Weight and see: Line bisection in neglect reliably measures the allocation of attention, but not the perception of length

The line bisection bias as a deficit of proportional reasoning - evidence from number line estimation in neglect

This study aimed to investigate whether neurological patients presenting with a bias in line bisection show specific problems in bisecting a line into two equal parts or their line bisection bias rather reflects a special case of a deficit in proportional reasoning more generally. In the latter case, the bias should also be observed for segmentations into thirds or quarters. To address this question, six neglect patients with a line bisection bias were administered additional tasks involving horizontal lines (e.g., segmentation into thirds and quarters, number line estimation, etc.). Their performance was compared to five neglect patients without a line bisection bias, 10 patients with right hemispheric lesions without neglect, and 32 healthy controls. Most interestingly, results indicated that neglect patients with a line bisection bias also overestimated segments on the left of the line (e.g., one third, one quarter) when dissecting lines into parts smaller than halves. In contrast, such segmentation biases were more nuanced when the required line segmentation was framed as a number line estimation task with either fractions or whole numbers. Taken together, this suggests a generalization of line bisection bias towards a segmentation or proportional processing bias, which is congruent with attentional weighting accounts of line bisection/neglect. As such, patients with a line bisection bias do not seem to have specific problems bisecting a line, but seem to suffer from a more general deficit processing proportions.

A systematic review of vestibular stimulation in post-stroke visual neglect

Unilateral visual neglect is a condition that negatively impacts the lives of many stroke survivors. Studies have investigated different forms of vestibular stimulation as a potential therapy, but evidence is yet to be systematically reviewed. We therefore reviewed the effects of vestibular stimulation on outcomes of neglect and activities of daily living (ADL) for people with visual neglect. We searched relevant databases up until September 2022. Eligible articles included any form of vestibular stimulation, study design, or control condition. Included participants were 18 years or older, presenting with neglect following a haemorrhagic or ischaemic stroke. Relevant outcomes were clinically validated measures of neglect and ADL. Cochrane risk of bias tools were used to assess study quality. Meta-analyses and narrative methods were used to synthesize the data. Our search returned 17 relevant studies comprising 180 participants. Meta-analyses showed no difference between galvanic vestibular stimulation and sham conditions on outcomes, whereas caloric vestibular stimulation led to improvement compared to pre-stimulation scores. Narrative syntheses showed mixed results. Clinical and methodological heterogeneity was found both within and between studies. Overall, results were inconsistent regarding the effects of vestibular stimulation as a treatment for neglect. Further trials are warranted but require more careful methodological planning.

Left Cerebellar Lesions may be Associated with an Increase in Spatial Neglect-like Symptoms

Each cerebellar hemisphere projects to the contralateral cerebral hemisphere. Previous research suggests a lateralization of cognitive functions in the cerebellum that mirrors the cerebral cortex, with attention/visuospatial functions represented in the left cerebellar hemisphere, and language functions in the right cerebellar hemisphere. Although there is good evidence supporting the role of the right cerebellum with language functions, the evidence supporting the notion that attention and visuospatial functions are left lateralized is less clear. Given that spatial neglect is one of the most common disorders arising from right cortical damage, we reasoned that damage to the left cerebellum would result in increased spatial neglect-like symptoms, without necessarily leading to an official diagnosis of spatial neglect. To examine this disconnection hypothesis, we analyzed neglect screening data (line bisection, cancellation, figure copying) from 20 patients with isolated unilateral cerebellar stroke. Results indicated that left cerebellar patients (n = 9) missed significantly more targets on the left side of cancellation tasks compared to a normative sample. No significant effects were observed for right cerebellar patients (n = 11). A lesion overlap analysis indicated that Crus II (78% overlap), and lobules VII and IX (66% overlap) were the regions most commonly damaged in left cerebellar patients. Our results are consistent with the notion that the left cerebellum may be important for attention and visuospatial functions. Given the poor prognosis typically associated with neglect, we suggest that screening for neglect symptoms, and visuospatial deficits more generally, may be important for tailoring rehabilitative efforts to help maximize recovery in cerebellar patients.

Reducing alertness does not affect line bisection bias in neurotypical participants

Alertness, or one's general readiness to respond to stimulation, has previously been shown to affect spatial attention. However, most of this previous research focused on speeded, laboratory-based reaction tasks, as opposed to the classical line bisection task typically used to diagnose deficits of spatial attention in clinical settings. McIntosh et al. (Cogn Brain Res 25:833-850, 2005) provide a form of line bisection task which they argue can more sensitively assess spatial attention. Ninety-eight participants were presented with this line bisection task, once with and once without spatial cues, and both before and after a 50-min vigilance task that aimed to decrease alertness. A single participant was excluded due to potentially inconsistent behaviour in the task, leaving 97 participants for the full analyses. While participants were, on a group level, less alert after the 50-min vigilance task, they showed none of the hypothesised effects of reduced alertness on spatial attention in the line bisection task, regardless of with or without spatial cues. Yet, they did show the proposed effect of decreased alertness leading to a lower level of general attention. This suggests that alertness has no effect on spatial attention, as measured by a line bisection task, in neurotypical participants. We thus conclude that, in neurotypical participants, the effect of alertness on spatial attention can be examined more sensitively with tasks requiring a speeded response compared to unspeeded tasks.

Spatial Neglect Therapy With the Augmented Reality App "Negami" for Active Exploration Training: A Randomized Controlled Trial on 20 Stroke Patients With Spatial Neglect

OBJECTIVE

To investigate the efficacy of the augmented reality (AR) app "Negami" as an active exploration training for the treatment of spatial neglect. Improvements of the ipsilesional attention and orientation bias (and resulting contralesional neglect) will be examined in stroke patients with spatial neglect and compared with a control group.

DESIGN

Randomized controlled trial with an experimental Negami group, consisting of patients with spatial neglect, and a group of neglect patients receiving standard neglect therapy.

SETTING

Three rehabilitation hospitals.

PARTICIPANTS

Twenty right hemispheric stroke patients with spatial neglect (N=20).

INTERVENTION

Over a period of 2 weeks, both groups received 5 training sessions per week (à 25 minutes). Neglect behavior was assessed weekly over a 5-week period, with the Negami therapy group receiving a second follow-up assessment at 1-to-2-month intervals after completion of training.

MAIN OUTCOME MEASURES

Letter Cancellation, Bells Test, Copying Task, Line Bisection Task, and a self-developed "Exploration Test".

RESULTS

Both groups improved significantly. While the Negami therapy group improved in 4 of 5 neglect tests used, the standard therapy group improved in only 1 of these tests. We observed significantly better improvement in the Negami group already after the first week of training. This difference was also significant after the end of the training as well as 1 week after the end of training and remained stable 1-2 months after the end of treatment.

CONCLUSION

Negami can be used as an effective alternative or addition to current standard neglect therapy, and may even be superior to it.

No short-term treatment effect of prism adaptation for spatial neglect: An inclusive meta-analysis

Despite 25 years of research on the topic, there is still no consensus on whether prism adaptation is an effective therapy for visuospatial neglect. We have addressed this question through a meta-analysis of the most well-controlled studies on the topic. Our main meta-analytic model included studies with a placebo/sham/treatment-as-usual control group from which data from right hemisphere stroke patients and left-sided neglect could be aggregated. The short-term treatment effects on the two commonly used standard tests for neglect, the conventional Behavioural Inattention Test (BIT-C) and cancellation test scores were combined into one random effect model justified by the fact that 89% of the BIT-C score is determined by cancellation tasks. With this approach, we were able to obtain a larger and more homogeneous dataset than previous meta-analyses: sixteen studies including 430 patients. No evidence for beneficial effects of prism adaptation was found. The secondary meta-analysis including data from the Catherine Bergego Scale, a functional measure of activities of daily living, also found no evidence for the therapeutic effects of prism adaptation, although half as many studies were available for this analysis. The results were consistent after the removal of influential outliers, after studies with high risk-of-bias were excluded, and when an alternative measure of effect size was considered. These results do not support the routine use of prism adaptation as a therapy for spatial neglect.

Full-field input generated from right visual field information for healthy participants reproduces performance simulating left unilateral spatial neglect in line bisection

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre when bisecting a horizontal line. This pathological phenomenon may be explained as a result of greater dependence on the right endpoint in the external reference frame (Koyama et al., Brain Cogn, 35, 1997, 271; McIntosh et al., Cogn Brain Res, 25, 2005, 833). Ishiai et al. (Brain, 112, 1989, 1485) reported that once patients with USN fixated on a certain point on the right part of the presented line, they persisted with this point and marked the subjective midpoint there without leftward searches. Ishiai et al.'s interpretation was that the patients saw a totalised line representation that extended equidistantly to the right and left sides, based on the information of the attended rightward extent from the subjective midpoint. Accordingly, we used virtual reality goggles (VRG) and devised a mirror-image viewing (MV) condition that showed a full-field view based on the right visual field information to test whether healthy participants would thereby show neglect-like bisection performance. The participants were 30 healthy adults (22-37 years old; 15 women and 15 men). In this condition, 96.7% (29/30) of participants were judged to exhibit USN-like performance of line bisection, indicating the effectiveness of MV condition to simulate USN. The novelty of the present study lies in the use of a task-specific intervention of neglect-like visuospatial processing during line bisection without attempting to modify the direction of spatial attention. This approach may contribute to the understanding of the pathological visuospatial processing of USN.

Neglecting the bottom space: an object-based disorder? A two-case observational study

Altitudinal neglect is an atypical form of spatial neglect where brain-damaged patients neglect the lower, or sometimes the upper, part of the space. Our understanding of this phenomena is limited, with unknown occurrence across different reference frames, such as distance (peripersonal vs. extrapersonal) and system of reference (egocentric vs. allocentric). Two patients with acute bilateral (P1) or right hemispheric (P2) stroke, with signs of bottom altitudinal neglect, underwent an extensive evaluation of neglect within 10 days post-stroke. Assessments involved altitudinal neglect and unilateral spatial neglect (USN) in peripersonal space, exploring egocentric and allocentric signs and in extrapersonal space. Compared to a control group of 15 healthy age-matched subjects, patients showed allocentric and egocentric left USN in peripersonal space, and mostly allocentric signs of altitudinal neglect. No signs of neglect were evidenced in extrapersonal space. Altitudinal neglect could thus present as an allocentric form of spatial neglect, suggesting that allocentric representations may not only affect the deployment of attentional resources along horizontal dimensions but also operate along vertical dimensions. Future studies should deepen our understanding of altitudinal neglect, eventually leading to further unravel spatial processes that control attention, their corresponding brain mechanisms, and implications for patients' rehabilitation and functional outcome.

[Clinical examination of spatial neglect and other disorders of spatial cognition]

Neglect occurring after stroke, neoplasms or degenerative processes can lead to considerable disability in everyday life as can other disorders of spatial orientation. Therefore, a dedicated examination and early diagnostic classification are obligatory. Behavioral tests are helpful in this respect, enabling the clinician to obtain an initial overview of the existing deficits even at the patient's bedside. The clinical (bedside) examination of spatial neglect as well as the corresponding differential diagnostic procedure for the clarification of (possibly additionally or exclusively existing) hemianopia and extinction, as well as the examination of disorders of visuospatial perception, visuoconstructive disorders, topographic disorders, Bálint's syndrome, simultanagnosia, and optic ataxia are presented. The presentation is based on the newly revised (year 2023) guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) on this subject area.

Physically real and virtual reality exposed line bisection response patterns: visuospatial attention allocation in virtual reality

INTRODUCTION

To understand the nature of hemispatial attention allocation in virtual reality (VR), a line bisection task (LBT) was administered both in a real environment and a virtual environment to assess the rate of pseudoneglect. The mental construction of real and virtual environments was assumed to increase visuospatial activity in right hemisphere-related cognitive processes; an alteration in the activity that manifests in the direction and rate of line bisection lateral error.

METHODS

In the present study, fifty-one right-handed healthy college students were recruited. They performed a line bisection task in real and virtual environments.

RESULTS

The obtained data showed that LBT errors in real and VR environments were correlated and individually consistent. Furthermore, a leftward LBT error was found in the physically real environment, however, in a VR the line bisection bias drifted towards the right hemispace. Participants with a lower right-handedness score showed a lower rate of left LBT bias in a real environment, but in VR, their LBT error showed a stronger rightwards error.

DISCUSSION

Participants showed an individually consistent pattern in both real and VR environments, but VR-induced visuospatial reality construction was associated with rightward LBT bias in a virtual environment.

Negami: An Augmented Reality App for the Treatment of Spatial Neglect After Stroke

BACKGROUND

A widely applied and effective rehabilitation method for patients experiencing spatial neglect after a stroke is "visual exploration training." Patients improve their ipsilesional bias of attention and orientation by training exploration movements and search strategies toward the contralesional side of space. In this context, gamification can have a positive influence on motivation for treatment and thus on the success of treatment. In contrast to virtual reality applications, treatment enhancements through augmented reality (AR) have not yet been investigated, although they offer some advantages over virtual reality.

OBJECTIVE

This study aimed to develop an AR-based app (Negami) for the treatment of spatial neglect that combines visual exploration training with active, contralesionally oriented rotation of the eyes, head, and trunk.

METHODS

The app inserts a virtual element (origami bird) into the real space surrounding the patient, which the patient explores with the camera of a tablet. Subjective reports from healthy elderly participants (n=10) and patients with spatial neglect after stroke (n=10) who trained with the new Negami app were analyzed. Usability, side effects, and game experience were assessed by various questionnaires.

RESULTS

Training at the highest defined difficulty level was perceived as differently challenging but not as frustrating by the group of healthy elderly participants. The app was rated with high usability, hardly any side effects, high motivation, and entertainment. The group of patients with spatial neglect after stroke consistently evaluated the app positively on the dimensions of motivation, satisfaction, and fun.

CONCLUSIONS

The Negami app represents a promising extension by adding AR to traditional exploration training for spatial neglect. Through participants' natural interaction with the physical surrounding environment during playful tasks, side effects as symptoms of cybersickness are minimized and patients' motivation appeared to markedly increase. The use of AR in cognitive rehabilitation programs and the treatment of spatial neglect seems promising and should receive further investigation.

Disconnectomics to unravel the network underlying deficits of spatial exploration and attention

Spatial attention and exploration are related to a predominantly right hemispheric network structure. However, the areas of the brain involved and their exact role is still debated. Spatial neglect following right hemispheric stroke lesions has been frequently viewed as a model to study these processes in humans. Previous investigations on the anatomical basis on spatial neglect predominantly focused on focal brain damage and lesion-behaviour mapping analyses. This approach might not be suited to detect remote areas structurally spared but which might contribute to the behavioural deficit. In the present study of a sample of 203 right hemispheric stroke patients, we combined connectome lesion-symptom mapping with multivariate support vector regression to unravel the complex and disconnected network structure in spatial neglect. We delineated three central nodes that were extensively disconnected from other intrahemispheric areas, namely the right superior parietal lobule, the insula, and the temporal pole. Additionally, the analysis allocated central roles within this network to the inferior frontal gyrus (pars triangularis and opercularis), right middle temporal gyrus, right temporal pole and left and right orbitofrontal cortices, including interhemispheric disconnection. Our results suggest that these structures-although not necessarily directly damaged-might play a role within the network underlying spatial neglect in humans.

Study protocol of transcranial electrical stimulation at alpha frequency applied during rehabilitation: A randomized controlled trial in chronic stroke patients with visuospatial neglect

BACKGROUND

A frequent post stroke disorder in lateralized attention is visuospatial neglect (VSN). As VSN has a strong negative impact on recovery in general and independence during daily life, optimal treatment is deemed urgent. Next to traditional stroke treatment, non-invasive brain stimulation offers the potential to facilitate stroke recovery as a complementary approach. In the present study, visual scanning training (VST; the current conventional treatment) will be combined with transcranial alternating current stimulation (tACS) to evaluate the additive effects of repeated sessions of tACS in combination with six-weeks VST rehabilitation.

METHODS

In this double-blind randomized placebo-controlled intervention study (RCT), we will compare the effects of active tACS plus VST to sham (placebo) tACS plus VST, both encompassing 18 VST training sessions, 40 minutes each, during 6 weeks. Chronic stroke patients with VSN (> 6 months post-stroke onset) are considered eligible for study participation. In total 22 patients are needed for the study. The primary outcome is change in performance on a cancellation task. Secondary outcomes are changes in performance on a visual detection task, two line bisection tasks, and three measures to assess changes in activities of daily living. Assessment is at baseline, directly after the first and ninth training session, after the last training session (post training), and 1 week and 3 months after termination of the training (follow-up).

DISCUSSION

If effective, a tACS-VST rehabilitation program could be implemented as a treatment option for VSN.

TRIAL REGISTRATION

ClinicalTrials.gov ; registration number: NCT05466487; registration date: July 18, 2022 retrospectively registered; https://clinicaltrials.gov/ct2/show/NCT05466487.

Ambiguous handedness and visuospatial pseudoneglect in schizotypy in physical and computer-generated virtual environments

Virtual reality (VR) technology has increased clinical attention in the health care of schizophrenia spectrum disorders in both diagnoses of the symptoms and assessment of schizotypal traits. However, the exact nature of VR-induced positive treatment effect in schizotypy is still unknown. In this study, VR technology was used as a non-invasive neurocognitive trigger to test the asymmetric visuospatial representational instability found in individuals with high schizotypy. The study aimed to reveal the brain functional hemispheric laterality in physical and virtual realities in individuals with schizotypal traits. Fifty-one healthy, right-handed participants (24 males and 27 females) were enrolled through public advertisements. Hemispheric functional asymmetry was measured by the Line Bisection Task (LBT). The results revealed that (a) LBT bias in the physical reality showed a handedness-related leftward pseudoneglect, however, similar handedness-related pseudoneglect in VR has not been found. (b) Comparing LBT bias in physically real and VR environments showed rightward drift in VR environments independently to the degree of handedness. (c) The schizotypy has no association with handedness, however, the cognitive schizotypy is related to the LBT bias. Higher cognitive schizotypy in VR associated with left hemispatial pseudoneglect. In conclusion, schizotypy is associated with ambiguous behavioral and cognitive functional laterality. In individuals with high cognitive schizotypy, the VR environment enhanced the representational articulation of the left hemispace. This effect may be originated from the enhancement of the right hemisphere overactivation and is followed by a lower mental control of the overt behavior.

On line bisection: Validity and reliability of online measures of pseudoneglect

This study assessed pseudoneglect using line bisection and perceptual landmark tasks in two matched online sessions. Line bisection bias was characterized by the traditional measure of Directional Bisection Error (DBE), and by Endpoint Weightings Bias (EWB), derived from an "endpoint weightings" analysis, made possible by the independent manipulation of left and right endpoints. EWB is proposed to index the relative attentional allocation to the two ends of the line. The expected leftward bias (pseudoneglect) was found, with larger effect sizes for EWB (d = -0.34 in both sessions) than for DBE (-0.22 in Session 1 and -0.14 in Session 2). Although EWB was slightly less reliable than DBE, it was more sensitive to pseudoneglect, and the endpoint weightings method has further advantages, including the option of an additional measure of non-lateralized attention. A substantial proportion of participants had difficulty following the instructions for the landmark task, which highlights the need for clear instructions and performance checks for this task. This study shows that line bisection can be used to measure pseudoneglect online, and provides grounds to suggest that the task should routinely include the independent manipulation of left and right endpoints, so that an endpoint weightings analysis can be performed.

Hemispheric functional segregation facilitates target detection during sustained visuospatial attention

Visuospatial attention is strongly lateralized, with the right hemisphere commonly exhibiting stronger activation and connectivity patterns than the left hemisphere during attentive processes. However, whether such asymmetry influences inter‐hemispheric information transfer and behavioral performance is not known. Here we used a region of interest (ROI) and network‐based approach to determine steady‐state fMRI functional connectivity (FC) in the whole cerebral cortex during a leftward/rightward covert visuospatial attention task. We found that the global FC topology between either ROIs or networks was independent on the attended side. The side of attention significantly modulated FC strength between brain networks, with leftward attention primarily involving the connections of the right visual network with dorsal and ventral attention networks in both the left and right hemisphere. High hemispheric functional segregation significantly correlated with faster target detection response times (i.e., better performance). Our findings suggest that the dominance of the right hemisphere in visuospatial attention is associated with an hemispheric functional segregation that is beneficial for behavioral performance.

Efficacy of Unilateral and Bilateral Parietal Transcranial Direct Current Stimulation on Right Hemispheric Stroke Patients With Neglect Symptoms: A Proof-of-Principle Study

Different transcranial direct current stimulation (tDCS) protocols have been tested to improve visuospatial neglect (VSN). So far, methodological heterogenity limits reliable conclusions about optimal stimualtion set-up. With this proof-of-principle study behavioral effects of two promising (uni- vs. bilateral) stimulation protocols were directly compared to gain more data for an appropriate tDCS protocol in subacute neglect patients. Notably, each tDCS set-up was combined with an identical sham condition to improve comparability. In a double-blind sham-controlled cross-over study 11 subacute post-stroke neglect patients received 20 minutes or 30 seconds (sham) tDCS (2 mA, 0.8 A/m²) parallel to neglect therapy randomized in unilateral (anode-reference: P4-Fp2 10-20 electroencephalography [EEG] system) and bilateral manner (anode-cathode: P4-P3) and 48h wash-out in-between. Before and immediately after stimulation performance were measured in cancellation task (bell test), and line bisection (deviation error). Significant difference between active and assigned sham condition was found in line bisection but not cancellation task. Particularly, deviation error was reduced after bilateral tDCS (hedges g^* = 0.6) compared to bilateral sham, no such advantage were obtained for unilateral stimulation (hedges g^* = 0.2). Using a direct comparison approach findings add further evidence that stimulating both hemispheres (bilateral) is superior in alleviating VSN symptoms than unilateral stimulation in subacute neglect.

Endpoints and viewpoints on spatial neglect

In this issue of the Journal of Neuropsychology, Abe and Ishiai (2022) report an experiment designed to probe the subjective experience of line bisection in neglect. A re-analysis of their data can also offer insights into how best to characterise neglect performance for this and other tasks. We show that sensitive measures of neglect can be obtained by quantifying the difference in the influence (or 'weighting') that each endpoint has on the response. The right endpoint is dramatically more influential than the left in people with neglect performing line bisection and endpoint reproduction tasks. This supports the view that neglect may limit the ability to simultaneously represent two locations, so that the response is determined primarily with respect to the right endpoint. We also discuss Abe and Ishiai's conclusion that bisection responses in neglect are accompanied by the subjective experience of a complete line extending equally to either side of the chosen midpoint.

Mental representation of a line when patients with left unilateral spatial neglect bisect it: A study with an endpoint reproduction task

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre. Based on the previous findings (e.g., Ishiai et al. 1989, Brain, 112, 1485), we hypothesized that the patients with left USN may see the representational image of a line that extends equally towards either side of the subjective midpoint depending not upon the information about the leftward extent. The present study tested whether patients with left USN would place the subjective midpoint at the centre of their mental representation of the line. The participants were 10 patients with left USN and 10 neurologically healthy controls. We devised a new 'endpoint reproduction task' using a computer display with a touch panel to seek the representational image when patients with left USN bisect lines and asked the participants to reproduce the location of the right or left endpoint after bisecting lines. The results showed that the representational image of the bisected line depends primarily on the location of the objective right endpoint, not on the location of the objective left endpoint in space. The analyses of the estimated right and left representational extents confirmed our hypotheses that patients with left USN would bisect a line seeing the representational line image that centred across their subjective midpoint. We believe that the findings of the present study with the use of the endpoint reproduction task will contribute to a better understanding of the visuospatial process underlying line bisection of patients with left USN.

The effect of cognitive load on horizontal and vertical spatial asymmetries

Healthy individuals typically show a leftward attentional bias in the allocation of spatial attention along the horizontal plane, a phenomenon known as pseudoneglect, which relies on a right hemispheric dominance for visuospatial processing. Also, healthy individuals tend to overestimate the upper hemispace when orienting attention along the vertical plane, a phenomenon that may depend on asymmetric ventral and dorsal visual streams activation. Previous research has demonstrated that when attentional resources are reduced due to increased cognitive load, pseudoneglect is attenuated (or even reversed), due to decreased right-hemispheric activations. Critically, whether and how the reduction of attentional resources under load modulates vertical spatial asymmetries has not been addressed before. We asked participants to perform a line bisection task both with and without the addition of a concurrent auditory working memory task with lines oriented either horizontally or vertically. Results showed that increasing cognitive load reduced the typical leftward/upward bias with no difference between orientations. Our data suggest that the degree of cognitive load affects spatial attention not only in the horizontal but also in the vertical plane. Lastly, the similar effect of load on horizontal and vertical judgements suggests these biases may be related to only partially independent mechanisms.

Exploring the relationship between impaired illness awareness and visuospatial inattention in patients with schizophrenia

Anosognosia, described as impairment in an individual's ability to perceive and understand their illness, and visuospatial inattention commonly co-occur as a result of structural brain lesions in the right posterior parietal area. Anosognosia or impaired illness awareness is a common feature of schizophrenia that contributes to medication nonadherence and poor clinical outcomes. A recent pilot study suggests patients with impaired illness awareness have a rightward visuospatial bias. We aimed to examine this relationship in a large sample of patients. This study consisted of 106 patients with schizophrenia spectrum disorder (henceforth, schizophrenia) and 20 healthy controls. Visuospatial attention was assessed using the line bisection test (LBT). Illness awareness was assessed using the VAGUS self-report version. A Welch's t-test was used to examine differences in LBT scores between patients with schizophrenia and healthy controls. Correlation analyses between LBT and VAGUS scores were performed in patients with schizophrenia. For exploratory purposes, intra-subject reliability of the LBT was also examined using a two-way mixed intra-class correlation coefficient (ICC). There were no differences in LBT scores between patients with schizophrenia and healthy controls. In patients, there were no associations between LBT and VAGUS scores. ICCs between two consecutively acquired LBTs were 0.92 (95% CI: 0.81-0.96) in patients with schizophrenia and 0.93 (95% CI: 0.81-0.97) in healthy controls. Our results, using a reliable measure, did not support our previous preliminary finding that suggested a relationship between impaired illness awareness and visuospatial bias in patients with schizophrenia. Future studies should consider more sensitive visuospatial attention tasks when testing this hypothesis.

The anatomy of spatial neglect after posterior cerebral artery stroke

Spatial neglect is a common consequence of stroke in the territory of the right middle cerebral artery. Damage to a perisylvian fronto-temporo-parietal network has been demonstrated to underlie this disorder. Less common, stroke to the posterior cerebral artery territory may also lead to spatial neglect. This study aimed to uncover the anatomical underpinnings of spatial neglect after posterior cerebral artery infarction. A sample of 50 posterior cerebral artery infarct patients was screened for spatial neglect. Neural correlates of neglect were investigated both with voxel-based lesion behaviour mapping and with region-of-interest analyses. Brain damage neither to the splenium, nor to the parahippocampal gyrus, nor to the thalamus was predictive of spatial neglect. Only damage to the perisylvian fronto-temporo-parietal network of spatial neglect was significantly associated with neglect severity. We conclude that both posterior and middle cerebral artery stroke induce spatial neglect after damage to the same perisylvian brain network. The findings contradict previous theories that postulated neural correlates of spatial neglect specifically supplied by the posterior cerebral artery. In posterior cerebral artery stroke patients, affected parts of this network are located at the border zone between the posterior and middle cerebral artery territories. Inter-individual variability in the localization of the border between both artery territories appears to mediate the occurrence of spatial neglect after posterior cerebral artery stroke.

Disconnection somewhere down the line: Multivariate lesion-symptom mapping of the line bisection error

Line Bisection is a simple task frequently used in stroke patients to diagnose disorders of spatial perception characterized by a directional bisection bias to the ipsilesional side. However, previous anatomical and behavioural findings are contradictory, and the diagnostic validity of the line bisection task has been challenged. We hereby aimed to re-analyse the anatomical basis of pathological line bisection by using multivariate lesion-symptom mapping and disconnection-symptom mapping based on support vector regression in a sample of 163 right hemispheric acute stroke patients. In line with some previous studies, we observed that pathological line bisection was related to more than a single focal lesion location. Cortical damage primarily to right parietal areas, particularly the inferior parietal lobe, including the angular gyrus, as well as damage to the right basal ganglia contributed to the pathology. In contrast to some previous studies, an involvement of frontal cortical brain areas in the line bisection task was not observed. Subcortically, damage to the right superior longitudinal fasciculus (I, II and III) and arcuate fasciculus as well as the internal capsule was associated with line bisection errors. Moreover, white matter damage of interhemispheric fibre bundles, such as the anterior commissure and posterior parts of the corpus callosum projecting into the left hemisphere, was predictive of pathological deviation in the line bisection task.

How Does Attention Alter Length Perception? A Prism Adaptation Study

How perceived size (length) of an object is influenced by attention is in debate. Prism adaptation (PA), as a type of sensory motor adaptation, has been shown to affect performance on a variety of spatial tasks in both neglect patient and healthy individuals. It has been hypothesized that PA's effects might be mediated by attentional mechanisms. In this study, we used PA to laterally shift spatial attention, and employed a precise psychophysical procedure to examine how the perceptual length of lines was influenced by this attentional shifting. Participants were presented with two separate lines in the left and right visual fields, and compared the length of the two lines. Forty-five healthy participants completed this line-length judgment task before and after a short period of adaptation to either left- (Experiment 1) or right-shifting (Experiment 2) prisms, or control goggles that did not shift the visual scene (Experiment 3). We found that participants initially tended to perceive the line presented in the left to be longer. This leftward bias of length perception was reduced by a short period of visuomotor adaptation to the left-deviating PA. However, for the right-shifting PA and plain glass goggles conditions, the initial length perception bias to the left line was unaffected. Mechanisms of this asymmetric effect of PA was discussed. Our results demonstrate that the length perception of a line can be influenced by a simple visuomotor adaptation, which might shift the spatial attention. This finding is consistent with the argument that attention can alter appearance.

Non-Spatial Impairments Affect False-Positive Neglect Diagnosis Based on Cancellation Tasks

OBJECTIVE

To diagnose egocentric neglect after stroke, the spatial bias of performance on cancellation tasks is typically compared to a single cutoff. This standard procedure relies on the assumption that the measurement error of cancellation performance does not depend on non-spatial impairments affecting the total number of cancelled targets. Here we assessed the impact of this assumption on false-positive diagnoses.

METHOD

We estimated false positives by simulating cancellation data using a binomial model. Performance was summarised by the difference in left and right cancelled targets (R-L) and the Centre of Cancellation (CoC). Diagnosis was based on a fixed cutoff versus cutoffs adjusted for the total number of cancelled targets and on single test performance versus unanimous or proportional agreement across multiple tests. Finally, we compared the simulation findings to empirical cancellation data acquired from 651 stroke patients.

RESULTS

Using a fixed cutoff, the rate of false positives depended on the total number of cancelled targets and ranged from 10% to 30% for R-L scores and from 10% to 90% for CoC scores. The rate of false positives increased even further when diagnosis was based on proportional agreement across multiple tests. Adjusted cutoffs and unanimous agreement across multiple tests were effective at controlling false positives. For empirical data, fixed versus adjusted cutoffs differ in estimation of neglect prevalence by 13%, and this difference was largest for patients with non-spatial impairments.

CONCLUSIONS

Our findings demonstrate the importance of considering non-spatial impairments when diagnosing neglect based on cancellation performance.

Can auditory cues improve visuo-spatial neglect? Results of two pilot studies

Although neglect is known to be a multimodal deficit, current interventions often address the visual modality only. Experimental studies, however, found that neglect patients can partially overcome their spatial inattention temporarily when being exposed to auditory cues that move towards the neglected side of space. Two pilot studies investigated the impact of dynamic auditory cueing on egocentric neglect severity in a clinical-therapeutic setting. In both studies, the patient groups received 15 sessions of intervention. Study 1, designed as double-blinded trial with a historical control group, targeted severely impaired early-acute patients who listened to music or audio books which were presented as moving dynamically from right to left. Results showed a reduction in egocentric neglect severity that persisted after therapy termination in the intervention but not in the historical control group. In study 2, based on the comparison with reported effect sizes of previous studies, dynamic meaningful auditory cues and optokinetic stimulation were combined in a computer-based training. Both studies found a significant reduction of neglect severity. Results provide evidence for the reduction of egocentric neglect severity after repetitive auditory cueing therapy in both severely and moderately impaired patients. Our promising findings should be verified thoroughly in randomized-controlled trials.

Using machine learning-based lesion behavior mapping to identify anatomical networks of cognitive dysfunction: Spatial neglect and attention

Previous lesion behavior studies primarily used univariate lesion behavior mapping techniques to map the anatomical basis of spatial neglect after right brain damage. These studies led to inconsistent results and lively controversies. Given these inconsistencies, the idea of a wide-spread network that might underlie spatial orientation and neglect has been pushed forward. In such case, univariate lesion behavior mapping methods might have been inherently limited in detecting the presumed network due to limited statistical power. By comparing various univariate analyses with multivariate lesion-mapping based on support vector regression, we aimed to validate the network hypothesis directly in a large sample of 203 newly recruited right brain damaged patients. If the exact same correction factors and parameter combinations (FDR correction and dTLVC for lesion size control) were used, both univariate as well as multivariate approaches uncovered the same complex network pattern underlying spatial neglect. At the cortical level, lesion location dominantly affected the temporal cortex and its borders into inferior parietal and occipital cortices. Beyond, frontal and subcortical gray matter regions as well as white matter tracts connecting these regions were affected. Our findings underline the importance of a right network in spatial exploration and attention and specifically in the emergence of the core symptoms of spatial neglect.

Culturally influenced performance on tasks of line bisection and symbol cancellation in Arabs

The objective of this study was to administer line bisection (LB) and symbol cancellation (SC) tasks on a sample of healthy Arabs in Saudi Arabia, to determine if normative performance would differ from that of the Western population. A total of 136 healthy individuals were enrolled. Deviation direction from the veridical center and percentage deviation scores (PDS) were determined for LB. The overall performance on SC was calculated. Differences according to gender, education and age were measured. Out of the 2,287 times lines were bisected, 1025 (44.82%) deviated rightward (p < 0.0001). Mean (SD) PDS showed a rightward bias 1.57(3.4), (p < 0.0001). Rightward deviation odds modestly increased with age (OR 1.04, P 0.038). In SC, 63% started searching from the left and 67.5% used a horizontal strategy. The mean (SD) performance score was 0.468 (0.248) with no significant cancellation asymmetry. Female gender, education, and age significantly associated with performance. No correlation was found between the two tasks (p = 0.09). Line bisection error biases in Arabs are opposite of Western biases. Scanning for symbols started on the left side; however, this was smaller than that seen in existing Western reports. Normative performances are different from Western studies, but similarly influenced by the same demographic variables.

Leftward Optical Shift Induces Bias in Line Bisection: A Study with Healthy Subjects Using a Head-mounted Display

Objective

The purpose of this study was to verify the effect on spatial perception in healthy young subjects of an unconscious leftward optical shift created by a head-mounted display (HMD) with an offset camera.

Methods

We recruited 40 healthy right-handed adults who were divided into four groups according to the hand used in the tests and the visual direction displayed by the HMD (centered or 10° left). Each of the four groups (n = 10) undertook line bisection tasks across four combinations of variables: using a finger/stick or a mouse to point at a touch panel located 60 or 120 cm away from the subject.

Results

According to the results, regardless of the hand used, when the index finger or a stick was used (reaching condition), the line bisection point was displaced significantly to the left of the center. Additionally, a major left-displacement trend was observed in the short-distance reaching task, which did not require the use of a stick. In contrast, the long-distance task required a stick to be used, and the left displacements were all smaller than those for the short-distance tasks that used the index finger.

Conclusion

This finding may be explained by the subjects having sufficient experience coordinating hand and eye movements in the condition where they used their dominant hand and reached with their own arms without using a stick.

The Influence of Focused and Sustained Spatial Attention on the Allocation of Spatial Attention

OBJECTIVE

The objective of this study was to evaluate the impact of directed and sustained attention on the allocation of visuospatial attention. Healthy people often have left lateral and upward vertical spatial attentional biases. However, it is not known whether there will be an increase in bias toward the attended portion of the stimulus when volitional spatial attention is allocated to a portion of a stimulus, whether there are asymmetrical spatial alterations of these biases, and how sustained attention influences these biases.

METHODS

We assessed spatial bias in 36 healthy, right-handed participants using a variant of horizontal and vertical line bisections. Participants were asked to focus on one or the other end of vertical or horizontal lines or entire vertical or horizontal lines, and then to bisect the line either immediately or after a 20 second delay.

RESULTS

We found a significant main effect of attentional focus and an interaction between attentional focus and prolonged viewing with delayed bisection. Focusing on a certain portion of the line resulting in a significant deviation toward the attended portion and prolonged viewing of the line prior to bisection significantly enhanced the degree of deviation toward the attended portion.

CONCLUSIONS

The enhanced bias with directed and sustained attention may be useful modifications of the line bisection test, particularly in clinical populations. Thus, future studies should determine whether prolonged viewing with delayed bisection and spatially focused attention reveals attentional biases in patients with hemispheric lesions who perform normally on the traditional line bisection test. (JINS, 2019, 25, 65-71).

The end of the line: Antagonistic attentional weightings in unilateral neglect

The line bisection task is widely used in the study of neglect. Some years ago, McIntosh, Schindler, Birchall, & Milner (2005) proposed a radical reframing of this ubiquitous task. Rather than using the traditional measure of directional bisection error, they quantified the sensitivities of the response to the changing locations of the left and right endpoints of the line, expressing these as 'endpoint weightings'. A novel prediction generated from their analysis was that manipulations increasing attention to the left end of the line should cause an increase in the left endpoint weighting and a corresponding reduction in the right endpoint weighting. The present study fulfilled this prediction, using a forced-report cueing method in a group of 12 patients with left neglect. The data confirm an antagonistic relationship between endpoint weightings, consistent with the idea that they represent the sharing of a finite resource. It is argued that the endpoint weightings model of line bisection offers a sensitive and uniquely useful framework for studying competitive lateral biases of attention in neglect, and may also provide insight into non-lateralised attentional impairments.