Left Neglect Patients Research Articles

The effect of offline anosognosia for hemispatial neglect on neglect rehabilitation in patients with subacute and chronic right hemispheric brain injury. A retrospective cohort study

ABSTRACT We investigated the effects of offline anosognosia for hemispatial neglect on neglect severity, functional ability, mobility, and motor recovery in left hemispatial neglect (HN) patients with right hemisphere injury. Eighty-five patients were included in this retrospective study. All patients had undergone a routine neglect rehabilitation programme. Neglect and anosognosia severities were determined by the Catherine Bergego Scale. Functional Independence Measure (FIM) scores, Functional Ambulation Classification (FAC) levels, and Brunnstrom motor recovery stages were noted. The prevalence of anosognosia for HN was 81.2% (69 of 85 patients). Neglect and neglect anosognosia severities were strongly correlated (r = 0.85, p < 0.001). Patients with anosognosia had more severe hemispatial neglect. There was no difference in median FIM score between those with and without anosognosia. The severity of anosognosia negatively correlated with FIM and FAC scores. Linear mixed model analysis revealed a significant decrease in neglect scores in patients with anosognosia than in those without. Anosognosia severity also decreased through rehabilitation and the decrease in anosognosia significantly predicted neglect improvement. Our study emphasizes that neglect anosognosia is related to severe hemispatial neglect, poor functional ability, and limited mobility. Addressing neglect anosognosia may be a valuable component of neglect rehabilitation. Clinical Trials Registration Number NCT05145855.

'See Me, Feel Me': Prismatic Adaptation of an Alien Limb Ameliorates Spatial Neglect in a Patient Affected by Pathological Embodiment.

Pathological embodiment (E+) is a specific contralesional delusion of body ownership, observed following brain damage, in which patients embody someone else’s arm and its movements within their own body schema whenever the contralesional ‘alien’ arm is presented in a body-congruent position (i.e., 1st person perspective and aligned with the patient’s shoulder). This disorder is often associated with spatial neglect, a neurological syndrome in which patients are unaware of stimuli presented in the contralesional (often the left) space. Capitalizing on previous evidence demonstrating that prismatic adaptation of the ipsilesional arm to right-deviating prisms is effective in ameliorating neglect symptoms, here we investigated whether such amelioration also occurs in E+ patients with neglect when prismatic training is performed by the ‘alien’ embodied arm. Four left neglect patients (one with and three without pathological embodiment) underwent visuomotor prismatic training performed by an ‘alien’ arm. Specifically, while patients were wearing prismatic goggles shifting the visual field rightward, a co-experimenter’s left arm presented in a body-congruent perspective was repeatedly moved toward visual targets by another examiner. In a control condition, the co-experimenter’s arm was moved toward the targets from a body-incongruent position (i.e., 3rd person perspective). Neglect symptoms were assessed before and after training through paper-and-pencil tasks. In the E+ patient, neglect improved significantly more in 1st than in 3rd person perspective training, suggesting that prismatic adaptation of the ‘alien’ embodied arm is effective in modulating spatial representation. Conversely, for control E- patients (not embodying the ‘alien’ arm), we observed more limited improvements following training. These findings indicate that the ‘alien’ embodied arm is so deeply embedded in the patient body and motor schema that adaptation to prismatic lenses can affect multiple processing stages, from low level sensory-motor correspondences, to higher level body, motor and spatial maps, similarly as it occurs in normal subjects and neglect patients without pathological embodiment.

Ipsilesional deficit of selective attention in left homonymous hemianopia and left unilateral spatial neglect

AimsPatients with homonymous hemianopia may present a subtle ipsilesional deficit, recently referred to as ‘sightblindness’ in addition to the contralesional visual field defect. We recently demonstrated that this deficit could be worse in right brain-damaged patients with left hemianopia than in left brain-damaged patients with right hemianopia, confirming right hemisphere dominance for visuo-spatial and attentional capacities. In the present study we investigate whether this ipsilesional deficit could be attentional in nature and to what extent it is comparable in right brain-damaged (RBD) patients with left hemianopia and in RBD patients with left neglect. The study was also conducted in RBD patients with neither left hemianopia nor left neglect signs in order to test if a right hemisphere lesion per se could be responsible for subtle ipsilesional attentional deficit. To reach this aim, we tested selective attentional capacities in both visual fields of 10 right brain-damaged patients with left neglect (LN), 8 right brain-damaged patients with left homonymous hemianopia (LHH), 8 right brain-damaged patients with no signs of left neglect or left hemianopia (RBD controls), and 17 healthy age-matched participants (Normal controls). MethodA lateralized letter-detection task was used to test if right-brain damaged patients with LN or LH may present a deficit of selective attention in their right, ipsilesional visual field, in comparison to Normal and RBD controls. Participants were asked to detect a target letter in either a single large stimulus (low attentional load) or a small stimulus surrounded by flankers (high attentional load). Stimuli were displayed either in the left or in the right visual field. Accuracy and reaction times were recorded. ResultsResults on accuracy showed that both LN and LH patients exhibited lower correct responses than Normal controls in their ipsilesional right visual field, suggesting an attentional deficit in their ipsilesional, supposed healthy visual field. More specifically, LH patients exhibited a specific deficit for processing single large stimuli, but not for processing flanked stimuli, relative to normal controls. LN patients exhibited lower correct responses for processing all types of stimulus than normal controls, but also than right brain damaged controls, in both visual fields suggesting a non-lateralized deficit not only due to the right hemisphere lesion. Furthermore, this deficit is more pronounced for flanked small stimuli, requiring higher attentional load. ConclusionsThe present results bring further evidence that patients with left homonymous hemianopia or left unilateral neglect both present a weaker but significant ipsilesional deficit in addition to their well-known massive contralesional deficit. The presence of a specific attentional deficit in the right ipsilesional visual field of left hemianopic and left neglect patients is discussed regarding the hypothesis of hemispheric specialization for selective spatial attention and may have clinical implications for both conditions.

Duration and numerical estimation in right brain-damaged patients with and without neglect: Lack of support for a mental time line

Previous studies have shown that left neglect patients are impaired when they have to orient their attention leftward relative to a standard in numerical comparison tasks. This finding has been accounted for by the idea that numerical magnitudes are represented along a spatial continuum oriented from left to right with small magnitudes on the left and large magnitudes on the right. Similarly, it has been proposed that duration could be represented along a mental time line that shares the properties of the number continuum. By comparing directly duration and numerosity processing, this study investigates whether or not the performance of neglect patients supports the hypothesis of a mental time line. Twenty-two right brain-damaged patients (11 with and 11 without left neglect), as well as 11 age-matched healthy controls, had to judge whether a single dot presented visually lasted shorter or longer than 500ms and whether a sequence of flashed dots was smaller or larger than 5. Digit spans were also assessed to measure verbal working memory capacities. In duration comparison, no spatial-duration bias was found in neglect patients. Moreover, a significant correlation between verbal working memory and duration performance was observed in right brain-damaged patients, irrespective of the presence or absence of neglect. In numerical comparison, only neglect patients showed an enhanced distance effect for numerical magnitude smaller than the standard. These results do not support the hypothesis of the existence of a mental continuum oriented from left to right for duration. We discuss an alternative account to explain the duration impairment observed in right brain-damaged patients.

Does left-handedness confer resistance to spatial bias?

We recently demonstrated that drowsiness, indexed using EEG, was associated with left-inattention in a group of 26 healthy right-handers. This has been linked to alertness-related modulation of spatial bias in left neglect patients and the greater persistence of left, compared with right, neglect following injury. Despite handedness being among the most overt aspects of human lateralization, studies of this healthy analogue of left neglect have only been conducted with predominantly or exclusively right-handed individuals. Here, with a group of 26 healthy non-right-handers we demonstrate that, unlike right-handers who showed a rightward shift in attention with drowsiness, non-right-handers showed the opposite pattern on an auditory spatial localization task. The current results are the first indication that factors linked to handedness can affect the development and extremity of spatial biases, potentially conferring resilience to clinical symptoms in non-right-handers and, given that 90% of us are right-handed, why left neglect is disproportionately persistent.

Reducing chronic visuo-spatial neglect following right hemisphere stroke through instrument playing.

Unilateral visuo-spatial neglect is a neuropsychological syndrome commonly resulting from right hemisphere stroke at the temporo-parietal junction of the infero-posterior parietal cortex. Neglect is characterized by reduced awareness of stimuli presented on patients’ contralesional side of space. Inspired by evidence of increased spatial exploration of patients’ left side achieved during keyboard scale-playing, the current study employed a music intervention that involved making sequential goal-directed actions in the neglected part of space, in order to determine whether this would bring about clinically significant improvement in chronic neglect. Two left neglect patients completed an intervention comprising four weekly 30-min music intervention sessions involving playing scales and familiar melodies on chime bars from right to left. Two cancellation tests [Mesulam shape, Behavioral Inattention Test (BIT) star], the neglect subtest from the computerized TAP (Test of Attentional Performance) battery, and the line bisection test were administered three times during a preliminary baseline phase, before and after the four intervention sessions during the intervention phase to investigate short-term effects, and 1 week after the last intervention session to investigate whether any changes in performance would persist. Both patients demonstrated significant short-term and longer-lasting improvements on the Mesulam shape cancellation test. One patient also showed longer-lasting effects on the BIT star cancellation test and scored in the normal range 1 week after the intervention. These findings provide preliminary evidence that active music-making with a horizontally aligned instrument may help neglect patients attend more to their affected side.

Visual Scanning Training, Limb Activation Treatment, and Prism Adaptation for Rehabilitating Left Neglect: Who is the Winner?

We compared, for the first time, the overall and differential effects of three of the most widely used left neglect (LN) treatments: visual scanning training (VST), limb activation treatment (LAT), and prism adaptation (PA). Thirty-three LN patients were assigned in quasi-random order to the three groups (VST, LAT, or PA). Each patient received only one type of treatment. LN patients’ performance on everyday life tasks was assessed four times (over a period of 6 weeks): A1 and A2 (i.e., the two pre-treatment assessments); A3 and A4 (i.e., the two post-treatment assessments). LN patients in each of the three treatment conditions were treated for the same number of sessions (i.e., 20). The results showed that improvements were present in the majority of the tests assessing the peripersonal space in everyday life activities. Our findings were independent of unspecific factors and lasted for at least 2 weeks following the end of the treatments. There were no interactions, however, between LN treatments and assessments. We suggest that all three treatments can be considered as valid rehabilitation interventions for LN and could be employed for ameliorating LN signs.

Is Two Better than One? Limb Activation Treatment Combined with Contralesional Arm Vibration to Ameliorate Signs of Left Neglect

In the present study, we evaluated the effects of the Limb Activation Treatment (LAT) alone and in combination with the Contralateral Arm Vibration (CAV) on left neglect (LN) rehabilitation. We conceived them as techniques that both prompt the activation of the lesioned right hemisphere because of the activation (with the LAT as an active technique) and the stimulation (with the CAV as a passive technique) of the left hemibody. To test the effect of the simultaneous use of these two techniques (i.e., LAT and CAV) on visuo-spatial aspects of LN, we described the case of an LN patient (GR), who showed high intra-individual variability (IIV) in performance. Given the high IIV of GR, we used an ABAB repeated-measures design to better define the effectiveness of the combined application of LAT and CAV, as a function of time. The results showed an improvement of GR’s performance on the Bells test following the combined application of LAT and CAV, with respect to the application of LAT alone. We did not find, however, significant effects of treatment on two other LN tests (i.e., Line bisection and Picture scanning). We propose that the combined application of LAT and CAV can be beneficial for some aspects of LN.

Processing temporal events simultaneously in healthy human adults and in hemi-neglect patients

Many theories have been advanced to explain how the brain incorporates time into its computations, in particular for the purpose of estimating the duration of an event. In the present study we examine with a new paradigm the ability to compare the duration of two visual stimuli in the parafoveal visual field, presented either sequentially or overlapping in time. We found that judging the duration of a pair of objects is more difficult when they overlap in time. Furthermore, all healthy participants presented a bias to over-estimate the duration of the second event (a negative time-order-error). We then presented the same task to eight left neglect patients with extinction (N-patients). Relative to the healthy participants, the patients displayed similar loss of sensitivity and increased bias in the time overlap condition. However, N-patients were particularly impaired when the first object was presented in their right visual field and the second one appeared on their left before the first one vanished. Rather than a simple engage/disengage disorder, these results highlight a specific problem with shifting attention to the impaired visual field. We discuss these findings in the light of contemporary models of time estimation.

Plasticity of Adult Sensorimotor System

Plasticity of Adult Sensorimotor System

Optokinetic stimulation modulates neglect for the number space: evidence from mental number interval bisection.

Behavioral, neuropsychological, and neuroimaging data support the idea that numbers are represented along a mental number line (MNL), an analogical, visuospatial representation of number magnitude. The MNL is left-to-right oriented in Western cultures, with small numbers on the left and larger numbers on the right. Left neglect patients are impaired in the mental bisection of numerical intervals, with a bias toward larger numbers that are relatively to the right on the MNL. In the present study we investigated the effects of optokinetic stimulation (OKS) – a technique inducing visuospatial attention shifts by means of activation of the optokinetic nystagmus – on number interval bisection. One patient with left neglect following right-hemisphere stroke (BG) and four control patients with right-hemisphere damage, but without neglect, performed the number interval bisection task in three conditions of OKS: static, leftward, and rightward. In the static condition, BG misbisected to the right of the true midpoint. BG misbisected to the left following leftward OKS, and again to the right of the midpoint following rightward OKS. Moreover, the variability of BG’s performance was smaller following both leftward and rightward OKS, suggesting that the attentional bias induced by OKS reduced the “indifference zone” that is thought to underlie the length effect reported in bisection tasks. We argue that shifts of visuospatial attention, induced by OKS, may affect number interval bisection, thereby revealing an interaction between the processing of the perceptual space and the processing of the number space.

Asynchronous stimulus presentation in visual extinction: A psychophysical study

Patients showing visual extinction as a consequence of a unilateral brain lesion can correctly detect a single stimulus in either hemifield but fail to detect the contralesional stimulus (or at least process the stimulus less efficiently) when it is presented simultaneously with an ipsilesional stimulus. In an attempt to uncover the nature of the underlying deficit, some studies have manipulated the temporal characteristics of stimulus presentation. Contra- and ipsilesional stimuli with different stimulus onset asynchronies are typically used. In the present study, visual extinction was investigated in a group of left neglect patients (N=10) using a psychophysical paradigm with different stimulus onset asynchronies of target and distractor stimuli presented in different hemifields. Contrast thresholds for a target grating were determined with the target either in isolation or in the presence of an irrelevant distractor grating. When target and distractor gratings were presented simultaneously, neglect patients showed a significant extinction effect, i.e., a significant interference from the right hemifield distractor with left hemifield contrast sensitivity. When the right hemifield distractor preceded the left hemifield target stimulus by 250 ms, two different patterns of results were observed in the neglect patients. Five patients showed a significant improvement compared to the simultaneous presentation condition, five other patients showed a significant increase of the extinction effect. The results suggest that different underlying mechanisms, maybe due to different lesion locations, can cause extinction in neglect patients.

“Where is the sun” for hemi-neglect patients?

Human observers use prior constraints to disambiguate a scene; in particular, light is preferentially seen as coming from above but also slightly from the left. One explanation of this lateral bias could be a cerebral hemispheric difference. The aim of the present study was to determine the preferred light source position for neglect patients. For this purpose, we used the ambiguous shaded “Polo Mint” stimulus, a ring divided into eight equal sectors. All sectors but one were the same shape, convex or concave, as determined by the light source position. Participants had to report the side (left or right) of the odd sector or, in a separate experiment, to report its shape (convex or concave). Eight patients with spatial neglect (left neglect N = 7, right neglect N = 1) after a right or left temporo-parietal or thalamic lesion and 14 control participants ran the experiment. Left neglect patients showed a significantly different light bias from the bias observed for controls and for the right neglect patient (i.e., a reduction of the left bias or a right bias rather than a left bias). We conclude that some disabilities presented by patients with spatial neglect may be due to difficulties processing information that is not present in the visual field or imagined in the representational scene.

Object-centred pseudoneglect for non-verbal visual stimuli

The rightward spatial bias shown by left neglect patients and the small leftward bias displayed by healthy subjects (pseudoneglect) have been interpreted as phenomena sharing a common attentional imbalance mechanism. Here we investigated whether pseudoneglect, similarly as neglect, can occur in an object-centred frame of reference. Thirty healthy participants repeatedly bisected the elongated caricature of a basset hound with the head on the left and the tail on the right or viceversa. In the last critical trials, the figure appeared horizontally mirrored. The bisection error reversed from the left to the right space in the critical trials. This result shows that it is possible to induce object-centred pseudoneglect on newly established knowledge about the canonical orientation of non-verbal visual stimuli.

Mental number line disruption in a right-neglect patient after a left-hemisphere stroke

A right-neglect patient with focal left-hemisphere damage to the posterior superior parietal lobe was assessed for numerical knowledge and tested on the bisection of numerical intervals and visual lines. The semantic and verbal knowledge of numbers was preserved, whereas the performance in numerical tasks that strongly emphasize the visuo-spatial layout of numbers (e.g. number bisection) was impaired. The behavioral pattern of error in the two bisection tasks mirrored the one previously described in left-neglect patients. In other words, our patient misplaced the subjective midpoint (numerical or visual) to the left as function of the interval size. These data, paired with the patient’s lesion site are strictly consistent with the tripartite organization of number-related processes in the parietal lobes as proposed by Dehaene and colleagues. According to these authors, the posterior superior parietal lobe on both hemispheres underpins the attentional orientation on the putative mental number line, the horizontal segment of the intraparietal sulcus is bilaterally related to the semantic of the numerical domain, whereas the left angular gyrus subserves the verbal knowledge of numbers. In summary, our results suggest that the processes involved in the navigation along the mental number line, which are related to the parietal mechanisms for spatial attention, and the processes involved in the semantic and verbal knowledge of numbers, are dissociable.

Processing of peripersonal and extrapersonal space using tools: Evidence from visual line bisection in real and virtual environments

The dissociation between peripersonal space (within reaching) and extrapersonal space (beyond reaching) has been reported in studies using the line bisection task in left neglect patients and in healthy participants. Furthermore, this dissociation can be modulated by tool use. We conducted two experiments to compare line bisection in peripersonal (i.e., 30, 60cm) and extrapersonal space (i.e., 90, 120cm). Healthy participants bisected visual lines using sticks and a laser pointer, according to the experimental paradigm of Longo and Lourenco [On the nature of near space: Effects of tool use and the transition to far space. Neuropsychologia, 44, 977–981, 2006]. In Experiment 1 participants performed line bisection in a real environment, whereas in Experiment 2 participants performed line bisection in a virtual environment. Results from both experiments revealed an abrupt midpoint shift from the peripersonal to the extrapersonal space but only when a laser pointer was used. In addition, we confirmed that peripersonal space can be extended to extrapersonal space when participants used a stick. Notably, virtual reality can be a useful technique for studying the dissociation between peripersonal and extrapersonal space and their interaction by means of tool use.

Pseudoneglect in schizophrenia: A line bisection study with cueing

Introduction. Numerous authors have reported the existence of lateralised abnormalities towards the right side in patients with schizophrenia. Methods. In the present study, a manual line bisection task was used to assess the existence of a visuospatial bias in patients with schizophrenia as compared to healthy subjects and left unilateral neglect patients. In addition, we used a local cueing paradigm (consisting of a number placed on the right, on the left, or at both ends of the line). Results. Healthy subjects showed a leftwards trend in the “no cue” condition (known as pseudoneglect) and neglect patients showed a right bias in all cue conditions. In contrast, patients with schizophrenia placed their manual estimation of the centre further to the left than healthy subjects in all cue conditions, reflecting neglect of the right side of the line. Moreover, like healthy subjects and neglect patients, patients with schizophrenia were affected by the local cueing. Conclusion. Hence, patients with schizophrenia show a bias in their spatial representation, which does not interfere with local context processing.

Understanding the effects of moving visual stimuli on unilateral neglect following stroke

Moving visual stimuli have been shown to reduce unilateral neglect (ULN), however, the mechanisms underlying these effects remain poorly understood. This study compared lateralised and non-lateralised moving visual stimuli to investigate whether the spatial characteristics or general alerting properties of moving visual stimuli are responsible for reducing neglect. Post-stroke left neglect patients as well as healthy and patient control subjects were tested on a computerised line bisection task under six visual stimulus conditions. The key finding was that, relative to the no stimulus condition, leftward moving and left-sided moving visual stimuli shifted neglect patients’ bisection errors leftward while the non-lateralised random moving visual stimuli did not reduce neglect patients’ rightward bisection errors. The results provide evidence that spatial characteristics rather than general alerting properties of moving visual stimuli reduce rightward bisection errors in ULN. Moreover, the pattern of findings strongly supports the notion that moving visual stimuli reduce neglect by capturing attention and drawing it to a spatial location rather than by activating the attentional system via superior collicular neurons.

Poster 56: Comparison of 2 Methods of Standard Clinical Neuropsychologic Evaluation for Evaluation of Spatial Neglect

Objective: To compare 2 methods of standard clinical neuropsychologic evaluation for evaluation of spatial neglect. Design: Retrospective analysis of clinical data. Setting: Acute inpatient rehabilitation unit. Participants: 36 consecutive admissions to an acute inpatient rehabilitation unit. Interventions: Evaluation of neglect using “blank-page bisection,” line bisection, and standard bedside screening tasks for spatial neglect. Main Outcome Measure: Observational report of performance on spatial bias tasks. Results: As part of clinical neuropsychologic screening, 36 consecutive patients were asked to “mark the center” of 5 blank pages and bisect 5 horizontal lines and perform other spatial neglect screening tasks. Patients were categorized as having left neglect, no neglect, right neglect, or other (mild right or left neglect or atypical). Retrospective comparison of page and line bisection performance revealed that there was a high correlation between the 2 tasks. Compared with no-neglect patients, left-neglect patients bisected lines rightward but only tended to bisect pages rightward. Conclusions: Blank-page bisection may be a valuable bedside test in screening for neglect along with the other standardized screening tests, especially if patients cannot perform line bisection. Further testing in a prospective manner needs to be done to validate this task in screening for spatial neglect.

Acceleration Perception and Spatial Distortion in a Left Unilateral Neglect Patient

To explain relative leftward overextension in a line extension task by left unilateral neglect subjects, Bisiach et al. (1998) suggested that the representation of space is distorted – i.e., dilated towards the left side. If perception of the velocity of a moving stimulus is due to a calculation of the distance covered per unit time in representational space, then a stimulus with uniform linear motion should be perceived as decelerating when moving leftwards in the visual field of a subject with left unilateral neglect. We investigated the perception of acceleration in a patient with left unilateral neglect and spatial distortion (revealed as relative left overextension in a line extension task) using a task in which the stimuli were right and left moving targets with variable acceleration. The patient's ability to perceive acceleration was much lower (higher acceleration threshold) for leftward movements than rightward movements. Fourteen months later unilateral neglect had improved, and the relative left overextension and decreasing acceleration threshold for leftward movements were reduced. By contrast, alterations in the perception of acceleration for leftward movements were not found in a patient with left unilateral neglect and left underextension and in a patient with right brain damage and left hemianopia. These findings in one patient with left spatial unilateral neglect and a relative left overextension in a line extension task are consistent with the hypothesis that representational space is distorted, with a disproportionate leftward expansion, that affects perception of movement.