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// ══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════
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// SLIDE 2 — Outline
addBulletSlide("Overview & Learning Objectives", "What we will cover in this presentation",
  [
    "1. Introduction: language vs. speech — definitions and distinctions",
    "2. Neuroanatomy of language — Broca's area, Wernicke's area, arcuate fasciculus",
    "3. Classification of aphasias — fluent vs. non-fluent",
    "4. Broca's aphasia (non-fluent / expressive)",
    "5. Wernicke's aphasia (fluent / receptive)",
    "6. Global aphasia",
    "7. Conduction aphasia",
    "8. Transcortical aphasias (motor & sensory)",
    "9. Anomic aphasia",
    "10. Pure word deafness & pure word blindness",
    "11. Subcortical aphasias",
    "12. Dysarthria — classification & causes",
    "13. Dysphonia & mutism",
    "14. Developmental & acquired language disorders",
    "15. Assessment & rehabilitation"
  ]
);

// SLIDE 3 — Section title
addSectionTitle("PART 1: INTRODUCTION", "Language, Speech & Neuroanatomical Foundations");

// SLIDE 4
addDefinitionSlide("Language vs. Speech — Definitions",
  "Language",
  "A system of symbols (words, grammar, meaning) used to communicate thoughts and ideas. A cognitive function mediated by specific cortical regions.",
  [
    "Speech: the motor act of producing sounds — articulation, phonation, resonance",
    "Language disorder (aphasia): impaired ability to use or understand language symbols",
    "Speech disorder (dysarthria, dysphonia): impaired execution of the motor act of speaking",
    "The two can coexist or occur independently — a key clinical distinction",
    "DeJong emphasized systematic testing of BOTH components at the bedside"
  ]
);

// SLIDE 5
addBulletSlide("The Clinical Relevance of the Distinction",
  "Why language vs. speech matters at the bedside",
  [
    "Aphasia implies cortical or subcortical lesion of the dominant hemisphere",
    "Dysarthria alone suggests brainstem, cerebellar, or motor-pathway involvement",
    "A mute patient may have aphemia (frontal), akinetic mutism, or dysarthria — very different lesions",
    "Correct classification guides anatomical localization",
    "Errors in classification lead to incorrect lesion localization and missed diagnoses",
    "Example: confusing severe Broca aphasia with 'confusion' or psychiatric mutism"
  ]
);

// SLIDE 6
addBulletSlide("Cerebral Dominance for Language",
  "Hemispheric specialization — a foundation of clinical neurology",
  [
    "~95% of right-handed individuals: left hemisphere dominant for language",
    "~70% of left-handed individuals: left hemisphere dominant",
    "Remaining ~30% of left-handers: right or mixed dominance",
    "Lesions of the dominant hemisphere cause aphasia; non-dominant lesions cause prosody, pragmatics deficits",
    "The Wada test (intracarotid amobarbital) is the gold standard for lateralization pre-operatively",
    "fMRI language mapping has largely replaced the Wada test in clinical practice"
  ]
);

// SLIDE 7 — Neuroanatomy
addBulletSlide("Language Areas — Broca's Area",
  "Inferior frontal gyrus, pars triangularis & opercularis (BA 44, 45)",
  [
    "Located in posterior portion of left inferior frontal gyrus",
    "Paul Broca (1861): described patients with speech loss — 'Tan' (Leborgne) and 'Lelo' (Lelong)",
    "Primary role: motor programming of speech — phonological encoding, syntax",
    "Damage produces non-fluent, effortful, agrammatic speech",
    "Modern view: Broca's area is part of a larger speech production network",
    "Connected to Wernicke's area via the arcuate fasciculus (dorsal stream)",
    "Also involved in working memory, syntactic comprehension, and non-speech motor sequencing"
  ]
);

// SLIDE 8
addBulletSlide("Language Areas — Wernicke's Area",
  "Posterior superior temporal gyrus (BA 22), dominant hemisphere",
  [
    "Described by Carl Wernicke (1874) — the 'sensory' speech center",
    "Involved in decoding and comprehending spoken and written language",
    "Also participates in selecting appropriate words and meanings during speech output",
    "Lesion causes fluent aphasia with paraphasias, neologisms, and comprehension failure",
    "Extends into supramarginal and angular gyri of the inferior parietal lobule",
    "Angular gyrus (BA 39): integrates visual (reading) and auditory (language) information",
    "Supramarginal gyrus (BA 40): phonological processing, reading, spelling"
  ]
);

// SLIDE 9
addBulletSlide("The Perisylvian Language Network",
  "Connecting Broca and Wernicke: the arcuate fasciculus",
  [
    "Arcuate fasciculus: major white matter tract connecting anterior and posterior language areas",
    "Dorsal stream: arcuate fasciculus — carries phonological information for production",
    "Ventral stream: uncinate and extreme capsule — semantic and conceptual processing",
    "Perisylvian cortex: surrounds the Sylvian (lateral) fissure — critical for language",
    "Extra-sylvian cortex: regions outside perisylvian zone — when intact, permit preserved repetition",
    "Disconnection of the arcuate fasciculus produces conduction aphasia (fluent speech, impaired repetition)",
    "Damage outside perisylvian zone produces transcortical aphasias (repetition preserved)"
  ]
);

// SLIDE 10 — Table: Anatomical localization summary
addTableSlide("Anatomical Localization of Language Functions",
  "Key cortical regions and their functional roles",
  ["Region", "Brodmann Area", "Function", "Lesion Effect"],
  [
    ["Broca's area", "BA 44, 45", "Motor speech programming, syntax", "Non-fluent aphasia, agrammatism"],
    ["Wernicke's area", "BA 22", "Auditory language comprehension", "Fluent aphasia, poor comprehension"],
    ["Angular gyrus", "BA 39", "Reading, cross-modal language integration", "Alexia, acalculia, agraphia"],
    ["Supramarginal gyrus", "BA 40", "Phonological processing", "Conduction aphasia, dyslexia"],
    ["Arcuate fasciculus", "White matter", "Connects Broca ↔ Wernicke", "Conduction aphasia"],
    ["Supplementary motor area", "BA 6 (medial)", "Speech initiation", "Transcortical motor aphasia, mutism"],
    ["Thalamus / Basal ganglia", "Subcortical", "Language modulation, relay", "Subcortical aphasia"]
  ]
);

// SLIDE 11 — Section title
addSectionTitle("PART 2: BEDSIDE LANGUAGE EXAMINATION", "How to Systematically Assess Language");

// SLIDE 12
addBulletSlide("Bedside Language Assessment — Key Domains",
  "DeJong's systematic approach to examining language",
  [
    "1. SPONTANEOUS SPEECH: fluency, rate, prosody, effort, grammar, paraphasia",
    "2. NAMING: show objects — body parts, common items, uncommon items",
    "3. COMPREHENSION: yes/no questions, one-step commands, complex commands",
    "4. REPETITION: words, phrases, sentences — 'No ifs, ands, or buts'",
    "5. READING: aloud and for comprehension (newspaper headline, short paragraph)",
    "6. WRITING: name, sentence to dictation, spontaneous sentence",
    "7. Note associated neurological signs: hemiparesis, visual field defect, limb apraxia"
  ]
);

// SLIDE 13
addTwoColSlide("Fluency — The Primary Classifier",
  "Fluent vs. Non-fluent: first step in aphasia classification",
  [
    "Non-fluent (< 50 words/minute)",
    "Effortful, halting speech",
    "Reduced phrase length (< 5 words)",
    "Agrammatic, telegraphic",
    "Preserved nouns/verbs, missing function words",
    "Dysarthria may be present",
    "Location: anterior (frontal) lesion"
  ],
  [
    "Fluent (> 100 words/minute)",
    "Effortless, often excessive",
    "Normal or long phrase length",
    "Paraphasias: verbal or phonemic",
    "Neologisms, jargon in severe forms",
    "No dysarthria",
    "Location: posterior (temporal/parietal) lesion"
  ],
  "NON-FLUENT", "FLUENT"
);

// SLIDE 14
addBulletSlide("Types of Paraphasia",
  "Errors in word production — important for classification",
  [
    "PHONEMIC (literal) paraphasia: sound substitution within a word — 'spoon' → 'poon' or 'stoon'",
    "VERBAL (semantic) paraphasia: wrong word from same semantic category — 'fork' → 'spoon'",
    "NEOLOGISM: non-word production — 'fork' → 'blifter'",
    "JARGON: strings of neologisms — frequent in severe Wernicke's aphasia",
    "Phonemic paraphasia: more characteristic of anterior/Broca or conduction aphasia",
    "Verbal paraphasia: more characteristic of Wernicke's aphasia",
    "CIRCUMLOCUTION: describing a word instead of naming it — 'the thing you eat with'"
  ]
);

// SLIDE 15 — Section title
addSectionTitle("PART 3: THE APHASIC SYNDROMES", "Classification, Features & Localization");

// SLIDE 16 — Classification table
addTableSlide("Classification of Aphasic Syndromes",
  "The perisylvian framework (Adams & Victor / Bradley & Daroff)",
  ["Type", "Fluency", "Comprehension", "Repetition", "Localization"],
  [
    ["Broca's", "Non-fluent", "Relatively preserved", "Impaired", "Frontal, suprasylvian (BA 44/45)"],
    ["Wernicke's", "Fluent", "Greatly impaired", "Impaired", "Temporal, infrasylvian (BA 22)"],
    ["Global", "Non-fluent", "Very impaired", "Impaired", "Large perisylvian"],
    ["Conduction", "Fluent", "Relatively preserved", "Impaired", "Supramarginal gyrus / Insula"],
    ["Transcortical Motor", "Non-fluent", "Good", "Preserved", "Anterior/superior to Broca"],
    ["Transcortical Sensory", "Fluent", "Impaired", "Preserved", "Surrounding Wernicke's area"],
    ["Anomic", "Fluent", "Good", "Good", "Angular gyrus or diffuse"],
    ["Pure Word Deafness", "Normal/paraphasic", "Impaired", "Impaired", "Bilateral superior temporal"]
  ]
);

// SLIDE 17 — Broca
addBulletSlide("Broca's Aphasia — Clinical Features",
  "Non-fluent (expressive / motor / anterior) aphasia",
  [
    "Paul Broca 1861: patient 'Tan' (Leborgne) — could say only 'tan-tan'",
    "Speech: hesitant, labored, telegraphic — 'wife come hospital' (agrammatism)",
    "Omits function words and grammatical morphemes; retains content words",
    "Phonemic paraphasias; inconsistent errors across utterances",
    "Naming: impaired — 'tip of the tongue' phenomenon, phonemic cues help",
    "Comprehension: apparently intact but deficient for complex syntax",
    "Repetition: impaired, resembles spontaneous speech"
  ]
);

// SLIDE 18 — Broca continued
addTwoColSlide("Broca's Aphasia — Exam Findings & Lesion",
  "Bedside features and neuroanatomy",
  [
    "Reading: often impaired ('third alexia')",
    "Writing: impaired — dysmorphic and dysgrammatical",
    "Uses nondominant (left) hand; worse than a normal left-hander would be",
    "Associated: right hemiparesis (face and arm > leg)",
    "Right hemisensory loss",
    "Oral and limb apraxia",
    "Apraxia may be mistaken for comprehension failure — test with yes/no"
  ],
  [
    "Lesion: left inferior frontal gyrus (BA 44, 45 — Broca's area)",
    "Classic Broca = small inferior frontal lesion only",
    "Persistent Broca aphasia requires larger lesion including insula and adjacent cortex",
    "Acute mutism may occur, evolving to Broca over days–weeks",
    "Minimal Broca ('mini-Broca'): slightly halting speech — recovers quickly",
    "MRI shows hypodensity / restricted diffusion in left frontal operculum",
    "Blood supply: upper division of left middle cerebral artery"
  ],
  "CLINICAL FEATURES", "ANATOMY & LESION"
);

// SLIDE 19 — Wernicke
addBulletSlide("Wernicke's Aphasia — Clinical Features",
  "Fluent (receptive / sensory / posterior) aphasia",
  [
    "Carl Wernicke 1874 — posterior superior temporal gyrus lesion",
    "Speech: effortless, fluent, sometimes logorrheic — 'press of speech'",
    "Content is empty of meaning; listener detects jargon even if speaker doesn't",
    "Verbal paraphasias: 'fork' → 'spoon'; phonemic: 'dog' → 'log'",
    "Neologisms: 'daskipper' for 'telephone'",
    "Naming: severely impaired — bizarre paraphasic misnaming",
    "Comprehension: severely impaired, even for simple yes/no questions"
  ]
);

// SLIDE 20 — Wernicke continued
addTwoColSlide("Wernicke's Aphasia — Additional Features & Anatomy",
  "The key characteristics and lesion location",
  [
    "Repetition: impaired",
    "Reading comprehension: usually impaired (parallels auditory)",
    "Writing: well-formed letters but paragraphic errors; useful for detection",
    "Rarely has hemiparesis (no motor cortex involvement)",
    "Right hemianopia may be present (optic radiation nearby)",
    "Psychiatric manifestations: unconcerned or paranoid",
    "Patient often unaware of own deficit (anosognosia)"
  ],
  [
    "Lesion: posterior superior temporal gyrus (BA 22)",
    "May extend into supramarginal and angular gyri",
    "Blood supply: lower division of left MCA (posterior temporal branch)",
    "Infarction in posterior temporal region is hallmark",
    "CT/MRI: hypodensity in left posterior temporal region",
    "PET shows reduced metabolism in left temporal-parietal cortex",
    "Depression less common than in Broca's; paranoid behavior more likely"
  ],
  "ADDITIONAL FEATURES", "ANATOMY & LESION"
);

// SLIDE 21 — Global aphasia
addBulletSlide("Global Aphasia — Features & Prognosis",
  "Severe, combined loss of all language functions",
  [
    "All language modalities severely impaired: no fluent speech, no comprehension",
    "Repetition, naming, reading, writing: all severely or completely impaired",
    "Typically non-fluent: restricted to a few stereotyped utterances or expletives",
    "Usually associated with right hemiplegia (involvement of entire MCA territory)",
    "Lesion: large left hemisphere — combined frontal + temporal, or entire perisylvian zone",
    "Caused by left internal carotid or proximal MCA occlusion",
    "Prognosis: generally poor — limited recovery compared to other aphasia types",
    "With time: may evolve toward severe Broca aphasia as posterior regions recover"
  ]
);

// SLIDE 22 — Conduction aphasia
addBulletSlide("Conduction Aphasia — Features & Anatomy",
  "Fluent speech with disproportionately impaired repetition",
  [
    "Key feature: repetition dramatically worse than spontaneous speech",
    "Speech: fluent with frequent phonemic paraphasias and self-corrections",
    "Comprehension: relatively preserved",
    "Patient aware of errors and makes repeated attempts to correct ('conduit d'approche')",
    "Naming: impaired; phonemic paraphasias",
    "Reading aloud: impaired; comprehension relatively better",
    "Writing: paraphasic errors present",
    "Lesion: arcuate fasciculus (disconnects Broca ↔ Wernicke) or supramarginal gyrus / insula",
    "Blood supply: upper division MCA or posterior branch"
  ]
);

// SLIDE 23 — Transcortical aphasias
addTwoColSlide("Transcortical Aphasias — Overview",
  "Extra-perisylvian lesions: repetition is the hallmark preserved function",
  [
    "TRANSCORTICAL MOTOR (TCM):",
    "Non-fluent spontaneous speech",
    "Impaired initiation — 'difficulty getting started'",
    "Comprehension: good",
    "Repetition: preserved (sometimes echolalic)",
    "Lesion: anterior/superior to Broca — SMA or anterior watershed",
    "Cause: ACA territory or watershed infarct (hypotension)",
    "May resemble Broca but repetition distinguishes them"
  ],
  [
    "TRANSCORTICAL SENSORY (TCS):",
    "Fluent, often with echolalia and semantic paraphasias",
    "Comprehension: severely impaired (like Wernicke's)",
    "Repetition: preserved — patient echoes questions back",
    "Lesion: posterior to Wernicke — posterior watershed zone",
    "Cause: posterior MCA-PCA watershed infarct, Alzheimer dementia",
    "MIXED TRANSCORTICAL: all modalities impaired except repetition",
    "Rare; bilateral watershed lesions, hypoxic-ischemic injury"
  ],
  "TRANSCORTICAL MOTOR", "TRANSCORTICAL SENSORY"
);

// SLIDE 24 — Anomic aphasia
addBulletSlide("Anomic Aphasia",
  "Isolated naming deficit — the mildest and most common aphasia",
  [
    "Fluent, grammatically normal speech",
    "Comprehension and repetition: intact",
    "Primary deficit: word-finding difficulty (anomia)",
    "Circumlocution is prominent: 'the thing you use to... you know...'",
    "Anomia is present in ALL types of aphasia — isolated anomia = anomic aphasia",
    "Lesion: angular gyrus (BA 39) of dominant hemisphere, or many cortical sites",
    "Also seen in: mild diffuse cortical disease, post-traumatic, toxic/metabolic states",
    "Prognosis: best of all aphasia types; often recovers fully",
    "When anomia is the residual deficit after recovery from other aphasias, lesion has resolved"
  ]
);

// SLIDE 25 — Pure word deafness
addBulletSlide("Pure Word Deafness (Auditory Verbal Agnosia)",
  "Inability to understand spoken words despite normal hearing",
  [
    "Patient cannot understand spoken language but hears sounds normally",
    "Speech is fluent with mild paraphasias; comprehension of written language preserved",
    "Spontaneous speech: normal or near-normal in mild cases",
    "Repetition: severely impaired (cannot decode phonemic input)",
    "Key test: patient cannot repeat words but can read and write normally",
    "Non-verbal sounds understood normally (environmental sounds, music)",
    "Lesion: bilateral superior temporal gyri or left superior temporal gyrus with callosal disruption",
    "Mechanism: auditory input cannot reach Wernicke's area for decoding",
    "Distinguished from Wernicke's aphasia by preserved reading and writing"
  ]
);

// SLIDE 26 — Pure alexia / word blindness
addBulletSlide("Pure Word Blindness (Alexia Without Agraphia)",
  "Inability to read despite preserved writing — a disconnection syndrome",
  [
    "Patient cannot read but can write spontaneously (cannot read own writing either)",
    "Oral speech: normal",
    "Auditory comprehension and repetition: normal",
    "Writing: intact — a key distinguishing feature",
    "Letter-by-letter reading may be present ('letter-by-letter dyslexia')",
    "Associated with right homonymous hemianopia (nearly always)",
    "Lesion: left occipital cortex (calcarine) + posterior corpus callosum (splenium)",
    "Mechanism: visual input from right hemisphere cannot cross to left angular gyrus",
    "Blood supply: left posterior cerebral artery — infarction of occipital lobe and splenium",
    "Alexia WITH agraphia: angular gyrus lesion — cannot read or write"
  ]
);

// SLIDE 27 — Pure word mutism / aphemia
addBulletSlide("Pure Word Mutism (Aphemia / Cortical Anarthria)",
  "Mutism with preserved internal language",
  [
    "Sudden mutism or severely reduced output after small frontal lesion",
    "After initial mutism, patient may whisper or use a hoarse, monotone voice",
    "Internal language intact: patient can communicate by writing, reading, and understanding",
    "Comprehension: normal; reading: normal; writing: normal",
    "Differentiated from Broca aphasia: writing is not aphasic",
    "Lesion: lower motor cortex (Broca's area proper) or subcortical lesion of anterior language area",
    "Considered a motor speech programming disorder rather than true aphasia",
    "Prognosis: recovery is often rapid and complete",
    "Synonyms: subcortical motor aphasia, cortical anarthria, apraxia of speech (in chronic form)"
  ]
);

// SLIDE 28 — Section title
addSectionTitle("PART 4: SUBCORTICAL & THALAMIC APHASIAS", "Deep lesions that disrupt language");

// SLIDE 29 — Subcortical
addBulletSlide("Subcortical Aphasias",
  "Basal ganglia and thalamic lesions causing language disturbances",
  [
    "Basal ganglia lesions (caudate, putamen): hypophonic, dysarthric speech; reduced fluency",
    "Left caudate infarction: may produce hypophonic, anomic speech with paraphasia",
    "Left putaminal hemorrhage: global-like aphasia acutely; may improve substantially",
    "Thalamic aphasia: typically fluent with anomia, perseveration, hypophonia",
    "Thalamus acts as a 'gating' mechanism for cortical language areas",
    "Thalamic lesions may disinhibit or fail to activate cortical speech areas",
    "Recovery from subcortical aphasia is often better than from cortical aphasia",
    "Mechanism: subcortical lesions cause diaschisis (remote metabolic depression) of cortical areas"
  ]
);

// SLIDE 30 — Section title
addSectionTitle("PART 5: DISORDERS OF ARTICULATION & PHONATION", "Dysarthria, Dysphonia & Apraxia of Speech");

// SLIDE 31 — Dysarthria intro
addBulletSlide("Dysarthria — Definition and Mechanism",
  "Impaired motor execution of speech — distinct from aphasia",
  [
    "Dysarthria: disorder of articulation due to weakness, incoordination, or spasticity of speech muscles",
    "Language is intact — the patient knows what they want to say, but execution fails",
    "Structures involved: respiratory muscles, larynx, pharynx, palate, tongue, lips",
    "Innervation: vagal (X), hypoglossal (XII), facial (VII), phrenic nerves",
    "These nuclei are controlled by bilateral corticobulbar tracts",
    "Also subject to extrapyramidal control (cerebellum, basal ganglia)",
    "Lesion localization: UMN (corticobulbar), LMN (cranial nerve nuclei), cerebellar, extrapyramidal"
  ]
);

// SLIDE 32 — Classification
addBulletSlide("Classification of Dysarthrias",
  "Darley, Aronson & Brown (1969) — the classic six types",
  [
    "1. FLACCID dysarthria — LMN / cranial nerve lesion (bulbar palsy)",
    "2. SPASTIC dysarthria — bilateral UMN lesion (pseudobulbar palsy)",
    "3. ATAXIC dysarthria — cerebellar lesion",
    "4. HYPOKINETIC dysarthria — Parkinson disease / basal ganglia (rigid-akinetic)",
    "5. HYPERKINETIC dysarthria — chorea, dystonia, myoclonus",
    "6. MIXED dysarthria — combination (e.g., ALS: spastic + flaccid; MSA: multiple types)",
    "Modern: unilateral UMN dysarthria (stroke) — a 7th type",
    "Clinical testing: 'la-la-la' (lingual), 'me-me-me' (labial), 'ka-ka-ka' (guttural / palatal)"
  ]
);

// SLIDE 33 — Flaccid dysarthria
addTwoColSlide("Flaccid & Spastic Dysarthria",
  "Lower and upper motor neuron patterns",
  [
    "FLACCID (LMN / Bulbar):",
    "Hypernasality — palatopharyngeal weakness",
    "Breathy / weak voice",
    "Imprecise consonants",
    "Short phrases (respiratory weakness)",
    "Nasal emission of air",
    "Causes: bulbar palsy (ALS, GBS, MG, polio), vocal cord palsy",
    "Tongue: wasted, fasciculations (ALS)"
  ],
  [
    "SPASTIC (UMN / Pseudobulbar):",
    "Strained-strangled voice quality",
    "Slow, labored, low pitch",
    "Hypernasality (less than flaccid)",
    "Imprecise consonants",
    "Associated: dysphagia, drooling, emotional lability",
    "Jaw jerk: brisk",
    "Causes: bilateral MCA strokes, TBI, MS, progressive supranuclear palsy",
    "Tongue: small, slow, spastic"
  ],
  "FLACCID DYSARTHRIA", "SPASTIC DYSARTHRIA"
);

// SLIDE 34 — Ataxic
addBulletSlide("Ataxic Dysarthria",
  "Cerebellar lesion — the 'scanning' or drunken speech",
  [
    "Irregular articulatory breakdowns — sudden excess loudness",
    "Irregular rhythm and rate — 'scanning speech'",
    "Excessive stress on each syllable equally (equal and even stress)",
    "Distorted vowels; imprecise consonants",
    "Breaks in rhythm resemble explosive bursts",
    "Voice: harsh, tremorous in some cases",
    "Associated cerebellar signs: nystagmus, limb ataxia, intention tremor",
    "Causes: hereditary ataxias (SCA), MS, alcohol, cerebellar stroke or tumor",
    "Assessment: dysarthria worsens with rapid alternating movements (DDK testing)"
  ]
);

// SLIDE 35 — Hypokinetic / Hyperkinetic
addTwoColSlide("Hypokinetic & Hyperkinetic Dysarthria",
  "Basal ganglia disorders — Parkinson disease and movement disorders",
  [
    "HYPOKINETIC (Parkinson disease):",
    "Monotone — reduced pitch and loudness variation",
    "Hypophonia: soft, breathy voice",
    "Short rushes of speech (festination)",
    "Reduced stress; blurred articulation",
    "Palilalia: repetition of syllables or words",
    "Rate may be fast (festinating) or slow",
    "Treatment: LSVT LOUD therapy — amplification training",
    "Deep brain stimulation (DBS) may improve voice"
  ],
  [
    "HYPERKINETIC (choreoathetosis, dystonia):",
    "Chorea: sudden irregular voice quality interruptions",
    "Dystonia: prolonged strained voice, bizarre distortions",
    "Variable rate — sudden stops mid-utterance",
    "Causes: Huntington disease, tardive dyskinesia, dystonia",
    "Myoclonic dysarthria: voice tremor, rhythmic interruptions",
    "Spasmodic dysphonia: adductor (strained, strangled) or abductor (breathy, whispered)",
    "Hyperkinetic pattern worsens with emotional stress"
  ],
  "HYPOKINETIC", "HYPERKINETIC"
);

// SLIDE 36 — Apraxia of speech
addBulletSlide("Apraxia of Speech",
  "Motor planning / programming disorder — distinct from dysarthria",
  [
    "Impaired ability to plan and sequence voluntary speech movements",
    "Articulatory muscles are not weak (distinguishes from dysarthria)",
    "Inconsistent phonemic errors — same word produced differently each time",
    "Groping articulation; effortful 'islands of clear speech'",
    "More errors on longer, more complex words",
    "Prosodic disturbances: slow, equal stress",
    "Automatic speech (overlearned phrases) is better than voluntary speech",
    "Lesion: left frontal operculum, Broca's area (may coexist with Broca aphasia)",
    "Often associated with Broca aphasia, but can occur independently"
  ]
);

// SLIDE 37 — Dysphonia
addBulletSlide("Dysphonia & Voice Disorders",
  "Impaired phonation — laryngeal and neurological causes",
  [
    "Dysphonia: abnormal voice quality — not a speech (articulation) disorder per se",
    "Hoarseness: inflammatory, structural, or neurological laryngeal disease",
    "Unilateral vocal cord palsy (recurrent laryngeal nerve): breathy, weak voice; aspiration risk",
    "Bilateral vocal cord palsy: stridor, respiratory distress, aphonia",
    "Causes of cord palsy: thyroid/mediastinal mass, neck surgery, aortic aneurysm, skull base tumor",
    "Psychogenic (functional) dysphonia: sudden aphonia, whispering; no organic cause; normal cords on laryngoscopy",
    "Spasmodic dysphonia: focal laryngeal dystonia; strained-strangled or breathy voice",
    "Management: voice therapy, botulinum toxin injection for spasmodic dysphonia"
  ]
);

// SLIDE 38 — Section title
addSectionTitle("PART 6: MUTISM & RELATED SYNDROMES", "Complete loss of speech output");

// SLIDE 39
addBulletSlide("Mutism — Classification and Causes",
  "Complete absence of verbal output — multiple mechanisms",
  [
    "Aphonia: no voice — vocal cord or respiratory origin",
    "Aphemia / pure word mutism: frontal lesion — internal language intact",
    "Global aphasia: severe cortical language destruction",
    "Akinetic mutism: profoundly reduced responsiveness — anterior cingulate / bifrontal lesion",
    "Locked-in syndrome: midbrain/pons lesion — alert but cannot speak or move",
    "Psychiatric mutism: catatonia, conversion disorder, selective mutism",
    "Post-traumatic mutism: after severe TBI; transient",
    "Cerebellar mutism: after posterior fossa surgery in children — transient",
    "Each cause has a distinct examination profile and prognosis"
  ]
);

// SLIDE 40 — Akinetic mutism
addBulletSlide("Akinetic Mutism & Locked-In Syndrome",
  "Distinctive syndromes of absent speech — differential diagnosis",
  [
    "AKINETIC MUTISM: bilateral medial frontal / anterior cingulate or thalamic lesion",
    "Eyes open, follows movement, but does not speak or move voluntarily",
    "'Wakeful but speechless' — no clear aphasia; responds briefly if strongly stimulated",
    "Causes: bilateral ACA infarction, hydrocephalus, bifrontal tumor, severe TBI",
    "LOCKED-IN SYNDROME: bilateral ventral pontine infarction (basilar artery occlusion)",
    "Quadriplegia + aphonia; preserved consciousness and vertical eye movements",
    "Communication via vertical gaze or blinking",
    "NOT akinetic mutism — patient is alert and aware but cannot produce motor output",
    "MRI: bilateral pontine lesion; EEG: normal or near-normal (confirms consciousness)"
  ]
);

// SLIDE 41 — Section title
addSectionTitle("PART 7: READING & WRITING DISORDERS", "Alexia, Agraphia, and Related Conditions");

// SLIDE 42
addTwoColSlide("Alexia — Classification",
  "Acquired reading disorders — three main types",
  [
    "ALEXIA WITH AGRAPHIA (central alexia):",
    "Cannot read OR write",
    "Lesion: angular gyrus (BA 39), dominant hemisphere",
    "Often associated with Gerstmann syndrome",
    "Comprehension of spoken language preserved",
    "ALEXIA WITHOUT AGRAPHIA (pure alexia):",
    "Cannot read; can write normally",
    "Lesion: left occipital cortex + splenium of corpus callosum",
    "Right homonymous hemianopia almost always present"
  ],
  [
    "FRONTAL (THIRD) ALEXIA:",
    "Impaired reading aloud; reading comprehension relatively spared",
    "Associated with Broca aphasia",
    "Lesion: left inferior frontal gyrus",
    "DEVELOPMENTAL DYSLEXIA:",
    "Phonological processing deficit in children",
    "Not an acquired lesion-based disorder",
    "Persistent letter reversal and reading delay",
    "Modern neuroimaging: reduced activation of left posterior temporal cortex"
  ],
  "TYPES I–II", "TYPES III + DEVELOPMENTAL"
);

// SLIDE 43
addBulletSlide("Agraphia — Disorders of Writing",
  "Acquired inability to write — multiple forms",
  [
    "Agraphia is rarely isolated — almost always accompanies aphasia",
    "Aphasic agraphia: parallels the spoken language disturbance in quality",
    "Broca aphasia: agrammatic writing — omitted function words, labored letters",
    "Wernicke aphasia: well-formed letters but misspellings and paragraphias (semantic errors)",
    "Spatial agraphia: neglect of left margin, letters tilted — non-dominant parietal lesion",
    "Pure agraphia (rare): isolated writing loss without aphasia; left premotor or parietal lesion",
    "Gerstmann syndrome: angular gyrus lesion = agraphia + acalculia + left-right disorientation + finger agnosia"
  ]
);

// SLIDE 44 — Section title
addSectionTitle("PART 8: DEVELOPMENTAL LANGUAGE DISORDERS", "Childhood acquisition and delay");

// SLIDE 45
addBulletSlide("Normal Language Development — Milestones",
  "Basis for assessing developmental language delay",
  [
    "2–3 months: cooing, social smile",
    "6 months: babbling (ba-ba, da-da)",
    "10–12 months: first words ('mama', 'dada')",
    "18 months: ~50 words; 2-word phrases beginning",
    "24 months: 2-word combinations; vocabulary of 200+ words",
    "3 years: sentences of 3–4 words; strangers understand 75% of speech",
    "4 years: mostly intelligible; complex sentences; narrative ability",
    "5 years: nearly adult grammar; 2,000+ word vocabulary",
    "Language delay: failure to meet milestones — warrants formal assessment"
  ]
);

// SLIDE 46
addBulletSlide("Developmental Language Disorders",
  "Specific Language Impairment (SLI) and related conditions",
  [
    "Specific Language Impairment (SLI) / Developmental Language Disorder (DLD): language delay without intellectual disability, sensory loss, or autism",
    "Affects ~7% of kindergarten-age children",
    "Deficits in morphosyntax, vocabulary, narrative — all domains may be affected",
    "Phonological disorder: difficulty with sound system of language — 'wabbit' for 'rabbit'",
    "Childhood apraxia of speech (CAS): motor programming disorder in children",
    "Cluttering: excessively rapid, irregular, dysrhythmic speech",
    "Stuttering: repetitions and prolongations of sounds/syllables; onset in early childhood",
    "Congenital aphasia / Landau-Kleffner syndrome: acquired epileptic aphasia in childhood"
  ]
);

// SLIDE 47 — Stuttering
addBulletSlide("Stuttering (Developmental Fluency Disorder)",
  "Core features, neurobiology, and management",
  [
    "Core features: repetitions, prolongations, blocks on sounds, syllables, or words",
    "Secondary behaviors: facial grimacing, head nodding, avoidance behaviors",
    "Onset: typically 2–5 years; ~4:1 male predominance in persistent stuttering",
    "~80% of children recover spontaneously by adolescence",
    "Neuroimaging: functional differences in left frontal, temporal, and basal ganglia activity",
    "Genetic: 60–70% concordance in identical twins; GNPTAB, GNPTG, NAGPA mutations identified",
    "Fluency enhancers: choral reading, delayed auditory feedback, singing",
    "Treatment: fluency shaping therapy, stuttering modification therapy, electronic devices",
    "Pharmacology: no established drug — dopamine antagonists have been trialed"
  ]
);

// SLIDE 48 — Section title
addSectionTitle("PART 9: SPECIFIC BEDSIDE TESTS & CLINICAL EXAMINATION", "Step-by-step neurological assessment");

// SLIDE 49
addBulletSlide("The Mental Status Language Examination",
  "Systematic bedside protocol — DeJong / Adams & Victor",
  [
    "Begin by observing spontaneous speech during history-taking",
    "Note fluency, word-finding pauses, paraphasias, prosody, effort",
    "NAMING: body parts (ear, elbow, knuckle), common objects (pen, watch), uncommon items (watchband, lapel)",
    "COMPREHENSION: 'Close your eyes', 'Touch your nose with your left hand', multi-step commands",
    "REPETITION: 'No ifs, ands, or buts'; 'The president lives in Washington'",
    "READING ALOUD and READING COMPREHENSION (command card: 'Close your eyes')",
    "WRITING: name, address, spontaneous sentence, sentence to dictation",
    "Document findings: fluent/non-fluent, comprehension intact/impaired, repetition intact/impaired"
  ]
);

// SLIDE 50
addBulletSlide("Testing Comprehension — Pitfalls",
  "Common errors in assessing language comprehension",
  [
    "Do NOT rely on yes/no to verbal commands only — limb apraxia can mimic comprehension failure",
    "Test with pointing to named objects: avoids motor response entirely",
    "Eye blinking or gaze direction can test comprehension in non-verbal patients",
    "Complex grammar commands: 'Touch the pen after you touch the comb'",
    "Token Test: standardized test of auditory comprehension sensitivity",
    "Distinguish from inattention (neglect) and hearing impairment — not language",
    "For right-hemisphere non-dominant lesions: test prosody, pragmatics, discourse",
    "Test writing INDEPENDENTLY: reveals agraphia when speech appears intact"
  ]
);

// SLIDE 51 — Associated signs
addBulletSlide("Associated Neurological Signs — Localizing Value",
  "Neurological findings that help localize the aphasia",
  [
    "Right hemiparesis (face + arm > leg): Broca or global aphasia — frontal/anterior MCA",
    "Right hemisensory loss: accompanies most Broca aphasia (parietal extension)",
    "Right homonymous hemianopia: Wernicke aphasia — temporal involvement of optic radiation",
    "Oral apraxia: associated with Broca aphasia — cannot perform voluntary oral movements",
    "Limb apraxia: Broca aphasia — left limb apraxia (disconnection of motor areas)",
    "Gerstmann syndrome (acalculia, agraphia, finger agnosia, L-R disorientation): angular gyrus",
    "Bilateral UMN signs: pseudobulbar palsy — spastic dysarthria",
    "Absent gag, tongue fasciculations: LMN / bulbar — flaccid dysarthria"
  ]
);

// SLIDE 52 — Section title
addSectionTitle("PART 10: IMAGING & INVESTIGATION", "Localizing the lesion");

// SLIDE 53
addBulletSlide("Neuroimaging in Aphasia",
  "MRI, CT, and functional imaging for language disorders",
  [
    "CT: first-line in acute stroke — identifies hemorrhage, large infarct, mass",
    "MRI-DWI: detects acute ischemic stroke within minutes — defines exact lesion boundaries",
    "MRI-FLAIR: best for subacute and chronic lesions; demyelination (MS)",
    "PET and SPECT: functional imaging — shows hypometabolism beyond structural lesion",
    "Useful in: semantic dementia, Alzheimer-related aphasia, Landau-Kleffner",
    "fMRI language mapping: pre-surgical — identifies eloquent cortex to spare during resection",
    "Transcranial magnetic stimulation (TMS): research tool — maps language areas non-invasively",
    "EEG: Landau-Kleffner syndrome — continuous spike-wave during slow sleep (CSWS)"
  ]
);

// SLIDE 54 — Vascular causes
addBulletSlide("Vascular Causes of Aphasia — Arterial Territories",
  "Stroke is the most common cause of acquired aphasia",
  [
    "Left MCA superior division: Broca aphasia — frontal opercular + anterior perisylvian",
    "Left MCA inferior division: Wernicke aphasia — posterior temporal-parietal",
    "Left MCA entire territory: global aphasia — entire perisylvian zone",
    "Left ACA territory: transcortical motor aphasia — SMA, medial frontal",
    "Left PCA territory: pure alexia (alexia without agraphia) — occipital + splenium",
    "Posterior watershed zone: transcortical sensory aphasia",
    "Left thalamic perforators: thalamic aphasia — hypophonic, fluent, anomic",
    "Left internal carotid occlusion: global aphasia with hemispheric signs"
  ]
);

// SLIDE 55 — Degenerative
addBulletSlide("Degenerative & Other Causes of Language Disorders",
  "Beyond stroke — a broad differential",
  [
    "Primary Progressive Aphasia (PPA): insidious onset, progressive — three variants:",
    "  - Nonfluent/Agrammatic PPA: effortful speech, agrammatism; tau pathology (CBD, PSP)",
    "  - Semantic PPA (semantic dementia): fluent; severe anomia; loss of word meaning; TDP-43",
    "  - Logopenic PPA: word-finding pauses; impaired sentence repetition; Alzheimer pathology",
    "Brain tumors: glioma in dominant hemisphere — progressive aphasia",
    "Traumatic brain injury: mixed aphasia, anomia — usually recovers",
    "Herpes simplex encephalitis: Wernicke area involved — fluent aphasia",
    "Creutzfeldt-Jakob disease: rapidly progressive aphasia + dementia + myoclonus"
  ]
);

// SLIDE 56 — Section title
addSectionTitle("PART 11: DIFFERENTIAL DIAGNOSIS", "Distinguishing aphasia from similar syndromes");

// SLIDE 57
addTwoColSlide("Aphasia vs. Confusion & Dementia",
  "Critical distinctions in altered communication",
  [
    "APHASIA:",
    "Specific language deficit in an alert patient",
    "Attention and orientation may be preserved",
    "Language is the primary impairment",
    "Usually due to focal cortical lesion",
    "Writing mirrors speech errors",
    "No global cognitive impairment (in pure aphasia)",
    "Clock drawing and visuospatial tasks often intact"
  ],
  [
    "CONFUSION / DELIRIUM:",
    "Global cognitive impairment — attention impaired first",
    "Disoriented, poor short-term memory",
    "Language is tangential but not aphasic",
    "Cause: metabolic, toxic, infectious",
    "Writing: confused content, poor penmanship",
    "DEMENTIA: gradual, progressive — anomia early",
    "Aphasia occurs in dementia but with global cognitive decline"
  ],
  "APHASIA", "CONFUSION / DEMENTIA"
);

// SLIDE 58
addBulletSlide("Dysarthria vs. Aphasia — The Essential Distinction",
  "Cannot be overemphasized in clinical neurology",
  [
    "Dysarthria: impaired execution — patient knows the word; language rules intact",
    "Aphasia: impaired language itself — patient may not know the word or understand it",
    "Dysarthric patients: write normally (if limbs functional); language tests normal",
    "Aphasic patients: writing is typically abnormal (mirrors spoken language deficit)",
    "Dysarthria: no naming errors, no paraphasia, comprehension intact",
    "Aphasia: naming errors, paraphasia, comprehension may be impaired",
    "Both can coexist: Broca aphasia + dysarthria is common",
    "Quick test: ask patient to write — a clear sentence rules out significant aphasia"
  ]
);

// SLIDE 59 — Section title
addSectionTitle("PART 12: APHASIA REHABILITATION", "Evidence-based recovery and treatment");

// SLIDE 60
addBulletSlide("Prognosis of Aphasia",
  "Factors that predict recovery — Adams & Victor, Bradley & Daroff",
  [
    "Lesion size: most powerful predictor — larger lesions have worse outcomes",
    "Aphasia type: global aphasia and severe Broca/Wernicke recover less than conduction/anomic",
    "Age: younger patients generally recover better (neural plasticity)",
    "Time since onset: greatest recovery in first 3 months; continues up to 2 years",
    "Left-handedness: more favorable prognosis (greater bilateral representation)",
    "Etiology: trauma > stroke for recovery; degenerative = progressive worsening",
    "Minimal 'mini-Broca' and pure word mutism (aphemia): recover rapidly and often completely",
    "Pure alexia, conduction, and transcortical aphasias: good prognosis for recovery"
  ]
);

// SLIDE 61
addBulletSlide("Aphasia Rehabilitation",
  "Principles and evidence-based approaches",
  [
    "Speech-language pathology (SLP): cornerstone of aphasia treatment",
    "Intensive therapy (>3 hours/week) shows better outcomes than low-intensity",
    "Constraint-induced aphasia therapy (CIAT): forced verbal communication without compensatory strategies",
    "Melodic intonation therapy (MIT): leverages right hemisphere musical-prosodic networks — effective for non-fluent aphasia",
    "Script training and semantic feature analysis: specific lexical retrieval techniques",
    "Technology: tablet-based apps, AAC (augmentative and alternative communication) devices",
    "Family involvement and patient education: reduces frustration, improves generalization",
    "Pharmacology: memantine, piracetam studied; no definitive benefit in RCTs",
    "rTMS and tDCS: emerging — modulate language cortex excitability; research stage"
  ]
);

// SLIDE 62 — Section title
addSectionTitle("PART 13: SPECIAL TOPICS", "Prosody, Right Hemisphere & Functional Disorders");

// SLIDE 63
addBulletSlide("Right Hemisphere Language Functions",
  "Non-dominant hemisphere: prosody, pragmatics, and discourse",
  [
    "Right hemisphere: prosody (emotional intonation), pragmatics, narrative structure, humor",
    "Right hemisphere lesion: aprosodia — flat, monotone voice; difficulty interpreting emotional tone",
    "Motor aprosodia: cannot produce emotional speech; lesion = right inferior frontal (mirror of Broca)",
    "Sensory aprosodia: cannot interpret emotional speech; lesion = right posterior temporal",
    "Right hemisphere damage: difficulty with metaphors, indirect requests, sarcasm",
    "Discourse and narrative: impaired coherence after right hemisphere damage",
    "Neglect dyslexia: failure to read left side of words/text — right parietal lesion",
    "Testing: ask patient to read with angry/sad/happy intonation; interpret emotional sentences"
  ]
);

// SLIDE 64
addBulletSlide("Functional (Psychogenic) Speech Disorders",
  "Conversion and psychiatric speech disturbances",
  [
    "Functional aphonia: whispered or absent voice with normal laryngoscopy",
    "Functional dysphonia: abnormal voice quality; inconsistent; responds to suggestion",
    "Selective mutism (children): speaks in some contexts (home) but not others (school)",
    "Conversion dysarthria: inconsistent articulation; not matching any known neurological pattern",
    "Functional stuttering: sudden onset in adults; acquired, not developmental",
    "Key clinical clues: inconsistency of deficits; normal cough voice; improvement with distraction",
    "Management: direct laryngoscopy (normal), neurological examination, reassurance, voice therapy",
    "Liaison psychiatry involvement: underlying anxiety, trauma, somatoform disorder"
  ]
);

// SLIDE 65 — Summary table / take-home
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    ["Distinguish language (aphasia) from speech (dysarthria) — lesion localization depends on this", BLACK],
    ["Classify aphasia first by fluency, then comprehension, then repetition", ACCENT],
    ["Non-fluent = anterior (frontal); Fluent = posterior (temporal/parietal)", BLACK],
    ["Preserved repetition → transcortical (extra-perisylvian) lesion", ACCENT],
    ["Broca: non-fluent, agrammatic, poor repetition, right hemiparesis", BLACK],
    ["Wernicke: fluent, jargon, poor comprehension, right hemianopia; no hemiparesis", ACCENT],
    ["Writing is an essential bedside test — reflects the aphasia type accurately", BLACK],
    ["Dysarthria types: flaccid, spastic, ataxic, hypokinetic, hyperkinetic, mixed", ACCENT],
    ["Prognosis: lesion size > aphasia type; greatest recovery in first 3 months", BLACK],
    ["Intensive SLP therapy including MIT and CIAT has best evidence for recovery", ACCENT],
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Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/speech-language-ppt/build.js'

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// ─────────────────────────────────────────────────────────
// SLIDE 1 — TITLE
// ─────────────────────────────────────────────────────────
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// ─────────────────────────────────────────────────────────
// SLIDE 2 — Chapter Outline
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Chapter Outline",
  "Disorders of Articulation and Phonation — Adams & Victor / DeJong",
  [
    "1.  Definitions: dysarthria, dysphonia, anarthria — and how they differ from aphasia",
    "2.  Neuroanatomy of speech production: muscles, nerves, cortical control",
    "3.  Classification of dysarthrias (Darley-Aronson-Brown framework)",
    "4.  Flaccid (LMN) dysarthria — bulbar palsy",
    "5.  Spastic (UMN / pseudobulbar) dysarthria",
    "6.  Rigid (extrapyramidal / hypokinetic) dysarthria — Parkinson disease",
    "7.  Ataxic (cerebellar) dysarthria",
    "8.  Hyperkinetic dysarthrias — chorea, dystonia, myoclonus",
    "9.  Mixed dysarthrias — ALS, MSA",
    "10. Apraxia of speech — definition, features, localization",
    "11. Oral/buccolingual apraxia",
    "12. Clinical testing and differential diagnosis",
    "13. Management and rehabilitation"
  ],
  14
);

// ─────────────────────────────────────────────────────────
// SLIDE 3 — Definitions
// ─────────────────────────────────────────────────────────
defSlide(
  "Key Definitions",
  "Dysarthria vs. Aphasia vs. Dysphonia",
  "Dysarthria = impaired articulation due to neuromuscular dysfunction of the speech apparatus. Language (grammar, vocabulary, comprehension) is intact.",
  [
    "Anarthria: most severe form of dysarthria — complete loss of intelligible speech; writing and comprehension preserved",
    "Dysphonia: abnormal voice quality (phonation) — laryngeal dysfunction; articulation is otherwise normal",
    "Aphasia: impaired language itself — distinguished from dysarthria by testing writing and comprehension",
    "Key bedside test: ask the patient to WRITE — a dysarthric patient writes normally (if limbs are functional)",
    "Dysarthria + normal language = motor pathway lesion (LMN, UMN, cerebellar, basal ganglia)",
    "Both dysarthria AND aphasia can coexist (e.g., Broca aphasia with apraxia of speech)"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 4 — Neuroanatomy of Speech Production
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Neuroanatomy of Speech Production",
  "The motor apparatus: muscles, nerves, and cortical control",
  [
    "Speech requires coordinated action of: respiratory muscles, larynx, pharynx, palate, tongue, lips",
    "Phonation: larynx / vocal cords (tensioned by intrinsic laryngeal muscles) — vowels are laryngeal in origin",
    "Articulation: pharynx, palate, tongue, lips interrupt and shape airflow — m/b/p = labial, l/t = lingual, ng/nk = guttural",
    "Cranial nerves: CN V (jaw), CN VII (lips/face), CN X (palate, larynx), CN XII (tongue), phrenic (diaphragm)",
    "Corticobulbar tracts: both motor cortices send fibers to each bulbar motor nucleus — bilateral representation",
    "Consequence: unilateral UMN lesion causes transient, mild dysarthria — bilateral UMN lesion causes severe spastic dysarthria",
    "Extrapyramidal control: cerebellum and basal ganglia modulate rate, rhythm, and tone of speech movements",
    "Bedside test: 'la-la-la' (lingual/tongue tip), 'me-me-me' (labial), 'ka-ka-ka' or 'Methodist Episcopal' (palatal/guttural)"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 5 — Classification Table
// ─────────────────────────────────────────────────────────
tableSlide(
  "Classification of Dysarthrias",
  "Darley, Aronson & Brown (1969) — the classical framework",
  ["Type", "Lesion Site", "Voice Quality", "Key Features", "Common Cause"],
  [
    ["Flaccid (LMN)", "LMN / cranial nerve nuclei", "Breathy, hypernasal", "Imprecise consonants, nasal emission", "Bulbar ALS, MG, GBS, polio"],
    ["Spastic (UMN)", "Bilateral corticobulbar tracts", "Strained-strangled", "Slow, labored; exaggerated reflexes", "Bilateral MCA strokes, MS, ALS"],
    ["Ataxic", "Cerebellum", "Irregular, scanning", "Equal stress, explosive, irregular rhythm", "SCA, MS, alcoholic, cerebellar stroke"],
    ["Hypokinetic", "Basal ganglia (substantia nigra)", "Soft, monotone", "Reduced loudness, short rushes, palilalia", "Parkinson disease, PSP"],
    ["Hyperkinetic", "Basal ganglia / extrapyramidal", "Irregular interruptions", "Sudden voice stoppages, distorted", "Huntington, dystonia, myoclonus"],
    ["Mixed", "Multiple levels", "Variable", "Combination of above patterns", "ALS, MSA, TBI, Wilson disease"]
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 6 — Flaccid Dysarthria
// ─────────────────────────────────────────────────────────
sectionSlide("FLACCID DYSARTHRIA", "Lower Motor Neuron / Bulbar Palsy");

// ─────────────────────────────────────────────────────────
// SLIDE 7
// ─────────────────────────────────────────────────────────
twoCol(
  "Flaccid (LMN) Dysarthria — Features & Causes",
  "Weakness or paralysis of articulatory muscles — lower motor neuron",
  "CLINICAL FEATURES",
  [
    "Tongue: shriveled, inert, fasciculating — lies on floor of mouth",
    "Lips: lax, tremulous — labial consonants (p, b) poorly formed",
    "Voice: breathy, weak, nasal, monotone (dysphonia from cord paralysis)",
    "Drooling and dysphagia: constant saliva pooling",
    "Hypernasality: palatal weakness — nasal emission of air",
    "Difficulty with vibratives: 'r' sounds poorly formed",
    "Jaw: may hang open — poor masseter tone",
    "Advanced: speech becomes unintelligible; total anarthria"
  ],
  "CAUSES",
  [
    "Progressive bulbar palsy (ALS — lower motor neuron variant)",
    "Bilateral vocal cord palsy (thyroid, neck surgery, mediastinal mass)",
    "Myasthenia gravis: fatigable — worsens through conversation; nasal escape",
    "Guillain-Barré syndrome: facial diplegia — labial consonants (p/b → f/v)",
    "Poliomyelitis: palatal paralysis — historic; hypernasality",
    "Diphtheria: bilateral palatal palsy (now rare)",
    "Lyme disease / sarcoidosis: bilateral VII palsy",
    "Syringobulbia: lower cranial nerve involvement"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 8 — Spastic Dysarthria
// ─────────────────────────────────────────────────────────
sectionSlide("SPASTIC DYSARTHRIA", "Upper Motor Neuron / Pseudobulbar Palsy");

// ─────────────────────────────────────────────────────────
// SLIDE 9
// ─────────────────────────────────────────────────────────
twoCol(
  "Spastic (UMN / Pseudobulbar) Dysarthria",
  "Bilateral corticobulbar tract disease — no atrophy, no fasciculations",
  "CLINICAL FEATURES",
  [
    "Voice: strained, strangled quality — 'talking through a tight larynx'",
    "Rate: slow, labored — low and slightly high pitch",
    "Tongue: small, slow, spastic — cannot move rapidly side to side",
    "Jaw jerk: brisk or exaggerated (key sign — reflex hyperactivity)",
    "Gag reflex: retained or increased",
    "Emotional lability: pathological crying and laughing (pseudobulbar affect)",
    "Dysphagia: present, may be severe",
    "No atrophy, no fasciculations — distinguishes from LMN/flaccid"
  ],
  "CAUSES & ANATOMY",
  [
    "Bilateral MCA territory strokes (stepwise onset — lacunar)",
    "Foix-Chavany-Marie syndrome: bilateral anterior opercular syndrome",
    "  — 1st stroke silent, 2nd stroke causes sudden anarthria + dysphagia",
    "Amyotrophic lateral sclerosis (ALS): spastic + flaccid MIXED",
    "Multiple sclerosis: bilateral corticobulbar demyelination",
    "Traumatic brain injury: diffuse axonal injury",
    "Progressive supranuclear palsy (PSP)",
    "Treatment of pseudobulbar affect: dextromethorphan/quinidine (Nuedexta)"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 10 — Rigid / Hypokinetic Dysarthria
// ─────────────────────────────────────────────────────────
sectionSlide("HYPOKINETIC & HYPERKINETIC DYSARTHRIA", "Extrapyramidal Disorders of Speech");

// ─────────────────────────────────────────────────────────
// SLIDE 11
// ─────────────────────────────────────────────────────────
twoCol(
  "Rigid (Hypokinetic) Dysarthria — Parkinson Disease",
  "Extrapyramidal / basal ganglia — substantia nigra dopaminergic loss",
  "SPEECH FEATURES",
  [
    "Hypophonia: reduced vocal loudness — cardinal feature",
    "Monotone: reduced pitch variation and intonation",
    "Reduced stress: syllables receive equal, flat emphasis",
    "Festinating speech: short rushes with increasing rate",
    "Articulation: blurred, imprecise — all movements small (hypokinesia)",
    "Palilalia: repetition of syllables or words at increasing rate",
    "Voice: breathy or rough quality",
    "Hypomimia: masked facies reduces non-verbal communication"
  ],
  "MANAGEMENT",
  [
    "LSVT LOUD therapy: Lee Silverman Voice Treatment — trains high-effort loud phonation",
    "Patient practices: 'aaah' at maximum loudness for extended duration",
    "Transfers loudness to conversational speech",
    "Evidence: RCTs show significant improvement in loudness and intelligibility",
    "Dopaminergic medications (levodopa): modest improvement in speech",
    "Deep brain stimulation (DBS): variable effect on speech — may worsen hypophonia",
    "Delayed auditory feedback (DAF) devices: reduce festination",
    "Multiple system atrophy (MSA): more severe hypokinetic dysarthria; poor prognosis"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 12 — Hyperkinetic Dysarthria
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Hyperkinetic Dysarthria",
  "Chorea, dystonia, myoclonus, tremor — involuntary movements disrupt speech",
  [
    "CHOREIC dysarthria (Huntington disease): sudden, unpredictable voice quality changes mid-utterance",
    "  — Involuntary respiratory movements interrupt airflow; prosody is irregular and variable",
    "DYSTONIC dysarthria: prolonged, sustained muscle contractions — distorted vowels and consonants",
    "  — Spasmodic dysphonia: focal laryngeal dystonia",
    "  — Adductor type (most common): strained, strangled, effortful voice with voice breaks",
    "  — Abductor type: breathy, whispering voice; words cut off mid-utterance",
    "MYOCLONIC dysarthria: rhythmic or arrhythmic voice tremor — palatopharyngolaryngeal myoclonus",
    "ESSENTIAL TREMOR: vocal tremor — wavy, oscillating pitch during sustained vowels",
    "TARDIVE DYSKINESIA: orobuccal dyskinesia — lip smacking, tongue movements disrupt articulation",
    "Botulinum toxin injection: treatment of choice for spasmodic dysphonia"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 13 — Ataxic Dysarthria
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Ataxic (Cerebellar) Dysarthria",
  "Cerebellar dysfunction — scanning, irregular, explosive speech",
  [
    "Classic description: 'scanning speech' — each syllable separated, equal stress",
    "Irregular articulatory breakdowns: sudden excess loudness on a syllable (explosive speech)",
    "Equal and even stress on all syllables — normal stress pattern is lost",
    "Prosody: slow, monotone with intermittent bursts of loudness",
    "Voice: may be harsh, tremorous (vocal tremor from cerebellar output dysfunction)",
    "Distorted vowels; imprecise consonants",
    "Diadochokinesis (DDK): poor — ask patient to repeat 'pa-ta-ka' rapidly — irregular timing",
    "Associated cerebellar signs: nystagmus, intention tremor, limb ataxia, gait ataxia",
    "Causes: hereditary spinocerebellar ataxias (SCA), multiple sclerosis, chronic alcoholism, paraneoplastic, Friedreich ataxia, posterior fossa tumor",
    "Dysarthria is often the EARLIEST sign in cerebellar disease — monitor carefully"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 14 — Mixed Dysarthria
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Mixed Dysarthria",
  "Multiple-level lesions — combination of dysarthria types",
  [
    "AMYOTROPHIC LATERAL SCLEROSIS (ALS): SPASTIC + FLACCID mixed dysarthria",
    "  — Simultaneous UMN (spastic) + LMN (flaccid/atrophic) degeneration of corticobulbar and bulbar motor neurons",
    "  — Tongue: wasted AND spastic; jaw jerk elevated AND fasciculations present",
    "  — Dysarthria progresses to anarthria; eventually requires AAC device",
    "MULTIPLE SYSTEM ATROPHY (MSA): ataxic + hypokinetic + spastic — cerebellar and extrapyramidal",
    "WILSON'S DISEASE: mixed dysarthria — basal ganglia + cerebellar copper deposition; tremorous, scanning",
    "TRAUMATIC BRAIN INJURY (TBI): variable mix — diffuse axonal injury affects multiple levels",
    "MULTIPLE SCLEROSIS: ataxic + spastic — cerebellar + bilateral corticobulbar plaques",
    "Clinical tip: identifying MIXED pattern should prompt search for multi-system disease (ALS, MSA, Wilson)"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 15 — Section divider
// ─────────────────────────────────────────────────────────
sectionSlide("APRAXIA OF SPEECH", "Motor Programming Disorder — Distinct from Dysarthria and Aphasia");

// ─────────────────────────────────────────────────────────
// SLIDE 16 — AOS Definition
// ─────────────────────────────────────────────────────────
defSlide(
  "Apraxia of Speech — Definition & Core Concept",
  "A disorder of motor programming of articulation, not of muscle strength",
  "The motor speech system makes errors in the selection and sequencing of consonant phonemes in the ABSENCE of any weakness, slowness, or incoordination of the muscles of articulation (Wertz et al., 1991).",
  [
    "The patient 'knows what they want to say and how it should sound' — yet cannot articulate it properly (Hillis et al., 2004)",
    "Errors are in planning/programming voluntary speech movements — an apraxia by analogy with limb apraxia",
    "Key distinction from dysarthria: AOS errors are INCONSISTENT — same word produces different errors on each attempt",
    "Dysarthria: errors are CONSISTENT — the distortion is predictable and mechanical",
    "AOS: consonants are substituted; dysarthria: consonants are distorted (different error type)",
    "Patients show 'conduit d'approche': repeated attempts at self-correction with variable outcomes",
    "Polysyllabic words produce more errors: 'catastrophe' → variable errors each time"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 17 — Four Cardinal Features
// ─────────────────────────────────────────────────────────
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    { num: "3", title: "Inconsistency of errors", detail: "Same word produces different errors on different attempts — not reproducibly distorted" },
    { num: "4", title: "Difficulty initiating utterances", detail: "Greatest difficulty at the START — especially the first phoneme of a polysyllabic word" }
  ];

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// ─────────────────────────────────────────────────────────
// SLIDE 18 — AOS: Lesion, Relationship to Aphasia
// ─────────────────────────────────────────────────────────
twoCol(
  "Apraxia of Speech — Anatomy & Relationship to Aphasia",
  "Localization, associated deficits, and the Broca aphasia connection",
  "LESION LOCALIZATION",
  [
    "Classic Broca area: left inferior frontal gyrus (BA 44, 45) — motor programming of articulation",
    "Hillis et al. (2004): acute MRI correlations point to left frontal cortex (Broca area) as site of AOS",
    "Dronkers (1996): proposed left hemisphere insula as critical region — overlapping lesion evidence",
    "Current consensus: left frontal operculum + possibly anterior insula",
    "Often coexists with Broca aphasia — requires careful separation at bedside",
    "Primary Progressive Apraxia of Speech (PPAOS): progressive, degenerative form",
    "  — Related to frontotemporal dementia and primary progressive aphasia",
    "  — Tau pathology (CBD, PSP) most common"
  ],
  "RELATIONSHIP TO APHASIA",
  [
    "AOS rarely occurs in isolated pure form",
    "Most commonly accompanies Broca aphasia — the two are closely linked anatomically",
    "Patient with AOS + aphasia: writes BETTER than they speak — writing partially spared",
    "Comprehension: relatively preserved in isolated AOS",
    "Distinguish from Broca aphasia: writing in AOS is not aphasic (no agrammatism)",
    "Oral/buccolingual apraxia often coexists: separate from AOS — different examination",
    "Severity: ranges from mild hesitancy to near-total inability to initiate speech",
    "Recovery: with treatment, significant improvement is possible — especially with intensive drilling"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 19 — Clinical Testing
// ─────────────────────────────────────────────────────────
bulletSlide(
  "Clinical Testing for Dysarthria and Apraxia of Speech",
  "Bedside examination protocol — DeJong's approach",
  [
    "LISTEN first: observe spontaneous speech — rate, effort, articulation clarity, prosody, voice quality",
    "ORAL MOTOR EXAM: inspect tongue (atrophy, fasciculations, spasticity), lips, palate at rest and in movement",
    "DDK (Diadochokinetic) testing:",
    "  • 'la-la-la' — tests tongue tip / lingual agility",
    "  • 'me-me-me' — tests labial muscles",
    "  • 'ka-ka-ka' — tests posterior tongue / palatal / guttural articulation",
    "  • 'pa-ta-ka' sequence — tests motor sequencing (slowed or irregular in AOS and ataxic)",
    "CONTRIVED PHRASES: 'Methodist Episcopal', 'artillery', 'Biblical criticism'",
    "APRAXIA TEST: repeat 'catastrophe' or 'television' 5 times — inconsistent errors = AOS",
    "ORAL APRAXIA: 'lick your upper lip', 'whistle', 'blow out a match' — tests non-speech oral movements",
    "VOICE QUALITY: sustained 'aah' for maximum duration — reduced in flaccid/spastic; tremulous in cerebellar/ET",
    "WRITING: ask patient to write name and a sentence — normal in pure dysarthria; abnormal in aphasia"
  ]
);

// ─────────────────────────────────────────────────────────
// SLIDE 20 — Differential Diagnosis & Summary
// ─────────────────────────────────────────────────────────
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  hdr(s, "Differential Diagnosis & Clinical Summary", "Putting it all together — the key distinctions");

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      { text: "Feature", options: { bold: true, color: WHITE, fill: BLUE, fontSize: 12, fontFace: "Calibri", align: "center" } },
      { text: "Dysarthria", options: { bold: true, color: WHITE, fill: BLUE, fontSize: 12, fontFace: "Calibri", align: "center" } },
      { text: "Apraxia of Speech", options: { bold: true, color: WHITE, fill: BLUE, fontSize: 12, fontFace: "Calibri", align: "center" } },
      { text: "Aphasia (Broca's)", options: { bold: true, color: WHITE, fill: BLUE, fontSize: 12, fontFace: "Calibri", align: "center" } }
    ],
    ...([
      ["Language intact?", "YES", "YES", "NO — agrammatic"],
      ["Writing normal?", "YES", "Mostly YES", "NO — reflects speech"],
      ["Comprehension", "Normal", "Relatively preserved", "May be impaired"],
      ["Error type", "Consistent distortion", "Inconsistent substitution", "Paraphasia, anomia"],
      ["Self-correction", "None (mechanical)", "Yes — groping", "Attempts — paraphasia"],
      ["Articulation errors", "Predictable / distorted", "Variable each attempt", "Not the primary issue"],
      ["Muscle weakness", "Present (flaccid) or spastic", "ABSENT", "ABSENT"],
      ["Lesion site", "LMN, UMN, CB, BG", "Left frontal operculum", "Left perisylvian"],
    ]).map(row => row.map((cell, ci) => ({
      text: cell,
      options: { fontSize: 11, color: GRAY, fontFace: "Calibri", fill: ci === 0 ? LBLUE : WHITE }
    })))
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  // footer
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    x: 0, y: 5.38, w: "100%", h: 0.23,
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  s.addText("Source: Adams & Victor's Principles of Neurology, 12th Ed. | Bradley & Daroff's Neurology in Clinical Practice | DeJong's The Neurological Examination", {
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// ─────────────────────────────────────────────────────────
// WRITE
// ─────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/speech-language-ppt/Dysarthria_Apraxia_of_Speech_DeJong.pptx" })
  .then(() => console.log("SUCCESS"))
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