Right hemispatial neglect: frequency and characterization following acute left hemisphere stroke

The frequency of various types of unilateral spatial neglect and associated areas of neural dysfunction after left hemisphere stroke are not well characterized. Unilateral spatial neglect (USN) in distinct spatial reference frames have been identified after acute right, but not left hemisphere stroke. We studied 47 consecutive right handed patients within 48h of left hemisphere stroke to determine the frequency and distribution of types of right USN using cognitive testing and MRI imaging. The distribution of USN types was different from the previously reported distribution following acute right hemisphere stroke. In this left hemisphere stroke population, allocentric neglect was more frequent than egocentric neglect.     

You never know where you are going until you know where you have been: Disorganized search after stroke

Disorders in spatial exploration can be expressed in a disorganized fashion of target cancellation. There is debate regarding whether disorganized search is related to stroke in general, to right brain damage or to unilateral spatial neglect (USN) in particular. In this study, 280 stroke patients and 37 healthy control subjects performed a computerized shape cancellation test. We investigated the number of perseverations and several outcome measures regarding disorganized search: Consistency of search direction (best r), distance between consecutive cancelled targets and intersections with paths between previous cancelled targets. We compared performance between patients with left and right brain damage (L, R) and with and without USN (USN+, USN?), resulting in four subgroups: LUSN?, RUSN?, LUSN+, and RUSN+. Higher numbers of intersections were found for the left brain‐ and right brain‐damaged patients with USN and for the right brain‐damaged patients without USN, compared to healthy control subjects. Furthermore, right brain‐damaged patients with USN showed a higher number of intersections compared to right brain‐damaged patients without USN and compared to left brain‐damaged patients with USN. To conclude, disorganized search was most strongly related to the neglect syndrome, and patients with more severe USN were even more impaired.     

Dissociable Coordinate Frames of Unilateral Spatial Neglect: “Viewer-Centered” Neglect

Detailed analyses of reading and nonlexical tasks by three patients with unilateral spatial neglect (USN) secondary to stroke indicate that the USN in each of these patients affects the left side (contralateral to brain damage) of the viewer, with respect to the viewer's head, mid-sagittal plane of the body, or line of sight. In one case, the neglect was further specified as concerning the left side of the viewer's line of sight (the left half of her residual visual field). Thus, the frame of reference of USN in these three cases appears to have viewer-centered (in at least one case, specifically retinotopic) coordinates. The performance of these patients is contrasted to that of other patients in the literature whose USN appears to have a frame of reference with stimulus-centered or object-centered coordinates. These results are interpreted within a model of visual processing (adapted from Marr, 1980 and others) with at least three coordinate frames. It is argued that USN can affect one or more of these coordinate frames independently.     

Selective spatial attention and length representation in normal subjects and in patients with unilateral spatial neglect

The aim of this study was to assess whether perceptual representation along the horizontal axis is affected by hemispace position of the stimulus or by orienting attention to one side. Ten control subjects and 10 right brain damaged patients with left unilateral spatial neglect (USN) were asked to bisect lines of five lengths in three space positions (left, center, right) and under three cueing conditions (no cue, left cue, right cue). Normal controls showed significant displacement of bisection opposite to the side of hemispace presentation and toward the side of cueing. USN patients showed a bisection error toward the right end which increased with lines placed in the left hemispace and decreased with lines placed in the right hemispace and when attention was oriented toward the left side. We conclude that (1) In absence of cues normal subjects tend to overestimate the portions of space closer to their body midline; (2) both normal and USN patients tend to overestimate portions of space that they direct their attention to; (3) USN patients' performance without cueing is consistent with an attentional shift toward the right hemispace implying a gradient of overestimation of the right-most portions of space. A common neural substratum for directing attention and space representation can explain these findings.     

Pseudoneglect for the bisection of mental number lines

Patients with unilateral neglect of the left side bisect physical lines to the right whereas individuals with an intact brain bisect lines slightly to the left (pseudoneglect). Similarly, for mental number lines, which are arranged in a left-to-right ascending sequence, neglect patients bisect to the right. This study determined whether individuals with an intact brain show pseudoneglect for mental number lines. In Experiment 1, participants were presented with visual number triplets (e.g., 16, 36, 55) and determined whether the numerical distance was greater on the left or right side of the inner number. Despite changing the spatial configuration of the stimuli, or their temporal order, the numerical length on the left was consistently overestimated. The fact that the bias was unaffected by physical stimulus changes demonstrates that the bias is based on a mental representation. The leftward bias was also observed for sets of negative numbers (Experiment 2)—demonstrating not only that the number line extends into negative space but also that the bias is not the result of an arithmetic distortion caused by logarithmic scaling. The leftward bias could be caused by a rounding-down effect. Using numbers that were prone to large or small rounding-down errors, Experiment 3 showed no effect of rounding down. The task demands were changed in Experiment 4 so that participants determined whether the inner number was the true arithmetic centre or not. Participants mistook inner numbers shifted to the left to be the true numerical centre—reflecting leftward overestimation. The task was applied to 3 patients with right parietal damage with severe, moderate, or no spatial neglect (Experiment 5). A rightward bias was observed, which depended on the severity of neglect symptoms. Together, the data demonstrate a reliable and robust leftward bias for mental number line bisection, which reverses in clinical neglect. The bias mirrors pseudoneglect for physical lines and most likely reflects an expansion of the space occupied by lower numbers on the left side of the line and a contraction of space for higher numbers located on the right.     

Prose Reading in Neglect

Prose reading has been shown to be a very sensitive measure of Unilateral Spatial Neglect. However, little is known about the relationship between prose reading and other measures of neglect and its severity, or between prose reading and single word reading. Thirty participants with a first stroke in the right hemisphere and clear symptoms of spatial neglect in everyday life were assessed with tests of prose reading (text in one column book-like, and in two columns magazine-like), single words reading, and a battery of 13 tests investigating neglect. Seventy percent of these participants omitted words at the beginning of the text (left end), showing Prose Reading Neglect (PRN). The participants showing PRN differed from those not showing PRN only for the overall severity of neglect, and had a lesion centred on the insula, putamen and superior temporal gyrus. Double dissociations emerged between PRN and single word reading neglect, suggesting different cognitive requirements between the two tests: parallel processing in single word reading vs. serial analysis in text reading. Notably, the pattern of neglected text varied dramatically across participants presenting with PRN, including dissociations between reading performance of one and two columns text. Prose reading proved a complex and unique task which should be directly investigated to predict the effects of unilateral neglect. The outcome of this study should also inform clinical assessment and advises given to patients and care-givers.     

Mental representation of a line when patients with left unilateral spatial neglect bisect it: A study with an endpoint reproduction task

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre. Based on the previous findings (e.g., Ishiai et al. 1989, Brain, 112, 1485), we hypothesized that the patients with left USN may see the representational image of a line that extends equally towards either side of the subjective midpoint depending not upon the information about the leftward extent. The present study tested whether patients with left USN would place the subjective midpoint at the centre of their mental representation of the line. The participants were 10 patients with left USN and 10 neurologically healthy controls. We devised a new ‘endpoint reproduction task’ using a computer display with a touch panel to seek the representational image when patients with left USN bisect lines and asked the participants to reproduce the location of the right or left endpoint after bisecting lines. The results showed that the representational image of the bisected line depends primarily on the location of the objective right endpoint, not on the location of the objective left endpoint in space. The analyses of the estimated right and left representational extents confirmed our hypotheses that patients with left USN would bisect a line seeing the representational line image that centred across their subjective midpoint. We believe that the findings of the present study with the use of the endpoint reproduction task will contribute to a better understanding of the visuospatial process underlying line bisection of patients with left USN.     

Spatial analysis after perinatal stroke: patterns of neglect and exploration in extra-personal space

This study was conducted to determine whether school-aged children who had experienced a perinatal stroke demonstrate evidence of persistent spatial neglect, and if such neglect was specific to the visual domain or was more generalized. Two studies were carried out. In the first, 38 children with either left hemisphere (LH) or right hemisphere (RH) damage and 50 age-matched controls were given visual cancellation tasks varying in two factors: target stimuli and stimulus array. In the second study, tactile neglect was evaluated in 41 children with LH or RH damage and 72 age-matched controls using a blindfolded manual exploration task. On the visual cancellation task, LH subjects omitted more target stimuli on the right, but also on the left, compared with controls. Children with RH lesions also produced a larger number of omissions on both the left and right sides than controls, but with poorer performance on the left. On the manual exploration task, LH children required significantly longer times to locate the target on both sides of the board than did controls. RH children had significantly prolonged search times on the left side, but not on the right, compared with controls. In both tasks, LH subjects employed unsystematic search strategies more often than both control and RH children. The search strategy of RH children also tended to be erratic when compared to controls, but only in the random arrays of the visual cancellation tasks; structure of the target stimuli improved their organization. These results demonstrate that children with early LH brain damage display bilateral difficulties in visual and tactile modalities; a pattern that is in contrast to that seen in adults with LH damage. This may result from disorganized search strategies or other subtle spatial or attentional deficits. Results of performance of RH children suggests the presence of contralateral neglect in both the visual and tactile modalities; a finding that is similar to the neglect in adult stroke patients with RH lesions. The fact that deficits in spatial attention and organizational strategies are present after very early focal damage to either the LH or the RH broadens our understanding of the differences in functional lateralization between the immature and mature brain. These results also add to evidence for limitations to plasticity in the developing brain. Our findings may have therapeutic and rehabilitative implications for the management of children with early focal brain lesions.     

Full-field input generated from right visual field information for healthy participants reproduces performance simulating left unilateral spatial neglect in line bisection

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre when bisecting a horizontal line. This pathological phenomenon may be explained as a result of greater dependence on the right endpoint in the external reference frame (Koyama et al., Brain Cogn, 35, 1997, 271; McIntosh et al., Cogn Brain Res, 25, 2005, 833). Ishiai et al. (Brain, 112, 1989, 1485) reported that once patients with USN fixated on a certain point on the right part of the presented line, they persisted with this point and marked the subjective midpoint there without leftward searches. Ishiai et al.'s interpretation was that the patients saw a totalised line representation that extended equidistantly to the right and left sides, based on the information of the attended rightward extent from the subjective midpoint. Accordingly, we used virtual reality goggles (VRG) and devised a mirror-image viewing (MV) condition that showed a full-field view based on the right visual field information to test whether healthy participants would thereby show neglect-like bisection performance. The participants were 30 healthy adults (22–37 years old; 15 women and 15 men). In this condition, 96.7% (29/30) of participants were judged to exhibit USN-like performance of line bisection, indicating the effectiveness of MV condition to simulate USN. The novelty of the present study lies in the use of a task-specific intervention of neglect-like visuospatial processing during line bisection without attempting to modify the direction of spatial attention. This approach may contribute to the understanding of the pathological visuospatial processing of USN.     

Temporal order judgements as a sensitive measure of the spatial bias in patients with visuospatial neglect

Visuospatial neglect is not a unitary phenomenon, but can be better considered a syndrome, consisting of a multitude of different spatial and non‐spatial components. In this study, we used a temporal order judgement (TOJ) test in a large sample of stroke patients (n = 73) to scrutinize the contribution of a spatial bias to the performance on shape cancellation and line bisection tests. In the TOJ test, patients were presented with two elements, one in each visual field, after which the one needed to indicate which of the two elements was presented earlier. For each visual field, the presentation of the stimuli was determined by a staircase procedure where the interval between the two stimuli was determined by the performance of the patient. Results indicated that the strength of the spatial bias was strongly correlated with an object cancellation test, but not with a line bisection test. We argue that these findings are explained by differences in the extent to which a spatial bias determines performance on both tasks: In contrast to shape cancellation tests, successful performance on line bisection tests depends primarily on an object‐based, allocentric representation of space, unrelated to any spatial bias in the detection of elements in the contralesional visual field.     

Gender differences in remembering and inferring spatial distances

The abilities of males and females to make spatial inferences were compared. Spatial inference is concerned with the ability to work out new spatial information from memory. In two experiments, participants had to study line drawings depicting shapes linked either by straight or meandering lines. Afterwards, they had to remember the straight-line distances or to infer the straight-line distances. Several spatial abilities were also assessed: perceptual discrimination, mental rotation, and visuo-spatial working memory span. The results showed that males outperformed females in spatial inference and mental rotation. Experiment 2 extended the study to old people. The results replicated and clarified those obtained in Experiment 1. Spatial inference and mental rotation showed age-related and gender-related differences; in addition, age reduced the visuo-spatial memory span. Overall, the findings suggest that gender differences favouring males are maximised with tasks requiring active processing and strategic control of metric information.     

Lateral specialization in unilateral spatial neglect: a cognitive robotics model

In this paper, we present the experimental results of an embodied cognitive robotic approach for modelling the human cognitive deficit known as unilateral spatial neglect (USN). To this end, we introduce an artificial neural network architecture designed and trained to control the spatial attentional focus of the iCub robotic platform. Like the human brain, the architecture is divided into two hemispheres and it incorporates bio-inspired plasticity mechanisms, which allow the development of the phenomenon of the specialization of the right hemisphere for spatial attention. In this study, we validate the model by replicating a previous experiment with human patients affected by the USN and numerical results show that the robot mimics the behaviours previously exhibited by humans. We also simulated recovery after the damage to compare the performance of each of the two hemispheres as additional validation of the model. Finally, we highlight some possible advantages of modelling cognitive dysfunctions of the human brain by means of robotic platforms, which can supplement traditional approaches for studying spatial impairments in humans.     

Visual neglect in the first weeks after a stroke in the right hemisphere

The aim of the study was to characterize symptoms of visual neglect among patients who recently survived a stroke in the right hemisphere (RH), and to contribute to the understanding of change in symptoms during the first months after a RH stroke. Thirteen patients with a RH stroke and twenty controls were assessed by using standard neglect tests. Five patients were followed up by repetitive test sessions during the next four months. To assess more subtle symptoms, reaction-time (RT) measures derived from an experimental cue-target paradigm were included in the final test session. A high frequency of neglect symptoms was documented at the first test session. The changes in performance during the first weeks were characterized by a high inter-individual as well as a high intra-individual variability. Although the remission rate on standard tests was high in the follow-up study, the RT measures indicated sustained symptoms of visual extinction in all patients. The long-term implication of the changes of neglect symptoms during the first weeks after a stroke and signs of sustained symptoms of visual extinction calls for further longitudinal studies including a larger group of patients.     

Pseudoneglect for the bisection of mental number lines

Patients with unilateral neglect of the left side bisect physical lines to the right whereas individuals with an intact brain bisect lines slightly to the left (pseudoneglect). Similarly, for mental number lines, which are arranged in a left-to-right ascending sequence, neglect patients bisect to the right. This study determined whether individuals with an intact brain show pseudoneglect for mental number lines. In Experiment 1, participants were presented with visual number triplets (e.g., 16, 36, 55) and determined whether the numerical distance was greater on the left or right side of the inner number. Despite changing the spatial configuration of the stimuli, or their temporal order, the numerical length on the left was consistently overestimated. The fact that the bias was unaffected by physical stimulus changes demonstrates that the bias is based on a mental representation. The leftward bias was also observed for sets of negative numbers (Experiment 2)--demonstrating not only that the number line extends into negative space but also that the bias is not the result of an arithmetic distortion caused by logarithmic scaling. The leftward bias could be caused by a rounding-down effect. Using numbers that were prone to large or small rounding-down errors, Experiment 3 showed no effect of rounding down. The task demands were changed in Experiment 4 so that participants determined whether the inner number was the true arithmetic centre or not. Participants mistook inner numbers shifted to the left to be the true numerical centre--reflecting leftward overestimation. The task was applied to 3 patients with right parietal damage with severe, moderate, or no spatial neglect (Experiment 5). A rightward bias was observed, which depended on the severity of neglect symptoms. Together, the data demonstrate a reliable and robust leftward bias for mental number line bisection, which reverses in clinical neglect. The bias mirrors pseudoneglect for physical lines and most likely reflects an expansion of the space occupied by lower numbers on the left side of the line and a contraction of space for higher numbers located on the right.     

Spatial probability cuing and right hemisphere damage

In this experiment we studied statistical learning, inter-trial priming, and visual attention. We assessed healthy controls and right brain damaged (RBD) patients with and without neglect, on a simple visual discrimination task designed to measure priming effects and probability learning. All participants showed a preserved priming effect for item color. Contrary to healthy controls and RBD participants without neglect, RBD participants with neglect did not show positional priming and both RBD groups learned the underlying spatial probability distribution of target locations to a lesser degree. To see if the latter deficiency could be improved, we tested a patient with long standing chronic spatial neglect on three separate days and observed improved identification times for left sided, high probability, targets. In summary, we found preservation of priming per se in people with spatial neglect. However, this was only clearly demonstrable for color priming and not for positional priming. Associated with this impairment was a difficulty in learning the overall statistical structure of target locations. In a patient with severe persistent neglect we were able to demonstrate that the deficit in statistical learning was not absolute, as this subject improved his identification times for targets appearing in high probability regions of the test display.     

Is ‘object-centred neglect’ a homogeneous entity?

The nature of object-centred (allocentric) neglect and the possibility of dissociating it from egocentric (subject-centred) forms of neglect are controversial. Originally, allocentric neglect was described by  and  in patients who reproduced all the elements of a multi-object scene, but left unfinished the left side of one or more of them. More recently, however, Karnath, Mandler, and Clavagnier (2011) have claimed that the severity of allocentric neglect worsens when a complex ‘object’ shifts from an ipsilesional to a contralesional egocentric position. On the basis of these and of other clinical data, showing that allocentric and egocentric neglect are strongly associated, they have questioned the possibility of dissociating these two forms of neglect, suggesting that egocentric and allocentric neglect constitute different manifestations of the same disturbed system. Since these statements were inconsistent with the clinical findings which had prompted the construct of object-centred neglect, we checked in a group of right brain-damaged patients, who had copied the original multi-object scene, if the degree of neglect for the left side of figures varied as a function of their position on the horizontal axis. Furthermore, we reviewed all papers where copies of other multi-object scenes had been reported. Results of both studies failed to confirm the assumption of a relationship between spatial location of the stimulus and severity of object-centred neglect. This discrepancy between our data and those obtained by Karnath et al. (2011) could be due to the characteristics of stimuli and of procedures used to evaluate ‘object-centred’ neglect. If the stimulus is complex and the task requires its thorough exploration, the spatial location of the stimulus will influence the severity of ‘object-centred neglect’. If, on the contrary, the stimulus is simple and can be identified with few eye fixations, the spatial location of the stimulus should not influence the severity of ‘object-centred neglect’. In any case, our data confirm the possibility of dissociating allocentric from egocentric neglect.     

A Search for the Optimal Stimulus

How do stimulus size and item number relate to the magnitude and direction of error on center estimation and line cancellation tests? How might this relationship inform theories concerning spatial neglect? These questions were addressed by testing twenty patients with right hemisphere lesions, eleven with left hemisphere lesions and eleven normal control subjects on multiple versions of center estimation and line cancellation tests. Patients who made large errors on these tests also demonstrated an optimal or pivotal stimulus value, i.e., a particular size center estimation test or number of lines on cancellation that either minimized error magnitude relative to other size stimuli (optimal) or marked the boundary between normal and abnormal performance (pivotal). Patients with right hemisphere lesions made increasingly greater errors on the center estimation test as stimuli were both larger and smaller than the optimal value, whereas those with left hemisphere lesions made greater errors as stimuli were smaller than a pivotal value. In normal subjects, the direction of errors on center estimation stimuli shifted from the right of true center to the left as stimuli decreased in size (i.e., the crossover effect). Right hemisphere lesions exaggerated this effect, whereas left hemisphere lesions diminished and possibly reversed the direction of crossover. Error direction did not change as a function of stimulus value on cancellation tests. The demonstration of optimal and pivotal stimulus values indicates that performances on center estimation and cancellation tests in neglect are only relative to the stimuli used. In light of other studies, our findings indicate that patients with spatial neglect grossly overestimate the size of small stimuli and underestimate the size of large stimuli, that crossover represents an “apparent” shift in error direction that actually results from normally occurring errors in size perception, and that the left hemisphere is specialized for one aspect of size estimation, whereas the right performs dual roles.     

Transcranial alternating brain stimulation at alpha frequency reduces hemispatial neglect symptoms in stroke patients

Background/ObjectiveNon-invasive brain stimulation techniques such as transcranial alternating current stimulation (tACS) may help alleviate attention deficits in stroke patients with hemispatial neglect by modulating oscillatory brain activity. We applied high-definition (HD)-tACS at alpha frequency over the contralesional hemisphere to support unilateral oscillatory alpha activity and correct for the pathologically altered attention bias in neglect patients.MethodsWe performed a within-subject, placebo-controlled study in which sixteen stroke patients with hemispatial neglect underwent 10 Hz (alpha) as well as sham (placebo) stimulation targeting the contralesional posterior parietal cortex. Attentional bias was measured with a computerized visual detection paradigm and two standard paper-and-pencil neglect tests.ResultsWe revealed a significant shift of attentional resources after alpha-HD-tACS, but not sham tACS, toward the ipsilateral and thus contralesional hemifield leading to a reduction in neglect symptoms, measured with a computerized visual detection paradigm and a widely used standard paper and pencil neglect tests.ConclusionsWe showed a significant alpha-HD-tACS-induced shift of attentional resources toward the contralesional hemifield, thus leading to a reduction in neglect symptoms. Importantly, HD-tACS effects persisted after the stimulation itself had ended. This tACS protocol, based on intrinsic oscillatory processes, may be an effective and well-tolerated treatment option for neglect.     

Women are not less field independent than men—the role of stereotype threat

Prior research has shown that females are less field independent (FI) than males. However, when gender identity is salient, performance on tests assessing constructs similar to FI may be hindered, because of stereotype threat. This study examined the impact of stereotype threat on gender differences in FI. We expected that (a) reporting one's own gender prior to FI testing and (b) having an opposite‐gender experimenter would activate stereotype threat, and in turn result in lower performance on a test of FI among females. Overall, 170 participants were randomly assigned to one of eight conditions in a between‐participants design varying the participant's gender, experimenter's gender and timing of the gender question (before vs. after test). Results showed that reporting one's gender before the FI test led to lower FI performance among females. Furthermore, females achieved higher FI when experimenters were females and gender questions were administered after the FI test.     

The mental representation of ordinal sequences is spatially organized

In the domain of numbers the existence of spatial components in the representation of numerical magnitude has been convincingly demonstrated by an association between number magnitude and response preference with faster left- than right-hand responses for small numbers and faster right- than left-hand responses for large numbers (Dehaene, S., Bossini, S., & Giraux, P. (1993) The mental representation of parity and number magnitude. Journal of Experimental Psychology: General, 122, 371-396). Because numbers convey not only real or integer meaning but also ordinal meaning, the question of whether non-numerical ordinal information is spatially coded naturally follows. While previous research failed to show an association between ordinal position and spatial response preference, we present two experiments involving months (Experiment 1) and letters (Experiment 2) in which spatial coding is demonstrated. Furthermore, the response-side effect was obtained with two different stimulus-response mappings. The association occurred both when ordinal information was relevant and when it was irrelevant to the task, showing that the spatial component of the ordinal representation can be automatically activated.