Unilateral Spatial Neglect

The study assessed whether the auditory reference provided by a music scale could improve spatial exploration of a standard musical instrument keyboard in right-brain-damaged patients with left spatial neglect. As performing music scales involves the production of predictable successive pitches, the expectation of the subsequent note may facilitate patients to explore a larger extension of space in the left affected side, during the production of music scales from right to left. Eleven right-brain-damaged stroke patients with left spatial neglect, 12 patients without neglect, and 12 age-matched healthy participants played descending scales on a music keyboard. In a counterbalanced design, the participants' exploratory performance was assessed while producing scales in three feedback conditions: With congruent sound, no-sound, or random sound feedback provided by the keyboard. The number of keys played and the timing of key press were recorded. Spatial exploration by patients with left neglect was superior with congruent sound feedback, compared to both Silence and Random sound conditions. Both the congruent and incongruent sound conditions were associated with a greater deceleration in all groups. The frame provided by the music scale improves exploration of the left side of space, contralateral to the right hemisphere, damaged in patients with left neglect. Performing a scale with congruent sounds may trigger at some extent preserved auditory and spatial multisensory representations of successive sounds, thus influencing the time course of space scanning, and ultimately resulting in a more extensive spatial exploration. These findings offer new perspectives also for the rehabilitation of the disorder.

The acclaimed Italian directors Luchino Visconti and Federico Fellini had very different life trajectories that led them to become major figures in the history of cinema. Similarities, however, can be found in their debuts with the neorealist genre, their personalities, creative styles and politicocultural involvement, and ultimately in the neurological disease that struck them at the end of their careers. Both suffered a right-hemispheric stroke that left them hemiplegic on the left side. We review their life and career to put that event into perspective, and then discuss its aftermath for both artists in the light of our current knowledge of right-hemispheric functions. Visconti showed a tremendous resilience following the accident and managed to direct several films and plays as an infirm, whereas Fellini had to put an end to his career but still was able to display his talents to the neuropsychologists that treated him. A speculative account is given of the links between right-hemispheric symptomatology and the premorbid personality of these highly prolific patients.

According to a longstanding view, inferior as opposed to superior parietal cortex critically contributes to the spatial attentional deficits encountered following unilateral parietal ischemic lesions. We review the evidence on which this view is based and contrast it with more recent structural lesion evidence concerning the critical role of the intraparietal sulcus in spatial attention deficits. In a classical spatial cueing paradigm, focal lesions of the posterior and of the middle segment of the intraparietal sulcus
give rise to a pathological invalidity effect that is indistinguishable from that seen after classical inferior parietal lesions. When a competing distracter is added to a target stimulus, the deleterious consequences of focal IPS lesions are again very similar to those classically observed following inferior parietal lesions. The deficit could not be accounted for by functional effects at a distance affecting inferior parietal cortex. These single-case lesion data establish the critical role of the posterior and the middle IPS segment in spatially selective attention and are in line with a vast amount of functional imaging evidence in the intact brain pointing to the prominent role of the intraparietal sulcus in spatial attention, along with inferior parietal cortex under specific circumstances. Functional imaging has also provided hints about
the differences in functional contribution between inferior and superior parietal cortex. These hypotheses await further confirmation based on lesion evidence.

The neural correlates of left extrapersonal visual unilateral spatial neglect (VUSN), the more extensively investigated component of the neglect syndrome, are reviewed. Damage to a number of right-hemisphere regions brings about VUSN: the posterior parietal cortex (inferior parietal lobule) and, although less frequently, the premotor cortex and subcortical structures, such as the thalamus and the basal ganglia, and white matter fiber tracts. In recent years, a number of studies have investigated the possible association of specific components of left VUSN with damage to specific brain regions within the right hemisphere. The putative distinction most extensively investigated from an anatomical perspective concerns the perceptual vs premotor components of VUSN. In addition, a fine-grain componential analysis of the behavioral tasks used to investigate VUSN is providing more specific insight into the pathological mechanisms underlying the variety of its manifestations. The emerging pattern is that USN is a multifarious disorder, in which specific deficits are associated with damage localized in discrete brain regions and neural circuits. These data concur with evidence from other domains (functional neuroimaging, neurophysiology) to suggest a highly multicomponential neural and functional architecture of spatial cognition.

Recently, several theorists have proposed that we can perceive a range of high-level features, including natural kind features (e.g., being a lemur), artifactual features (e.g., being a mandolin), and the emotional features of others (e.g., being surprised). I clarify the claim that we perceive high-level features and suggest one overlooked reason this claim matters: it would dramatically expand the range of actions perception-based theories of action might explain. I then describe the influential phenomenal contrast method of arguing for high-level perception and discuss some of the objections that have been raised against this strategy. Finally, I describe two emerging defenses of high-level perception, one of which appeals to a certain class of perceptual deficits and one of which appeals to adaptation effects. I sketch a challenge for the latter approach.

For many historians, sociologists, and anthropologists of medicine, “disease” and “illness” are not equivalent. Whereas “disease” denotes the physician’s ostensibly objective criteria, “illness” emphasizes the patient’s subjective experience. This dissertation examines that distinction precisely at a point where it breaks down, in the history of a diagnosis called “anosognosia,” also known as the denial of illness.
    In the 1890s, Austrian psychiatrist Gabriel Anton observed a number of patients who denied being blind, deaf, or paralyzed. “That is just how it is,” a patient demurred, “one sees better in youth.” The question to Anton was, were such patients truly unaware of their loss or did they sense it on some level, if only to deny it?
    The history of Anton’s syndrome, later named “anosognosia” by the French neurologist Joseph Babinski, spans more than a century and a half across two continents and through both world wars. I treat its history as a special type of lens to focus on some of the broader intellectual and professional differences between neurology and psychiatry. I argue that the clinical perception and portrayal of this apparent loss of the patient’s experience depended on historical patterns of thinking about the distinction between conscious and unconscious perception as well as categories of health and disease. To think about the denial of illness was to think about the very meaning of illness and awareness, and the difference, if any, between the mind and the brain.

Although dissociations between anosognosia for motor deficit and neglect have been reported, several authors consider anosognosia and neglect as deeply related syndromes. Different techniques, such as optokinetic stimulation, adaptation to prismatic shift of the visual field to the right, or transcutaneous electrical nerve stimulation (TENS), have been shown to alleviate neglect at least temporarily. However, their effect on anosognosia has not been systematically investigated. The aim of this study is to investigate the effect of these techniques on anosognosia and to investigate whether the therapeutic effect, if any, matches that on neglect. A disparity in the outcome of treatment between anosognosia and neglect would support the dissociation between the two syndromes. We have named this procedure “Treatment Response Bias”.

According to the dominant focus model, the differential activation of the thalamocortical network is a sufficient condition for the diversity of states of consciousness to occur, and coherent patterns of interactive forebrain activation peaks are sufficient to generate specific conscious figures against ground. These minimal assumptions are consonant with the known properties of unilateral neglect. It becomes unnecessary to suppose that consciousness is an independent entity, occupies a dedicated location in the brain, is contingent on a minimal level of neural complexity, plays a causal role in enabling perception or action, or evolved because it plays any such role.

"The Milner Landmark Task allows the disentanglement of perceptual and response-related components of unilateral neglect. If these two components reflect separate functional systems, then cases should be observed in which the two components evolve differently across time. To test this hypothesis we surveyed a continuous series of 21 right hemisphere stroke patients. Five patients from the sample were affected by unilateral neglect at the outset and could be submitted to repeated administrations of the Landmark task in the first weeks post stroke. Two versions of the task were used, Landmark-Manual and Landmark-Verbal, differing in the type of response required. Two patients showed independent changes in the perceptual and the response-related component of neglect, hence confirming the view of separate functional systems underlying them. Dissociations between the task versions were found, witnessing a role of the type of response. Unexpectedly, one patient showed an initial leftward deviation of the subjective midpoint of the stimulus line, which later reversed to a classical rightward deviation. We interpreted such a pattern in terms of co-existing “productive” and “negative” components of perceptual neglect."

Spatial neglect (SN) is commonly associated with poor functional outcome. Adaptation to a rightward optical deviation of vision has been shown to benefit to SN rehabilitation. The neurophysiological foundations and the optimal modalities of prism adaptation (PA) therapy however remain to be validated. This study is aimed at exploring the long-term sensory-motor, cognitive and functional effects produced by weekly PA sessions over a period of four weeks. A double-blind, monocentric randomized and controlled trial (RCT) was carried out. Twenty patients with left SN secondary to stroke were included, 10 in the “prism” group and 10 in the “control” group. The sensory-motor effects of PA were evaluated by measurement of manual and visual straight-ahead, and also by precision of pointing without visual feedback before and after each PA session. The functional independence measure (FIM) was evaluated before and at 1, 3 and 6 months after PA, while SN severity was assessed using the Behavioural Inattention Test (BIT) before and 6 months after PA. Before the intervention, only manual straight-ahead pointing constituted a reproducible sensory-motor measurement. During prism exposure, a questionnaire showed that not a single patient were aware of the direct effects of optical deviation on pointing movement performance. The sensory-motor after-effects produced by the PA produced a more rapid reduction of the rightward manual straight-ahead, which was secondarily followed by visual straight-ahead. These sensory-motor effects helped to clarify the action mechanisms of PA on SN. At the conclusion of the 6-month follow-up, the two groups showed similar improvement, indicating that a weekly PA session over 4 weeks was not sufficient to produce long-term functional benefit. This improvement was correlated with the evolution of visual straight-ahead, which can be proposed as a marker for patients outcome.

A complex link exists between vision and unilateral spatial neglect (USN). Firstly, USN is not a perceptual deficit, secondly, USN is not necessarily accompanied by a visual deficit and finally, USN can be observed in non-visual modalities as well as in mental spatial imagery. This apparent supramodality of USN stands in sharp contrast to the fact that neglect signs are often more severe and more durable in the visual than in other sensory modalities (Chokron et al., 2002). The influence of vision on spatial representation has rarely been studied. In the present study we assessed six right brain-damaged patients suffering from left USN on two tasks involving spatial representations: a clock-drawing task and a drawing from memory task in two experimental conditions, with and without visual control. We confirm that even in mental imagery, the absence of visual feedback may decrease and even suppress left neglect signs (Bartolomeo and Chokron, 2001b; 2002). Since vision is largely involved in the orientation of attention in space, suppressing visual control could reduce the magnetic attraction towards the right ipsilesional hemispace and in this way could allow a re-orientation of attention towards the left neglected hemispace. We discuss the theoretical and therapeutic implications of these findings.

Visual Neglect (VN) is a common neuropsychological deficit associated with a person having a stroke (approximately 1/3/ of cases). Visual neglect is characterised by an inability to notice things on the side contralateral to the stroke site, typically the left. Currently in the clinical setting, pen and paper-based techniques such as the Behavioural Inattention Test (BIT) and Star Cancellation are used to assess the presence of VN in patients but they are purely binary classifiers and lack sensitivity so may fail to pick up subtle neglect. Regarding rehabilitation, there have been a number of programs developed to try and ameliorate the symptoms of VN with limited/varying degrees of success. Using the Leap Motion Controller, the associated SDK and the Processing programming language, this project sets out to develop a novel measurement paradigm for the mapping the spatial distribution of visual neglect to give a more nuances assessment of severity. It also lays the groundwork for developing a novel rehabilitative intervention based on Visual Scanning and Limb Activation.

In the last decade a number of theories have been formulated hypothesizing a “distortion” of representational space in neglect patients, in order to explain their impairment on tasks investigating the perception of horizontal extents. Trying to compensate for the relative lack of formalization in this field of research, a mathematical model of what a spatial distortion should be is formulated on the basis of theoretical considerations and of some neurophysiological evidence; furthermore, a psychophysical task is proposed that estimates the amount of distortion and is able to overcome some of the limits in the currently used methods. On this task, 32 normal subjects showed two different kinds of deviation from the ideal performance, neither of which is attributable to perceptual factors. Out of five neglect patients, two showed reliable distortion, another two showed a trend towards distortion (but in opposite directions with respect to one another), and one showed no sign of distortion. In conclusion, a new method for estimating distortion suggested that the explorative impairment—neglect—can dissociate from the metric one—distortion, as one would expect on grounds of a (evolutionarily plausible) separation between the two operations of exploring and measuring space.

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.

Despite decades of research, the question of whether the rapid eye movements (REMs) of paradoxical sleep (PS) are equivalent to waking saccades and whether their direction is congruent with visual spatial events in the dream scene is still very controversial. We gained an insight into these questions through the study of a right brain damaged patient suffering attentional neglect for the left side of space and drop of the optokinetic nystagmus (OKN) with alternating rightward slow/leftward fast phases evoked by rightward optic flow. During PS the patient had frequent Nystagmoid REMs with alternating leftward slow/rightward fast phases and reported dreams with visual events evoking corresponding OKN such as a train running leftward. By contrast, just as in waking OKN, Nystagmoid REMs with alternating rightward slow/leftward fast phases were virtually absent. REMs followed by staring eye position or by consecutive REMs were also observed: these showed no asymmetry comparable to that of Nystagmoid ones. The selective disappearance of Nystagmoid REMs in one horizontal direction proves, for the first time, that in humans different types of REMs exists and that these are driven by different premotor mechanisms. Concomitant drop of OKN and Nystagmoid REMs toward the same horizontal direction demonstrates that phylogenetically ancient oculomotor mechanisms, such as the OKN, are shared by waking and PS. On this evidence and converging findings from animal, neuropsychological and brain imaging studies, a new evolutionary account of dream bizarreness is proposed. Classification and labelling of the different types of REMs are also provided.

This article was originally published in the Encyclopedia of Human Behavior published by Elsevier, and the attached copy is provided by Elsevier for the author's benefit and for the benefit of the author's institution, for non-commercial research and educational use including without limitation use in instruction at your institution, sending it to specific colleagues who you know, and providing a copy to your institution's administrator. All other uses, reproduction and distribution, including without limitation commercial reprints, selling or licensing copies or access, or posting on open internet sites, your personal or institution's website or repository, are prohibited. For exceptions, permission may be sought for such use through Elsevier's permissions site at: http://www.elsevier.com/locate/permissionusematerial Berti A. and Neppi-Modona M. (2012) Agnosia (including Prosopagnosia and Anosognosia). In: V.S. Ramachandran (ed.) The Encyclopedia of Human Behavior, vol. 1, pp. 60-67. Academic Press.

RÉSUMÉ Introduction. La Négligence Spatiale Unilatérale (NSU) est l'un des principaux syndromes observables après une lésion touchant l'hémisphère non dominant pour le langage. Le handicap important qu'elle entraîne justifie la nécessité d'un diagnostic et d'une prise en charge appropriés. États des connaissances. L'étude de la NSU est motivée par son lien avec des phénomènes cognitifs importants sur le plan théorique (attention visuospatiale et conscience perceptive). Les localisations cérébrales des lésions pouvant ...

Neglect of contralesional stimuli and perseverative behavior on ipsilesional stimuli may co-occur on a target cancellation task. Our aim was to investigate whether the presence vs. absence of contralesional targets can modify perseveration on ipsilesional targets. We studied four right brain-damaged patients with left neglect and perseverative behavior on screening cancellation tasks. We compared their cancellation performance in two conditions: (i) targets equally distributed on both sides of space and (ii) targets confined to the right side. One patient showed no significant difference in perseveration between these two conditions; in contrast, three patients perseverated significantly more in condition (i) than in condition (ii). These results suggest that, at least in some patients, information from the 'neglected' targets is not completely lost, but rather it affects behavior in the ipsilesional side. The traditional dichotomy 'bad space-good space' would not apply here.

Virtual reality (VR) entails the use of advanced technologies, including computers and various multimedia peripherals, to produce a simulated (that is, virtual) environment that users perceive as comparable to real world objects and events. In recent years, virtual reality technologies have begun to be used as an assessment and treatment tool in occupational therapy, in part because of the ability to create environments that provide patients with opportunities to engage in meaningful, purposeful tasks that are related to real-life interests and activities. The objective of this study was to determine the suitability and feasibility of using a PC-based, nonimmersive, VR system (that is, a system in which the user has a reduced sense of actual presence in and control over the simulated environment) for training individuals with unilateral spatial neglect to cross streets in a safe and vigilant manner. A virtual environment, consisting of a typical city street, was programmed using Superscape's™TM 3D-Webmaster, a 3D web-authoring tool. Twelve subjects, aged 55 to 75 years, participated in the initial feasibility study and, to date, a further eight subjects have participated in the intervention study. Six of the initial subjects and all eight of the intervention subjects had sustained a right hemispheric stroke at least 6 weeks prior to the study. The remaining subjects were healthy age-matched adults who were independently mobile and had no difficulty in crossing streets. The results show that this virtual environment was suitable in both its cognitive and motor demands for the targeted population and indicate that the virtual reality training is likely to prove beneficial to people who have difficulty with crossing streets. The generalizability of these results, and recommendations regarding the use of virtual reality as an occupational therapy intervention, must be substantiated by further studies using a range of VR platforms with people with different cognitive and motor disabilities. Copyright © 2003 Whurr Publishers Ltd.