A kinematic analysis of distractor interference effects during visually guided action in spatial neglect.

Patients with left spatial neglect following right hemisphere damage may show anomalies in ipsilesional-limb movements directed to targets on their affected side, in addition to their characteristic perceptual deficits. In this study we examined the extent to which visually guided movements made by neglect patients are susceptible to interference from concurrent visual distractors on the contralesional or ipsilesional side of a designated target. Eleven right hemisphere patients with visual neglect, plus 11 matched healthy controls, performed a double-step movement task upon a digitizing tablet, using their ipsilesional hand to respond. On each double-step trial the first component of the movement was cued to a common central target, whereas the second component was cued unpredictably to a target on either the contralesional or ipsilesional side. On separate trials lateral targets either appeared alone or together with a concurrent distractor in an homologous location in the opposite hemispace. In addition to being significantly slower and more error prone than controls, neglect patients also exhibited a number of interference effects from ipsilesional distractors. They often failed to move to left targets in the presence of a right-sided distractor, or else they moved to the distractor itself rather than to a contralesional target. The initial accelerative phase of their movements to contralesional targets tended to be interrupted prematurely, and they spent significantly more time in the terminal guidance phase of movements to contralesional targets in the presence of an ipsilesional distractor. In contrast, contralesional distractors had little effect on patients' movements to ipsilesional targets. We conclude that right hemisphere damage induces a competitive bias that favors actions to ipsilesional targets. This bias affects multiple stages of processing within the visuomotor system, from initial programming through to the final stages of terminal guidance.     

Multiple object tracking and pupillometry reveal deficits in both selective and intensive attention in unilateral spatial neglect

Introduction: Unilateral spatial neglect is typically associated with a spatial attention deficit, as neglect patients fail to respond to objects in their contralesional hemispace. However, growing evidence suggests that also nonspatial attention impairments (e.g., arousal) play a role and influences the recovery from this syndrome.

Method: Nonspatial and spatial attentional functions were assessed in 13 right-hemisphere stroke patients with neglect, 13 right-hemisphere stroke patients without neglect, and 26 healthy control participants, by investigating pupillary responses and performance on a multiple object tracking task (MOT)—that is, a dynamic task of divided attention where cognitive load can be manipulated precisely. The task was alternately presented in the left and right hemispace to assess spatial attention functioning.

Results: Results revealed smaller pupillary dilations in both patient groups than in controls, suggesting reduced attentional resources or arousal, and while patients without neglect and controls revealed significant effects of cognitive load on their pupillary responses, neglect patients did not. Both MOT and visual search (VS) tasks revealed spatial symptoms of neglect, while MOT performance measures additionally indicated reduced cognitive functioning in the ipsilateral hemispace. Moreover, the MOT task revealed severely reduced divided attention in neglect patients, as they only managed to track one target in the contralesional hemispace and occasionally two targets at the time in the ipsilesional hemispace.

Conclusion: Our results suggest that a stroke may lead to reduced attentional resources. Furthermore, as neglect patients showed no indications in their pupillary responses that they were able to regulate the allocation of resources in accordance with the varying task demands, it appears they additionally had impaired mechanisms for adjusting arousal levels. Our findings suggest that neglect involves nonspatial as well as spatial attention impairments, as also ipsilesional performance was reduced in this group.     

Impact of dynamic bottom-up features and top-down control on the visual exploration of moving real-world scenes in hemispatial neglect

Patients with hemispatial neglect are severely impaired in orienting their attention to contralesional hemispace. Although motion is one of the strongest attentional cues in humans, it is still unknown how neglect patients visually explore their moving real-world environment. We therefore recorded eye movements at bedside in 19 patients with hemispatial neglect following acute right hemisphere stroke, 14 right-brain damaged patients without neglect and 21 healthy control subjects. Videos of naturalistic real-world scenes were presented first in a free viewing condition together with static images, and subsequently in a visual search condition. We analyzed number and amplitude of saccades, fixation durations and horizontal fixation distributions. Novel computational tools allowed us to assess the impact of different scene features (static and dynamic contrast, colour, brightness) on patients' gaze. Independent of the different stimulus conditions, neglect patients showed decreased numbers of fixations in contralesional hemispace (ipsilesional fixation bias) and increased fixation durations in ipsilesional hemispace (disengagement deficit). However, in videos left-hemifield fixations of neglect patients landed on regions with particularly high dynamic contrast. Furthermore, dynamic scenes with few salient objects led to a significant reduction of the pathological ipsilesional fixation bias. In visual search, moving targets in the neglected hemifield were more frequently detected than stationary ones. The top-down influence (search instruction) could neither reduce the ipsilesional fixation bias nor the impact of bottom-up features. Our results provide evidence for a strong impact of dynamic bottom-up features on neglect patients' scanning behaviour. They support the neglect model of an attentional priority map in the brain being imbalanced towards ipsilesional hemispace, which can be counterbalanced by strong contralateral motion cues. Taking into account the lack of top-down control in neglect patients, bottom-up stimulation with moving real-world stimuli may be a promising candidate for future neglect rehabilitation schemes.     

Re‐fixation and perseveration patterns in neglect patients during free visual exploration

The literature suggests that neglect patients not only show impairments in directing attention toward the left, contralesional space, but also present with perseverative behavior. Moreover, previous studies described re‐fixations during visual search tasks, and interpreted this finding as an impairment of spatial working memory. The aim of the present study was to study re‐fixations and perseverations (i.e., recurrent re‐fixations to same locations) during free visual exploration, a task with high ecological validity. We hypothesized that: (1) neglect patient would perform re‐fixations more frequently than healthy controls within the right hemispace; and, (2) the re‐fixation behavior of neglect patients would be characterized by perseverative fixations. To test these hypotheses, we assessed 22 neglect patients and 23 healthy controls, measuring their eye movements during free exploration of naturalistic pictures. The results showed that neglect patients tend to re‐fixate locations within the ipsilesional hemispace when they freely explore naturalistic pictures. Importantly, the saliency of discrete locations within the pictures has a stronger influence on fixation behavior within the contralesional than within the ipsilesional hemispace in neglect patients. Finally, the results indicated that, for re‐fixations, saliency plays a more important role within the contralesional than the ipsilesional hemispace. Moreover, we found evidence that re‐fixation behavior of neglect patients is characterized by frequent recurrent re‐fixations back to the same spatial locations which may be interpreted as perseverations. Hence, with the present study, we could better elucidate the mechanism leading to re‐fixations and perseverative behavior during free visual exploration in neglect patients.     

Right hemispatial ipsilesional neglect with chronic right hemisphere strokes

Background: Patients who present with spatial neglect after stroke often perform normally on tests for neglect after a few weeks. Whereas tests for neglect are often performed directly in front of a patient, in their actual environments many important stimuli may be present within their left or right hemispace. The presence and severity of neglect often depends on the hemisphere injured. It is possible, in chronic stroke, for spatial judgments to be influenced by an interaction of stroke laterality and the spatial location of stimuli. The objective of this study was to learn if unilateral hemispheric chronic strokes contribute to a spatial bias with laterally presented stimuli.

Method: There were 70 participants, 62 with unilateral chronic strokes (>6 months post onset) including 35 with left hemisphere damage (LHD), 27 with right hemisphere damage (RHD), and 8 demographically similar people without history of stroke. Participants were asked to bisect 300 lines presented with distractors on the left, right, or both sides of the line, or no distractor, on a touch-screen monitor in right, center or left hemispace.

Results: There was a significant interaction between the side of the hemispheric lesion and the side of the body where these lines were presented. Specifically, in right space, patients with RHD deviated leftward in comparison to the other groups. Furthermore, there was an interaction between group and distractor induced bias. All three groups approached the left distractor, and the patients with LHD also approached the right distractor.

Conclusions: Although spatial neglect is more severe in contralesional than ipsilesional hemispace in the period immediately following a stroke, over time patients with RHD may develop ipsilesional neglect that is more severe in ipsilesional than contralesional space. The mechanism underlying this bias is not known and may be related to attempted compensation or the development of a contralateral attentional/intentional grasp.     

Ipsilesional versus contralesional neglect depends on attentional demands

Right hemisphere injuries often produce contralesional hemispatial neglect (CN). In contrast to CN, some patients with right hemisphere damage can also show so-called ipsilesional neglect (IN). Previous reports found that patients tend to show IN on line bisection tasks but CN on other tasks such as target cancellation. To learn why these two tasks induce different spatial biases in patients with right hemisphere injury, conventional (i.e. solid) line bisection was compared with two novel bisection tasks consisting of horizontally aligned strings of characters. The subjects' task was to mark a target character that was at or closest to the true midpoint of the simulated line. Four of the 5 patients showed a dissociation whereby IN occurred for solid lines while CN was observed on character lines. The two patients assessed with an antisaccade paradigm showed a "visual grasp" for leftward stimuli. The present results suggest that neglect on line bisection may reflect two opposing forces, an approach behavior or "visual grasp" toward left hemispace and an attentional bias toward right hemispace.     

P300 in neglect

ObjectiveAttentional deficits have been thought to underlie hemispatial neglect. The present study investigates this using the P300 component of the event-related potential, which is assumed to reflect the allocation of attention.MethodsWe recorded the P300 and oddball detection performance from patients with neglect. Infrequent targets appeared either in the affected contralesional or the unaffected ipsilesional visual hemifield.ResultsContralesional targets produced weaker average P300 responses than ipsilesional ones, but stronger responses than when only distractors were presented. In the affected hemifield, the difference in P300 amplitude between identified and missed targets was correlated with the miss rate. The number of missed contralesional targets for a given participant was positively correlated with the time required for completion of standard neglect tests.ConclusionsThe P300 not only reflects a general attentional impairment in neglect, but also varies as a function of the participants’ awareness of individual stimuli.SignificanceThe findings reflect an important link between attentional dysfunction and impaired stimulus processing in neglect and extinction.     

Visuospatial neglect is more severe when stimulus density is large

Patients with visuospatial neglect (VSN) suffer from an imbalance in visual attention between their left and right (egocentric or allocentric) hemispace. The view of VSN as an attentional imbalance between two hemispaces ignores the fact that—in our daily life—we are presented with varying levels of stimulus density, within but also across hemispaces. Therefore, we developed a novel experimental paradigm in which stroke patients (n = 207) were presented with a different number of simple objects in the left and right (egocentric) hemispaces and were asked to indicate whether there were more objects in the left or the right hemispace. We systematically varied the density of visual stimuli to investigate whether a high level of stimulus density impairs task performance of patients with VSN to a larger degree than it does for patients without VSN. Error rate increased when more objects were presented in the display, but this effect was most pronounced in patients with VSN, especially when more objects were presented in their contralesional than in their ipsilesional hemispace. Our findings reveal that deficits in early visual processing in patients with VSN become especially apparent when overall stimulus density is high. The degree of stimulus density should therefore be taken into account when considering the impact of attentional deficits on activities in daily life.     

Spatiotemporal dynamics of attention in visual neglect: a case study

Patients with visual neglect are often unaware of contralesional visual stimuli. Recent studies have demonstrated non-spatial as well as spatial deficits in allocating attention in neglect patients. We examined the spatiotemporal dynamics of directing attention in a patient with neglect for visual objects appearing in the left side of space by using a version of the attentional blink paradigm. presenting two visual stimuli in succession. The first target (T1) was presented at fixation. The location of the second target (T2) and time between the two targets was varied. When T2 appeared to the left, the patient required more time between targets to identify both accurately, compared to when T2 appeared at fixation or to the right. Our findings demonstrate a spatial and temporal gradient of attention. The results are discussed with respect to current models of visual processing in visual neglect.     

Ipsilesional intentional neglect and the effect of cueing

BACKGROUND: Contralesional hemispatial neglect may be induced by an attentional deficit where patients are inattentive to or unaware of stimuli in contralesional hemispace, an intentional deficit where patients are unable to act in or towards contralesional hemispace, or both. The deficits associated with ipsilesional neglect have not been as well characterized. Because cueing may be used as a rehabilitative assistive device, we wanted to learn whether the efficacy of an attentional or intentional cue was related to the type of bias. METHODS: We studied a patient with a right frontotemporal stroke who had ipsilesional neglect by using a video apparatus that dissociates sensory-attentional and motor-intentional systems. We also performed a cueing experiment with primarily sensory-attentional cues (i.e., read the letter at the end of the line) and primarily motor-intentional cues (i.e., touch the end of the line). RESULTS AND CONCLUSIONS: Ipsilesional neglect was primarily a motor-intentional deficit with a motor-action bias to the left and a secondary sensory-attentional bias for stimuli to the right. With cueing we found a double dissociation: the rightwards motor-intentional cue improved the primary left-sided intentional bias and the leftwards sensory-attentional cue improved the secondary right-sided attentional bias. Effective rehabilitation strategies need to address both sensory-attentional and motor-intentional deficits in patients with neglect.     

A review of the evidence for a disengage deficit following parietal lobe damage

We review the literature on response times to ipsilesional and contralesional targets following spatial precues in patients with damage involving the left- and right-parietal lobes with the aim of appraising the 'disengage deficit' reported initially by Posner and colleagues (Posner MI, Cohen A, Rafal RD. Neural systems control of spatial orienting. Proceedings of the Royal Society of London, B 1982;298:187-98). The data of individual subjects from a sub-sample of studies were submitted to analyses of variance, and data from all studies meeting our selection criteria were submitted to meta-analytic procedures (Hunter JE, Schmidt FL. Methods of meta-analysis: correcting error and bias in research. Newberg Park: Sagge Publications, 1990). Findings from both types of analysis conducted on data from patients with right-hemisphere lesions indicate that: (1) the disengage deficit phenomenon is robust following peripheral cues, but not following central cues; (2) the disengage deficit is large at shorter cue-target stimulus onset asynchronies (SOAs), and decreases as SOA increases; (3) the disengage deficit is larger in patients with a diagnosis of hemispatial neglect; and (4) although the magnitude of the disengage deficit appears to increase with increases in lesion size, multilobar vs unilobar involvement did not significantly alter the pattern of the disengage deficit. We also show that responses to validly cued targets in the contralesional hemispace were significantly slower than for validly cued targets in ipsilesional hemispace. Similar, but usually smaller, effects were observed in patients with homologous left-hemisphere damage. The implications of these results for current models of the role of the parietal lobes in attentional orienting are discussed.     

Competition between simultaneous stimuli modulated by location probability in hemispatial neglect

Many aspects of spatial neglect can be explained as arising from competition for attentional selection, with salient ipsilesional stimuli emerging as the winner more often than contralesional stimuli. The outcome of the competition, however, can be affected both by bottom-up perceptual factors such as the gestalt properties of the display and by top-down factors such as expectancy or stimulus blocking. This study examines whether the competition for attentional selection can be modulated by manipulating the probability of the target's location in hemispatial neglect. Five patients with left-sided hemispatial neglect and a group of control participants performed a visual target discrimination task. In equal probability blocks, the target appeared randomly in any of six possible horizontal locations (three left, three right) whereas in biased blocks, the target appeared in the mid-location on the left on 50% of the trials and in each of the other locations on 10% of the trials. The target appeared either alone or was accompanied by a distractor on the opposite side. The results showed that the spatial bias facilitated detection of all left-sided targets in the neglect group, but was more spatially specific in the control group. Furthermore, while distractors on either side interfered with target processing in both groups, the patterns differed across the visual field. Finally, the magnitude of facilitation due to the bias was greatest in the condition with the most inhibition, i.e. a left-sided target accompanied by a right-sided distractor in the neglect group. These data underscore the competitive push-pull relationship between different bottom-up and top-down attentional factors, particularly within neglect patients, in whom a strong ipsilesional attentional bias already exists.     

Ipsilesional 'where' with contralesional 'what' neglect

Whereas contralesional spatial neglect is usually caused by right temporo-parietal lesions, ipsilesional spatial neglect is induced primarily by right frontal lesions. This report describes a 73-year-old woman with a right inferior parietal lesion who on 'where' tasks (line bisection and midline pointing) demonstrated ipsilesional neglect, but on 'what' tests (gap vs. no-gap detection cancellation and clothing tape removal) demonstrated contralesional neglect. This 'what' and 'where' directional dissociation provides evidence for independent 'what' and 'where' attentional networks; however, the reason this parietal lesion causes this contralesional vs. ipsilesional spatial attentional 'what' and 'where' dichotomy remains to be determined.     

Cerebral hemispheric specialization for spatial attention: spatial distribution of search-related eye fixations in the absence of neglect

The "specialization" of the right hemisphere for spatial attention is widely accepted but poorly understood. While several theories have been supported by studies of patients with acute hemispatial neglect, generalizability beyond this population remains unclear. In this study, we compared the predictions of two attention models [Brain 119 (1996) 841; Trans. Am. Neurol. Assoc. 95 (1970) 143] when applied to data obtained from subjects with unilateral right- or left-cerebral lesions, but without clinical evidence of neglect during a visual search task. Both Left Lesion and Right Lesion subjects detected fewer targets in the contralesional hemispace. However, the Right Lesion subjects also made fewer visual fixations and longer saccades in the contralesional hemispace, suggesting a fundamental alteration in the architecture of visual search. The spatial distribution of fixations made by Right Lesion subjects more closely fits the prediction of a "salience" model than of the strict interpretation of a linear "gradient" model. These data support the long-standing notion of right hemisphere dominance for spatial attention, especially for the top-down processes entailed in self-directed visual search, and extend this to lesion patients without clinically evident neglect. A theoretical model based on the salience of extrapersonal space appears useful for understanding alterations of attentional allocation, particularly after recovery from stroke.     

Misrepresentation of horizontal space in left unilateral neglect: role of hemianopia.

BACKGROUND: Right-brain-damaged patients with left unilateral neglect are reported to misperceive the horizontal extension of contralesional stimuli as being shorter than that of ipsilesional stimuli. OBJECTIVE: To investigate the functional and anatomic correlates of horizontal space misrepresentation. METHODS: Eight right-brain-damaged patients with contralesional neglect and complete hemianopia (N+H+), nine right-brain-damaged patients with contralesional neglect and no visual field defect (N+H-), and five unilateral brain-damaged patients with contralesional complete hemianopia and no neglect (N-H+) reproduced a horizontal distance (10 cm) in the contralesional and ipsilesional hemispace. RESULTS: N+H+ patients overextended the distance contralesionally and underextended the same distance ipsilesionally. N+H- and N-H+ patients reproduced equivalent distances contralesionally and ipsilesionally. Compared with N+H- patients, N+H+ patients had a greater ipsilesional shift when bisecting horizontal lines; however, these two groups of patients had comparable neglect severity on multiple-item cancellation tasks. In the N+H+ group the area of maximal overlapping of the lesion was in the posterior cerebral lobes. CONCLUSION: Complete contralesional hemianopia after posterior brain damage is an important factor in determining misrepresentation of horizontal space in patients with left unilateral neglect.     

Contralesional cross-over in chronic neglect: Visual search patterns reveal neglect of the ipsilesional hemispace

Introduction: With neuropsychological rehabilitation approaches neglect patients can learn to compensate for the reduced awareness of the contralesional hemispace that is often observed after right brain damage. Here, we report contralesional "cross-over" deviations in line bisection that are hypothesized to be a result of focusing on the contralesional hemispace while the intact hemispace is "neglected". We investigate whether this unexpected pattern of deviation is related to defects in the visual field, motor intention/hypokinesia deficits or deficits in working memory.Methods: Neglect patients with and without homonymous field defects were screened for contralesional cross-over deviations in line bisection of long lines. During line bisection eye movements were recorded in two conditions with and without requiring hand movements in order to search for directional hypokinesia. Visual fields were tested with near-threshold perimetry and with supra-threshold campimetry.Results: Of 53 chronic neglect patients only 8 showed cross-over in line bisection. Evidence for directional hypokinesia was found in only one patient. Patients with cross-over focused more often to the left than to the right of the objective line midpoint. Patients with and without visual field defects did not differ in the extent of cross-over deviations. Cross-over deviation and inconsistent stimulus detection in left hemispace were correlated irrespective of the presence of a visual field deficit. Larger cross-over deviations were associated with poorer verbal working memory span, and disorganized patterns of eye movement were related to reduced visuo-spatial working memory capacity.Conclusion: Increasing awareness of the disorder and the use of compensatory strategies may have led to a cross-over shift of visual search dominance towards the neglected side resulting in an exploration deficit of the ipsilesional side.     

Dynamic assessment of visual neglect: The Mobility Assessment Course as a diagnostic tool

Introduction: Visual neglect is a frequent disorder following stroke and is often diagnosed by neuropsychological assessment. However, paper-and-pencil tasks have low predictive value as they lack sensitivity to capture neglect in complex, dynamic situations, such as activities of daily living. Aims of the current study were to assess the feasibility of the Mobility Assessment Course (MAC), a visual search multitask, to assess neglect, and its relation with existing neglect tasks. Method: Stroke patients admitted for inpatient rehabilitation and healthy controls were tested with the MAC in different corridors. Participants had to move through a corridor, finding and reporting 24 targets attached to the walls. In addition, the shape cancellation, line bisection, and Catherine Bergego Scale (CBS) were used in order to compare the MAC with existing diagnostic tools for neglect. Results: Administering the MAC was feasible, as 112 of 113 patients completed the MAC with a median duration of 4.09 min. Depending on the corridor where the assessment took place, in 88.5–93.3% of assessments all targets were visible. The number of omissions (total and contralesional) and the asymmetry score (contralesional–ipsilesional omissions) on the MAC as well as collisions and corrections, were higher for patients with neglect than for those without neglect. Depending on the neglect task used, 4.0–18.6% of patients without neglect on neuropsychological tasks or the CBS showed neglect on the MAC. Vice versa, 17.2–29.3% of patients who showed neglect at neuropsychological assessment or the CBS did not do so on the MAC. Finally, a moderate to strong positive relation was seen between neglect at neuropsychological assessment, the CBS, and the MAC. Conclusions: The MAC is an ecological task in which both quantitative and qualitative data on neglect can be collected. In order to assess the presence of neglect and neglect severity in a dynamic way, the MAC could be administered in conjunction with neuropsychological assessment.     

Prism adaptation produces neglect-like patterns of hand path curvature in healthy adults

Visuospatial neglect is a common consequence of brain injury in which patients fail to respond appropriately to stimuli or events occurring within their contralesional hemispace and may restrict eye and hand movements to objects or events occurring within ipsilesional space. Emerging evidence suggests, however, that neglect is a syndrome consisting of several components, including the impaired representation of corporeal and extrapersonal space. To better understand the neglect syndrome it is important to develop experimental models of each of these components. Here we develop an experimental model of the spatial impairment associated with visuospatial neglect based upon adaptation to laterally displacing optical prisms. We demonstrate that after a short period spent adapting to rightward displacing prisms, healthy subjects exhibit increases in hand-path curvature during reaches executed under visual guidance, but, not during reaches executed to proprioceptively-defined targets without vision.     

Modulation of unilateral neglect as a function of direction of object motion.

Unilateral neglect is a disorder involving difficulty in attending to the side of space contralesional to brain injury. Two recent experiments have shown that task-irrelevant background motion reduces neglect on line bisection tasks; however, task-relevant motion has not been assessed. We investigated the effect of task-relevant object motion on left neglect using a moving cube presented on a computer screen. Subjects responded to cued corners of the cube as it moved across the screen. Direction of cube motion had a significant impact on the magnitude of neglect. Responses to left hemispace targets appearing on a leftward moving cube were equal to patients' fastest responses. In contrast, responses to left hemispace targets appearing on a rightward moving cube were the slowest of all responses. These results demonstrate that contralesional object motion is capable of normalising neglect patients' detection of contralesional targets.