Brain networks of visuospatial attention and their disruption in visual neglect

Hemispatial Neglect Shows That "Before" Is "Left"

Recent research has led to the hypothesis that events which unfold in time might be spatially represented in a left-to-right fashion, resembling writing direction. Here we studied fourteen right-hemisphere damaged patients, with or without neglect, a disorder of spatial awareness affecting contralesional (here left) space processing and representation. We reasoned that if the processing of time-ordered events is spatial in nature, it should be impaired in the presence of neglect and spared in its absence. Patients categorized events of a story as occurring before or after a central event, which acted as a temporal reference. An asymmetric distance effect emerged in neglect patients, with slower responses to events that took place before the temporal reference. The event occurring immediately before the reference elicited particularly slow responses, closely mirroring the pattern found in neglect patients performing numerical comparison tasks. Moreover, the first item elicited significantly slower responses than the last one, suggesting a preference for a left-to-right scanning/representation of events in time. Patients without neglect showed a regular and symmetric distance effect. These findings further suggest that the representation of events order is spatial in nature and provide compelling evidence that ordinality is similarly represented within temporal and numerical domains.

Chronic spatial working memory deficit associated with the superior longitudinal fasciculus: a study using voxel-based lesion-symptom mapping and intraoperative direct stimulation in right prefrontal glioma surgery

OBJECTIVE Although the right prefrontal region is regarded as a silent area, chronic deficits of the executive function, including working memory (WM), could occur after resection of a right prefrontal glioma. This may be overlooked by postoperative standard examinations, and the disabilities could affect the patient's professional life. The right prefrontal region is a part of the frontoparietal network and is subserved by the superior longitudinal fasciculus (SLF); however, the role of the SLF in spatial WM is unclear. This study investigated a persistent spatial WM deficit in patients who underwent right prefrontal glioma resection, and evaluated the relationship between the spatial WM deficit and the SLF. METHODS Spatial WM was examined in 24 patients who underwent prefrontal glioma resection (right, n = 14; left, n = 10) and in 14 healthy volunteers using a spatial 2-back task during the long-term postoperative period. The neural correlates of spatial WM were evaluated using lesion mapping and voxel-based lesion-symptom mapping. In addition, the spatial 2-back task was performed during surgery under direct subcortical electrical stimulation in 2 patients with right prefrontal gliomas. RESULTS Patients with a right prefrontal lesion had a significant chronic spatial WM deficit. Voxel-based lesion-symptom mapping analysis revealed a significant correlation between spatial WM deficit and the region that overlapped the first and second segments of the SLF (SLF I and SLF II). Two patients underwent awake surgery and had difficulties providing the correct responses in the spatial 2-back task with direct subcortical electrical stimulation on the SLF I, which was preserved and confirmed by postoperative diffusion tensor imaging tractography. These patients exhibited no spatial WM deficits during the postoperative immediate and long-term periods. CONCLUSIONS Spatial WM deficits may persist in patients who undergo resection of the tumor located in the right prefrontal brain parenchyma. Injury to the dorsal frontoparietal subcortical white matter pathway, i.e., the SLF I or SLF I and II, could play a causal role in this chronic deficit. A persistent spatial WM deficit, without motor and language deficits, could affect the professional life of the patient. In such cases, awake surgery would be useful to detect the spatial WM network with appropriate task during tumor exploration.

Pharmacological interventions for unilateral spatial neglect after stroke

BACKGROUND

Unilateral spatial neglect (USN) is characterized by the inability to report or respond to people or objects presented on the side contralateral to the lesioned side of the brain and has been associated with poor functional outcomes and long stays in hospitals and rehabilitation centers. Pharmacological interventions (medical interventions only, use of drugs to improve the health condition), such as dopamine and noradrenergic agonists or pro-cholinergic treatment, have been used in people affected by USN after stroke, and effects of these treatments could provide new insights for health professionals and policy makers.

OBJECTIVES

To evaluate the effectiveness and safety of pharmacological interventions for USN after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2015), the Cochrane Central Register of Controlled Trials (April 2015), MEDLINE (1946 to April 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to April 2015), EMBASE (1980 to April 2015), PsycINFO (1806 to April 2015) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to April 2015). We also searched trials and research registers, screened reference lists, and contacted study authors and pharmaceutical companies (April 2015).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) of pharmacological interventions for USN after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias in the included studies and extracted data.

MAIN RESULTS

We included in the review two studies with a total of 30 randomly assigned participants. We rated the quality of the evidence as very low as the result of study limitations, small numbers of events, and small sample sizes, with imprecision in the confidence interval (CI). We were not able to perform meta-analysis because of heterogeneity related to the different interventions evaluated between included studies. Very low-quality evidence from one trial (20 participants) comparing effects of rivastigmine plus rehabilitation versus rehabilitation on overall USN at discharge showed the following: Barrage (mean difference (MD) 0.30, 95% confidence interval (CI) -0.18 to 0.78); Letter Cancellation (MD 10.60, 95% CI 2.07 to 19.13); Sentence Reading (MD 0.20, 95% CI -0.69 to 1.09), and the Wundt-Jastrow Area Illusion Test (MD -4.40, 95% CI -8.28 to -0.52); no statistical significance was observed for the same outcomes at 30 days' follow-up. In another trial (10 participants), study authors showed statistically significant reduction in omissions in the three cancellation tasks under transdermal nicotine treatment (mean number of omissions 2.93 ± 0.5) compared with both baseline (4.95 ± 0.8) and placebo (5.14 ± 0.9) (main effect of treatment condition: F (2.23) = 11.06; P value < 0.0001). One major adverse event occurred in the transdermal nicotine treatment group, and treatment was discontinued in the affected participant. None of the included trials reported data on several of the prespecified outcomes (falls, balance, depression or anxiety, poststroke fatigue, and quality of life).

AUTHORS' CONCLUSIONS

The quality of the evidence from available RCTs was very low. The effectiveness and safety of pharmacological interventions for USN after stroke are therefore uncertain. Additional large RCTs are needed to evaluate these treatments.

Dissociating temporal attention from spatial attention and motor response preparation: A high-density EEG study

Engagement of various forms of attention and response preparation determines behavioral performance during stimulus-response tasks. Many studies explored the respective properties and neural signatures of each of these processes. However, very few experiments were conceived to explore their interaction. In the present work we used an auditory target detection task during which both temporal attention on the one side, and spatial attention and motor response preparation on the other side could be explicitly cued. Both cueing effects speeded response times, and showed strictly additive effects. Target ERP analysis revealed modulations of N1 and P3 responses by these two forms of cueing. Cue-target interval analysis revealed two main effects paralleling behavior. First, a typical contingent negative variation (CNV), induced by the cue and resolved immediately after target onset, was found larger for temporal attention cueing than for spatial and motor response cueing. Second, a posterior and late cue-P3 complex showed the reverse profile. Analyses of lateralized readiness potentials (LRP) revealed both patterns of motor response inhibition and activation. Taken together these results help to clarify and disentangle the respective effects of temporal attention on the one hand, and of the combination of spatial attention and motor response preparation on the other hand on brain activity and behavior.

[Attention system functions and their relationship with self-reported health in patients with brain damage due to tumor]

AIM

To compare parameters of attention in healthy people and patients with neoplasms in different regions of the cerebral cortex and to evaluate quality of life (QoL) indices with regard to impairment of different attention systems.

MATERIAL AND METHODS

Twenty patients with oncological lesions of the brain (mean age 56.5±8.8 years) who did not undergo surgery were studied. Tumor localization was confirmed using contrast-enhanced computed tomography, the tumor type was histologically verified. A control group included 18 healthy people matched for age, sex and education level. To determine attention system functions, we developed a computed version of the Attention Network Test. Error rate and reaction time for correct responses to the target stimulus, displayed along with neutral, congruent and incongruent signals, were the indicators of the efficacy of selective processes. QoL indices were assessed using SF-36 health survey questionnaire.

RESULTS AND CONCLUSION

The readiness to respond to incoming stimuli was mostly impaired in patients with brain tumors. Efficacy of executive attention, assessed as the increase in the number of errors in selection of visual stimuli, was decreased while temporary parameters of the functions of this system were not changed in patients compared to controls. The SF-36 total score was stable in patients with marked reduction in scores on the Role and Emotional Functioning scales. The most severe health impairment measured on the SF-36 scales of role/social emotional functioning and viability was recorded in patients with the lesions of frontal cortical areas compared to temporal/parietal areas. The relationship between SF-36 Health self-rating and attention systems was found. This finding puts the question of the importance of attention characteristics and QoL for survival prognosis of patients with brain tumors.

Deployment of spatial attention without moving the eyes is boosted by oculomotor adaptation

Vertebrates developed sophisticated solutions to select environmental visual information, being capable of moving attention without moving the eyes. A large body of behavioral and neuroimaging studies indicate a tight coupling between eye movements and spatial attention. The nature of this link, however, remains highly debated. Here, we demonstrate that deployment of human covert attention, measured in stationary eye conditions, can be boosted across space by changing the size of ocular saccades to a single position via a specific adaptation paradigm. These findings indicate that spatial attention is more widely affected by oculomotor plasticity than previously thought.

Unveiling residual, spontaneous recovery from subtle hemispatial neglect three years after stroke

A common and disabling consequence of stroke is the difficulty in processing contralesional space (i.e., hemispatial neglect). According to paper-and-pencil tests, neglect remits or stabilizes in severity within a few months after a brain injury. This arbitrary temporal limit, however, is at odds with neglect’s well-known dependency on task-sensitivity. The present study tested the hypothesis that the putative early resolution of neglect might be due to the insensitivity of testing methods rather than to the lack of spontaneous recovery at later stages. A right hemisphere stroke patient was studied longitudinally for 3 years. According to paper-and-pencil tests the patient showed no symptom of hemispatial neglect 1 month post stroke. Awareness of spatially lateralized visual targets was then assessed by means of computer-based single- and dual-tasks requiring an additional top-down deployment of attention for the parallel processing of visual or auditory stimuli. Errorless performance at computer-based tasks was reached at month 12 and maintained until month 29 after stroke. A bottom-up manipulation was then implemented by reducing target diameter. Following this change, more than 50% of contralesional targets were omitted, mostly under dual-tasking. At months 40 and 41 the same task revealed a significant (but not complete) reduction in the number of contralesional omissions. Ipsilesional targets were, in contrast, still errorless detected. The coupling of a bottom-up (target change) and a top-down (dual-tasking) manipulation revealed the presence of a long-lasting spontaneous recovery from contralesional spatial awareness deficits. In contrast, neither manipulation was effective when implemented separately. After having excluded the potential confound of practice effects, it was concluded that not only the presence but also the time course of hemispatial neglect strongly depends on the degree of attentional engagement required by the task.

A review on functional and structural brain connectivity in numerical cognition

Only recently has the complex anatomo-functional system underlying numerical cognition become accessible to evaluation in the living brain. We identified 27 studies investigating brain connectivity in numerical cognition. Despite considerable heterogeneity regarding methodological approaches, populations investigated, and assessment procedures implemented, the results provided largely converging evidence regarding the underlying brain connectivity involved in numerical cognition. Analyses of both functional/effective as well as structural connectivity have consistently corroborated the assumption that numerical cognition is subserved by a fronto-parietal network including (intra)parietal as well as (pre)frontal cortex sites. Evaluation of structural connectivity has indicated the involvement of fronto-parietal association fibers encompassing the superior longitudinal fasciculus dorsally and the external capsule/extreme capsule system ventrally. Additionally, commissural fibers seem to connect the bilateral intraparietal sulci when number magnitude information is processed. Finally, the identification of projection fibers such as the superior corona radiata indicates connections between cortex and basal ganglia as well as the thalamus in numerical cognition. Studies on functional/effective connectivity further indicated a specific role of the hippocampus. These specifications of brain connectivity augment the triple-code model of number processing and calculation with respect to how gray matter areas associated with specific number-related representations may work together.

Prism adaptation and spatial neglect: the need for dose-finding studies

Spatial neglect is a devastating disorder in 50–70% of right-brain stroke survivors, who have problems attending to, or making movements towards, left-sided stimuli, and experience a high risk of chronic dependence. Prism adaptation is a promising treatment for neglect that involves brief, daily visuo-motor training sessions while wearing optical prisms. Its benefits extend to functional behaviors such as dressing, with effects lasting 6 months or longer. Because one to two sessions of prism adaptation induce adaptive changes in both spatial-motor behavior (Fortis et al., 2011) and brain function (Saj et al., 2013), it is possible stroke patients may benefit from treatment periods shorter than the standard, intensive protocol of ten sessions over two weeks—a protocol that is impractical for either US inpatient or outpatient rehabilitation. Demonstrating the effectiveness of a lower dose will maximize the availability of neglect treatment. We present preliminary data suggesting that four to six sessions of prism treatment may induce a large treatment effect, maintained three to four weeks post-treatment. We call for a systematic, randomized clinical trial to establish the minimal effective dose suitable for stroke intervention.

Ready, set, point: the effects of alertness on prism adaptation in healthy adults

Prism adaptation (PA) is a promising rehabilitation technique for visuo-spatial neglect, an attention disorder that is characterized by spatial attention deficits (i.e., deficits in orienting). PA involves visuo-motor adaptation to rightward shifting prism goggles. Following goggle removal, this adaptation results in leftward shifts in visuo-motor aiming and amelioration of spatial neglect. Even though some studies clearly support the beneficial effects of PA for spatial neglect, not all studies find benefits, thus it remains unclear how PA effects could be improved. Taking advantage of the known interactions between orienting and alerting reported in the attention literature (i.e., alerting enhances orienting function; e.g., Ishigami and Klein in J Individ Differ 30:220-237. doi: 10.1027/1614-0001.30.4.220 , 2009, in J Neurosci Methods 190:117-28. doi: 10.1016/j.jneumeth.2010.04.019 , 2010; Robertson et al. in Nature 395:169-72. doi: 10.1038/25993 , 1998), we examined the effects of alerting tones on PA with healthy young and older adults. We found that the effects of alerting on PA with young adults were negative, while there was a positive effect with older adults, specifically on a visuo-motor outcome task. Thus, enhancement of PA effects by alerting may be age specific and task specific. Therefore, we can conclude that while the impact of alerting tones is not always positive, further research in patients with neglect may be warranted.

White matter lesional predictors of chronic visual neglect: a longitudinal study

Chronic visual neglect prevents brain-damaged patients from returning to an independent and active life. Detecting predictors of persistent neglect as early as possible after the stroke is therefore crucial to plan the relevant interventions. Neglect signs do not only depend on focal brain lesions, but also on dysfunction of large-scale brain networks connected by white matter bundles. We explored the relationship between markers of axonal degeneration occurring after the stroke and visual neglect chronicity. A group of 45 patients with unilateral strokes in the right hemisphere underwent cognitive testing for neglect twice, first at the subacute phase (<3 months after onset) and then at the chronic phase (>1 year). For each patient, magnetic resonance imaging including diffusion sequences was performed at least 4 months after the stroke. After masking each patient's lesion, we used tract-based spatial statistics to obtain a voxel-wise statistical analysis of the fractional anisotropy data. Twenty-seven patients had signs of visual neglect at initial testing. Only 10 of these patients had recovered from neglect at follow-up. When compared with patients without neglect, the group including all subacute neglect patients had decreased fractional anisotropy in the second (II) and third (III) branches of the right superior longitudinal fasciculus, as well as in the splenium of the corpus callosum. The subgroup of chronic patients showed reduced fractional anisotropy in a portion the splenium, the forceps major, which provides interhemispheric communication between regions of the occipital lobe and of the superior parietal lobules. The severity of neglect correlated with fractional anisotropy values in superior longitudinal fasciculus II/III for subacute patients and in its caudal portion for chronic patients. Our results confirm a key role of fronto-parietal disconnection in the emergence and chronic persistence of neglect, and demonstrate an implication of caudal interhemispheric disconnection in chronic neglect. Splenial disconnection may prevent fronto-parietal networks in the left hemisphere from resolving the activity imbalance with their right hemisphere counterparts, thus leading to persistent neglect.

Hearing and music in unilateral spatial neglect neuro-rehabilitation

Unilateral spatial neglect (USN) is an attention deficit in the contralesional side of space which occurs after a cerebral stroke, mainly located in the right hemisphere. USN patients are disabled in all daily activities. USN is an important negative prognostic factor of functional recovery and of socio-professional reinsertion. Thus, patient rehabilitation is a major challenge. As this deficit has been described in many sensory modalities (including hearing), many sensory and poly-sensory rehabilitation methods have been proposed to USN patients. They are mainly based on visual, tactile modalities and on motor abilities. However, these methods appear to be quite task-specific and difficult to transfer to functional activities. Very few studies have focused on the hearing modality and even fewer studies have been conducted in music as a way of improving spatial attention. Therefore, more research on such retraining needs is neccessary in order to make reliable conclusions on its efficiency in long-term rehabilitation. Nevertheless, some evidence suggests that music could be a promising tool to enhance spatial attention and to rehabilitate USN patients. In fact, music is a material closely linked to space, involving common anatomical and functional networks. The present paper aims firstly at briefly reviewing the different procedures of sensory retraining proposed in USN, including auditory retraining, and their limits. Secondly, it aims to present the recent scientific evidence that makes music a good candidate for USN patients’ neuro-rehabilitation.

Can the exploration of left space be induced implicitly in unilateral neglect?

The purpose of the present study was to explore the ability of neglect patients to detect and exploit the predictive value of a cue to respond more quickly and accurately to targets on their contralesional side in a Posner spatial cueing task. The majority of the cues (i.e. 80%) were invalid, indicating that the target would appear on the opposite side, although patients were not informed of this bias. Our results demonstrate that some neglect patients were able to extract the cue's predictability and use it to orient faster toward the left. This cueing effect was present even in patients who were subsequently unable to describe the predictive character of the cues, and thus was not modulated by reportable awareness of the cue-target relation.

Large-scale changes in network interactions as a physiological signature of spatial neglect

The relationship between spontaneous brain activity and behaviour following focal injury is not well understood. Here, we report a large-scale study of resting state functional connectivity MRI and spatial neglect following stroke in a large (n=84) heterogeneous sample of first-ever stroke patients (within 1-2 weeks). Spatial neglect, which is typically more severe after right than left hemisphere injury, includes deficits of spatial attention and motor actions contralateral to the lesion, and low general attention due to impaired vigilance/arousal. Patients underwent structural and resting state functional MRI scans, and spatial neglect was measured using the Posner spatial cueing task, and Mesulam and Behavioural Inattention Test cancellation tests. A principal component analysis of the behavioural tests revealed a main factor accounting for 34% of variance that captured three correlated behavioural deficits: visual neglect of the contralesional visual field, visuomotor neglect of the contralesional field, and low overall performance. In an independent sample (21 healthy subjects), we defined 10 resting state networks consisting of 169 brain regions: visual-fovea and visual-periphery, sensory-motor, auditory, dorsal attention, ventral attention, language, fronto-parietal control, cingulo-opercular control, and default mode. We correlated the neglect factor score with the strength of resting state functional connectivity within and across the 10 resting state networks. All damaged brain voxels were removed from the functional connectivity:behaviour correlational analysis. We found that the correlated behavioural deficits summarized by the factor score were associated with correlated multi-network patterns of abnormal functional connectivity involving large swaths of cortex. Specifically, dorsal attention and sensory-motor networks showed: (i) reduced interhemispheric functional connectivity; (ii) reduced anti-correlation with fronto-parietal and default mode networks in the right hemisphere; and (iii) increased intrahemispheric connectivity with the basal ganglia. These patterns of functional connectivity:behaviour correlations were stronger in patients with right- as compared to left-hemisphere damage and were independent of lesion volume. Our findings identify large-scale changes in resting state network interactions that are a physiological signature of spatial neglect and may relate to its right hemisphere lateralization.

The hybrid model of attentional control: New insights into hemispheric asymmetries inferred from TMS research

Several competing theories on the mechanisms underlying attentional control have emerged over the years that, despite their substantial differences, all emphasize the importance of hemispheric asymmetries. Transcranial magnetic stimulation (TMS) has proven particularly successful in teasing them apart by selective perturbation of the dorsal and ventral fronto-parietal network. We here critically review the TMS literature and show that hemispheric asymmetries within the dorsal attention network differ between parietal and frontal cortex. Specifically, posterior parietal cortex seems to be characterized by a contralateral bias of each hemisphere and competition between them. In contrast, the right frontal eye field seems to be involved in shifting attention toward both hemifields, whereas left frontal eye field is only involved on shifting attention toward the contralateral hemifield. In the light of presented evidence, we propose to revise the functional-anatomical model originally proposed by Corbetta and Shulman (2011, 2002) and introduce a hybrid model of hemispheric asymmetries in attentional control.

Behavioural asymmetries on the greyscales task: The influence of native reading direction

Reliable leftward attentional and perceptual biases demonstrated in a variety of visuospatial tasks have been found to deviate from the left in research examining the influence of scanning habits. The aim of the current research was to examine the influence of native script direction on pseudoneglect during the greyscales task in a representative sample of native right-to-left readers. Fifty-four native left-to-right readers and 43 right-to-left readers completed the greyscales task, which required judging the darker of two left-right mirrored brightness gradients. Native left-to-right readers demonstrated a left response bias on the greyscales task, whereas right-to-left readers failed to demonstrate a bias, however, both groups responded more quickly when making leftward choices. The research suggests that the strength of attentional biases are influenced by behavioural biases, such as scanning habits, and neural and anatomical asymmetries in the right parietal and frontal cortices. Thus, to improve the clinical utility of the greyscales task for diagnosing neglect, right-to-left readers should be examined to fully understand the normal range of biases displayed by neurologically healthy individuals.

Reading direction shifts visuospatial attention: an Interactive Account of attentional biases

A growing amount of evidence confirms the influence of reading and writing habits on visuospatial processing, although this phenomenon has been so far testified mainly as a lateralized shift of a single behavioral sign (e.g., line bisection), with lack of proof from pure right-to-left readers. The present study contributed to this issue by analyzing multiple attentional and motor indexes in monolingual Italian (i.e., reading from left-to-right), and monolingual (i.e., reading from right-to-left) and bilingual Israeli (i.e., reading from right-to-left in Hebrew but also from left-to-right in English) participants' visuospatial performance. Subjects were administered a computerized standard star cancellation task and a modified version in which English letters and words were replaced by Hebrew ones. Tasks were presented on a graphics tablet, allowing recording of both chronometric and spatial parameters (i.e., measured in (x, y) vector coordinates). Results showed that reading direction modulated the on-line visuomotor performance (i.e., left-to-right vs. right-to-left shifts) from the beginning (i.e., first mark) to the end of the task (i.e., spatial distribution of omissions and subjective epicenter). Additionally, the spatial bias observed in a computerized line bisection task was also related to the participants' habitual reading direction. Overall, the results favor the proposal of an Interactive Account of visuospatial asymmetries, according to which both cultural factors, such as the directional scanning associated with language processing, and biological factors, such as hemispheric specialization, modulate visuospatial processing. Results are discussed in light of recent behavioral and neuroanatomical findings.

Functional fractionation of the stimulus-driven attention network

A novel, salient event in the environment powerfully captures attention. This stimulus-driven attentional capture not only includes orienting of attention toward the event, but also an evaluative process to determine the behavioral significance and appropriate response to the event. Whereas a network of human brain regions composed of prefrontal and temporoparietal regions have been associated with stimulus-driven attention, the neural substrates of orienting have never been teased apart from those of evaluative processes. Here we used fMRI to measure the human brain's response to the temporally extended presentations of salient, task-irrelevant stimuli, and found a clear functional dissociation in the stimulus-driven attention network; the anterior insula and cingulate cortex showed transient orienting responses to the onsets and offsets of the stimuli, whereas the temporoparietal cortex exhibited sustained activity throughout event evaluation. The lateral prefrontal cortex was implicated in both attentional and evaluative processes, pointing to its central, integrative role in stimulus-driven attention.

Visual neglect: is there a relationship between impaired spatial working memory and re-cancellation?

In visual search tasks, neglect patients tend to explore and repeatedly re-cancel stimuli on the ipsilesional side, as if they did not realize that they had previously examined the rightward locations favoured by their lateral bias. The aim of this study was to explore the hypothesis that a spatial working memory deficit explains these ipsilesional re-cancellation errors in neglect patients. For the first time, we evaluated spatial working memory and re-cancellation through separate and independent tasks in a group of patients with right hemisphere damage and a diagnosis of left neglect. Results showed impaired spatial working memory in neglect patients. Compared to the control group, neglect patients cancelled fewer targets and made more re-cancellations both on the left side and on the right side. The spatial working memory deficit appears to be related to re-cancellations, but only for some neglect patients. Alternative interpretations of re-exploration of space are discussed.

Anatomo-functional study of the temporo-parieto-occipital region: dissection, tractographic and brain mapping evidence from a neurosurgical perspective

The temporo-parieto-occipital (TPO) junction is a complex brain territory heavily involved in several high-level neurological functions, such as language, visuo-spatial recognition, writing, reading, symbol processing, calculation, self-processing, working memory, musical memory, and face and object recognition. Recent studies indicate that this area is covered by a thick network of white matter (WM) connections, which provide efficient and multimodal integration of information between both local and distant cortical nodes. It is important for neurosurgeons to have good knowledge of the three-dimensional subcortical organisation of this highly connected region to minimise post-operative permanent deficits. The aim of this dissection study was to highlight the subcortical functional anatomy from a topographical surgical perspective. Eight human hemispheres (four left, four right) obtained from four human cadavers were dissected according to Klingler's technique. Proceeding latero-medially, the authors describe the anatomical courses of and the relationships between the main pathways crossing the TPO. The results obtained from dissection were first integrated with diffusion tensor imaging reconstructions and subsequently with functional data obtained from three surgical cases, all resection of infiltrating glial tumours using direct electrical mapping in awake patients. The subcortical limits for performing safe lesionectomies within the TPO region are as follows: within the parietal region, the anterior horizontal part of the superior longitudinal fasciculus and, more deeply, the arcuate fasciculus; dorsally, the vertical projective thalamo-cortical fibres. For lesions located within the temporal and occipital lobes, the resection should be tailored according to the orientation of the horizontal associative pathways (the inferior fronto-occipital fascicle, inferior longitudinal fascicle and optic radiation). The relationships between the WM tracts and the ventricle system were also examined. These results indicate that a detailed anatomo-functional awareness of the WM architecture within the TPO area is mandatory when approaching intrinsic brain lesions to optimise surgical results and to minimise post-operative morbidity.

Tricks of the mind: Visual hallucinations as disorders of attention

Visual hallucinations are common across a number of disorders but to date, a unifying pathophysiology underlying these phenomena has not been described. In this manuscript, we combine insights from neuropathological, neuropsychological and neuroimaging studies to propose a testable common neural mechanism for visual hallucinations. We propose that 'simple' visual hallucinations arise from disturbances within regions responsible for the primary processing of visual information, however with no further modulation of perceptual content by attention. In contrast, 'complex' visual hallucinations reflect dysfunction within and between the Attentional Control Networks, leading to the inappropriate interpretation of ambiguous percepts. The incorrect information perceived by hallucinators is often differentially interpreted depending on the time-course and the neuroarchitecture underlying the interpretation. Disorders with 'complex' hallucinations without retained insight are proposed to be associated with a reduction in the activity within the Dorsal Attention Network. The review concludes by showing that a variety of pathological processes can ultimately manifest in any of these three categories, depending on the precise location of the impairment.

Presence of Motor-Intentional Aiming Deficit Predicts Functional Improvement of Spatial Neglect With Prism Adaptation

Background Spatial neglect is a debilitating disorder for which there is no agreed on course of rehabilitation. The lack of consensus on treatment may result from systematic differences in the syndrome's characteristics, with spatial cognitive deficits potentially affecting perceptual-attentional "Where" or motor-intentional "Aiming" spatial processing. Heterogeneity of response to treatment might be explained by different treatment impacts on these dissociated deficits: prism adaptation, for example, might reduce Aiming deficits without affecting Where spatial deficits.

OBJECTIVE

Here, we tested the hypothesis that classifying patients by their profile of Where-versus-Aiming spatial deficit would predict response to prism adaptation and specifically that patients with Aiming bias would have better recovery than those with isolated Where bias. Methods We classified the spatial errors of 24 subacute right stroke survivors with left spatial neglect as (1) isolated Where bias, (2) isolated Aiming bias, or (3) both. Participants then completed 2 weeks of prism adaptation treatment. They also completed the Behavioral Inattention Test and Catherine Bergego Scale (CBS) tests of neglect recovery weekly for 6 weeks. Results As hypothesized, participants with only Aiming deficits improved on the CBS, whereas those with only Where deficits did not improve. Participants with both deficits demonstrated intermediate improvement. Conclusion These results support behavioral classification of spatial neglect patients as a potential valuable tool for assigning targeted, effective early rehabilitation.

Brain Activation during Masked and Unmasked Semantic Priming: Commonalities and Differences

Using fMRI during a lexical decision task, we investigated the neural correlates of semantic priming under masked and unmasked prime presentation conditions in a repeated measurement design of the same group of 24 participants (14 women). The task was to discriminate between pseudowords and words. Masked and unmasked prime words differed in their degree of semantic relatedness with target stimuli. Neural correlates of priming were defined as significantly different neural activations upon semantically unrelated minus related trials. Left fusiform gyrus, left posterior inferior frontal gyrus, and bilateral pre-SMA showed priming effects independent of the masking condition. By contrast, bilateral superior temporal gyri, superior parietal lobules, and the SMA proper demonstrated greater neural priming in the unmasked compared with the masked condition. The inverted contrast (masked priming minus unmasked priming) did not show significant differences even at lowered thresholds of significance. The conjoint effects of priming in the left fusiform gyrus suggest its involvement as a direct consequence of the neural organization of semantic memory. Activity in brain regions showing significantly more neural priming in the unmasked condition possibly reflected participants' evaluation of the prime–target relationship, presumably in the context of semantic matching. The present results therefore indicate that masked and unmasked semantic priming partially depend on dissociable mechanisms at the neural and most likely also at the functional level.

Visual Scanning Training for Neglect after Stroke with and without a Computerized Lane Tracking Dual Task

Neglect patients typically fail to explore the contralesional half-space. During visual scanning training, these patients learn to consciously pay attention to contralesional target stimuli. It has been suggested that combining scanning training with methods addressing non-spatial attention might enhance training results. In the present study, a dual task training component was added to a visual scanning training (i.e., Training di Scanning Visuospaziale - TSVS; Pizzamiglio et al., 1990). Twenty-nine subacute right hemisphere stroke patients were semi-randomly assigned to an experimental (N = 14) or a control group (N = 15). Patients received 30 training sessions during 6 weeks. TSVS consisted of four standardized tasks (digit detection, reading/copying, copying drawings, and figure description). Moreover, a driving simulator task was integrated in the training procedure. Control patients practiced a single lane tracking task for 2 days a week during 6 weeks. The experimental group was administered the same training schedule, but in weeks 4-6 of the training, the TSVS digit detection task was combined with lane tracking on the same projection screen, so as to create a dual task (computerized visual reaction time task designed for training). Various neglect tests and driving simulator tasks were administered before and after training. No significant group and interaction effects were found that might reflect additional positive effects of dual task training. Significant improvements after training were observed in both groups taken together on most assessment tasks. Ameliorations were generally not correlated to post-onset time, but spontaneous recovery, test-retest variability, and learning effects could not be ruled out completely, since these were not controlled for. Future research might focus on increasing the amount of dual task training, the implementation of progressive difficulty levels in driving simulator tasks, and further exploration of relationships between dual task training and daily functioning.

Mapping the functional neuroanatomy of spatial neglect and human parietal lobe functions: progress and challenges

Spatial neglect is generally defined by various deficits in processing information from one (e.g., left) side of space contralateral to focal (e.g., right) hemisphere damage. Although classically associated with parietal lobe functions, there is now compelling evidence that neglect can follow lesions in many different cortical and subcortical sites, suggesting a dysfunction in distributed brain networks. In addition, neglect is likely to result from a combination of distinct deficits that co-occur due to concomitant damage affecting juxtaposed brain areas and their connections, but the exact nature of core deficits and their neural substrates still remains unclear. The present review describes recent progress in identifying functional components of the neglect syndrome and relating them to distinct subregions of parietal cortex. A comprehensive understanding of spatial neglect will require a more precise definition of cognitive processes implicated in different behavioral manifestations, as well as meticulous mapping of these processes onto specific brain circuits, while taking into account functional changes in activity that may arise in structurally intact areas subsequent to damage in distant portions of the relevant networks.

Fronto-tectal white matter connectivity mediates facilitatory effects of non-invasive neurostimulation on visual detection

The causal ability of pre-target FEF activity to modulate visual detection for perithreshold stimuli has been recently demonstrated in humans by means of non-invasive neurostimulation. Yet in spite of the network-distributed effects of these type of techniques, the white matter (WM) tracts and distant visual nodes contributing to such behavioral impact remain unknown. We hereby used individual data from a group of healthy human subjects, who received time-locked pulses of active or sham Transcranial Magnetic Stimulation (TMS) to the right Frontal Eye Field (FEF) region, and experienced increases in visual detection sensitivity. We then studied the extent to which interindividual differences in visual modulation might be dependent on the WM patterns linking the targeted area to other regions relevant for visuo-attentional behaviors. We report a statistically significant correlation between the probability of connection in a right fronto-tectal pathway (FEF-Superior Colliculus) and the modulation of visual sensitivity during a detection task. Our findings support the potential contribution of this pathway and the superior colliculus in the mediation of visual performance from frontal regions in humans. Furthermore, we also show the ability of a TMS/DTI correlational approach to contribute to the disambiguation of the specific long-range pathways driving network-wide neurostimulatory effects on behavior, anticipating their future role in guiding a more efficient use of focal neurostimulation.

Neural dynamics of neglected targets in patients with right hemisphere damage

We studied the neural correlates of target omissions in five patients with right hemisphere damage and varying signs of left spatial neglect. Benefiting from the high temporal resolution of magneto-encephalography, we directly compared brain regional synchrony events of detected and omitted left-sided targets. Results showed that before stimulus presentation, a low beta synchronization activity was specifically increased within left frontal areas before pathological response omissions of left-sided targets. In the same pre-stimulus period, there were no such beta oscillations when patients correctly detected the target, or when no target was presented. Our findings emphasize the importance of neural activity during the pre-stimulus period on subsequent stimulus processing, and highlight the consequences of episodic interruptions of large-scale interhemispheric networks on target detection. Furthermore, our data suggest that prefrontal activity is not necessarily beneficial to target detection, but can be detrimental to it.

Visual search and line bisection in hemianopia: computational modelling of cortical compensatory mechanisms and comparison with hemineglect

Hemianopia patients have lost vision from the contralateral hemifield, but make behavioural adjustments to compensate for this field loss. As a result, their visual performance and behaviour contrast with those of hemineglect patients who fail to attend to objects contralateral to their lesion. These conditions differ in their ocular fixations and perceptual judgments. During visual search, hemianopic patients make more fixations in contralesional space while hemineglect patients make fewer. During line bisection, hemianopic patients fixate the contralesional line segment more and make a small contralesional bisection error, while hemineglect patients make few contralesional fixations and a larger ipsilesional bisection error. Hence, there is an attentional failure for contralesional space in hemineglect but a compensatory adaptation to attend more to the blind side in hemianopia. A challenge for models of visual attentional processes is to show how compensation is achieved in hemianopia, and why such processes are hindered or inaccessible in hemineglect. We used a neurophysiology-derived computational model to examine possible cortical compensatory processes in simulated hemianopia from a V1 lesion and compared results with those obtained with the same processes under conditions of simulated hemineglect from a parietal lesion. A spatial compensatory bias to increase attention contralesionally replicated hemianopic scanning patterns during visual search but not during line bisection. To reproduce the latter required a second process, an extrastriate lateral connectivity facilitating form completion into the blind field: this allowed accurate placement of fixations on contralesional stimuli and reproduced fixation patterns and the contralesional bisection error of hemianopia. Neither of these two cortical compensatory processes was effective in ameliorating the ipsilesional bias in the hemineglect model. Our results replicate normal and pathological patterns of visual scanning, line bisection, and differences between hemianopia and hemineglect, and may explain why compensatory processes that counter the effects of hemianopia are ineffective in hemineglect.

Neuro-anatomical correlates of a number bisection bias: A neuropsychological voxel-based morphometry study

The number bisection tasks, whereby participants estimate the midpoint of a given number interval, is frequently used to explore the idea that numbers are spatially represented within the brain across a 'mental number line'. Some neuropsychological research supports the argument that number bisection is a spatial task, recruiting parietal brain regions, whereas other data suggest that number bisection is dissociable from spatial processing and is instead dependent on working memory in the prefrontal cortices. This study explored the anatomical correlates of deficits in the number bisection task, using voxel-based morphometry in a sample of 25 neuropsychological patients with both left and right hemisphere damage. Interestingly, impairments in number bisection were strongly associated with grey matter lesions in the left hemisphere including both frontal and prefrontal cortices, extending to inferior parietal cortex. Similar prefrontal and frontal grey matter areas were found to be associated with increased leftward deviations (underestimations of the midpoint), whereas no suprathreshold clusters were observed for rightward deviations from the midpoint. Analysis of white matter integrity revealed that lesions in the tracts connecting the parietal and frontal cortices (i.e. the superior longitudinal fasciculus) were highly associated with leftward deviation impairments in number bisection. The data suggest that there is a common parieto-frontal number processing network underlying performances on number bisection, with larger numbers represented on the left side.