Understanding Right Hemisphere Stroke: Communication and Cognitive Impacts
A right hemisphere stroke occurs when there is a disruption in blood flow to the right side of the brain, affecting functions like spatial awareness, visual processing, and certain cognitive and communication skills. While left hemisphere strokes often result in more apparent language deficits, right hemisphere strokes can lead to subtle yet impactful challenges, especially in social communication and understanding the perspectives of others.
These communication challenges, often referred to as pragmatic deficits, were historically overlooked by speech-language pathologists and occupational therapists. In fact, up until the 1980s, it was generally believed that the right hemisphere was responsible mainly for visual-spatial skills, with little connection to higher levels of cognition or communication. However, research led by Howard Gardner and his colleagues at Harvard University, along with speech-language pathologists across the U.S., began to reveal cognitive-linguistic deficits linked to right hemisphere brain damage.1 This research marked a turning point in therapeutic approaches, leading to the development of new assessments and treatments for these specific deficits.
Causes and effects of a right hemisphere stroke
A right hemisphere stroke affects areas of the brain essential for perceiving and organizing spatial and visual information and for interpreting complex social and emotional cues that guide interaction. Damage from either an ischemic (blocked blood vessel) or hemorrhagic (ruptured blood vessel) event disrupts oxygen flow, leading to localized cell death in the right hemisphere and affecting a person’s ability to process their environment accurately and engage meaningfully in social communication.
This disruption can impair spatial awareness, visual recognition, and pragmatic communication skills, leading to challenges that are often more nuanced than those seen in left hemisphere strokes. Patients with right hemisphere damage may struggle to maintain conversational relevance, understand social nuances, and interpret others’ perspectives—a set of skills collectively known as pragmatic language abilities. Unlike left hemisphere strokes, which more directly impact language production and comprehension, right hemisphere strokes affect the underlying cognitive processes that enable smooth, socially appropriate communication.
Signs and indicators of a right hemisphere stroke
Right hemisphere strokes present unique indicators, often centered around cognitive-communication deficits rather than traditional language disorders. Patients may struggle with impulsivity, reduced awareness of their own limitations, and difficulties in maintaining attention. These symptoms can make it challenging for individuals to navigate social settings, often impacting relationships and overall quality of life. Additionally, certain cognitive processes, such as maintaining focus during conversations or understanding others’ perspectives, may be compromised, leading to communication challenges that extend beyond simple language use.
According to the American Speech-Language-Hearing Association, right hemisphere stroke patients often exhibit pragmatic language deficits—difficulties with humor, sarcasm, and understanding implied meanings—alongside discourse impairments, such as trouble with coherence, conversational repair, and turn-taking.2 These challenges significantly affect the flow and coherence of conversations, as well as patients’ ability to relate to others’ viewpoints.
Two of the most common and impactful deficits observed after a right hemisphere stroke are tangentiality and impairments in theory of mind. Let’s explore each of these in more detail.
Tangentiality
A common communication problem observed after a right hemisphere stroke is tangentiality—the tendency for a patient to veer off into tangents, far removed from the main topic of conversation. This issue can complicate interactions, as it often disrupts the coherence and flow of dialogue, leaving listeners confused or disengaged.
To address tangentiality, therapists often work on “topic maintenance” as a conversational goal, helping patients learn strategies to stay focused on relevant points during discussions. However, newer neuroscience research suggests that tangentiality may be linked to deeper cognitive processes, specifically deficits in theory of mind. Addressing these underlying theory of mind deficits could provide a more efficient and lasting solution to some of the communication challenges faced by these patients.
Theory of mind
Theory of mind refers to the cognitive ability to understand others’ thoughts, emotions, and perspectives, which is often affected by right hemisphere stroke. A deficit in theory of mind can impact various aspects of communication, making it difficult for patients to interpret social cues or respond appropriately in conversations. For instance, patients may fail to recognize when their conversational partner is confused or when a particular response is expected, leading to misunderstandings.
By targeting theory of mind deficits in therapy, clinicians can help improve patients’ overall social cognition and adaptability in interactions. This approach may address a broader range of communication issues beyond tangentiality, offering a more comprehensive path to improved social interactions. Join Dr. Martha Burns for updates on neuroscience research on right hemisphere disorders, including effective treatment goals tailored to enhance communication and social engagement in patients with these challenges.
Right hemisphere and language
In the past decade, neuroscience research has clarified the deficits associated with right hemisphere brain damage and its role in language and cognition. This shift in understanding has led therapists to recognize that the right hemisphere supports nuanced aspects of communication, such as interpreting humor, understanding implied meanings, and managing conversational flow.
For example, a speech-language pathologist might establish a goal around helping a patient interpret indirect requests or sarcasm—skills that require subtle cognitive processing. Tailoring intervention to include role-playing exercises, social scenarios, and practice with implied meanings helps patients build these pragmatic skills, focusing on concrete language abilities and the underlying cognitive processes necessary for smooth, socially appropriate interactions.
Fostering effective communication in right hemisphere stroke recovery
Right hemisphere stroke rehabilitation goes beyond traditional language therapy. It involves addressing the unique cognitive and social challenges patients face after a stroke on the brain’s right side, tackling subtle yet impactful challenges like tangentiality and deficits in theory of mind. By focusing on these areas, clinicians can help patients rebuild confidence and improve social interactions. With personalized interventions and ongoing research, this approach fosters meaningful communication and enhances the quality of life for individuals recovering from a right hemisphere stroke.
References
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- Gardner, H. (1981). The Shattered Mind: The Person After Brain Damage. New York: Knopf.
- American Speech-Language-Hearing Association. (n.d.). Right hemisphere disorder. ASHA Practice Portal. Retrieved [insert date you accessed the webpage], from https://www.asha.org/practice-portal/clinical-topics/right-hemisphere-disorder/
