Exploring auditory neglect: Anatomo-clinical correlations of auditory extinction

Auditory motion stimulation as an add-on therapeutical approach is feasible, enjoyable, and associated with a significant improvement of neglect outcome: A non-randomized, controlled group-matched study

Auditory motion stimulation is a promising new therapeutical approach for visual neglect, whereby patients listen to music which repeatedly moves from the ipsi - to the contralateral hemispace. In this study, we investigated the feasibility, enjoyability, and efficacy of auditory motion simulation in an inpatient neurorehabilitation setting. 30 patients with left-sided visual neglect due to a right-hemispheric subacute stroke participated in the study. 15 patients were included prospectively and received 45 minutes of auditory motion stimulation per day for three weeks in addition to best possible standard neglect therapy. 15 further patients - who were matched based on neglect severity at admission, time since stroke, rehabilitation duration, and age - received best possible standard neglect therapy alone and served as a control group. Feasibility was assessed using remote time tracking, whereas enjoyability was measured with the Flow State Scale for Rehabilitation Tasks (FSSRT). Efficacy was evaluated using video-oculography during free visual exploration (FVE) at admission, discharge, and after three months. Our findings indicate that auditory motion stimulation is feasible and enjoyed by patients. Auditory motion stimulation significantly improved visual neglect at discharge. Randomized controlled studies are needed to confirm that auditory motion stimulation represents a valuable add-on therapy for visual neglect.

Dual Representation of the Auditory Space

Auditory spatial cues contribute to two distinct functions, of which one leads to explicit localization of sound sources and the other provides a location-linked representation of sound objects. Behavioral and imaging studies demonstrated right-hemispheric dominance for explicit sound localization. An early clinical case study documented the dissociation between the explicit sound localizations, which was heavily impaired, and fully preserved use of spatial cues for sound object segregation. The latter involves location-linked encoding of sound objects. We review here evidence pertaining to brain regions involved in location-linked representation of sound objects. Auditory evoked potential (AEP) and functional magnetic resonance imaging (fMRI) studies investigated this aspect by comparing encoding of individual sound objects, which changed their locations or remained stationary. Systematic search identified 1 AEP and 12 fMRI studies. Together with studies of anatomical correlates of impaired of spatial-cue-based sound object segregation after focal brain lesions, the present evidence indicates that the location-linked representation of sound objects involves strongly the left hemisphere and to a lesser degree the right hemisphere. Location-linked encoding of sound objects is present in several early-stage auditory areas and in the specialized temporal voice area. In these regions, emotional valence benefits from location-linked encoding as well.

Comparison of uni- and multimodal motion stimulation on visual neglect: A proof-of-concept study

Spatial neglect is characterized by the failure to attend stimuli presented in the contralesional space. Typically, the visual modality is more severely impaired than the auditory one. This dissociation offers the possibility of cross-modal interactions, whereby auditory stimuli may have beneficial effects on the visual modality. A new auditory motion stimulation method with music dynamically moving from the right to the left hemispace has recently been shown to improve visual neglect. The aim of the present study was twofold: a) to compare the effects of unimodal auditory against visual motion stimulation, i.e., smooth pursuit training, which is an established therapeutical approach in neglect therapy and b) to explore whether a combination of auditory + visual motion stimulation, i.e., multimodal motion stimulation, would be more effective than unimodal auditory or visual motion stimulation. 28 patients with left-sided neglect due to a first-ever, right-hemispheric subacute stroke were included. Patients either received auditory, visual, or multimodal motion stimulation. The between-group effect of each motion stimulation condition as well as a control group without motion stimulation was investigated by means of a one-way ANOVA with the patient's visual exploration behaviour as an outcome variable. Our results showed that unimodal auditory motion stimulation is equally effective as unimodal visual motion stimulation: both interventions significantly improved neglect compared to the control group. Multimodal motion stimulation also significantly improved neglect, however, did not show greater improvement than unimodal auditory or visual motion stimulation alone. Besides the established visual motion stimulation, this proof-of-concept study suggests that auditory motion stimulation seems to be an alternative promising therapeutic approach to improve visual attention in neglect patients. Multimodal motion stimulation does not lead to any additional therapeutic gain. In neurorehabilitation, the implementation of either auditory or visual motion stimulation seems therefore reasonable.

A novel computerized assessment of manual spatial exploration in unilateral spatial neglect

Unilateral spatial neglect is a neuropsychological syndrome commonly observed after stroke and defined by the inability to attend or respond to contralesional stimuli. Typically, symptoms are assessed using clinical tests that rely upon visual/perceptual abilities. However, neglect may affect high-level representations controlling attention in other modalities as well. Here we developed a novel manual exploration test using a touch screen computer to quantify spatial search behaviour without visual input. Twelve chronic stroke patients with left neglect and 27 patients without neglect (based on clinical tests) completed our task. Four of the 12 "neglect" patients exhibited clear signs of neglect on our task as compared to "non-neglect" patients and healthy controls, and six other patients (from both groups) also demonstrated signs of neglect compared to healthy controls only. While some patients made asymmetrical responses on only one task, generally, patients with the strongest neglect performed poorly on multiple tasks. This suggests that representations associated with different modalities may be affected separately, but that severe forms of neglect are more likely related to damage in a common underlying representation. Our manual exploration task is easy to administer and can be added to standard neglect screenings to better measure symptom severity.

Prism Adaptation in M1

During prism adaptation (PA), active exposure to an optical shift results in sustained modifications of the sensorimotor system, which have been shown to expand to the cognitive level and serve as a rehabilitation technique for spatial cognition disorders. Several models based on evidence from clinical and neuroimaging studies offered a description of the cognitive and the neural correlates of PA. However, recent findings using noninvasive neurostimulation call for a reexamination of the role of the primary motor cortex (M1) in PA. Specifically, recent studies demonstrated that M1 stimulation reactivates previously vanished sensorimotor changes 1 day after PA, induces after-effect strengthening, and boosts therapeutic effects up to the point of reversing treatment-resistant unilateral neglect. Here, we articulate findings from clinical, neuroimaging, and noninvasive brain stimulation studies to show that M1 contributes to acquiring and storing PA, by means of persisting latent changes after the behavioral training is terminated, consistent with studies on other sensorimotor adaptation procedures. Moreover, we describe the hierarchical organization as well as the timing of PA mechanisms and their anatomical correlates, and identify M1 as an anatomo-functional interface between low- and high-order PA-related mechanisms.

Implicit representation of the auditory space: contribution of the left and right hemispheres

Spatial cues contribute to the ability to segregate sound sources and thus facilitate their detection and recognition. This implicit use of spatial cues can be preserved in cases of cortical spatial deafness, suggesting that partially distinct neural networks underlie the explicit sound localization and the implicit use of spatial cues. We addressed this issue by assessing 40 patients, 20 patients with left and 20 patients with right hemispheric damage, for their ability to use auditory spatial cues implicitly in a paradigm of spatial release from masking (SRM) and explicitly in sound localization. The anatomical correlates of their performance were determined with voxel-based lesion-symptom mapping (VLSM). During the SRM task, the target was always presented at the centre, whereas the masker was presented at the centre or at one of the two lateral positions on the right or left side. The SRM effect was absent in some but not all patients; the inability to perceive the target when the masker was at one of the lateral positions correlated with lesions of the left temporo-parieto-frontal cortex or of the right inferior parietal lobule and the underlying white matter. As previously reported, sound localization depended critically on the right parietal and opercular cortex. Thus, explicit and implicit use of spatial cues depends on at least partially distinct neural networks. Our results suggest that the implicit use may rely on the left-dominant position-linked representation of sound objects, which has been demonstrated in previous EEG and fMRI studies.