Laterally directed arm movements and right unilateral neglect after left hemisphere damage

Spatial Neglect Subtypes, Definitions and Assessment Tools: A Scoping Review

Objective: The objective of this scoping review was to capture the reported definitions for the subtypes of neglect post stroke and map the range of assessment tools employed for each neglect subtype.

Methods: EMBASE, Emcare, Medline, and psychINFO were searched from database inception. Searching included all allied terms and mesh headings for stroke, spatial neglect, measurement, screening tools, psychometric properties. Two reviewers independently screened studies for inclusion. Primary studies with documented protocols of a spatial neglect tool for adults post stroke, with some aspect of validity or reliability were included. Two reviewers independently reviewed the documented protocols of each tool to determine the underlying subtypes and disagreements were resolved through discussion.

Results: There were 371 articles included with 292 tools used for the screening or diagnosis of neglect. The majority of studies (67%) included a tool that did not specify the neglect subtype being assessed, therefore an analysis of the underlying subtypes for each tool is presented.

Conclusions: There is no consistency with the terms used to refer to the syndrome of spatial neglect with over 200 different terms used within the included studies to refer to the syndrome as a whole or one of its subtypes. It is essential to unify the terminology and definition for each neglect subtype. There are hundreds of neglect tools available, however many are not able to differentiate presenting subtypes. It is important for clinicians and researchers to critically evaluate the neglect tools being used for the screening and diagnosis of neglect.

The 'Neglected' Personal Neglect

A review of patients with brain injury showing personal neglect is presented. The aim is to shed light on this aspect of neglect often unresearched or only indirectly investigated, and to discuss recent findings concerning the methods used to assess personal neglect, its neural correlates and its association with the more often explored aspect of extrapersonal neglect. The review was performed using PubMed and PsychInfo databases to search for papers published in the last 123 years (until January 2018). We reviewed 81 papers describing either single or group studies for a total of 2247 patients. The results of this review showed that various aspects of personal neglect are still controversial and outcomes potentially contradictory. Despite the data reported in the present review suggest that personal neglect is more frequently associated with lesions of the right hemisphere, the left hemisphere may also play an important role. Not surprisingly, personal neglect and extrapersonal neglect seem to co-occur. However double dissociations of these two forms of neglect have been reported, and they seem to dissociate both from a functional and an anatomical perspective. More recent interpretations of personal neglect suggest that it may result from a disrupted body representation. The development of reliable psychometric tools with shared diagnostic criteria is essential to identify different degrees of personal neglect for different body parts and to better refine personal neglect in comparison to extrapersonal neglect and disorders related to distortions of personal domain.

Brain networks of visuospatial attention and their disruption in visual neglect

Visual neglect is a multi-component syndrome including prominent attentional disorders. Research on the functional mechanisms of neglect is now moving from the description of dissociations in patients' performance to the identification of the possible component deficits and of their interaction with compensatory strategies. In recent years, the dissection of attentional deficits in neglect has progressed in parallel with increasing comprehension of the anatomy and function of large-scale brain networks implicated in attentional processes. This review focuses on the anatomy and putative functions of attentional circuits in the brain, mainly subserved by fronto-parietal networks, with a peculiar although not yet completely elucidated role for the right hemisphere. Recent results are discussed concerning the influence of a non-spatial attentional function, phasic alertness, on conscious perception in normal participants and on conflict resolution in neglect patients. The rapid rate of expansion of our knowledge of these systems raises hopes for the development of effective strategies to improve the functioning of the attentional networks in brain-damaged patients.

Attentional routes to conscious perception

The relationships between spatial attention and conscious perception are currently the object of intense debate. Recent evidence of double dissociations between attention and consciousness cast doubt on the time-honored concept of attention as a gateway to consciousness. Here we review evidence from behavioral, neurophysiologic, neuropsychological, and neuroimaging experiments, showing that distinct sorts of spatial attention can have different effects on visual conscious perception. While endogenous, or top-down attention, has weak influence on subsequent conscious perception of near-threshold stimuli, exogenous, or bottom-up forms of spatial attention appear instead to be a necessary, although not sufficient, step in the development of reportable visual experiences. Fronto-parietal networks important for spatial attention, with peculiar inter-hemispheric differences, constitute plausible neural substrates for the interactions between exogenous spatial attention and conscious perception.

Mechanisms of spatial attention control in frontal and parietal cortex

Theories of spatial attentional control have been largely based upon studies of patients suffering from visuospatial neglect, resulting from circumscribed lesions of frontal and posterior parietal cortex. In the intact brain, the control of spatial attention has been related to a distributed frontoparietal attention network. Little is known about the nature of the control mechanisms exerted by this network. Here, we used a novel region-of-interest approach to relate activations of the attention network to recently described topographic areas in frontal cortex [frontal eye field (FEF), PreCC/IFS (precentral cortex/inferior frontal sulcus)] and parietal cortex [intraparietal sulcus areas (IPS1-IPS5) and an area in the superior parietal lobule (SPL1)] to examine their spatial attention signals. We found that attention signals in most topographic areas were spatially specific, with stronger responses when attention was directed to the contralateral than to the ipsilateral visual field. Importantly, two hemispheric asymmetries were found. First, a region in only right, but not left SPL1 carried spatial attention signals. Second, left FEF and left posterior parietal cortex (IPS1/2) generated stronger contralateral biasing signals than their counterparts in the right hemisphere. These findings are the first to characterize spatial attention signals in topographic frontal and parietal cortex and provide a neural basis in support of an interhemispheric competition account of spatial attentional control.

Control over conflict during movement preparation: role of posterior parietal cortex

Flexible behavior in humans often requires that rapid choices be made between conflicting action plans. Although much attention has focused on prefrontal regions, little is understood about the contribution of parietal cortex under situations of response conflict. Here we show that right parietal damage associated with spatial neglect leads to paradoxical facilitation (speeding) of rightward movements in the presence of conflicting leftward response plans. These findings indicate a critical role for parietal regions in action planning when there is response competition. In contrast, patients with prefrontal damage have an augmented cost of conflict for both leftward and rightward movements. The results suggest involvement of two independent systems in situations of response conflict, with right parietal cortex being a crucial site for automatic activation of competing motor plans and prefrontal regions acting independently to inhibit action plans irrelevant to current task goals.

Unilateral Neglect is not Unilateral: Evidence for Additional Neglect of Extreme Right Space

Six patients with visuospatial neglect following right hemisphere lesions were given three tasks that assessed performance in areas of space ranging from extreme left to extreme right. A line bisection task required the patients to detect and bisect lines of four different lengths at seven left-right spatial locations, a number report task required the patients to name 11 two-digit numbers in a left-right array, and a tiling task required patients to place small black tiles over the black squares of a grid that stretched from 65 degrees left to 65 degrees right. Performance was compared with that of 20 age-matched controls. The patients showed the characteristic signs of left-side neglect in left space, extending to the central midline. Performance was relatively normal in centre-right space but all 6 patients showed signs of neglect of extreme right space (60 degrees to the right of the midline and beyond). We propose that neglect is best characterised as a bilateral, asymmetrical compression of experienced space in which the constriction extends further from the left than from the right but nevertheless affects both sides of space.

Action control in visual neglect

Patients with unilateral neglect show a variety of impairments when reaching towards objects in contralesional space. The basis of these deficits could be perceptual, motor or at one of the intermediate stages linking these processes. Here, we review studies of visually guided reaching in neglect and integrate these results with findings from normal human and monkey action control. We consider evidence which shows that neglect patients can be slow to initiate or execute reaches particularly to a contralesional target. We discuss the directional and spatial deficits that may interact to contribute to such reaching abnormalities and highlight the importance of effective target selection and on-line guidance, exploring the idea that deficits in these mechanisms underlie increased susceptibility to ipsilesional visual distraction in neglect. We also examine the relationship between optic ataxia and neglect by considering two illustrative cases, one with pure optic ataxia and the other with optic ataxia plus neglect, which reveal differences in the anatomical substrates of the two syndromes. We conclude that many patients with neglect make abnormal visually guided reaches, but the pattern of reaching deficits is highly variable, most likely reflecting heterogeneity of lesion location across subjects. Rather than being specific to the neglect syndrome, abnormalities of reaching in these patients may correspond to the extent of damage to the visuomotor control system which involves critical regions in both the parietal and frontal cortex, the white matter tracts connecting them and subcortical regions. Thus, the action control deficits in neglect may be conceptualised as a range of impairments affecting multiple stages in the visuomotor control process.

The traffic light paradigm: a reaction time task to study laterally directed arm movements

Patients with unilateral brain damage may show slowed or hypometric arm movements toward the contralesional space, as compared to movements directed towards the side of the brain lesion. The present article describes a reaction time paradigm devised to study accuracy and latency of directional arm movements in normal human subjects and brain-damaged patients. Experimental paradigms hitherto used to explore directional motor disorders often do not reliably disentangle between perceptual and motor factors, because they employ lateralized perceptual stimuli. The traffic light paradigm, instead, consists of visual stimuli presented on the vertical midline (like a traffic light) and hand responses to be produced in either hemispace. Thus, participants have to produce lateralized arm responses to central visual stimuli. Performance on this 'motor' paradigm can be contrasted with performance on a 'perceptual' reaction time task, consisting of similar, but lateralized visual stimuli and central motor responses. Results obtained with these paradigms on normal participants and brain-damaged patients are presented and discussed. These results give empirical support to the claim that the traffic light paradigm is suitable to study directional motor disorders in relative isolation from perceptual biases.