When the whole is more than the sum of the parts: Evidence from visuospatial neglect

One possible pathological mechanism underlying the rightward bisection error of right‐brain‐damaged patients with left spatial neglect is a leftward relaxation of the spatial representational medium. This view was originally based on the finding that patients with left neglect, required to extend horizontal segments, in order to double their original length, may exhibit a relative left overextension of the drawn lines ( Bisiach et al., 1994 ). We investigated this putative distortion of representational space using a 16 cm ‘line segmentation’ task (Experiment 1). Were the representation of space relaxed contralesionally, a progressive increase from right to left of the size of the drawn segments would be expected. Right‐brain‐damaged patients with left unilateral neglect (N=12) performed the segmentation task with no left versus right differences, as right‐brain‐damaged patients without neglect (N=8), and neurologically unimpaired control subjects (N=10), did. Experiments 2 and 3 explored the effects of sample length (1, 2, 4, and 8 cm), by which the 16 cm lines had to be segmented. Neglect patients produced longer left‐sided segments only for the 8 cm sample (i.e. half of the length of the segment). This set of experiments suggests an impairment in the segmentation task only with the larger (8 cm) sample, when a more global level of processing may be involved. Experiment 4 assessed this hypothesis by a ‘part/whole’ bisection task, using 8 cm lines, presented either embedded in a longer 16 cm line or in isolation. Neglect patients made a larger rightward bisection error when the segment was not embedded. The suggestion is made that the lateral distortion of the representation of space in neglect patients (i.e. a leftward relaxation of the spatial medium) concerns tasks where a more ‘global’ representation of the visual stimulus has to be set up. The different demands of the segmentation and bisection tasks are discussed.     

Misprojection of landmarks onto the spatial map

It has been suggested that neglect patients misrepresent the metric spatial relations along the horizontal axis (anisometry). The "fabric" of their internal spatial medium would be distorted in such a way that physically equal distances appear relatively shorter on the contralesional side (canonical anisometry). The case of GL, a 76-year-old lady with left neglect on visual search tasks, is presented. GL showed severe relative overestimation on the left (contralesional) side on two independent tasks evaluating the metrics of her internal representation. A qualitatively similar pattern was found in two out of 10 other neglect patients who performed the second task. This behavior cannot be accounted for by the canonical anisometry hypothesis. Nevertheless, GL produced a relative left overextension (underestimation) when trying to set the endpoints of a virtual line given its midpoint (Endpoints Task). An interpretation of these results is offered in terms of a misprojection of relevant landmarks onto the internal representation without assuming distortion of its "fabric."     

Crossover by Line Length and Spatial Location

It is well known that line length has a systematic influence on line bisection error in neglect. Most patients with neglect misbisect long lines on the same side of true center as their brain lesion but then cross over on short lines, misbisecting them on the opposite side (i.e., crossover by line length). What is less recognized is that the spatial location of lines relative to the viewer can similarly induce a crossover effect when one considers line bisection error scores that have been averaged across individual line lengths. Patients with right hemisphere injury and neglect classically make averaged line bisection errors that fall right of true center on lines located either at midline or to the left of the viewer; however, we observed that the averaged line bisection error can fall left of true center when lines are located to the right of the viewer (i.e., crossover by spatial location). We hypothesized that crossover by both line length and spatial location stem from systematic errors in magnitude estimation, i.e., perceived line length. We tested predictions based on this hypothesis by examining how the crossover effect by line length is altered by the spatial location of lines along a horizontal axis relative to the viewer. Participants included patients with unilateral lesions of the right and left cerebral hemispheres and age-appropriate normal subjects. All groups demonstrated a crossover effect by line length at the midline location but the effect was altered by placing lines to the right and left of the viewer. In particular, patients with right hemisphere injury and neglect crossed-over across a broader range of line lengths when the lines were located to the right of the viewer rather than at either midline or left of the viewer. It is proposed that mental representations of stimulus magnitude are altered in neglect, in addition to mental representations of space, and that traditional accounts of neglect can be enhanced by including the psychophysical concept of magnitude estimation.     

Radial bisection of words and lines in right‐brain‐damaged patients with spatial neglect

The bisection of lines positioned radially (with the two ends of the line close and far, with respect to the participant's body) has been less investigated than that of lines placed horizontally (with their two ends left and right, with respect to the body's midsagittal plane). In horizontal bisection, patients with left neglect typically show a rightward bias for both lines and words, greater with longer stimuli. As for radial bisection, available data indicate that neurologically unimpaired participants make a distal error, while results from right‐brain‐damaged patients with left spatial neglect are contradictory. We investigated the bisection of radially oriented words, with the prediction that, during bisection, linguistic material would be recoded to its canonical left‐to‐right format in reading, with the performance of neglect patients being similar to that for horizontal words. Thirteen right‐brain‐damaged patients (seven with left spatial neglect) and fourteen healthy controls were asked to manually bisect 40 radial and 40 horizontal words (5–10 letters), and 80 lines, 40 radial and 40 horizontal, of comparable length. Right‐brain‐damaged patients with spatial neglect exhibited a proximal bias in the bisection of short radial words, with the proximal part corresponding to the final right part of horizontally oriented words. This proximal error was not found in patients without neglect and healthy controls. For bisection, short radial words may be recoded to the canonical orthographic horizontal format, unveiling the impact of left neglect on radially oriented stimuli.     

Unilateral neglect: the effect of competing stimuli on estimated line length

Normal subjects and patients with right hemisphere lesions with or without signs of left unilateral neglect judged the length of a horizontal line presented on the left or on the right side of space. In half of the trials, the line was presented with a centrally located square or diamond, and subjects had to identify the central stimulus before performing the judgment of length. The presence of the central stimulus improved accuracy of performance in controls and in patients without neglect; neglect patients, however, produced more overestimations of left-sided lines when these was presented with a central stimulus than when the lines occurred in isolation. This finding underlines the importance of attentional factors in length estimates performed by neglect patients in their neglected space.     

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 500 ms 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.     

Orthographic effects in the word substitutions of aphasic patients: an epidemic of right neglect dyslexia?

Aphasic patients with reading impairments frequently substitute incorrect real words for target words when reading aloud. Many of these word substitutions have substantial orthographic overlap with their targets and are classified as "visual errors" (i.e., sharing 50% of targets' letters in the same relative position). Fifteen chronic aphasic patients read a battery of words and non-words; non-word reading was poor for all patients, and more than 50% of errors on words involved the substitution of a non-target word. An investigation of the factors conditioning these word substitutions, as well as the production of visual errors, identified a number of similarities to patterns previously reported for patients with right neglect dyslexia, which has been said to occur relatively rarely. These included a strong tendency for errors to overlap targets in initial letter positions, maintenance of target length in errors, and the substitution of words higher in imageability than targets. It is proposed that left hemisphere damage frequently leads to disruption of a level of representation for written words in which letter position is ordinally coded, resulting in exacerbation of a normal processing advantage for early letter positions. A computational model is discussed that incorporates this level of representation and successfully simulates relevant normal and patient data.     

To drive or not to drive: Neuropsychological assessment for driver's license among stroke patients

Seventy-two stroke patients, 43 with right hemisphere (RHD) and 29 with left hemisphere damage (LHD), and 7 coronary infarct controls with no evidence of cerebral damage, were neuropsychologically tested as part of an assessment program for driver's license. Mean age in the group was 53 years. Stroke patients were tested on average 4 months post injury. The groups did not differ on major demographic variables except that RHD patients were more often hemiplegic than LHD patients. The test battery was factor analyzed into 4 valid principal components: (I) visual perception , (II) spatial attention , (III) visuospatial processing , and (IV) language/praxis. The presence of hemianopia (factor I) excludes driving. In addition, measures of neglect and reduced speed of mental processing from factor II, III and IV, were found to be the most discriminating variables when classifying patients for driving. Even though neglect was more frequently observed among RHD than LHD patients, the two hemisphere groups did not differ significantly in number of patients denied driving, 58% RHD compared to 41% LHD patients. The need for comprehensive neuropsychological assessment is underlined.     

What Is Line Bisection in Unilateral Spatial Neglect?: Analysis of Perceptual and Motor Aspects in Line Bisection Tasks

Three patients with unilateral spatial neglect could detect the difference of length between the right and left segments when a line had a transection mark. To examine the effect of response mode, the manual line bisection task and a new “line bisection task by fixation” were given to the patients. In tasks that used lines with no landmark, they showed apparent rightward errors. The results suggest that line bisection is not a task that examines the ability of patients with neglect to compare the right and left extents of a line. Where to fixate as the subjective midpoint may determine the rightward errors of bisection, whether manual response is used or not.     

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.     

Horizontal and vertical attentional orienting in Parkinson’s disease

Patients with Parkinson’s disease (PD) typically suffer from an asymmetric degeneration of dopaminergic cells in the substantia nigra, resulting in right-sided (RPD) or left-sided (LPD) predominance of motor symptomatology. As the dopaminergic system is also involved in attention, we examined horizontal and vertical orienting of attention in LPD (N = 10), RPD (N = 9) and controls (N = 10). Four LPD patients demonstrated left neglect and three LPD patients demonstrated neglect for the upper visual field. LPD patients demonstrated a slower performance in detecting targets in the left hemifield and did not demonstrate a validity effect, unlike RPD patients and controls. RPD patients performed similar to controls, with the exception of one patient showing left and another showing right neglect, and two RPD patients demonstrated lower neglect. In sum, horizontal and vertical orienting of attention can be affected in Parkinson’s disease – particularly in LPD – from very subtle slowing to clinically detectable horizontal and/or vertical neglect.     

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.     

The effect of hemispatial neglect on the perception of centre

Highly variable bisection performance in neglect patients has been attributed to an increased 'zone of indifference'. The indifference zone indicates the discrepancy between two line lengths which are judged as equal in length. Following this argumentation, the central area of a line should be expanded in neglect patients. The present two experiments investigated for the first time the expansion of the central area using a modified version of the Landmark Task. The location of a central or asymmetrical bisection mark on a horizontal line had to be judged (centre/left/right). In both experiments neglect patients, unlike healthy and patient controls, showed clear deficits in judging the location of the mark correctly and tended to judge asymmetrical marks of up to 4 cm as centrally positioned. The results are in agreement with and provide the first clear evidence of an enlarged perceptual zone of indifference in patients with hemispatial visual neglect.     

Horizontal and vertical attentional orienting in Parkinson’s disease

Patients with Parkinson’s disease (PD) typically suffer from an asymmetric degeneration of dopaminergic cells in the substantia nigra, resulting in right-sided (RPD) or left-sided (LPD) predominance of motor symptomatology. As the dopaminergic system is also involved in attention, we examined horizontal and vertical orienting of attention in LPD (N = 10), RPD (N = 9) and controls (N = 10). Four LPD patients demonstrated left neglect and three LPD patients demonstrated neglect for the upper visual field. LPD patients demonstrated a slower performance in detecting targets in the left hemifield and did not demonstrate a validity effect, unlike RPD patients and controls. RPD patients performed similar to controls, with the exception of one patient showing left and another showing right neglect, and two RPD patients demonstrated lower neglect. In sum, horizontal and vertical orienting of attention can be affected in Parkinson’s disease – particularly in LPD – from very subtle slowing to clinically detectable horizontal and/or vertical neglect.     

Representational neglect for words as revealed by bisection tasks

In the present study, we showed that a representational disorder for words can dissociate from both representational neglect for objects and neglect dyslexia. This study involved 14 brain-damaged patients with left unilateral spatial neglect and a group of normal subjects. Patients were divided into four groups based on presence of left neglect dyslexia and representational neglect for non-verbal material, as evaluated by the Clock Drawing test. The patients were presented with bisection tasks for words and lines. The word bisection tasks (with words of five and seven letters) comprised the following: (1) representational bisection: the experimenter pronounced a word and then asked the patient to name the letter in the middle position; (2) visual bisection: same as (1) with stimuli presented visually; and (3) motor bisection: the patient was asked to cross out the letter in the middle position. The standard line bisection task was presented using lines of different length. Consistent with the literature, long lines were bisected to the right and short lines, rendered comparable in length to the words of the word bisection test, deviated to the left (crossover effect). Both patients and controls showed the same leftward bias on words in the visual and motor bisection conditions. A significant difference emerged between the groups only in the case of the representational bisection task, whereas the group exhibiting neglect dyslexia associated with representational neglect for objects showed a significant rightward bias, while the other three patient groups and the controls showed a leftward bisection bias. Neither the presence of neglect alone nor the presence of visual neglect dyslexia was sufficient to produce a specific disorder in mental imagery. These results demonstrate a specific representational neglect for words independent of both representational neglect and neglect dyslexia.     

Systematic analysis of deficits in visual attention

A variety of impairments in visual attention can follow damage to the brain. The authors develop systematic methods for analyzing such impairments in terms of C. Bundesen's (1990) Theory of Visual Attention and apply these in a group of 9 patients with parietal lobe lesions and variable spatial neglect. In whole report, patients report letters from brief, vertical arrays in left or right visual field. The results show substantial, largely bilateral impairments in processing capacity, implying a major nonlateralized aspect to neglect. In partial report, arrays contain 1 or 2 letters in red and/or green. The task is to report only those letters in a specified target color. In addition to the expected bias against left-sided letters, patients show striking, bilateral preservation of top-down control, or attentional priority for targets. The results show how differentiation of attentional impairments can be informed by a theory of normal function.     

Auditory neglect after right frontal lobe and right pulvinar thalamic lesions

Auditory unilateral neglect or extinction to simultaneous stimulation is reported in a right-handed male with a lesion in the right frontal lobe and in the right thalamic pulvinar area. The patient was submitted to stereotactic thalamotomy for a post-traumatic intentional ataxia in the left extremities. He was subjected to repeated tests with dichotic listening to consonant-vowel syllables under three different attentional instructions. He was also tested monaurally with the same stimulus materials as used in the dichotic test. The results showed almost complete extinction of the left ear input during dichotic presentations, despite normal hearing when tested with audiometer screening. The left ear extinction effect was independent of instructions to attend to the left or right ear input. However, during monaural presentation, correct left ear reports increased to about 85%. The results are interpreted as showing an auditory attentional neglect caused by the right frontal and pulvinar lesions.     

Left of centre: asymmetries for the horizontal vertical line illusion

This study explored the mechanisms that underlie asymmetries for the horizontal vertical illusion (HVI), which deceives length perception, so that a vertical line is perceived as longer than a horizontal line of equivalent length. In Experiment 1, university students (n = 14) made length judgements for vertical and horizontal lines. The vertical line was shifted in eight steps from the far left of the horizontal line (⌊) to the far right (⌋). An HVI was observed for the medial positions (⊥), which diminished towards the lateral positions. The HVI was also stronger when the vertical line was on the left. Because the left/right asymmetry changed as a function of lateral/medial position, the asymmetry within the HVI stimulus is most likely the result of pseudoneglect, which affects judgements of horizontal length. In Experiment 2, participants (n = 15) made judgements for HVI stimuli presented to the left- and right-hemispace and the midline. The HVI was stronger in the left hemispace. Because the asymmetry between the left- and right-hemispaces did not interact with the asymmetry within the stimuli, it was concluded that the asymmetry between hemispatial positions was the result of right hemisphere susceptibility to illusory geometrical effects whereas the asymmetry within the stimulus is related to an object-centred attentional asymmetry. The HVI is affected by asymmetries in length judgements and susceptibility to illusions and may provide interesting insights into attentional disorders in clinical populations, such as neglect.     

Bisection of shapes and lines: analysis of the visual and motor aspects of pseudoneglect

This study examined the visual and motor components of pseudoneglect as expressed on horizontal bisection tasks. Ten participants were tested on bisection of lines and elliptical shapes and judgement of pretransected lines. Results showed the same magnitude of leftward error on all three tasks, in contrast to previous findings for patients with visuospatial neglect who are known to bisect ellipses and circles much more accurately than lines. Participants' mean line bisection error was significantly further to the left than the mean subjective midpoint found on the judgement task. The findings contradict the claim that the visual component of pseudoneglect is caused by the same mechanism that causes visuospatial neglect but support the hypothesis that the motor component of pseudoneglect is similar to directional hypometria.     

Top-down strategy in rehabilitation of spatial neglect: how about age effect?

The aim of this work is to verify the effectiveness of our treatment in patients with spatial neglect in relation to their age and to the severity of neglect. Lots of studies on rehabilitation were proposed and, in some of them, treatments based upon visual-scanning abilities were described. Our rehabilitation training is aimed to induce patients to find by themselves an adequate strategy to solve spatial problems and, after that, try to let this searching strategy as automatized as possible. In this study, forty-six patients with right brain damage and left visuo-spatial neglect underwent to this specific cognitive treatment. A neuropsychological battery was administered before and after treatment. Repeated measure MANOVA on test performances showed significant main effects of treatments, age, and severity of neglect; an interaction effect between these three variables was found as well. Our results confirm an effectiveness of treatment, in particular for elderly patients. Actually, they seem to show a better recovery of neglect after cerebral stroke, even for those of them affected by a severe neglect. These data could be explained in accordance with recent neurophysiological models that claim compensatory responses to reduce brain plasticity even in terms of reorganization of cognitive functions such as visuo-spatial attention.