Severity Of Unilateral Spatial Neglect Research Articles

Non-invasive Brain Stimulation Can Reduce Unilateral Spatial Neglect after Stroke: ELETRON Trial.

Rehabilitation top-down techniques based on brain stimulation present variable outcomes in unilateral spatial neglect (USN) after stroke. This study aimed to examine the effects of physical therapy after anodal and cathodal transcranial direct current stimulation (A-tDCS and C-tDCS, respectively) to improve visuospatial and functional impairments in individuals with USN after stroke. This double-blinded, pilot randomized clinical trial enrolled patients with USN after ischemic stroke. Randomization was stratified according to the Behavior Inattention Test-Conventional (BIT-C) and Catherine Bergego Scale (CBS). Outpatient physical therapy was conducted for 7.5 weeks after 20 minutes of tDCS. The primary outcome was the USN degree evaluated by the BIT-C. Secondary outcomes were the difference in CBS score, stroke severity (National Institutes of Health Stroke Scale [NIHSS]), disability (modified Rankin Scale), autonomy (Barthel Index, Functional Independence Measure), and quality of life (EuroQol Group 5-Dimension Self-Report Questionnaire). Outcomes were analyzed using an analysis of covariance model corrected by age, baseline NIHSS, and baseline BIT-C. Pairwise post hoc comparisons were performed using Bonferroni correction. In the primary outcomes, A-tDCS led to greater improvement in BIT-C after intervention (mean difference [MD]= 18.4, 95% confidence interval [CI]= 3.9-32.8, p= 0.008) compared to sham. However, no significant differences were observed between A-tDCS and C-tDCS (MD=13.9, 95% CI=-0.3 to 28.1, p= 0.057), or C-tDCS and sham (MD=4.5, 95% CI=-9.7 to 18.8, p= 0.99). There were no significant differences between groups in terms of secondary outcomes. A-tDCS associated with physical therapy can decrease the severity of USN after stroke. However, these preliminary findings must be confirmed by collecting additional evidence in a larger phase 3 trial. ANN NEUROL 2022;92:400-410.

The severity of unilateral spatial neglect was positively correlated with that of Pusher syndrome

While previous studies have reported that unilateral spatial neglect (USN) and pusher syndrome are related but independent symptoms, their relationship has not been investigated using a quantitative scale and causative lesions using brain imaging. This study aimed to clarify the relationship between evaluation scores and the extent of the damaged area revealed by brain imaging. We evaluated twenty patients with first-ever stroke and pusher syndrome (14 right and 6 left hemispheric patients). First, we analyzed the relationship between the Catherine Bergego Scale (CBS) and Scale for Contraversive Pushing (SCP). We also introduced a new way of quantifying the affected brain lesions at two levels of horizontal brain imaging slice. At each level, a brain hemisphere was divided into 3 areas, and the total number of damaged areas from these two levels was used as an indication of the extent of the damaged lesion, ranging 0 to 6 ( Fig. 1 ). By using this score, the relationship between the CBS and SCP scores was further examined. All patients with pusher syndrome had USN based on CBS. In each subject, the CBS score was positively correlated with the SCP score (Spearman = 0.805, P < 0.001) ( Fig. 2 ). Brain imagining showed that six patients had damage in both slice 1 and slice 2, while the fourteen patients had damage only in slice 2. The imaging score at slice 1 was correlated with the CBS score in the first group. The severity of USN was positively correlated with that of pusher syndrome with clinical scales. The location and extent of the damaged area in relation to SCP and CBS needs to be examined with a larger sample size in future.

Crossed Leg Sign Is Associated With Severity of Unilateral Spatial Neglect After Stroke.

The crossed leg sign in patients with right hemisphere stroke is thought to be associated with perceptual disorders, such as unilateral spatial neglect (USN). The aim of this study was to compare the crossed leg sign with the severity of USN during the acute phase of stroke. This was an observational and prospective clinical study of individuals with a diagnosis of right parietal stroke, as confirmed by neuroimaging. The occurrence of the crossed leg sign, the time at which this occurred after the stroke, and a clinical diagnosis of USN were measured and recorded. The patients' age, sex, and lesion severity, as determined by the National Institutes of Health Stroke Scale and Glasgow coma scale, were included in the analyses as confounding variables. The outcome of interest was the degree of USN, as measured by the cancellation and bisection tests. Binary logistic regression was used to analyze the effect of crossed leg syndrome on the severity of USN. In the adjusted multiple regression model, a p-value of <0.05 was considered statistically significant. Overall, 60 patients were included in this study. There were no associations between patient demographics and the presence of the crossed leg sign. There was, however, an association between the crossed leg sign and the absolute value of the deviation in the line bisection test (B = -0.234; p = 0.039). The crossed leg sign was not associated with other measures of USN. Based on the results of our study, we can conclude that a crossed leg sign in the acute phase of stroke is associated with USN severity, specifically the misinterpretation of the midline.

Unilateral spatial neglect in the acute phase of ischemic stroke can predict long-term disability and functional capacity

OBJECTIVE:The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence.METHODS:This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors.RESULTS:We studied 60 patients with a median age of 68 (34–89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03–1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13–2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78–0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48–0.92], p=0.017).CONCLUSION:The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.

Post-stroke unilateral spatial neglect treated with acupuncture and rehabilitation: a randomized controlled trial

To observe the impacts on post-stroke unilateral spatial neglect treated with acupuncture for "regaining consciousness, benefiting marrow and opening orifices" and rehabilitation. Forty patients of post-stroke unilateral spatial neglect were randomized into an observation group and a control group, 20 cases in each one. In the observation group, acupuncture was applied to the acupoints for "regaining consciousness, benefiting marrow and opening orifices", named Baihui (GV 20), Sishencong (EX-HN 1), Benshen (GB 13), Shenting (GV 24), and the bilateral yuan-primary points and luo-connecting points of the heart meridian, pericardium meridian and kidney meridian, as well as the acupoints along the affected meridians. Additionally, the rehabilitation was provided. In the control group, acupuncture at the acupoints along the affected meridians and rehabilitation were adopted. The treatment was given once a day, 5 times a week. After 8 weeks of treatment the evaluation was made. the indexes of unilateral spatial neglect such as line bisection test, the score of the mini-mental state examination (MMSE), the score of simple Fugl-Meyer motor function assessment and the modified Barthel indexes were adopted for the assessment of the severity of unilateral spatial neglect, cognitive function, motor function, and the activities of daily living. After treatment, the indexes of unilateral spatial neglect (line bisection test, line cancellation test, clock-drawing test and copying drawing test), MMSE score, the simple Fugl-Meyer motor function assessment and modified Barthel indexes were all improved as compared with those before treatment in the two groups (all P<0.01). The improvements in the observation group were more obvious than those in the control group (P<0.05, P<0.01). The combination of acupuncture treatment for "regaining consciousness, benefiting marrow and opening orifices" and rehabilitation much more effectively alleviates the severity of post-stroke unilateral spatial neglect and improves the motor function and the activities of daily living in the patients.

Disturbed resting functional inter-hemispherical connectivity of the ventral attentional network in alpha band is associated with unilateral spatial neglect.

Unilateral spatial neglect (USN) is one of the most common symptoms of right hemisphere damage; its classical symptom is that patients fail to respond to information on their left side. It has been postulated that disturbance of 2 separate attentional networks relates to the occurrence of USN. However, little is known about the underlying mechanism and neuronal substrates. In this study, we measured spontaneous neural activity by means of magnetoencephalography in 13 patients with brain damage and 5 control subjects. To study the relationship between functional connectivity at rest and severity of USN symptoms, we determined the imaginary coherence values relating to the inter-hemispherical ventral and dorsal attentional networks, as well as the clinical severity of USN using neuropsychological tests and behavioral rating scales. The present results showed that inter-hemispherical connectivity in the ventral attentional network, especially between the left and right angular gyri, detected in the alpha band is associated with the severity of USN symptoms. This may suggest that connectivity of inter-hemispherical homologous regions of the ventral attentional network in the alpha band could be one of the biomarkers of attentional network imbalance occurring in patients with USN.

Severity of Unilateral Spatial Neglect Is an Independent Predictor of Functional Outcome After Acute Inpatient Rehabilitation in Individuals With Right Hemispheric Stroke

Di Monaco M, Schintu S, Dotta M, Barba S, Tappero R, Gindri P. Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke. Objective To investigate the relationship between severity of unilateral spatial neglect (USN) and functional recovery in activities of daily living after a right-hemisphere stroke. Design Observational study. Setting Rehabilitation hospital in Italy. Participants We investigated 107 of 131 inpatients with right-hemisphere stroke who were consecutively admitted to our rehabilitation hospital. Interventions Not applicable. Main Outcome Measures To assess USN severity, conventional and nonconventional Behavioral Inattention Tests (BITs) were performed at admission to inpatient rehabilitation at a median of 19 days after stroke occurrence. FIM was performed both on admission to and discharge from inpatient rehabilitation to assess functional autonomy. FIM efficiency (improvement of FIM score per day of stay length) and FIM effectiveness (proportion of potential improvement achieved) were calculated. Results Fifty-four (50.5%) of the 107 patients were affected by USN. In these 54 patients, both conventional and nonconventional BIT scores were significantly correlated with FIM scores assessed at discharge from rehabilitation: ρ values were .385 ( P=.004) and .396 ( P=.003), respectively. After adjustment for 7 potential confounders, including FIM scores before rehabilitation, we found a significant positive association between either conventional or nonconventional BIT scores and FIM scores after rehabilitation ( r=.276, P=.047 and r=.296, P=.033, respectively), FIM efficiency ( r=.315, P=.022 and r=.307, P=.025, respectively), and FIM effectiveness ( r=.371, P=.006 and r=.306, P=.026, respectively). Conclusions Data support the independent prognostic role of USN severity assessed at admission to inpatient rehabilitation after a right-hemisphere stroke. Models aimed at predicting the functional outcome in stroke survivors may benefit from inclusion of USN severity.

Family Participation Can Improve Unilateral Spatial Neglect in Patients with Acute Right Hemispheric Stroke

Objective: Unilateral spatial neglect (USN) is one of the major behavioral disturbances in patients with cerebral lesions and often impairs the patients’ independence in activities of daily living (ADL). Although many studies have addressed the mechanism and assessment of USN, there have been only few reports on rehabilitation strategies for patients with USN. The present study examined whether family participation can contribute to an improvement in USN following an acute stroke. Design: This study compared the improvement at 3 weeks among patients treated with conventional exercise sessions and a program including the participation of family members. The study followed 34 stroke patients with hemiparesis and USN. Twenty had family participation in their therapy. The severity of USN was measured using the Behavioral Inattention Test (BIT) and a laterality index (LI). Mobility was assessed using the Rivermead Mobility Index (RMI), and ADL were assessed using the Barthel index. Results: The results showed a relationship between BIT score improvement and family participation, and the BIT score improvement reflected the LI improvement. The RMI and BIT scores showed that ADL improved more with than without family participation. Conclusion: Family participation improved not only the mobility but also USN, suggesting that it can make important contributions to acute stroke rehabilitation.

半側空間無視の長期経過―机上検査で所見が消失した患者の経過を中心に―

The long-term prognosis of unilateral spatial neglect (USN) in three elderly patients with stroke was investigated. Case 1 was a 62-year-old man who had suffered from right putaminal hemorrhage three years ago. Obvious right USN was found soon after the onset. After 6 months of rehabilitation he recovered and became independent in ADL without USN signs in daily circumstances. However, left USN signs appeared in some stressful situations such as traditional poetry-based competition or driving an electrical wheelchair on crowded roads. Case 2 was a 62-year-old man who had suffered from cerebral hemorrhage in the right putamen 6 years ago. He showed left USN soon after the onset, but it disappeared gradually. Cerebral infarction in the left basal ganglia occurred 6 years after the first attack. He showed decline of general attention accompanying left USN. Case 3 was a 70-year-old man who had showed left USN signs 7 years previously. He became independent and disappeared USN signs. However his activities of daily living declined gradually, and mental status became worse. Left USN signs were observed again on USN tests. Left USN was observed in three cases soon after the onset of the first stroke and then disappeared. However, USN signs became obvious in some specific situations. The appearance or disappearance of USN seemed to depend on the relationship among severity of USN, physical and mental functions, and circumstances in which USN was evaluated.

Left hand movements and right hemisphere activation in unilateral spatial neglect: a test of the interhemispheric imbalance hypothesis

The aim of the present study was to check one of the main assumptions of the interhemispheric imbalance hypothesis, namely, the prediction that the severity of neglect should be reduced by conditions activating the right hemisphere. To achieve this, a group of neglect patients was studied using a slightly modified version of the limb activation technique. The (verbal or visuo-spatial) nature of the stimuli to be processed by the patient and the (left or right) side of space where the left hand moved were considered as the critical variables to check the interhemispheric imbalance hypothesis. Three traditional and one new methods were used to measure changes induced in the severity of neglect by the material to be processed or by the side of space where the left hand moved. The traditional methods, all based on counting omissions, consisted of measuring: (a) the overall number of omissions; (b) the number of omissions made on the left half sheet; or (c) the difference between the omissions made on the left and right sides of the sheet. The new index, based on the notion of the ‘attentional field’ and defined as the spatial distribution of stimuli detected by the patient, was operationally measured by computing the distance between each stimulus crossed out by the patient and the right margin of the sheet. The study was conducted by rating the severity of neglect in 42 cancellation sheets which had used, respectively letters ( N=21) and small geometric figures ( N=21) as targets. The two sets of cancellation sheets were obtained from seven neglect patients during a limb activation task requiring the cancellation of a given target in three different conditions: (a) baseline; (b) active movements of the left hand in the left half space; (c) active movements of the left hand in the right half space. Results were at variance with the predictions based on Kinsbourne’s model, since the verbal or visual spatial nature of the material to be processed did not influence the severity of unilateral spatial neglect (USN) and since left hand movements produced a significant reduction in the severity of neglect only when these movements were made on the left side of space.

Why are some patients with severe neglect able to copy a cube? The significance of verbal intelligence

Cube-copying is often used to assess constructional ability of brain-damaged patients and the influence of unilateral spatial neglect is often pointed out in patients with right hemisphere lesions. However, some patients with severe neglect perform cube-copying satisfactorily. The aim of the present study is to identify the factors that affect the performance of cube-copying in patients with left unilateral spatial neglect. Constructional performance was investigated in 100 patients with unilateral spatial neglect using a task to copy the Necker cube. The relationship of the patients’ cube-copying performance to the severity of their neglect, as well as other factors (verbal intelligence, age, duration after onset of the disease, educational level, lesion site, piecemeal approach, and side of starting to copy) was analyzed. Twenty-two normal subjects also participated in this study as controls. Among many factors adopted for analysis, neglect severity and verbal intelligence were found to be primary factors affecting the cube-copying performance of the patients with unilateral spatial neglect. The effect of neglect severity on cube-copying performance was apparent in the patients whose verbal intelligence was deteriorated, but was not observed in the patients with preserved verbal intelligence. Similarly, the effect of verbal intelligence on cube-copying performance was apparent in the patients with severe neglect, but not in the patients with mild neglect. We conclude that constructional ability in the copying of a cube is determined by verbal intelligence, as well as by the severity of unilateral spatial neglect.

Diverse patterns of performance in copying and severity of unilateral spatial neglect.

We analysed the performances of 69 patients with left unilateral spatial neglect in copying a multi-object figure, as well as their performance of the line cancellation and line bisection tests. Three patterns of copying were mainly observed. The first pattern was almost satisfactory performance in copying the central figure with occasional omission of the elements located more laterally to the left. The second pattern was omission of the left half of the whole figure, which was the pattern expected of patients with typical left unilateral spatial neglect. The third pattern was left unilateral spatial neglect when copying the central figure, with favourable copying of left lateral objects; this may be regarded as "object-centered" neglect. Performance of the line cancellation test, which requires exploratory ability, was significantly better for the patients with the third pattern than for those with the second pattern. A significant difference was also observed between the two groups of patients in performance of the line bisection test, in which exploratory ability plays a more minor role. No significant difference was found in performance of the line cancellation and line bisection tests between the patients with the third and first patterns, in spite of remarkable differences in their copying performances. No distinctive characteristics were found for any group of patients as regards lesion, age, duration after onset, education, and WAIS scores. Therefore we concluded that in most of our patients with neglect, these diverse patterns of copying deficits resulted from different levels of neglect severity but not from different types of unilateral spatial neglect.

Horizontal visual motion modulates focal attention in left unilateral spatial neglect.

Patients with unilateral spatial neglect are impaired in directing focal attention toward the contralesional side of space. Provision of static spatial cues on the neglected side has previously been shown to help overcome this deficit. Common movement of visual stimuli may also guide the allocation of spatial attention, although such effects have not been examined in patients with unilateral spatial neglect. Eleven patients with right hemisphere damage and clinical evidence of left unilateral spatial neglect, and 11 matched, healthy controls were tested on a task of horizontal line bisection. Lines were presented on a computer display, with a neutral, static, or slowly drifting, random dot background. Under conditions of motion, background stimuli drifted either leftward or rightward, across the full width of the display, at speeds that did not elicit optokinetic nystagmus or perceptual aftereffects. Controls were accurate in all conditions, and showed minimal effects of background conditions. By contrast, patients with left unilateral spatial neglect were sensitive to leftward background motion, showing a significant leftward shift in bisection error, relative to neutral, static, and rightward moving backgrounds. There was no significant effect of rightward motion in comparison with the neutral and static conditions. The extent to which patients were susceptible to the effects of background motion was not related to severity of unilateral spatial neglect, as measured by clinical tests. The benefits of leftward motion may reflect activity of preserved motion processing mechanisms, which provide input to an otherwise dysfunctional attentional network. The use of visual motion to assist in contralesionally guiding focal attention may be useful in the rehabilitation of unilateral spatial neglect.