Neglect and hemianopia superimposed

In patients with posterior-parietal brain damage it is often difficult to decide whether left-sided omissions in perimetry are due to primary visual loss or due to visual neglect. We investigated 11 patients with combined neglect/hemianopia and 11 patients with pure hemianopia using a visual search task with single or double stimulation conditions. The second stimulus was either the fixation point itself (like in perimetry) or a distractor appearing in the hemifield opposite to the target. The fixation point did not worsen left-sided perception, but its disappearance led to a bias of exploration towards the right side in neglect patients but not in pure hemianopics. A distractor in the intact hemifield worsened the performance to left-sided stimuli, that is, neglect patients behaved as if they were completely hemianopic, even in intact parts of the visual field (VF). Three of the neglect patients showed unconscious processing of the distractor in the left VF, suggesting that the visual field defect was produced by neglect mechanisms rather than primary visual loss. This visual search paradigm appears to be helpful in understanding of the nature of hemianopia versus neglect deficits in individual patients.     

Repetition of distractor sets improves visual search performance in hemispatial neglect

Priming from repeated distractor sets, or search context, in conjunctive visual search was examined in four patients with hemispatial neglect. In the first experiment overall context was either changed or repeated while the target was always the same to control for any modulatory effect of target priming. Considerable priming was seen from repeated context. In the second experiment the context was either repeated on the left side, on the right side, on both sides, or the context was new. Priming from repeated context was found to arise from the left visual field, as well as the right visual field, as well as when overall context was repeated. Brief masked displays were used in experiment 3, the results again showing strong priming from repeated overall context. The results of the three experiments suggest that visual grouping, or perceptual organization, of distractor sets is relatively intact in the affected hemifield of parietal neglect patients. Furthermore, repetition of context may even temporarily ameliorate neglect symptoms in search. These findings are consistent with claims that grouping is distinct from attentional processing and that it operates at lower levels of the perceptual hierarchy.     

Eye movements and fixation characteristics in perception of stationary scenes: normal subjects as compared to patients with visual neglect or hemianopia

Saccade amplitudes, fixation times, and the spatial distribution of fixation points were comparatively studied in patients with visual hemineglect and/or homonymous hemianopia, as well as in normals (each group, n = 8). Two types of picture slides were presented (with and without search task) while eye movements were recorded with the infrared reflection technique. Self-developed software served to detect fixations, and to document their spatio-temporal parameters. Spectra of saccade amplitudes and fixation times were characteristic of each slide, while exhibiting notable similarities across subject groups. It is concluded that foveal information processing may not be much different in patients and in normals. Average saccade amplitudes and total scanpath lengths across all pictures were significantly smaller in the patients than in normals with both types of slides. In the neglect patients, saccades starting and terminating in the unaffected visual hemifield were larger, on an average, than those entirely located in the affected hemifield. The same was true for many of the hemianopic patients. Nevertheless, during free exploration, mean amplitudes of saccades restricted to the unaffected hemifield of the patients were apparently still smaller than those of normal controls within the corresponding hemifield. Average dwell time of fixations, total fixation time, as well as the total number of fixations did not vary significantly between groups. However, in the patient groups, average fixation times were shorter after large as compared to small saccades. This finding is discussed in the context of saccadic programming on the background of the sequential attention model of eye movement control. In subsamples of five hemianopic and six neglect patients, asymmetry in the distribution of fixation points was compared before and after a 4-week period of comprehensive rehabilitation that Included computerized scanning and attentional training. Only patients with pure hemianopia (who were less severely impaired from the beginning) improved according to this criterion, while neglect patients remained unchanged or deteriorated slightly. Total scanpath lengths, however, were not significantly different before and after therapy in any of the two groups of patients, indicating a persisting disturbance in scanning performance also in the hemianopic group.     

Implicit perception in patients with visual neglect: lexical specificity in repetition priming

Twelve patients with left-sided neglect, five patients with left-sided hemianopia, and 16 matched controls performed lexical decisions for foveally presented target words or pseudowords. Target words or pseudowords could be preceded by the same stimuli, presented for 150 ms as primes in either the left (LVF) or the right (RVF) visual hemifield. Primes in the RVF caused similar levels of priming across the three groups. In contrast, whereas primes in the affected LVF did not cause priming in hemianopic patients, patients with neglect showed highly significant priming from LVF primes, and the level of priming from these neglected primes was increased relative to normal control levels. This priming effect was attributed to lexical access, because no repetition priming was observed for pronounceable pseudowords. In striking contrast to the priming results, neglect patients' explicit recognition performance for these prime stimuli was at chance for the left hemifield, although it was near perfect for the right hemifield. This demonstrates that the observed priming effects in the left hemifield were indeed caused by stimuli that were not explicitly perceived.     

Audiovisual integration in patients with visual deficit

In the present study, we investigated the possibility that bimodal audiovisual stimulation of the affected hemifield can improve perception of the visual events in the blind hemifield of hemianopic patients, as it was previously demonstrated in neglect patients. Moreover, it has been shown that "hetero-modal" and "sensory-specific" cortices are involved in cross-modal integration. Thus, the second aim of the present study was to examine whether audiovisual integration influences visual detection in patients with different cortical lesions responsible of different kinds of visual disorders. More specifically, we investigated cross-modal, audiovisual integration in patients with visual impairment due to a visual field deficit (e.g., hemianopia) or visuospatial attentional deficit (e.g., neglect) and patients with both hemianopia and neglect. Patients were asked to detect visual stimuli presented alone or in combination with auditory stimuli that could be spatially aligned or not with the visual ones. The results showed an enhancement of visual detection in cross-modal condition (spatially aligned condition) comparing to unimodal visual condition only in patients with hemianopia or neglect; by contrast, the multisensory integration did not occur when patients presented both deficits. These data suggest that patients with visual disorders can enormously benefit the multisensory integration. Moreover, they showed a different influence of cortical lesion on multisensory integration. Thus, the present results show the important adaptive meaning of multisensory integration and are very promising with respect to the possibility of recovery from visual and spatial impairments.     

Parallel interhemispheric processing in hemineglect: Relation to visual field defects

Parallel interhemispheric processing is required to explore our visual environment and to integrate visual information from both hemifields simultaneously. Damage to the right temporo-parietal cortex can disrupt such parallel processes and result in neglect and visual extinction of stimuli in the left contralesional visual space. Neglected or extinguished stimuli can still be processed, yet without reaching the patient's awareness. Such unconscious processing has been attributed to structurally intact primary visual areas in neglect. To study whether unconscious parallel processing depends on visual functional integrity, we compared the performance of neglect patients with visual field defects (VFDs) (n = 11) and hemianopic patients with partial or complete blindness of one visual hemifield (n = 11) on redundant targets effects (RTE). The RTE manifests as faster reaction times to redundant paired (two stimuli, one in each hemifield) than single stimulation (in one hemifield). We found RTEs, i.e., unconscious processing, in neglect patients but not in hemianopic patients. Furthermore, neglect patients showed large crossed–uncrossed differences (CUDs), i.e., faster response times to ipsi- than contralesional hemifield stimulation, reflecting a difference in processing speed for single stimuli in the two hemispheres that were correlated with VFDs and visual extinction. The finding that extinction, but not RTE, was correlated with the CUD suggests that under competitive bilateral stimulus conditions the delayed contralesional visual field input may not be detected by the intact left hemisphere, which presumably mediates the task given the impairment of the right hemisphere. By contrast, unconscious parallel processing of contralesional stimuli (RTE) occurred even when contralesional visual field input is lacking (VFD) or delayed (CUD) and is possibly mediated via subcortical visual pathways.     

Does spatial cueing affect line bisection in chronic hemianopia?

Patients with homonymous hemianopia often show a contralesional shift towards their blind field when bisecting horizontal lines ("hemianopic line bisection error", HLBE). The reasons for this spatial bias are not well understood and debated. Cueing of spatial attention modulates line bisection significantly in patients with visuospatial neglect. Moreover, recent evidence showed that attention training significantly improves deficits of visual search in hemianopia. Here, we tested in 20 patients with chronic homonymous hemianopia (10 left-sided, 10 right-sided) without visual neglect, 10 healthy control subjects, 10 neurological control patients, and 3 patients with left visuospatial neglect and leftsided hemianopia whether spatial cueing influences the HLBE. Subjects indicated verbally the midpoint of horizontal lines in a computerized line bisection task under four experimental cue positions (cue far left, mid-left, mid-right or far-right within the horizontal line). All 20 hemianopic patients showed the typical HLBE towards their blind field, while the two control samples showed only a small but significant leftward shift (pseudoneglect). None of the 4 cueing manipulations had a significant effect on the HLBE in the hemianopic patients. Moreover, no differential effects of cueing on line bisection results were obtained when analyzed in lesion subgroups of hemianopic patients with circumscribed occipital lesions (N=8) as contrasted with patients having more extended (occipito-temporal or temporal) lesions (N=12). This null-effect contrasts with marked cueing effects observed in 3 neglect patients with left hemianopia in the same tasks, showing the principal efficacy of our cueing manipulation. These results argue against attentional explanations of the HLBE.     

A psychophysical study of visual extinction: ipsilesional distractor interference with contralesional orientation thresholds in visual hemineglect patients

Visual extinction was investigated in left (n=15) and right (n=25) brain-damaged patients with or without visual neglect, and in normal control subjects (n=14), using a psychophysical paradigm. Orientation discrimination thresholds were determined for both left and right hemifield gratings presented either in isolation or simultaneously with a contralateral distractor grating. To minimize the influence of possible sensory-perceptual deficits, the luminances of both target and distractor gratings were chosen to be 20 times the luminances necessary to discriminate between horizontal and vertical grating orientations. The location of the target grating was always cued, making the distractor grating task irrelevant. Even after equalizing the visibility of left and right hemifield stimuli, neglect patients still displayed an increased interference effect from an ipsilesional distractor (and no interference from a contralesional distractor). Left or right brain-damaged controls did not show this asymmetric interference of irrelevant distractors, even the patients who demonstrated extinction on standard extinction testing. This suggests that visual extinction is a critical component of the visual neglect syndrome and that it involves an attentional deficit.     

What kind of visual spatial attention is impaired in neglect?

The distribution of spatial attention across the horizontal meridian of the visual field, as assessed by a simple reaction time (RT) paradigm, is dramatically abnormal in neglect patients. In the contralesional hemifield, RT increases sharply from centre to periphery, while in the ipsilesional hemifield, it decreases paradoxically from centre to mid-periphery. In the present study, we firstly asked whether this abnormal distribution of spatial attention is still present when patients know in advance the location of the impending stimulus, and second whether and to which extent it may be influenced by the concomitant presence of hemianopia. In Experiment 1, the stimuli were presented either predictably (blocks of same-point presentations) or unpredictably (blocks of randomised presentations) to one of several contralesional and ipsilesional field locations. As was the case for control subjects, neglect patients showed an overall RT decrease with same-point presentations. However, their abnormal contralesional RT lengthening and ipsilesional speeding were still present. In Experiment 2, the trials were blocked to same-hemifield presentations. In the ipsilesional field condition, neglect patients with and without hemianopia showed the same distorted distribution of attention favouring mid-periphery over central field locations. Two conclusions can be drawn from these experiments: first, the bulk of the abnormal deployment of spatial attention in neglect patients is related to an impairment of exogenous attention which cannot be compensated for by a spared endogenous control. Second, hemianopia does not affect the paradoxical speeding up of RT typically found in the mid-periphery of the ipsilesional field of neglect patients.     

The word-length effect in acquired alexia, and real and virtual hemianopia

A word-length effect is often described in pure alexia, with reading time proportional to the number of letters in a word. Given the frequent association of right hemianopia with pure alexia, it is uncertain whether and how much of the word-length effect may be attributable to the hemifield loss. To isolate the contribution of the visual field defect, we simulated hemianopia in healthy subjects with a gaze-contingent paradigm during an eye-tracking experiment. We found a minimal word-length effect of 14 ms/letter for full-field viewing, which increased to 38 ms/letter in right hemianopia and to 31 ms/letter in left hemianopia. We found a correlation between mean reading time and the slope of the word-length effect in hemianopic conditions. The 95% upper prediction limits for the word-length effect were 51 ms/letter in subjects with full visual fields and 161 ms/letter with simulated right hemianopia. These limits, which can be considered diagnostic criteria for an alexic word-length effect, were consistent with the reading performance of six patients with diagnoses based independently on perimetric and imaging data: two patients with probable hemianopic dyslexia, and four with alexia and lesions of the left fusiform gyrus, two with and two without hemianopia. Two of these patients also showed reduction of the word-length effect over months, one with and one without a reading rehabilitation program. Our findings clarify the magnitude of the word-length effect that originates from hemianopia alone, and show that the criteria for a word-length effect indicative of alexia differ according to the degree of associated hemifield loss.     

Usefulness of multifocal VEP in a child requiring perimetry

We examined the reliability of multifocal visual evoked potentials for evaluating visual-field defects in a child with epilepsy and an arachnoid cyst. Multifocal visual evoked potentials were measured both when perimetry was difficult and several years later, when kinetic perimetry became possible in a child with epilepsy and homonymous hemianopia, as suggested by computed tomography of the brain. The peak latency and amplitude of response waves were used for assessment. The recordings of multifocal visual evoked potentials at both times revealed marked decreases in amplitude in the left visual hemifield. This area of decreased amplitude corresponded to the location of the lesion observed with imaging techniques, and was consistent with the left homonymous hemianopia observed via kinetic perimetry. The objective evaluation of visual-field defects through multifocal visual evoked potentials may be useful in children in whom conventional perimetry is difficult.     

The effect of lateralized dynamic stimuli on unilateral spatial neglect following right hemisphere lesions

Patients with unilateral (left-sided) spatial neglect following right-hemisphere stroke were tested for the effects of visual stimulation on performance of a line-bisection task. As predicted from research on brain mechanisms of spatial orientation and attention, dynamic visual stimuli presented on the left side substantially reduced neglect in the task. In contrast, left sided static stimuli reduced neglect significantly less and dynamic stimuli presented in the center had no effect on neglect. Neglect patients with hemianopia did not show significantly less benefit of left-sided dynamic stimuli compared to neglect patients without hemianopia, suggesting that the effect of these stimuli was unconscious and automatic. The potential advantages of lateralized dynamic stimuli in the rehabilitation of neglect are discussed.     

Contour-integration deficits on the intact side of the visual field in hemianopia patients

OBJECTIVE: Visual impairments in hemianopia are thought to be exclusively caused by the reduced visual field size. However, the primary lesion may affect the contralateral hemisphere through damage of interhemispheric projections. The question therefore arises if the presumed "intact" hemifield is perceptually impaired. METHODS: Three hemianopia patients and three matched controls carried out a Yes/No figure detection task with their intact side of the visual field. The figure (square) contours were composed of non-contiguous Gabor patches embedded in a random patch array of different background densities (low, delta=2; high, delta=1). Response accuracy and reaction times were recorded. RESULTS: A temporal-parietal patient revealed figure detection impairments, with accuracy rate, 77% (delta=2) and 53% (delta=1), below compared control values. An occipital patient was comparable to his match: 99% (delta=2); 84% (delta=1). Both patients exhibited frequent false alarms to random patterns and required longer presentation times to perform the task. In the third patient, with optic tract lesion, figure detection was nearly normal at low density (92%, delta=2) but impaired at noisy background (62%, delta=1). CONCLUSION: The "intact" visual field in hemianopes is impaired in detection of incomplete figures embedded in a noisy background. This deficit may be caused by damage to higher visual centers and/or loss of interhemispheric interactions.     

The relationship of visual extinction to luminance-contrast imbalances between left and right hemifield stimuli

Visual extinction was investigated in six right brain-damaged patients with left visual neglect, using a psychophysical paradigm. Orientation discrimination thresholds were determined for both left and right hemifield gratings presented either in isolation or simultaneously with a contralateral distractor grating. To minimize the influence of possible sensory-perceptual deficits, the luminances of both target and distractor gratings were chosen to be 20 times the luminances necessary to discriminate between horizontal and vertical grating orientations. When the visibility of target and distractor gratings was subjectively equalized in this way, neglect patients still showed a significant extinction effect, i.e. a significant interference of the right hemifield distractor with left hemifield orientation sensitivity. By manipulating the luminances of left and right hemifield gratings during bilateral simultaneous stimulus presentation, we demonstrated the role of luminance-contrast imbalances in eliciting visual extinction. Both decreasing the right distractor luminance and increasing the left target stimulus luminance resulted in an elimination of the observed extinction effects. These results show that not the absolute salience of one of two simultaneously presented stimuli, but the relative salience of both stimuli, is the crucial factor for inducing extinction.     

Disentangling neglect and hemianopia.

In this paper we report findings which question the diagnosis of a hemianopia in B.Q., a 66-year-old lady who shows unilateral spatial neglect following a lesion to the right parietal lobe. The presence of a hemianopia has been indicated following two independent assessments of B.Q.'s visual fields. We examined B.Q.'s performance on a visuo-spatial task in which single or double stimuli were displayed left and right of a central fixation point. B.Q. failed to report left stimuli when the fixation point was continuously displayed (OVERLAP CONDITION). This performance is consistent with the suggestion of a left hemianopia as indicated by perimetric field testing. In a further condition the fixation point was extinguished prior to stimuli onset (GAP CONDITION). B.Q. consistently responded to left stimuli in the gap condition and also showed improved performance to right stimuli. Eye movements were recorded on a separate testing session, in which B.Q. showed a normal saccadic response to left targets in the gap condition, but not during the overlap condition. These results suggest that B.Q.'s failure to report left stimuli during field plotting is due to her neglecting left stimuli and not because she has a visual field defect. By using a testing procedure which reduces the severity of neglect B.Q. is able to respond to left stimuli. Reducing the severity of B.Q.'s neglect also abolishes the apparent hemianopia. Standard field plotting techniques which use a consistently displayed fixation point may not be appropriate for the testing of neglect patients' visual fields.     

Parietal and occipital lobe contributions to perception of straight ahead orientation

OBJECTIVES: Several studies have investigated how peripheral stimulation affects the perception of body orientation in healthy subjects. The studies showed that opposing stimulation of two different input modalities can cancel out, leaving perception of body orientation unchanged. It was ascertained whether a comparable phenomenon could be found in brain damaged patients with two distinct disorders which individually lead to opposing shifts of the perceived midline. METHODS: The visual subjective straight ahead was measured in patients with pure neglect, pure hemianopia, or a combination of neglect and hemianopia. RESULTS: As in previous studies, patients with pure neglect displayed an ipsilesional displacement of the perceived straight ahead. Patients with pure hemianopia showed a contralesional shift. By contrast, no significant midline shift occurred in the patients with both neglect and hemianopia. CONCLUSIONS: Neglect and hemianopia interact so that opposing biases in the perception of body orientation neutralise each other. Both parietal and occipital areas seem to contribute to the perception of straight ahead body orientation and seem to have counteracting effects when lesioned in the same hemisphere.     

Unilateral occipital lesion causing hemianopia affects the acoustic saccadic programming

Infrared oculographic recordings of saccades evoked by auditory or visual targets in four patients with hemianopia due to an occipital lesion showed that these patients employed a different strategy to find visual and auditory targets in each hemifield. In the seeing hemifield, the patients acquired auditory targets with both monosaccadic and multiple saccadic refixations. The first saccade, the largest, brought the eyes toward the target; the following smaller saccades completed the search as in normal subjects. Saccades to visual targets consisted of one orthometric saccade or two saccades. By contrast, in the blind hemifield the patients acquired auditory targets by a staircase strategy consisting of stepwise saccadic search movements similar to those used for visual targets in the same hemifield. The similarity of strategy to auditory and visual targets suggests a common motor program controlled by the visual input. The latency, accuracy, and velocities of visual and acoustic responses were equal in both hemifields.     

Distortion of auditory space in hemianopia

Sound localization was investigated in patients with homonymous hemianopia, a visual field defect characterized by a loss of vision in one hemifield that is caused by unilateral brain lesions involving the visual cortex or its afferents. The primary aim was to clarify whether or not the known distortion of visual space in hemianopia results in processes of long-term cross-modal spatial adaptation, thus eventually inducing related alterations in auditory space perception. For this purpose, patients were tested by using tasks of either head pointing or manual pointing to acoustic targets in the azimuthal plane, under anechoic conditions in total darkness. The results obtained with both tasks consistently indicated slight, but significant, systematic errors compared with normal controls. In particular, the errors found can be interpreted by both rotation and compression of auditory space toward the anopic side. These findings can be explained by a visual miscalibration of the auditory space, as has been analogously demonstrated in studies on normal-sighted subjects after exposure to consistent auditory–visual disparity, for example by wearing prism lenses. The precision in sound localization of hemianopic patients was generally reduced across both hemispaces. Taken together, one may conclude that processes of cross-modal spatial adaptation, but not those of compensatory plasticity, occurred in patients with hemianopia.     

"Crossed homonymous hemianopia" and "crossed left hemispatial neglect" in a case of Marchiafava-Bignami disease.

"Crossed homonymous hemianopia" and "crossed left hemispatial neglect" were observed in a woman with Marchiafava-Bignami disease. Two forms of "crossed homonymous hemianopia" were observed. Initially, Goldmann perimeter testing showed a left homonymous hemianopia with the right hand and vice versa. Later, confrontation tests showed a left homonymous hemianopia, whereas visual field testing using the Goldmann perimeter (kinetic quantitative perimeter) and the OCTOPUS (Interzeag AG, static automated perimeter) showed a right homonymous hemianopia with either hand. "Crossed left hemispatial neglect" was not seen with the left hand, but neglect of the left hemifield was seen with the right hand. CT and MRI showed a lesion occupying almost the entire corpus callosum. PET showed no significant differences between comparable areas of the left and right cerebral hemispheres. These findings indicate that both signs of interhemispheric disconnection were due to the callosal lesion. Moreover, the "crossed left hemispatial neglect" can be explained as being a consequence of the dominance of the right cerebral hemisphere for visuospatial recognition.     

Impairments of Gestalt perception in the intact hemifield of hemianopic patients are reflected in gamma-band EEG activity

Gamma-band responses (GBRs) are associated with Gestalt perception processes. In the present EEG study, we investigated the effects of perceptual grouping on the visual GBR in the perimetrically intact visual field of patients with homonymous hemianopia and compared them to healthy participants.All observers were presented either random arrays of Gabor elements or arrays with an embedded circular arrangement. For the hemianopic patients, the circle was presented in their intact hemifield only. For controls, the hemifield for the circle presentation was counterbalanced across subjects. The participants were instructed to detect the circle by pressing a corresponding button. A wavelet transform based on Morlet wavelets was employed for the calculation of oscillatory GBRs.The early evoked GBR exhibited a larger amplitude and shorter latency for the healthy group compared to hemianopic patients and was associated with behavioral measures. The late total GBR between 200 and 400 ms after stimulus onset was significantly increased for Gestalt-like patterns in healthy participants. This effect was not manifested in patients.The present findings indicate deficits in the early and late visual processing of Gestalt patterns even in the intact hemifield of hemianopic patients compared to healthy participants.