Left-hand somatosensory stimulation combined with visual scanning training in rehabilitation for post-stroke hemineglect: a randomised, double-blind study

The aim of this randomised, double-blind study was to investigate the therapeutic effectiveness of left-hand electrical stimulation for patients with post-stroke left visuo-spatial neglect. This approach was hypothesised to enhance activation of the right hemisphere attention system and to improve visual exploration of extrapersonal space. Participants (n = 40) in the study were in a relatively early stage of recovery from their first right hemisphere stroke, and were randomly assigned to the experimental (E) or control (C) group. Group E received conventional visual scanning training combined with electrostimulation of the left hand, while Group C received scanning training with sham stimulation. Their visuo-spatial neglect was assessed twice, prior to the rehabilitation programme and on its completion, using cancellation tests and a letter-reading task. The effect of electrostimulation on hemineglect was assessed following a single administration and after a month-long rehabilitation programme. Although the immediate effect of stimulation was poor, after a month-long rehabilitation period we found significantly greater improvement in Group E patients than in Group C patients. Interestingly, the presence of hemisensory loss did not weaken the observed effect. Therefore, we claim that contralesional hand stimulation combined with visual scanning was a more effective treatment for hemineglect rehabilitation than scanning training alone.     

Left-hand somatosensory stimulation combined with visual scanning training in rehabilitation for post-stroke hemineglect: A randomised,double-blind study

The aim of this randomised, double-blind study was to investigate the therapeutic effectiveness of left-hand electrical stimulation for patients with post-stroke left visuo-spatial neglect. This approach was hypothesised to enhance activation of the right hemisphere attention system and to improve visual exploration of extrapersonal space. Participants (n = 40) in the study were in a relatively early stage of recovery from their first right hemisphere stroke, and were randomly assigned to the experimental (E) or control (C) group. Group E received conventional visual scanning training combined with electrostimulation of the left hand, while Group C received scanning training with sham stimulation. Their visuo-spatial neglect was assessed twice, prior to the rehabilitation programme and on its completion, using cancellation tests and a letter-reading task. The effect of electrostimulation on hemineglect was assessed following a single administration and after a month-long rehabilitation programme.

Although the immediate effect of stimulation was poor, after a month-long rehabilitation period we found significantly greater improvement in Group E patients than in Group C patients. Interestingly, the presence of hemisensory loss did not weaken the observed effect. Therefore, we claim that contralesional hand stimulation combined with visual scanning was a more effective treatment for hemineglect rehabilitation than scanning training alone.     

Transient improvement in motor function and hemineglect by vestibular stimulation in a patient with right middle cerebral artery embolism]

A 62-year-old Japanese man presented left hemiparesis and left visuospatial hemineglect following a right hemispheric stroke. His CTs and MRIs of the brain revealed a large embolic infarction of the middle cerebral artery territory. A month after the cerebrovascular event, his weakness of the left lower limb almost recovered fully. However, his upper limb motor function was still disabled; in particular, his ability of finger flexion in the left hand was almost lost. Then, vestibular stimulation using either a cold caloric stimulation to the left ear or a warm caloric stimulation to the right ear was performed, and the effect on the hemineglect symptoms were assessed by a line bisection task. After vestibular stimulation, not only his hemineglect symptoms but also his motor functions of left upper limb transiently improved; he became able to make a fist. The improvement of his hemineglect symptoms was obtained by vestibular stimulation using either a cold or a warm caloric stimulation. However, the effect on the motor function was obtained only by the cold caloric stimulation applied to the left ear. Based on the effect of the vestibular stimulation, we postulates that the impairment of the motor function in the present patient is not only a paresis caused by the pyramidal tract lesion but also symptoms related to the hemineglect syndrome.     

Abnormal eye movement behaviour during text reading in neglect syndrome: a case study.

The eye movement behaviour of a patient suffering from a right basal ganglia infarction with a left-sided hemineglect but without any visual field defects was investigated during reading. The eye movements were registered by means of an i.r. light technique (pupil-corneal reflection method). The main findings were abnormal return sweeps. Whereas in normal readers the end of one line of text is linked to the beginning of the new line by a long leftward saccade, the return sweeps of the hemineglect patient stereotypically ended in the middle of the next line. They were followed by sequences of short saccades indicating silent backward reading until a linguistically plausible continuation of sentences from the previous line was found, irrespective of the actual beginning of text. The shortened return sweeps could not be attributed to a general oculomotor disturbance. The spatial border for the occurrence of the patient's abnormal scanning pattern (left half of texts) clearly did not depend on a retinal coordinate frame of reference but rather has to be attributed to a different body-centred reference system.     

Visual processes in a hemialexic patient with posterior callosal section

A patient with surgical section of the splenium and, probably, the posterior end of the truncus of the corpus callosum was studied 9-13 yr after the operation. His reading aloud, reading comprehension and word-matching abilities were moderately disturbed only in the left hemifield. These three disturbances were equally disturbed. The disturbances were not the result of visual disturbances such as tachistoscopic hemiamblyopia or tachistoscopic hemineglect since Landolt's ring matching was intact in the left hemifield as well as in the right. The disturbances were also not due to the disturbance of tachistoscopic word perception since the patient correctly performed same-different judgment of pairs of words in each hemifield. In his reading aloud and reading comprehension disturbances, ideogram words were less impaired than phonogram words, even when the number of letters in the words was the same. His picture naming ability was not disturbed in each hemifield.     

Early visual processing in neglect patients: A study with steady-state VEPs

Reliable steady-state visual evoked potentials (VEPs) were recorded in a group of 19 right brain-damaged patients with visuospatial hemineglect (Neglect), and two control groups: 15 left brain-damaged (LBD) patients and 12 right brain-damaged (RBD) patients without neglect. Moreover, VEPs were recorded in two rare cases of left brain damage and right visuospatial hemineglect. Stimuli were gratings phase-reversed at various temporal frequencies presented in the left and right visual field. In the Neglect group, VEPs to stimuli displayed in the left visual field (contralesional stimuli) had longer latencies. The delay was not present for the two control groups. As regards the VEP amplitudes, the Neglect group data showed a less distinctive pattern than in the case of latency. VEPs to stimuli contralateral to the lesion were smaller than those recorded for stimuli ipsilateral to the lesion in both Neglect and RBD groups. On the contrary, the VEP amplitudes for the two hemifields were comparable in the LBD group. In the case of left brain damage and neglect, VEPs to right visual field stimuli had longer latencies and lower amplitudes compared to the ipsilesional responses in both patients. Overall, the data support the view that, in most cases, early visual processing is not intact in the neglected hemifield.     

Directional hypokinesia in spatial hemineglect: a case study.

A patient with an ischaemic lesion involving the right frontal lobe and basal ganglia showed left spatial hemineglect in visuomotor exploratory tasks, requiring the use of the right unaffected hand. Her performance was, however, entirely preserved, with no evidence of neglect, when she was required to identify targets among distractors in both the left and right halves of space, and in the Wundt-Jastrow illusion test. The latter tasks do not require any arm movement in extrapersonal space. In this patient spatial hemineglect may be explained in terms of defective organisation of movements towards the left half-space (directional hypokinesia). The frontal lesion of the patient may be the neural correlate of this selective disorder. This pattern of impairment may be contrasted with the typical deficit found in patients with right brain damage with perceptual neglect. One case had a defective performance both in visuomotor and in purely perceptual tasks.     

On why left events are the right ones: neural mechanisms underlying the left-hemifield advantage in rapid serial visual presentation

When simultaneous series of stimuli are rapidly presented left and right, containing two target stimuli T1 and T2, T2 is much better identified when presented in the left than in the right hemifield. Here, this effect was replicated, even when shifts of gaze were controlled, and was only partially compensated when T1 side provided the cue where to expect T2. Electrophysiological measurement revealed earlier latencies of T1- and T2-evoked N2(pc) peaks at the right than at the left visual cortex, and larger right-hemisphere T2-evoked N2(pc) amplitudes when T2 closely followed T1. These findings suggest that the right hemisphere was better able to single out the targets in time. Further, sustained contralateral slow shifts remained active after T1 for longer time at the right than at the left visual cortex, and developed more consistently at the right visual cortex when expecting T2 on the contralateral side. These findings might reflect better capacity of right-hemisphere visual working memory. These findings about the neurophysiological underpinnings of the large right-hemisphere advantage in this complex visual task might help elucidating the mechanisms responsible for the severe disturbance of hemineglect following damage to the right hemisphere.     

Using real-time fMRI neurofeedback to restore right occipital cortex activity in patients with left visuo-spatial neglect: proof-of-principle and preliminary results

Hemineglect is common after right parietal stroke, characterised by impaired awareness for stimuli in left visual space, with suppressed neural activity in the right visual cortex due to losses in top-down attention signals. Here we sought to assess whether hemineglect patients are able to up-regulate their right visual cortex activity using auditory real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback. We also examined any effect of this training procedure on neglect severity. Two different neurofeedback methods were used. A first group of six patients was trained to up-regulate their right visual cortex activity and a second group of three patients was trained to control interhemispheric balance between their right and left visual cortices. Over three sessions, we found that the first group successfully learned to control visual cortex activity and showed mild reduction in neglect severity, whereas the second group failed to control the feedback and showed no benefit. Whole brain analysis further indicated that successful up-regulation was associated with a recruitment of bilateral fronto-parietal areas. These findings provide a proof of concept that rt-fMRI neurofeedback may offer a new approach to the rehabilitation of hemineglect symptoms, but further studies are needed to identify effective regulation protocols and determine any reliable impact on clinical symptoms.     

Right side neglect in right cerebellar lesion

A patient is described who developed right side hemineglect after a right cerebellar lesion. This spatial disorder was interpreted as a secondary effect of a deficit of the motor organisation in the right hemispace due to left frontal diaschisis. The pathological base may be the interruption of a highly integrated system which includes the lateral cerebellum and the contralateral frontal lobe.     

Parietal hemineglect and motor deficits in the monkey

To study the parietal hemineglect syndrome, we trained and operated nine Macaca fasicularis monkeys. Contralateral to the lesion they showed response abnormalities to visual and somatic sensory stimuli, and misreaching toward targets in visual space, abberant finger and wrist postures and lack of pincer grasp. The latter did not appear during performance of a preoperatively practised task, nor depend for severity upon lesion size, whereas sensory response abnormalities did. We conclude that abnormal motor patterns are separable from hemineglect in parietal animals, and are worst when the movement is directed to a visual target in extrapersonal space.     

Does monocular viewing improve target detection in hemispatial neglect?

Experimental animals with large posterior-cortical lesions develop disturbances of visual perception and visually-guided behavior in the contralateral space, resembling the syndrome of unilateral spatial neglect (USN) in humans. The visuo-motor performance in the ignored space is recovered some time following additional lesion inflicted to the contralesional superior colliculus or section of the intercollicular pathways. Based on the model that explains this recovery by disinhibition of the ipsilesional superior colliculus (the 'Sprague effect') Posner and Rafal [37] proposed that ipsilesional monocular occlusion could possibly reduce the 'tone' of contralesional collicular neurons thereby removing an important contributor of hemineglect. A group of twenty-six right-hemisphere-damaged patients with USN was given a cancellation task under binocular and monocular (left and right) viewing conditions. Thirteen patients showed amelioration of left hemineglect in conditions of left-monocular viewing, as compared to the baseline binocular state. Although this result superficially resembles the Sprague effect, two patients benefited from right-monocular viewing whereas eleven patients showed no significant change in either right or left viewing conditions. The possible role of structures mediating interocular differences in target detection in cases of right hemisphere damage is discussed. It is suggested that even if the Sprague effect contributes to the salubrious influence of monocular viewing it is hardly the single factor involved.     

The use of optokinetic stimulation in rehabilitation of the hemineglect disorder

The aim of this study was to investigate whether it is possible to strengthen the rehabilitation of spatial hemineglect by combining standard training for spatial scanning with optokinetic stimulation. A simple randomized design was used: one group of neglect patients was treated with a combination of the two techniques, and a second group received only the standard treatment. Both treatments were given for six consecutive weeks and produced significant improvements. However, addition of the optokinetic stimulation did not improve the patients' performance. Also, none of the independent variables (i.e., presence/absence of hemianopia) predicted the positive effect occasionally observed in individual patients.     

Does monocular viewing improve target detection in hemispatial neglect?

Experimental animals with large posterior-cortical lesions develop disturbances of visual perception and visually-guided behavior in the contralateral space, resembling the syndrome of unilateral spatial neglect (USN) in humans. The visuo-motor performance in the ignored space is recovered some time following additional lesion inflicted to the contralesional superior colliculus (SC) or section of the intercollicular pathways. Based on the model that explains this recovery by disinhibition of the ipsilesional SC (the 'Sprague effect') Posner and Rafal [37] proposed that ipsilesional monocular occlusion could possibly reduce the 'tone' of contralesional collicular neurons thereby removing an important contributor of hemineglect. A group of twenty-six right-hemisphere-damaged patients with USN was given a cancellation task under binocular and monocular (left and right) viewing conditions. Thirteen patients showed amelioration of left hemineglect in conditions of left-monocular viewing, as compared to the baseline binocular state. Although this result superficially resembles the Sprague effect, two patients benefited from right-monocular viewing whereas eleven patients showed no significant change in either right or left viewing conditions. The possible role of structures mediating interocular differences in target detection in cases of right hemisphere damage is discussed. It is suggested that even if the Sprague effect contributes to the salubrious influence of monocular viewing it is hardly the single factor involved.     

Visual hypoemotionality and prosopagnosia associated with right temporal lobe isolation

Emotional hyporeactivity to visual stimuli (so-called visual hypoemotionality) was observed in a 71-yr-old woman following a cerebral infarction in the territory of the posterior cerebral arteries. Other visual disturbances included severe prosopagnosia, dense left hemianopia and mild left hemineglect. There was neither object agnosia nor any involvement of language, memory or intellectual functions. Hypoemotionality was found only for visual stimuli, since auditory and tactile modalities were totally spared, suggesting a visual-limbic disconnection mechanism. From CT data, and referring to previous evidence suggesting a right-hemisphere prevalence for emotional functions, it is postulated that the right occipital lesion, leading to a total right temporal lobe isolation, was mainly responsible for the patient's emotional disturbances.     

Postoperative reversal of complete (monocular) blindness in skull base meningioma: case report

BACKGROUND: Meningiomas of the anterior cranial fossa frequently present with impaired visual function. Recognition of this entity in the differential diagnosis of painless, progressive, and asymmetric optic neuropathy is important since reversal of visual loss is possible given timely surgical excision of the tumour. METHODS: A 76-year-old man presented with no perception of light in his right eye and a reduced visual acuity of 20/60 in his left eye with a markedly constricted visual field. His visual deterioration had progressed over the previous three months and was not associated with headache. Ophthalmoscopy showed normal optic discs. MRI scanning showed a large frontal basal meningioma, which was subsequently resected. RESULTS: The patient noticed an immediate improvement in his vision in his right eye. Visual acuity in his right eye improved to 20/50 at six weeks postoperatively and to 20/25 at five months, with corresponding improvement of the visual field. CONCLUSION: Complete monocular blindness due to tumour compressing or distorting the anterior visual pathways does not preclude recovery following timely decompressive surgery, especially when the appearance of the optic disc is normal.     

Unilateral pursuit-induced congenital nystagmus

We describe two patients with a lifelong history of oscillopsia only when following objects moving toward their left side. Neurologic examination was normal except for eye movements. The patients showed nystagmus during any tasks that required visual following toward the left (ie, smooth pursuit, optokinetic nystagmus, and vestibulo-ocular-reflex-suppression), but had no nystagmus during fixation of stationary targets or visual following tasks to the right. Eye-movement recordings showed waveforms during pursuit to the left that were typical of congenital nystagmus.     

Colour anomia restricted to the left visual hemifield after splenial disconnexion.

In a patient with damage to the right occipital lobe and to the splenium of the corpus callosum, an incomplete colour anopia in the left upper quadrants and a colour anomia was found for the complete left visual hemifield beyond 2 degrees eccentricity. The patient had no difficulty in recognising coloured targets when presented in the periphery of the left visual hemifield and in the foveal region, but could not name them correctly. The results suggest that the lesion of the splenium of the corpus callosum disconnects the right visual cortex from the language areas of the left hemisphere, and the specific disturbance of colour naming is the consequence.     

Primary cerebral abscess due to nocardia presenting as 'ghost tumor'. Clinical and pathological study

We report a case of a primary cerebral abscess due to Nocardia asteroides in a nonimmunocompromised patient with a particular clinical course. The first symptom (right subacute brachial palsy) and the lesion in a computed tomographic (CT) scan (left parietofrontal edema suggestive of brain tumor) disappeared after corticosteroid treatment and the patient was discharged with total recovery. After 2 months she complained of headache and visual disturbance. A new CT scan showed an annular lesion in the left occipital lobe. A cerebral biopsy was diagnosed of nocardia infection. The patient died 2 weeks after this biopsy. A postmortem study showed an occipital brain abscess but not structural abnormalities were seen in the left parietofrontal area. We believe that the first episode could be a local inflammatory response to cerebral implantation of nocardia which disappeared clinically in the CT scan and in the postmortem study after corticosteroid treatment. Then the nocardia could have displaced by the hematological route to the second and definitive cerebral lesion.     

Now you see it, now you don't: variable hemineglect in a commissurotomized man

We describe the case of a callosotomized man, D.D.V., who shows unusual neglect of stimuli in the left visual field (LVF). This is manifest in simple reaction time (RT) to stimuli flashed in the LVF and in judging whether pairs of filled circles in the LVF are of the same or different color. It may reflect strong left-hemispheric control and consequent attention restricted to the right side of space. It is not evident in simple RT when there are continuous markers in the visual fields to indicate the locations of the stimuli. In this condition, his RTs are actually faster to LVF than to right visual field (RVF) stimuli, suggesting a switch to right-hemispheric control that eliminates the hemineglect. Neglect is also not evident when D.D.V. responds by pointing to or touching the locations of the stimuli, perhaps because these responses are controlled by the dorsal rather than the ventral visual system. Despite his atypical manifestations of hemineglect, D.D.V. showed evidence of functional disconnection typical of split-brained subjects, including prolonged crossed-uncrossed different in simple reaction time, inability to match colors between visual fields, and enhanced redundancy gain in simple RT to bilateral stimuli even when the stimulus in the LVF was neglected.