ───────────────────────────────────────
// 12
sectionBanner("Section 3\nDysarthria & Anarthria");

// 13
contentSlide("Dysarthria: Definition & Overview", [
  "Dysarthria: disorder of speech articulation due to neuromuscular dysfunction",
  "Anarthria: most severe form — complete inability to articulate intelligible words",
  "In pure dysarthria: NO abnormality of cortical language mechanisms",
  "  → Patient understands speech, can read and write normally",
  "  → Only the motor execution of speech is impaired",
  "Subtypes based on anatomical level of dysfunction:",
  { text: "Lower Motor Neuron (neuromuscular)", sub: true },
  { text: "Spastic (pseudobulbar)", sub: true },
  { text: "Rigid / Extrapyramidal", sub: true },
  { text: "Cerebellar-Ataxic", sub: true },
  { text: "Hypo- and Hyperkinetic", sub: true },
]);

// 14
contentSlide("Lower Motor Neuron (Flaccid) Dysarthria", [
  "Cause: Weakness/paralysis of articulatory muscles",
  "Level: Disease of motor nuclei of medulla/lower pons OR their peripheral extensions",
  "Clinical features:",
  { text: "Shriveled, inert, fasciculating tongue on floor of mouth", sub: true },
  { text: "Lax and tremulous lips; drooling (dysphagia)", sub: true },
  { text: "Dysphonia — rasping monotone (vocal cord paralysis)", sub: true },
  { text: "Slurred, progressively less distinct speech", sub: true },
  { text: "Difficulty with vibratives (r); lingual/labial consonants lost", sub: true },
  { text: "Bilateral palatal paralysis → nasality of speech", sub: true },
  "Causes: Progressive bulbar palsy (MND), diphtheria (historical), Guillain-Barré, myasthenia gravis",
  "Nasal escape test, dysphonia, hypernasal resonance — hallmarks",
]);

// 15
contentSlide("Spastic (Pseudobulbar) Dysarthria", [
  "Cause: Bilateral upper motor neuron (corticobulbar) lesions",
  "Results in pseudobulbar palsy — bilateral UMN pattern",
  "Speech characteristics:",
  { text: "Slow, strained-strangled quality", sub: true },
  { text: "Low pitch, reduced volume", sub: true },
  { text: "Hypernasality", sub: true },
  { text: "Imprecise consonant production", sub: true },
  { text: "Short phrases, effortful articulation", sub: true },
  "Associated features: dysphagia, emotional lability (pathological laughing/crying), exaggerated jaw jerk",
  "Tongue movements slow and labored — tongue does not fasciculate (UMN)",
  "Causes: Bilateral strokes, MS, ALS (mixed UMN+LMN), progressive supranuclear palsy",
]);

// 16
contentSlide("Rigid (Extrapyramidal) Dysarthria", [
  "Associated with Parkinson disease and other extrapyramidal disorders",
  "Speech characteristics (hypokinetic dysarthria in Parkinson's):",
  { text: "Soft, monotone voice (reduced loudness and pitch variation)", sub: true },
  { text: "Rapid, festinating speech — words run together (tachyphemia)", sub: true },
  { text: "Imprecise consonants", sub: true },
  { text: "Reduced facial expression (hypomimia)", sub: true },
  { text: "Short rushes of speech with variable rate", sub: true },
  "Hyperkinetic dysarthria (Huntington's, dystonia):",
  { text: "Irregular articulatory breakdowns", sub: true },
  { text: "Strained-strangled voice, prolonged intervals", sub: true },
  { text: "Excess loudness variation", sub: true },
  "Treat underlying cause; speech therapy (LSVT LOUD for Parkinson's)",
]);

// 17
contentSlide("Cerebellar (Ataxic) Dysarthria", [
  "Caused by cerebellar disease or its connections",
  "Speech is 'scanning' or 'staccato' — characteristic pattern",
  "Features:",
  { text: "Irregular articulatory breakdowns", sub: true },
  { text: "Excess and equal stress on syllables (scanning speech)", sub: true },
  { text: "Prolonged phonemes and intervals", sub: true },
  { text: "Distorted vowels", sub: true },
  { text: "Slow rate overall", sub: true },
  "Often co-exists with ataxia, nystagmus, intentional tremor",
  "Causes: Multiple sclerosis, cerebellar stroke, hereditary ataxias, alcoholic cerebellar degeneration",
  "No effective pharmacotherapy for dysarthria per se; speech therapy helpful",
]);

// 18
tableSlide("Dysarthria Types — Summary Table", 
  ["Type", "Lesion Level", "Key Features", "Common Cause"],
  [
    ["Flaccid (LMN)", "Brainstem nuclei / LMN", "Hypernasal, breathy, weak", "Bulbar palsy, MG"],
    ["Spastic (UMN)", "Bilateral corticobulbar", "Strained, slow, harshly hoarse", "Bilateral strokes, ALS"],
    ["Ataxic", "Cerebellum", "Scanning, irregular stress", "MS, cerebellar stroke"],
    ["Hypokinetic", "Basal ganglia (PD)", "Soft, monotone, rapid", "Parkinson disease"],
    ["Hyperkinetic", "Basal ganglia (Chorea)", "Irregular, excess stress", "Huntington disease"],
    ["Mixed", "Multiple levels", "Mixed features", "ALS, MSA, TBI"],
  ],
  { hFontSize: 12, cFontSize: 11, rowH: 0.52 }
);

// ─── SECTION 4: DYSPHONIA ────────────────────────────────────────
// 19
sectionBanner("Section 4\nDysphonia & Voice Disorders");

// 20
contentSlide("Dysphonia: Voice Disorders", [
  "Dysphonia: any disorder of the voice — quality, pitch, or loudness",
  "Aphonia: complete loss of voice",
  "Pathological voice types:",
  { text: "Hoarseness — rough, irregular vocal quality (laryngeal pathology)", sub: true },
  { text: "Breathiness — excessive air escape (vocal cord weakness/paralysis)", sub: true },
  { text: "Strained-strangled voice — excessive tension (spasmodic dysphonia)", sub: true },
  { text: "Hypernasality — air escapes through nose (velopharyngeal insufficiency)", sub: true },
  { text: "Hyponasality — nasal obstruction (rhinitis, adenoids)", sub: true },
  "Assessment: laryngoscopy, videostroboscopy, acoustic analysis",
  "Recurrent laryngeal nerve palsy → unilateral vocal cord paralysis → breathy dysphonia",
]);

// 21
twoColSlide(
  "Organic vs. Functional Voice Disorders",
  "Organic",
  [
    "Structural or neurological cause",
    "Vocal cord nodules/polyps",
    "Laryngeal cancer",
    "Recurrent laryngeal nerve palsy",
    "Parkinson disease",
    "Spasmodic dysphonia (focal dystonia)",
    "Laryngopharyngeal reflux",
    "Manage underlying cause",
  ],
  "Functional",
  [
    "No identifiable organic pathology",
    "Muscle tension dysphonia (MTD)",
    "Psychogenic aphonia",
    "Conversion dysphonia",
    "Mutational falsetto (puberphonia)",
    "Often stress / psychological trigger",
    "Voice therapy is primary treatment",
    "Excellent prognosis with therapy",
  ]
);

// ─── SECTION 5: APHASIA OVERVIEW ─────────────────────────────────
// 22
sectionBanner("Section 5\nAphasia: Overview & Classification");

// 23
contentSlide("What is Aphasia?", [
  "Aphasia: acquired impairment of lexical or syntactic language performance",
  "Due to focal brain damage — most commonly vascular (stroke)",
  "Distinct from:",
  { text: "Dysarthria — motor speech impairment, language is intact", sub: true },
  { text: "Dysphonia — voice disorder only", sub: true },
  { text: "Cognitive-communication disorder — attention, memory, executive dysfunction", sub: true },
  { text: "Psychotic disorganized speech — psychiatric, not linguistic", sub: true },
  "Aphasia involves language itself: word selection, grammar, comprehension",
  "~20–38% of stroke survivors develop aphasia",
  "First description: Paul Broca (1861) — patient 'Tan' (Leborgne)",
]);

// 24
contentSlide("Key Bedside Language Domains", [
  "1. Spontaneous Speech",
  { text: "Fluency: phrase length, effort, prosody — ANTERIOR lesions → nonfluent", sub: true },
  { text: "Agrammatism (telegraphic): 'wife come hospital'", sub: true },
  { text: "Paraphasias: literal (phonemic) vs verbal (semantic) substitutions", sub: true },
  "2. Naming (Anomia)",
  { text: "Confrontation naming — 'What is this called?'", sub: true },
  { text: "Tip-of-tongue phenomenon common in Broca aphasia", sub: true },
  "3. Auditory Comprehension",
  { text: "Yes/no questions; pointing; complex syntax ('The rug that Bill...')", sub: true },
  "4. Repetition — 'Airplane' → 'He and she are here'",
  "5. Reading (comprehension ≠ reading aloud)",
  "6. Writing — sensitive probe; early marker in Alzheimer disease",
]);

// 25
contentSlide("Classification of Aphasia: Fluency-Based", [
  "Fluency is the single most important initial discriminator:",
  "FLUENT aphasias (posterior lesions, Wernicke/parietal territory):",
  { text: "Normal or increased rate; phrase length ≥ 5 words", sub: true },
  { text: "Paraphasias, neologisms, jargon may be prominent", sub: true },
  { text: "Wernicke, Conduction, Anomic, Transcortical Sensory", sub: true },
  "NONFLUENT aphasias (anterior lesions, Broca/frontal territory):",
  { text: "Reduced rate; short phrases (< 5 words); effortful, labored", sub: true },
  { text: "Agrammatism common; dysarthria may coexist", sub: true },
  { text: "Broca, Global, Transcortical Motor, Mixed Transcortical", sub: true },
  "Additional axes: comprehension (intact/impaired) and repetition (intact/impaired)",
]);

// ─── SECTION 6: APHASIC SYNDROMES ────────────────────────────────
// 26
sectionBanner("Section 6\nIndividual Aphasic Syndromes");

// 27
contentSlide("Broca Aphasia", [
  "Named after Paul Broca (1861) — described as 'aphemia' originally",
  "Lesion: Inferior frontal gyrus (BA 44/45), left hemisphere",
  "Vascular territory: Superior division of left MCA",
  "Spontaneous speech: nonfluent, telegraphic, agrammatic ('wife come hospital')",
  "Naming: impaired; tip-of-tongue phenomenon",
  "Comprehension: relatively intact (mild difficulty with complex syntax)",
  "Repetition: impaired",
  "Reading/Writing: both impaired",
  "Associated signs: right hemiparesis, right hemisensory loss, oral/limb apraxia",
  "Aware of deficits → depression common (Robinson 1997)",
  "Prognosis: often partial recovery with speech therapy",
]);

// 28
tableSlide("Broca Aphasia — Bedside Features",
  ["Domain", "Findings"],
  [
    ["Spontaneous Speech", { text: "Nonfluent, telegraphic, agrammatic", color: C.red }],
    ["Naming", { text: "Impaired — tip-of-tongue", color: C.red }],
    ["Comprehension", { text: "Relatively intact (mild syntax difficulty)", color: C.green }],
    ["Repetition", { text: "Impaired", color: C.red }],
    ["Reading", { text: "Often impaired (third alexia)", color: C.red }],
    ["Writing", { text: "Impaired — dysmorphic, dysgrammatical", color: C.red }],
    ["Associated Signs", { text: "Right hemiparesis, hemisensory loss, apraxia", color: C.slate }],
    ["Awareness", { text: "Usually aware — depression frequent", color: C.slate }],
  ],
  { rowH: 0.48, cFontSize: 12 }
);

// 29
contentSlide("Wernicke Aphasia", [
  "Lesion: Posterior superior temporal gyrus (BA 22), left hemisphere",
  "Vascular territory: Inferior division of left MCA",
  "Spontaneous speech: fluent; normal rate and phrase length",
  "  → Paraphasias: literal (phonemic) and verbal (semantic)",
  "  → Neologisms: new, non-words ('pilgrammer' for 'pencil')",
  "  → Jargon: fluent speech devoid of meaning",
  "Naming: severely impaired",
  "Comprehension: severely impaired — defining feature",
  "Repetition: impaired",
  "Reading/Writing: both impaired",
  "Patient often unaware of deficit (anosognosia) → agitation, paranoia",
  "Associated: right superior quadrantanopia (optic radiations)",
]);

// 30
tableSlide("Wernicke Aphasia — Bedside Features",
  ["Domain", "Findings"],
  [
    ["Spontaneous Speech", { text: "Fluent; paraphasic, neologisms, jargon", color: C.red }],
    ["Naming", { text: "Severely impaired", color: C.red }],
    ["Comprehension", { text: "Severely impaired (defining feature)", color: C.red }],
    ["Repetition", { text: "Impaired", color: C.red }],
    ["Reading", { text: "Impaired", color: C.red }],
    ["Writing", { text: "Impaired", color: C.red }],
    ["Visual Field", { text: "Right superior quadrantanopia possible", color: C.slate }],
    ["Awareness", { text: "Usually unaware — may be agitated", color: C.slate }],
  ],
  { rowH: 0.48, cFontSize: 12 }
);

// 31
contentSlide("Conduction Aphasia", [
  "Lesion: Arcuate fasciculus, insula, or supramarginal gyrus",
  "Key feature: disproportionately impaired repetition with fluent speech",
  "Spontaneous speech: fluent; literal (phonemic) paraphasias prominent",
  "  → Conduite d'approche: repeated attempts to self-correct (awareness preserved)",
  "Naming: impaired (literal paraphasias)",
  "Comprehension: relatively intact",
  "Repetition: severely impaired — hallmark of conduction aphasia",
  "Reading: oral reading impaired; reading comprehension relatively intact",
  "Writing: impaired",
  "Associated: cortical sensory loss; mild right arm weakness",
  "Prognosis: generally good — best recovery among aphasias",
]);

// 32
contentSlide("Global Aphasia", [
  "Most severe form of aphasia",
  "Lesion: Large left MCA territory infarction affecting both Broca and Wernicke areas",
  "ALL language modalities are severely impaired:",
  { text: "Spontaneous speech: nonfluent, often mute or stereotyped utterances ('ta-ta-ta')", sub: true },
  { text: "Comprehension: severely impaired", sub: true },
  { text: "Repetition: absent or severely impaired", sub: true },
  { text: "Naming: absent", sub: true },
  { text: "Reading and writing: both absent or severely impaired", sub: true },
  "Associated: right hemiplegia, hemisensory loss, right homonymous hemianopia",
  "Prognosis: poorest of all aphasia types",
  "Some improvement possible; augmentative/alternative communication (AAC) devices helpful",
]);

// 33
contentSlide("Anomic Aphasia", [
  "The most common and mildest form of aphasia",
  "Lesion: Angular gyrus (BA 39), posterior temporal lobe, or anywhere in left hemisphere",
  "Core feature: word-finding difficulty (anomia) in otherwise fluent speech",
  "Spontaneous speech: fluent; circumlocution to avoid target word",
  "  → 'The thing you write with...' instead of 'pen'",
  "Naming: impaired — primary and defining symptom",
  "Comprehension: intact",
  "Repetition: intact",
  "Reading/Writing: relatively intact",
  "Anomia is the LEAST localizing of all aphasia symptoms",
  "Seen in: mild stroke, TBI, early Alzheimer disease, metabolic encephalopathy",
]);

// ─── SECTION 7: TRANSCORTICAL & SUBCORTICAL ──────────────────────
// 34
sectionBanner("Section 7\nTranscortical & Subcortical Aphasias");

// 35
contentSlide("Transcortical Aphasias — Key Concept", [
  "Hallmark: INTACT REPETITION (perisylvian language circuit is spared)",
  "Lesions disrupt connections FROM other cortical centers INTO the language circuit",
  "Watershed territory lesions — anterior (ACA-MCA) or posterior (MCA-PCA)",
  "Three main subtypes:",
  { text: "Transcortical Motor Aphasia — analogue of Broca, repetition intact", sub: true },
  { text: "Transcortical Sensory Aphasia — analogue of Wernicke, repetition intact", sub: true },
  { text: "Mixed Transcortical Aphasia (Isolation Syndrome) — analogue of Global", sub: true },
  "Associated with echolalia — automatic repetition of examiner's words",
  "Often seen in watershed strokes, advanced dementias, hypotension/cardiac arrest",
]);

// 36
tableSlide("Transcortical Aphasias — Comparison",
  ["Feature", "Isolation Syndrome", "Transcortical Motor", "Transcortical Sensory"],
  [
    ["Speech", "Nonfluent, echolalic", "Nonfluent", "Fluent, echolalic"],
    ["Naming", "Impaired", "Impaired", "Impaired"],
    ["Comprehension", "Impaired", "Intact", "Impaired"],
    ["Repetition", "Intact ✓", "Intact ✓", "Intact ✓"],
    ["Reading", "Impaired", "± Intact", "Impaired"],
    ["Writing", "Impaired", "± Intact", "Impaired"],
    ["Lesion Location", "Bilateral watershed", "Frontal (ACA territory)", "Posterior (MCA-PCA)"],
  ],
  { hFontSize: 11, cFontSize: 11, rowH: 0.47 }
);

// 37
contentSlide("Subcortical Aphasias", [
  "Defined by lesion location: basal ganglia, thalamus, or deep white matter",
  "Two major groups:",
  "1. Thalamic Aphasia:",
  { text: "Usually hemorrhagic lesions of dominant (left) thalamus", sub: true },
  { text: "Fluent speech with semantic paraphasias, anomia", sub: true },
  { text: "Comprehension relatively preserved", sub: true },
  { text: "Spontaneous speech may be hypophonic", sub: true },
  "2. Basal Ganglia (Striatal) Aphasia:",
  { text: "Lesions of caudate nucleus or putamen", sub: true },
  { text: "Variable: hypophonia, dysarthria, mild comprehension deficits", sub: true },
  { text: "Better recovery than cortical aphasias", sub: true },
  "Mechanism: disruption of thalamocortical and striatocortical language loops",
]);

// ─── SECTION 8: READING, WRITING, RELATED ────────────────────────
// 38
sectionBanner("Section 8\nReading, Writing & Related Disorders");

// 39
contentSlide("Alexia (Acquired Dyslexia)", [
  "Alexia: acquired inability to read despite previously normal reading ability",
  "Alexia without Agraphia (Pure Alexia / Word Blindness):",
  { text: "Lesion: Left occipital lobe + splenium of corpus callosum (Dejerine 1892)", sub: true },
  { text: "Can write but cannot read their own writing", sub: true },
  { text: "Right homonymous hemianopia usually present", sub: true },
  "Alexia with Agraphia:",
  { text: "Lesion: Left angular gyrus (BA 39)", sub: true },
  { text: "Reading AND writing both lost", sub: true },
  { text: "Usually part of Gerstmann syndrome (see below)", sub: true },
  "Frontal Alexia (Third Alexia): seen in Broca aphasia — difficulty with syntax in reading",
  "Deep Dyslexia: semantic errors in reading (reads 'ship' for 'boat')",
]);

// 40
contentSlide("Agraphia (Acquired Writing Disorders)", [
  "Agraphia: acquired impairment of writing",
  "Almost universally present in aphasia — writing tests language function",
  "Types:",
  "1. Aphasic Agraphia — letter/word substitutions mirroring spoken language errors",
  "2. Apraxic Agraphia — poorly formed letters despite intact language; frontal/parietal lesion",
  "3. Pure Agraphia — writing impaired in isolation; rare; left posterior frontal lesion",
  "4. Spatial Agraphia — writing runs off page, duplicated strokes; right hemisphere",
  "Writing is a particularly sensitive probe for:",
  { text: "Early Alzheimer disease — anomia and disorganization", sub: true },
  { text: "Delirium — disorganized, illegible script", sub: true },
]);

// 41
contentSlide("Gerstmann Syndrome", [
  "Lesion: Left angular gyrus (BA 39) / inferior parietal lobule",
  "Classic tetrad (all four needed for full syndrome):",
  { text: "1. Finger Agnosia — cannot identify individual fingers", sub: true },
  { text: "2. Left-Right Disorientation — cannot distinguish left from right", sub: true },
  { text: "3. Acalculia — acquired inability to calculate", sub: true },
  { text: "4. Agraphia — acquired writing disorder", sub: true },
  "Often accompanied by alexia (alexia with agraphia)",
  "Vascular cause: inferior division left MCA (angular artery)",
  "Pure Gerstmann syndrome without aphasia is rare — usually part of larger parietal syndrome",
  "Must distinguish from developmental Gerstmann syndrome (children)",
]);

// 42
contentSlide("Apraxia of Speech (AOS)", [
  "AOS: neurological motor speech disorder — impaired programming of speech movements",
  "Distinct from aphasia (language intact) and dysarthria (no weakness)",
  "Features:",
  { text: "Inconsistent articulatory errors — vary from attempt to attempt", sub: true },
  { text: "Groping and trial-and-error movements of articulators", sub: true },
  { text: "Distorted substitutions rather than omissions", sub: true },
  { text: "Errors increase with longer/more complex words", sub: true },
  { text: "Islands of normal speech ('automatic' phrases intact)", sub: true },
  "Lesion: Broca's area and left premotor cortex (insula in some models)",
  "Often coexists with Broca aphasia",
  "Management: Motor learning-based speech therapy; DAMP, PROMPT techniques",
]);

// ─── SECTION 9: DEVELOPMENTAL DISORDERS ──────────────────────────
// 43
sectionBanner("Section 9\nDevelopmental Speech & Language Disorders");

// 44
contentSlide("Specific Language Impairment (SLI) / DLD", [
  "Now termed Developmental Language Disorder (DLD) — Bishop 2017",
  "Definition: significant language difficulty not explained by hearing loss, neurological, or intellectual disability",
  "Prevalence: ~7% of school-age children",
  "Domains affected (varies by child):",
  { text: "Grammar (morphosyntax) — most consistently affected", sub: true },
  { text: "Vocabulary — slower acquisition", sub: true },
  { text: "Narrative and discourse", sub: true },
  "Non-verbal IQ is intact — key distinction from intellectual disability",
  "Often persists into adulthood — affects literacy, academic achievement",
  "Management: SALT (Speech and Language Therapy), parent-mediated intervention, school support",
]);

// 45
contentSlide("Childhood Apraxia of Speech (CAS)", [
  "Rare, distinct neurodevelopmental disorder of speech motor programming",
  "Not due to muscle weakness — planning/programming deficit",
  "Core features (ASHA 2007 consensus):",
  { text: "1. Inconsistent errors on consonants and vowels", sub: true },
  { text: "2. Lengthened/disrupted coarticulation between sounds and syllables", sub: true },
  { text: "3. Inappropriate prosody (stress/intonation)", sub: true },
  "May co-occur with DLD, autism, genetic syndromes (FOXP2 mutations)",
  "Distinguished from phonological disorder: CAS errors are inconsistent, motor-based",
  "Management: high-frequency, intensive motor-based therapy (DDRSP, PROMPT, Nuffield)",
]);

// 46
contentSlide("Stuttering (Fluency Disorders)", [
  "Developmental stuttering: onset 2–5 years; M:F ratio 4:1",
  "Persistent developmental stuttering: ~1% adults",
  "Core disfluencies:",
  { text: "Part-word repetitions ('b-b-b-ball')", sub: true },
  { text: "Prolongations ('ssss-sun')", sub: true },
  { text: "Blocks — silent articulatory posturing", sub: true },
  "Secondary behaviors: eye blinks, facial grimaces, head jerks (escape/avoidance)",
  "Acquired neurogenic stuttering: stroke, TBI, brain tumor — atypical features",
  "Acquired psychogenic stuttering: rare; after psychological trauma",
  "Treatment: fluency shaping, stuttering modification therapy; pharmacology (limited evidence)",
  "Spontaneous recovery by age 7 in ~75% of children who stutter",
]);

// 47
contentSlide("Autism Spectrum Disorder & Language", [
  "Language impairment is a core and universal feature of ASD",
  "Domains affected:",
  { text: "Social pragmatics — conversational reciprocity, topic maintenance", sub: true },
  { text: "Prosody — atypical intonation ('robotic' or sing-song)", sub: true },
  { text: "Echolalia — immediate and delayed repetition of others' speech", sub: true },
  { text: "Pronoun reversal, idiosyncratic language", sub: true },
  "~25–30% of children with ASD are minimally verbal",
  "Hyperlexia: precocious word decoding with poor comprehension — common in ASD",
  "AAC (Augmentative and Alternative Communication) — critical for non-verbal children",
  "Language profile is heterogeneous — ranges from nonverbal to highly verbal",
]);

// 48
contentSlide("Selective Mutism", [
  "Definition: failure to speak in specific social situations (e.g., school) despite speaking in others",
  "Onset: typically 2–5 years; often at school entry",
  "Not explained by: knowledge of language, communication disorder, ASD, psychosis",
  "Strongly associated with social anxiety disorder (~90%)",
  "Features:",
  { text: "Child speaks fluently at home/familiar settings", sub: true },
  { text: "Silent or whispers in classroom, public settings", sub: true },
  { text: "May use gestures or nod/shake head", sub: true },
  "Assessment: rule out language disorder, hearing loss, trauma",
  "Management: CBT, exposure-based therapy, family involvement, SSRIs (adjunct)",
  "Prognosis: good if treated early; risk of generalized anxiety if untreated",
]);

// 49
contentSlide("Congenital Aphasia (Developmental Language)", [
  "Rare condition: absence or severe limitation of language acquisition from birth",
  "Distinct from acquired aphasia (post-natal brain damage)",
  "Associated with:",
  { text: "Congenital brain malformations (cortical dysplasia, schizencephaly)", sub: true },
  { text: "Perinatal stroke or hypoxic-ischemic injury", sub: true },
  { text: "Genetic syndromes (FOXP2, CNTNAP2 mutations)", sub: true },
  "Landau-Kleffner Syndrome (acquired epileptic aphasia):",
  { text: "Normal development → progressive language regression", sub: true },
  { text: "Associated with EEG abnormalities (temporal spike-wave)", sub: true },
  { text: "Peak onset 3–7 years; boys > girls", sub: true },
  { text: "Treatment: anticonvulsants, corticosteroids; surgical (subpial transection) in refractory cases", sub: true },
]);

// ─── SECTION 10: ASSESSMENT & MANAGEMENT ─────────────────────────
// 50
sectionBanner("Section 10\nAssessment & Management");

// 51
contentSlide("Clinical Assessment of Speech & Language", [
  "History: onset (sudden vs. gradual), progression, handedness, prior language ability",
  "Bedside language exam: fluency, naming, comprehension, repetition, reading, writing",
  "Formal assessments:",
  { text: "Boston Diagnostic Aphasia Examination (BDAE)", sub: true },
  { text: "Western Aphasia Battery (WAB-R)", sub: true },
  { text: "Token Test — sensitive for mild comprehension deficits", sub: true },
  { text: "Aphasia Quotient (WAB-AQ) — overall severity", sub: true },
  "Neuroimaging: CT/MRI to localize lesion; DWI for acute ischemia",
  "Neuropsychological testing: differentiates aphasia from dementia",
  "Speech-Language Pathologist (SLP) referral — essential for all confirmed language disorders",
]);

// 52
contentSlide("Neuroimaging in Speech & Language Disorders", [
  "MRI brain (standard): best for structural lesion localization",
  { text: "DWI: acute infarction within minutes of onset", sub: true },
  { text: "FLAIR: subacute-chronic lesions, white matter disease", sub: true },
  { text: "T2: demyelinating lesions (MS)", sub: true },
  "Functional imaging (research/surgical planning):",
  { text: "fMRI language mapping (verb generation, picture naming tasks)", sub: true },
  { text: "PET: cerebral blood flow, metabolism", sub: true },
  { text: "Wada test (intracarotid sodium amytal) — hemispheric dominance", sub: true },
  "CT angiography / MR angiography: for vascular cause",
  "EEG: Landau-Kleffner syndrome; delirium",
  "Laryngoscopy: dysphonia / vocal cord pathology",
]);

// 53
contentSlide("Principles of Aphasia Rehabilitation", [
  "Neuroplasticity underlies recovery — perilesional cortex and right hemisphere",
  "Intensity matters: evidence for high-intensity therapy (≥ 5 hours/week)",
  "Evidence-based aphasia therapies:",
  { text: "Constraint-Induced Language Therapy (CILT/CIAT) — force verbal output", sub: true },
  { text: "Treatment of Underlying Forms (TUF) — syntactic therapy", sub: true },
  { text: "Semantic Feature Analysis (SFA) — anomia treatment", sub: true },
  { text: "Melodic Intonation Therapy (MIT) — nonfluent/Broca aphasia via right hemisphere", sub: true },
  { text: "Script Training — functional conversational phrases", sub: true },
  "Augmentative/Alternative Communication (AAC): for severe/global aphasia",
  "Group therapy: social participation, peer support",
  "Family education and caregiver communication strategies — critical",
]);

// 54
twoColSlide(
  "Pharmacological Interventions",
  "Agents with Evidence",
  [
    "Bromocriptine — dopaminergic; nonfluent aphasia (mixed evidence)",
    "Piracetam — nootropic; some RCT evidence for language",
    "Memantine — early case series in primary progressive aphasia",
    "Amphetamines — facilitated therapy (small studies)",
    "Donepezil — post-stroke aphasia (limited RCT evidence)",
    "Levodopa — Parkinson-related hypokinetic dysarthria",
  ],
  "Caveats",
  [
    "No drug is currently FDA-approved for aphasia",
    "Effect sizes are modest",
    "Therapy remains the mainstay",
    "Pharmacology best used as adjunct to SLP therapy",
    "LSVT LOUD (voice) has strongest evidence for PD",
    "Botulinum toxin for spasmodic dysphonia",
  ]
);

// 55
contentSlide("Augmentative & Alternative Communication (AAC)", [
  "AAC: all forms of communication beyond natural speech",
  "Unaided systems: gestures, manual signs, facial expression",
  "Aided systems:",
  { text: "Low-tech: communication boards, letter boards, picture books", sub: true },
  { text: "High-tech: speech-generating devices (SGDs), iPads (Proloquo2Go, TouchChat)", sub: true },
  { text: "Eye-gaze technology — for patients with locked-in syndrome, ALS", sub: true },
  "Candidates: severe/global aphasia, ALS, severe dysarthria, non-verbal ASD, CAS",
  "AAC does NOT impede natural speech development",
  "Goal: maximize functional communication participation",
  "ASHA guidelines support AAC as primary option when natural speech insufficient",
]);

// ─── SPECIAL TOPICS ───────────────────────────────────────────────
// 56
contentSlide("Primary Progressive Aphasia (PPA)", [
  "PPA: neurodegenerative syndrome — progressive language impairment before other deficits",
  "Mesulam 1982 — original description",
  "Three variants (Gorno-Tempini 2011 criteria):",
  { text: "1. Nonfluent/Agrammatic PPA (nfvPPA): effortful, agrammatic speech; AOS common; frontal/insular atrophy", sub: true },
  { text: "2. Semantic Dementia (svPPA): fluent but empty; profound anomia and semantic memory loss; temporal atrophy", sub: true },
  { text: "3. Logopenic PPA (lvPPA): word-finding pauses; impaired sentence repetition; parietal atrophy; ~Alzheimer pathology", sub: true },
  "Underlying pathology: FTLD-TDP, FTLD-tau, or Alzheimer disease",
  "Management: symptomatic SLP therapy; no disease-modifying treatments yet",
  "Genetic causes: GRN, MAPT mutations in familial cases",
]);

// 57
contentSlide("Right Hemisphere Communication Disorders", [
  "Right hemisphere damage causes subtle but significant communication problems",
  "Often overlooked — 'right hemisphere syndrome'",
  "Key features:",
  { text: "Aprosodia — flat, monotone speech (motor aprosodia); difficulty understanding emotional tone", sub: true },
  { text: "Impaired discourse — poor narrative coherence, tangential", sub: true },
  { text: "Literal interpretation — difficulty with metaphor, sarcasm, humor", sub: true },
  { text: "Impaired inference and pragmatics", sub: true },
  { text: "Neglect dyslexia — omitting left side of text/words", sub: true },
  "Cause: right MCA stroke, TBI to right hemisphere",
  "Assessment: Right Hemisphere Battery, discourse analysis",
  "Management: SLP targeting pragmatics, social communication, prosody",
]);

// 58
contentSlide("Language in Dementia", [
  "Language disturbance is a feature of virtually all dementias",
  "Alzheimer Disease (AD):",
  { text: "Early: naming difficulties (anomia), word-finding pauses", sub: true },
  { text: "Middle: circumlocution, empty speech ('thing', 'it')", sub: true },
  { text: "Late: echolalia, palilalia, mutism", sub: true },
  "Frontotemporal Dementia (FTD):",
  { text: "Behavioral variant: reduced spontaneous speech, echolalia, mutism", sub: true },
  { text: "PPA variants (see slide 56)", sub: true },
  "Vascular Dementia: aphasia, dysarthria depending on lesion location",
  "Lewy Body Dementia: fluctuating speech; visual hallucinations affect discourse",
  "Key distinction from aphasia: dementia affects other cognitive domains too",
]);

// 59
contentSlide("Mutism", [
  "Mutism: complete absence of speech — multiple causes",
  "1. Akinetic Mutism:",
  { text: "Bilateral frontal, anterior cingulate, or thalamic lesions", sub: true },
  { text: "Patient appears awake but has no voluntary speech or movement", sub: true },
  "2. Cerebellar Mutism (post-surgical):",
  { text: "After posterior fossa surgery in children", sub: true },
  { text: "Transient; may evolve into cerebellar dysarthria", sub: true },
  "3. Psychogenic/Functional Mutism:",
  { text: "No structural lesion; often related to psychological trauma", sub: true },
  "4. Global Aphasia:",
  { text: "Severe language disruption; may be mute or stereotyped utterances", sub: true },
  "5. Selective Mutism: situational (see slide 48)",
  "Evaluation: MRI brain, psychiatric assessment, SLP evaluation",
]);

// 60
contentSlide("Palilalia, Echolalia & Logorrhea", [
  "PALILALIA: involuntary repetition of one's own words/phrases with increasing rate",
  { text: "Seen in: Parkinson disease, Gilles de la Tourette syndrome, frontal lesions", sub: true },
  { text: "Distinguished from stuttering by involuntary acceleration", sub: true },
  "ECHOLALIA: repetition of another person's words/phrases",
  { text: "Immediate echolalia: immediate repetition — autism, transcortical aphasias", sub: true },
  { text: "Delayed echolalia: repeated later — ASD, Alzheimer disease", sub: true },
  "LOGORRHEA: excessive, incoherent, rapid speech",
  { text: "Seen in: Wernicke aphasia (press of speech), mania, delirium, prefrontal lesions", sub: true },
  "TACHYPHEMIA / CLUTTERING: rapid, irregular speech rate; reduced intelligibility",
  { text: "Distinct from stuttering; language formulation issue; rare", sub: true },
]);

// 61 — Big comparison table
tableSlide("Aphasia Syndrome Summary Table",
  ["Aphasia Type", "Fluency", "Comprehension", "Repetition", "Naming", "Lesion Site"],
  [
    ["Broca", "Nonfluent", "Intact", "Impaired", "Impaired", "Inferior frontal (BA 44/45)"],
    ["Wernicke", "Fluent", "Impaired", "Impaired", "Impaired", "Post. sup. temporal (BA 22)"],
    ["Global", "Nonfluent", "Impaired", "Impaired", "Impaired", "Large MCA territory"],
    ["Conduction", "Fluent", "Intact", "Impaired ✦", "Impaired", "Arcuate fasciculus / Insula"],
    ["Anomic", "Fluent", "Intact", "Intact", "Impaired ✦", "Angular gyrus / Widespread"],
    ["TC Motor", "Nonfluent", "Intact", "Intact ✓", "Impaired", "Frontal (ACA territory)"],
    ["TC Sensory", "Fluent", "Impaired", "Intact ✓", "Impaired", "Temporo-occipital"],
    ["Mixed TC", "Nonfluent", "Impaired", "Intact ✓", "Impaired", "Bilateral watershed"],
  ],
  { hFontSize: 11, cFontSize: 10, rowH: 0.44 }
);

// 62
contentSlide("Prognosis in Aphasia", [
  "Factors associated with BETTER prognosis:",
  { text: "Younger age at onset", sub: true },
  { text: "Higher premorbid education and intelligence", sub: true },
  { text: "Smaller, more anterior lesions", sub: true },
  { text: "Anomic > Broca > Wernicke > Global (severity spectrum)", sub: true },
  { text: "Early, intensive speech therapy", sub: true },
  { text: "Preserved Wernicke area function", sub: true },
  "Factors associated with WORSE prognosis:",
  { text: "Global aphasia persisting > 4 weeks", sub: true },
  { text: "Large posterior lesions", sub: true },
  { text: "Older age, comorbidities", sub: true },
  "Recovery: greatest in first 3 months; continues for years with therapy",
  "Chronic aphasia (> 1 year) still responds to intensive treatment",
]);

// 63
contentSlide("Communication Across Disciplines", [
  "Speech-Language Pathologist (SLP):",
  { text: "Primary clinician for assessment and treatment of all speech/language disorders", sub: true },
  { text: "Dysarthria, aphasia, AOS, dysphagia, voice disorders, language development", sub: true },
  "Neurologist:",
  { text: "Diagnose and manage underlying neurological cause", sub: true },
  { text: "Stroke, TBI, neurodegenerative disease", sub: true },
  "Psychiatrist/Psychologist:",
  { text: "Depression in Broca aphasia; anxiety in stuttering; psychogenic disorders", sub: true },
  "Audiologist:",
  { text: "Rule out hearing loss as cause of language delay or comprehension difficulty", sub: true },
  "Educator / Special Education Teacher:",
  { text: "Language support in school settings; SLI/DLD, ASD, CAS", sub: true },
  "Team approach is essential for optimal outcomes",
]);

// 64 — Key Points
contentSlide("Key Clinical Pearls", [
  "Dysarthria ≠ Aphasia: dysarthria is a motor speech disorder; language is intact",
  "Always test repetition: it separates perisylvian from transcortical aphasias",
  "Fluency is the first discriminator: anterior lesions → nonfluent; posterior → fluent",
  "Broca aphasia: 'tan-tan' patient; nonfluent, agrammatic; aware, often depressed",
  "Wernicke aphasia: fluent jargon; unaware; check for superior quadrantanopia",
  "Conduction aphasia: fluent + poor repetition (arcuate fasciculus lesion)",
  "Global aphasia: all domains severely impaired; large MCA territory stroke",
  "Intact repetition → think transcortical aphasia (watershed lesion or dementia)",
  "Pure dysarthria with normal language = cortical language areas spared",
  "PPA: progressive language = neurodegenerative; refer for FTD/AD workup",
]);

// 65 — Closing
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    { text: "Adams & Victor's Principles of Neurology (12e)  •  Bradley & Daroff's Neurology in Clinical Practice  •  Kaplan & Sadock's Comprehensive Textbook of Psychiatry", options: {} }
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