The influence of limb crossing on left tactile extinction

BACKGROUND: Previous research on patients with left tactile extinction has shown that crossing of hands, so that each hand is on the opposite side of the body midline relative to the other, improves detection of stimuli given to the left hand. OBJECTIVES: To study the influence of the spatial position of limbs on left tactile extinction, and its relations with left visual neglect. METHODS: Normal participants and patients with right cerebral hemisphere damage and left tactile extinction were asked to detect single or double light touch stimuli applied to their cheeks, hands, or knees with their arm and legs either in anatomical or in crossed position, increasing the attentional load of the task. RESULTS: In patients with left extinction, limb crossing caused a deterioration in performance for stimuli applied to right body parts, with only a tendency to an improvement in detection for left body parts (only two of 24 patients showed substantial (>20%) improvement in left extinction after limb crossing). After crossing, left limb detections of double stimuli decreased with increasing degrees of visual neglect. CONCLUSIONS: In conditions of high attentional load, limb crossing may impair tactile detection in most patients with left extinction, and particularly in those showing signs of left visual neglect. These results underline the importance of general attentional capacity in determining tactile extinction. Attentional and somatotopic mechanisms of extinction may assume different weights in different patients.     

Visual,proprioceptive and tactile performance in left neglect patients

Patients with unilateral spatial neglect due to right-hemisphere lesions typically fail to attend to and explore left-sided stimulus objects. It has been postulated that in right-brain damaged (RBD) patients an ipsilesional displacement of the egocentric frame of reference (ER), whether visual or tactile, may be responsible for a contralesional supramodal spatial bias causing their left neglect behavior. However, this hypothesis had been proposed without testing, in the same patients, the position of the ER or their performance in the visual and tactile modalities. Thus, the aim of the present study was to test the hypothesis that an ipsilateral shift of the ER is responsible for a supramodal spatial bias in neglect.For this purpose, a within-subject design is required. Consequently, 12 left neglect patients and 12 control subjects were asked to perform a proprioceptive straight-ahead pointing task while blindfolded, as well as visual and tactile bisection tasks.In the left neglect patients, we found:no systematic deviation of the ER on the ipsilesional right side;a significant rightward bias in visual bisection, and normal performance in tactile bisection;no correlation among the three tasks;that only visual bisection correlated with the severity of neglect.These results are discussed with regard to the egocentric and attentional hypothesis of neglect.     

Visual attentional disturbance with unilateral lesions in the basal ganglia and deep white matter.

To elucidate the role of the basal ganglia and deep white matter in the visual attention mechanism, a new visual attention task was carried out by 15 patients, 9 with left-side and 6 with right-side basal ganglia and/or deep white matter damage without visual field defects, and by 12 normal subjects. Their reaction times were recorded in response to a random visual stimulation by pushing a button with the hand ipsilateral to the side of the lesion. All the patients with damage to the right side of the brain had a longer reaction time in the left space than in the right or middle space. With conventional test, only one of them showed left unilateral spatial neglect. Seven of the 9 patients with a left lesion had a significantly longer reaction time in the right space than in the left. None had unilateral spatial neglect. Both the right and left brain-damaged groups showed longer reaction times in both spaces, compared to the normal groups. There was no significant difference in reaction time among the control subjects. These findings suggest that the basal ganglia and deep white matter in each hemisphere play some role in directing visual attentional factors into both spaces. Visual attentional disturbance was highly evident even with left-side brain damage, and this kind of disturbance is not usually revealed with the current tasks used for testing unilateral spatial neglect.     

Dissociation between egocentric and allocentric visuospatial and tactile neglect in acute stroke

Previous investigations provide evidence for distinction between egocentric (viewer-centered) and allocentric (stimulus- or object-centered) hemispatial neglect. However, it has not been determined whether this dissociation is modality-independent or modality-specific. We identify the incidence of egocentric and allocentric neglect in visual and tactile modalities, as well as the frequency of their co-occurrences in each modality. One-hundred patients with acute, right supratentorial ischemic stroke were administered tests for egocentric and allocentric hemispatial neglect in visual (n=98) and tactile (n=58) modalities. The visual test consisted of a page of 30 circles; 10 with no gap, 10 with a gap on the right side, and 10 with a gap on the left. Patients were asked to circle all complete circles and cross out all circles with gaps. A tactile version consisted of the same stimulus types presented as raised circles. Patients were asked to explore the board of circles with their dominant hand and report whether each circle had a gap. To determine the presence of egocentric or allocentric neglect, each test was analyzed for a significantly higher number of errors on the contralesional versus ipsilesional side of the page/board, or of the stimulus, using the Chi square analysis. On the visual test, 17 patients exhibited egocentric neglect; four exhibited allocentric neglect; and only two exhibited both. In the tactile modality, 19 exhibited egocentric neglect; one exhibited allocentric neglect; and none demonstrated both. Only four patients showed egocentric neglect on both visual and tactile tests. We found one patient with bilateral lesions who showed left egocentric visual neglect and right allocentric tactile neglect. These data provide strong evidence that egocentric and allocentric neglect are distinct syndromes that often dissociate and likely reflect damage to different brain areas. They also show that selective egocentric or allocentric neglect can occur in visual or tactile modalities.     

Right cerebral specialization for tactile attention as evidenced by intracarotid sodium amytal

Although several components of neglect syndrome have been reported to occur more frequently following right cerebral lesions, a right cerebral predominance for directed tactile attention has not been demonstrated. The intracarotid sodium amytal procedure (ISA, or Wada test) offers the opportunity to investigate differential effects for symmetric acute dysfunction of each cerebral hemisphere in each subject. In the present study, 18 patients undergoing preoperative evaluation for epilepsy surgery were trained in a nonverbal task of tactile attention. Left/right mean ISA dosages and left/right tactile test times postinjection were matched. Results revealed more correct responses following left ISA, and greater tactile inattention with more extinction-type responses following right ISA. No effect of seizure focus, sex, order of injection, or dosage was present. The finding that tactile inattention occurs more frequently with right cerebral dysfunction is consistent with right cerebral dominance for scanning attentional mechanisms directed at the external milieu.     

A common basis for visual and tactile exploration deficits in spatial neglect?

One of the fundamental characteristics of spatial neglect is an imbalanced visual search behaviour favouring stimuli on the right side of space while largely ignoring those on the left side. Opinions differ as to whether this reflects a general orientational bias caused by impaired supramodal body-centred reference systems, or a modality-specific search disorder. A prediction of the former model would be that exploratory activity is similarly impaired both in vision and in the absence of visual control. We addressed this hypothesis by comparing patients' visual and tactile search in the same workspace. Our results show that the centre of exploration activity in both modalities was substantially shifted towards the ipsilesional right side in the neglect group as compared to healthy and patient controls. This bias was more accentuated for visual search. We found a clear linear relationship between the visual and tactile search biases in the patient group with spatial neglect. Our finding suggests that the critical component guiding search behaviour in neglect, whether visually or tactually, is a general rightward orientation bias. In addition, we observed an increased repetition rate in both modalities which affected the whole workspace. This implies that the apparent spatial working memory deficit dissociates from the mechanisms inducing the orientation bias.     

Influence of response modality on awareness of contralesional tactile stimuli in right brain damaged patients

Thirty right brain-damaged (RBD) patients with left tactile extinction (19 of whom also showed neglect) were given a sequence of 240 tactile stimuli – 80 right, 80 left, 80 bilateral – across 4 different response conditions: (a) verbal report of stimulated side/s, (b) motor report of stimulated side/s, (c) verbal report of unstimulated side/s, (d) motor report of unstimulated side/s. Earlier experiments based on similar tasks but involving RBD patients with visual extinction and/or neglect have shown that visual awareness of contralesional stimuli can be influenced by manipulation of response conditions.

Since neglect and extinction can be double-dissociated both anatomically and behaviourally, the question arises of whether the underlying neuronal mechanisms are different. To answer this question the present work investigated the role of perceptual and premotor factors in generating tactile extinction in response to Double Simultaneous Stimulation (DSS). The hypothesis was that a directional response bias would result in an overall higher frequency of errors for verbal or motor responses indicating the ipsilesional side (right); a perceptual bias would instead result in errors distributed with similar frequency on the ipsilesional and the contralesional (left) side.

Results showed that, in RBD patients, contralesional extinction was not influenced by response conditions (verbal/motor; report of stimulated/unstimulated side) and presence/absence of neglect. This suggests that: (1) among RBD patients, directional response biases are unlikely to play a role in extinction of tactile stimuli on DSS; (2) the mechanisms underlying extinction are, at least to some extent, different from those underlying unilateral neglect.     

Vertical bias in neglect: a question of time?

Neglect is defined as the failure to attend and to orient to the contralesional side of space. A horizontal bias towards the right visual field is a classical finding in patients who suffered from a right-hemispheric stroke. The vertical dimension of spatial attention orienting has only sparsely been investigated so far. The aim of this study was to investigate the specificity of this vertical bias by means of a search task, which taps a more pronounced top-down attentional component. Eye movements and behavioural search performance were measured in thirteen patients with left-sided neglect after right hemispheric stroke and in thirteen age-matched controls. Concerning behavioural performance, patients found significantly less targets than healthy controls in both the upper and lower left quadrant. However, when targets were located in the lower left quadrant, patients needed more visual fixations (and therefore longer search time) to find them, suggesting a time-dependent vertical bias.     

Hemispheric asymmetry in tactile forgetting induced by tactually-guided movement

Asymmetries in tactile short-term memory related to differential specialization of the cerebral hemispheres were studied in normal human adults using the Brown-Peterson distractor task. When the distractor was an auditory arithmetic task, no difference emerged between the two hands for the retention of touches to the fingers; however, when the distractor was a tactual maze task executed by the right hand, asymmetry in favor of the left hand was observed. Specifically, when the right hand performed the tactual maze, there was greater interference with tactile memory than when the left hand performed the maze, independent of which hand received the memory material. The results support a characterization of short-term memory as embracing multiple, limited storage capacities divided along the lines of processing demands, arising from different classes of material, placed on the two cerebral hemispheres.     

Spatial and temporal dynamics of visual search tasks distinguish subtypes of unilateral spatial neglect: Comparison of two cases with viewer-centered and stimulus-centered neglect

We developed a computerised test to evaluate unilateral spatial neglect (USN) using a touchscreen display, and estimated the spatial and temporal patterns of visual search in USN patients. The results between a viewer-centered USN patient and a stimulus-centered USN patient were compared. Two right-brain-damaged patients with USN, a patient without USN, and 16 healthy subjects performed a simple cancellation test, the circle test, a visuomotor search test, and a visual search test. According to the results of the circle test, one USN patient had stimulus-centered neglect and a one had viewer-centered neglect. The spatial and temporal patterns of these two USN patients were compared. The spatial and temporal patterns of cancellation were different in the stimulus-centered USN patient and the viewer-centered USN patient. The viewer-centered USN patient completed the simple cancellation task, but paused when transferring from the right side to the left side of the display. Unexpectedly, this patient did not exhibit rightward attention bias on the visuomotor and visual search tests, but the stimulus-centered USN patient did. The computer-based assessment system provided information on the dynamic visual search strategy of patients with USN. The spatial and temporal pattern of cancellation and visual search were different across the two patients with different subtypes of neglect.     

Disturbed sound lateralization in patients with spatial neglect

Previous studies on auditory space perception in patients with neglect have investigated localization of free-field-sound stimuli or lateralization of dichotic stimuli that are perceived intracranially. Since those studies in part revealed contradictory results, reporting either systematic errors to the left or systematic errors to the right, we reassessed the ability of auditory lateralization in patients with right hemispheric lesions with and without neglect. Unexpectedly, about half of the patients with neglect showed erratic judgments on sound position, that is, they were completely unable to lateralize sounds. The remaining neglect patients only showed a small deviation of the auditory median plane to the left side, indicating that they perceived the sounds as slightly shifted to the right side. The comparison between both groups revealed higher severity of neglect in the group of neglect patients who were unable to perform the task, suggesting that the inability of sound lateralization was associated with the strength of clinical neglect. However, we also observed 1 out of 9 patients with left brain damage who was not able to lateralize spatial sounds. This patient did not show any symptoms of spatial neglect. Thus, it may be that a spatial auditory deficit, such as that observed here in right-brain-damaged patients, only co-occurs with spatial neglect if the right superior temporal cortex is lesioned.     

Effects of same- and different-modality cues in a Posner task: extinction-type,spatial, and non-spatial deficits after right-hemispheric stroke

The response delay to left target stimuli preceded by right-side cues, first described by Posner et al. [J. Neurosci. 4 (1984) 1863-1874] appears to be a stable marker of right-parietal injury. However, only few studies compared patients' performance to age-matched controls. Furthermore, only few studies compared visual and auditory stimuli in this task. Therefore, two groups of right-hemisphere stroke patients, with and without left visual hemineglect, and a healthy control group were studied in three versions of Posner's paradigm. Visual or auditory target stimuli were presented to the subject's left or right, following a visual or auditory cue by 150 ms. The classical 'extinction-type' effect, an increase in missing responses for right visual cue/left visual target, was specifically observed in neglect patients. In the same condition, an 'extinction-type' response delay was present in patients with neglect and in those without neglect. No such delay occurred in any group when cues were auditory. Specifically in neglect patients, response times were generally longer for left than for right visual targets, regardless of cue side and of cue modality. Response times were generally prolonged in neglect patients regardless of target modality. This suggests that three components impair neglect patients' performance in this paradigm: a non-spatial, supramodal deficit, a global, neglect-type deficit of the contralesional hemi-field, and the extinction-type impairment. The latter two deficits appear to be most marked within the visual domain.     

Neglect-associated constructional disorders: a paradoxical phenomenon?

Five neglect patients without diffuse cognitive impairment or overt constructional disabilities were asked to bisect lines and rectangles and to copy rectangles bisected in their midplane. As a group, patients showed the usual rightward bias in bisecting lines and a milder deviation in bisecting horizontally-aligned rectangles, but showed a leftward deviation of the subjective midline in the copying task. This was due to drawing the left half shorter with respect to normal controls but three patients also drew the right half longer (the total length was the same as that of controls). A possible interpretation of rectangle copying results in these three patients is that they could create a representation of the stimulus to be copied accurately enough to reproduce its total length correctly but the subjective distribution of right and left space within that representation was unbalanced. However, specific experimental work is needed to verify why our patients with mild to moderate unilateral spatial neglect overrepresented the left side in a line bisection task and underrepresented it in a copying task.     

Spatial gradient for unique-feature detection in patients with unilateral neglect: Evidence from auditory and visual search

Patients with unilateral spatial neglect following right hemisphere damage are impaired in detecting contralesional targets in both visual and haptic search tasks, and often show a graded improvement in detection performance for more ipsilesional spatial locations. In audition, multiple simultaneous sounds are most effectively perceived if they are distributed along the frequency dimension. Thus, attention to spectro-temporal features alone can allow detection of a target sound amongst multiple simultaneous distracter sounds, regardless of whether these sounds are spatially separated. Spatial bias in attention associated with neglect should not affect auditory search based on spectro-temporal features of a sound target. We report that a right brain damaged patient with neglect demonstrated a significant gradient favouring the ipsilesional side on a visual search task as well as an auditory search task in which the target was a frequency modulated tone amongst steady distractor tones. No such asymmetry was apparent in the auditory search performance of a control patient with a right hemisphere lesion but no neglect. The results suggest that the spatial bias in attention exhibited by neglect patients affects stimulus processing even when spatial information is irrelevant to the task.     

Horizontal visual search in a large field by patients with unilateral spatial neglect

In this study, we investigated the horizontal visual search ability and pattern of horizontal visual search in a large space performed by patients with unilateral spatial neglect (USN). Subjects included nine patients with right hemisphere damage caused by cerebrovascular disease showing left USN, nine patients with right hemisphere damage but no USN, and six healthy individuals with no history of brain damage who were age-matched to the groups with brain right hemisphere damage. The number of visual search tasks accomplished was recorded in the first experiment. Neck rotation angle was continuously measured during the task and quantitative data of the measurements were collected. There was a strong correlation between the number of visual search tasks accomplished and the total Behavioral Inattention Test Conventional Subtest (BITC) score in subjects with right hemisphere damage. In both USN and control groups, the head position during the visual search task showed a balanced bell-shaped distribution from the central point on the field to the left and right sides. Our results indicate that compensatory strategies, including cervical rotation, may improve visual search capability and achieve balance on the neglected side.     

Leftward search in left unilateral spatial neglect.

The authors' previous study with an eye camera revealed that when asked to mark the centre of a line patients with left unilateral spatial neglect persist in fixating a point on its right part and place the subjective midpoint there without searching leftwards. The present study examined the patterns of leftward search of nine patients with left unilateral spatial neglect when they were required to search for the left endpoint of the line after the bisection. The patients could search leftwards beyond the subjective midpoint to place the mark at the subjective left endpoint. The initial fixation in this search always fell near the point located to the left of the subjective midpoint by the distance between the subjective midpoint and the right endpoint of the line. In patients with severe neglect the search further to the left of this point was laborious and fell short of the true left endpoint in about 80% of the trials. Our results suggest that when asked to bisect a line patients with left unilateral spatial neglect subjectively see the line as it extends equally to either side of the point where they are going to mark the subjective midpoint.     

Effects of passive tactile and auditory stimuli on left visual neglect

Patients with left-sided visual neglect fail to copy the left part of drawings or the drawings on the left side of a sheet of paper. Our aim was to study the variations in copying drawings induced by passive stimulation in patients with left-sided visual neglect. No stimulation at all, tactile unilateral and bilateral, binaural auditory verbal, and nonverbal stimuli were randomly applied to 14 patients with right-hemisphere strokes. Only nonverbal stimuli decreased the neglect. As nonverbal stimuli mainly activate the right hemisphere, the decrease in neglect suggests right-hemispheric hypoactivity at rest in these patients. The absence of modification of neglect during verbal stimulation suggests a bilateral hemispheric activation and the persistence of interhemispheric imbalance. Our results showed that auditory pathways take part in the network involved with neglect. Passive nonverbal auditory stimuli may be of interest in the rehabilitation of patients with left visual neglect.     

Impaired spatial working memory: one component of the visual neglect syndrome?

Both impaired spatial working memory (SWM) and unilateral neglect may follow damage to the right parietal lobe. We propose that impaired SWM can exacerbate visual neglect, due to failures in remembering locations that have already been searched. When combined with an attentional bias to the ipsilesional right side, such a SWM impairment should induce recursive search of ipsilesional locations. Here we studied a left neglect patient with a right temporoparietal haemorrhage. On a nonlateralised, purely vertical SWM task, he was impaired in retaining spatial locations.

In a visual search task, his eye position was monitored while his spatial memory was probed. He recursively searched through right stimuli, re-fixating previously inspected items, and critically treated them as if they were new discoveries, consistent with the SWM deficit. When his recovery was tracked over several months, his SWM deficit and left neglect showed concurrent improvements. We argue that impaired SWM may be one important component of the visual neglect syndrome.     

Response time of stroke patients to a visual stimulus

We used a computer program to test response time among stroke patients in a clinical setting. Visual stimuli were presented to 82 hospitalized stroke patients, to 21 hospitalized controls, and to 76 nonhospitalized controls. Stroke patients had longer mean response times than controls. Patients with right hemispheric lesions had longer response times than those with left hemispheric lesions when the stimuli were presented on the left. The corresponding phenomenon of longer response times in patients with left hemispheric lesions to stimuli presented on the right was not observed. Patients with right hemispheric lesions with visual hemineglect had a longer mean response time than those without visual hemineglect when the stimuli were presented on the left or centrally, whereas the patients with right hemispheric lesions without neglect had a mean response time similar to that of patients with left hemispheric lesions.