Assessing Older Adults' Functional Visual Performance Using the Performance Quality Rating Scale

Visual impairment has distinct impacts on the activities of older adults. Quantifying the functional impact of visual loss would facilitate targeted rehabilitation. The objectives of this study were to: (1) develop an observational assessment of the functional visual performance of older adults using the Performance Quality Rating Scale (PQRS); (2) test the feasibility and inter-rater agreement in a pilot sample of older adults with visual impairment. A convenience sample of older adults with vision loss (N = 20) performed seven pre-selected activities. Performance was videoed (N = 126 videos) and rated by two raters using specific operational definitions. All participants completed the seven activities with the given resources and 90% of videos were successfully rated using the developed PQRS. Inter-rater agreement was substantial (weighted Kappa = 0.71; 95% confidence interval [CI] = [0.64, 0.79]) for all activities. The developed PQRS for functional vision is feasible, with substantial inter-rater agreement, to assess functional vision of older adults in an outpatient setting.

Prevalence, Severity and Impact of Visuospatial Neglect in Geriatric Stroke Rehabilitation, a Cross-Sectional Study

OBJECTIVES

Visuospatial neglect (VSN) is a common cognitive deficit of lateralized attention after stroke and can have a negative influence on patients' daily activities, community participation, and caregiver burden. VSN prevalence has been investigated in several mixed-age populations, but rarely in only an older population. As the population in geriatric rehabilitation (GR) is understudied and VSN may influence rehabilitation goals in GR (return home), we examined the prevalence of VSN as well as associations between VSN (severity) and population characteristics and the impact of VSN on functioning, length of stay, and discharge destination after GR.

DESIGN

Multicenter cross-sectional study.

SETTING AND PARTICIPANTS

Stroke patients admitted to GR.

METHODS

Three VSN tests (Star cancelation task, Line bisection task, and Catherine Bergego Scale) were administered in the first 2 weeks of GR admission. To examine VSN severity, a composite score was calculated based on scores of the 3 tests.

RESULTS

A total of 114 stroke patients were included [55.3% female; mean age 80.2 (SD 8.0) years]. VSN prevalence was 47.4%, in which allocentric and egocentric neglect were more prevalent than VSN during activities of daily living. Participants with VSN spent more days in GR compared to participants without VSN (median 68.5 vs 35.5 days) and had fewer home returns. In addition, VSN participants showed less mobility, lower cognitive functioning, and less independence during self-care compared to participants without VSN. Mobility, self-care, cognition, duration of rehabilitation, and home return were negatively associated with VSN severity.

CONCLUSIONS AND IMPLICATIONS

VSN is very prevalent in the GR stroke population. VSN severely hampers older people during daily activities and their rehabilitation process and, therefore, has a major personal and societal impact. Accordingly, systematic assessment of VSN in the early phase of geriatric rehabilitation with multiple VSN screening tests is recommended.

Is Positive Affect as a Trait Related to Higher Heart Rate Variability in a Stressful Situation?

Most of the studies on the effect of trait positive affect (PA) and cardiovascular activity have focused on heart rate (HR) and blood pressure (BP) rather than heart rate variability (HRV). However, trait PA might sustain homeostasis for the autonomic system (ANS) by reducing activity in the sympathetic system (SNS) and increasing the activity in the parasympathetic system (PNS). A common index for the PNS is the vagal tone measured indirectly through HRV. The present study assessed whether trait PA influences cardiovascular response to various stress tasks by monitoring participants' HRV measured by RMSSD (root mean square of successive differences) along with HR and interbeat interval (IBI). A total of 54 participants performed various cognitive tasks and Trier Social Stress Tasks while their vital signs were monitored, and trait PA was measured with PANAS. The cognitive tasks included both high- and low-stress tasks, including fatigue-inducing 20 min Stroop tasks. The results showed overall higher HRV as measured by RMSSD for participants who have higher levels of trait PA, indicating more PNS activity compared with low-trait-PA individuals, particularly at the end of the task performance during the fatigue induction. High-trait-PA individuals also had a lower HR during the fatigue-inducing task and a higher IBI. The results support previous work by further indicating a more adaptive response and consequently better emotional regulation for high-trait-PA individuals in a complex, prolonged task setting.

Study of attentional deficits (unilateral spatial neglect) in Moroccan adolescents attending school-Rabat Sale Kenitra region

Objectives

Attention is an essential part of cognitive functions for all learning in the school environment. The screening of attentional deficits constitutes an important field of research, given its relationship with other cognitive functions and the neurocognitive profiling of Moroccan adolescents in school.

Materials and Methods

A study was conducted over 3 months. A comparative and predictive method is used, the Bells test, to assess the state of neglect of these students, as well as the detection of attention deficit.

Results

Two hundred and fifty students participated, including 152 girls [60.4%] and 98 boys [39.6%], the average age is 16.77 ± 1.23 years, range: 14-21, divided into three school levels: Common core (TC) 27.6%, 1st-year baccalaureate 50.8%, and 2nd-year baccalaureate 21.6%. This study found that 18.4% of the students had attentional deficits and 4% had a unilateral spatial neglect pattern in young adolescents in school.

Conclusion

The Bells Test is a useful screening tool to detect these attentional deficits. This implies that attentional disorders negatively influence the academic and motor performance of the subjects. This implies that attentional disorders negatively influence the academic and motor performance of the subjects and, therefore, increase the percentage of school failure.

Barriers to patient recruitment in a poststroke neurorehabilitation multicenter trial in Brazil

There is a high demand for stroke rehabilitation in the Brazilian public health system, but most studies that have addressed rehabilitation for unilateral spatial neglect (USN) after stroke have been performed in high-income countries. Therefore, the aim of this study was to analyze USN patient recruitment in a multicenter noninvasive brain stimulation clinical trial performed in Brazil and to provide study design recommendations for future studies. We evaluated the reasons for exclusion of patients from a multicenter, randomized, double-blinded clinical trial of rehabilitation of USN patients after stroke. Clinical and demographic variables were compared between the included and excluded patients. A descriptive statistical analysis was performed. Only 173 of the 1953 potential neglect patients (8.8%) passed the initial screening. After screening evaluation, 87/173 patients (50.3%) were excluded for clinical reasons. Cognitive impairment led to the exclusion of 21/87 patients (24.1%). Low socioeconomic status led to the exclusion of 37/173 patients (21.4%). Difficulty obtaining transportation to access treatment was the most common reason for their exclusion (16/37 patients, 43.3%). The analyzed Brazilian institutions have potential for conducting studies of USN. The recruitment of stroke survivors with USN was restricted by the study design and limited financial support. A history of cognitive impairment, intracranial stenting or craniectomy, and lack of transportation were the most common barriers to participating in a multicenter noninvasive brain stimulation trial among patients with USN after stroke.

Driving With Hemianopia X: Effects of Cross Traffic on Gaze Behaviors and Pedestrian Responses at Intersections

Purpose

We conducted a driving simulator study to investigate the effects of monitoring intersection cross traffic on gaze behaviors and responses to pedestrians by drivers with hemianopic field loss (HFL).

Methods

Sixteen HFL and sixteen normal vision (NV) participants completed two drives in an urban environment. At 30 intersections, a pedestrian ran across the road when the participant entered the intersection, requiring a braking response to avoid a collision. Intersections with these pedestrian events had either (1) no cross traffic, (2) one approaching car from the side opposite the pedestrian location, or (3) two approaching cars, one from each side at the same time.

Results

Overall, HFL drivers made more (p < 0.001) and larger (p = 0.016) blind- than seeing-side scans and looked at the majority (>80%) of cross-traffic on both the blind and seeing sides. They made more numerous and larger gaze scans (p < 0.001) when they fixated cars on both sides (compared to one or no cars) and had lower rates of unsafe responses to blind- but not seeing-side pedestrians (interaction, p = 0.037). They were more likely to demonstrate compensatory blind-side fixation behaviors (faster time to fixate and longer fixation durations) when there was no car on the seeing side. Fixation behaviors and unsafe response rates were most similar to those of NV drivers when cars were fixated on both sides.

Conclusion

For HFL participants, making more scans, larger scans and safer responses to pedestrians crossing from the blind side were associated with looking at cross traffic from both directions. Thus, cross traffic might serve as a reminder to scan and provide a reference point to guide blind-side scanning of drivers with HFL. Proactively checking for cross-traffic cars from both sides could be an important safety practice for drivers with HFL.

Change blindness in simulated driving in individuals with homonymous visual field loss

Individuals with homonymous visual field loss (HVFL) fail to perceive visual information that falls within the blind portions of their visual field. This places additional burden on memory to represent information in their blind visual field, which may make visual changes in the scene more difficult to detect. Failing to detect changes could have serious implications in the context of driving. A change blindness driving simulator experiment was conducted with individuals with HVFL (n = 17) and in those with normal vision (NV; n = 16) where changes (pedestrians appearing) were triggered based on the driver’s gaze location. Gaze was used to ensure that the location of the change was visible before and after the change occurred. There were wide individual differences in both vision groups, ranging from no change blindness to more than 33% of events. Those with HVFL had more change blindness than those with NV (16.7% vs. 6.3%, p < 0.001) and more change blindness to pedestrians appearing in their blind than seeing hemifield (34.6% vs. 10.4%, p < 0.001). Further, there was more change blindness for events appearing in the seeing hemifield for those with HVFL than normal vision (p = 0.023). These results suggest that individuals with HVFL may be more susceptible to failures of awareness, such as change blindness, than individuals with normal vision. Increased risk for failures of awareness may result in motor vehicle crashes where the driver fails to notice the other road user (looked-but-failed-to-see incidents).

Driving With Hemianopia VII: Predicting Hazard Detection With Gaze and Head Scan Magnitude

Purpose

One rehabilitation strategy taught to individuals with hemianopic field loss (HFL) is to make a large blind side scan to quickly identify hazards. However, it is not clear what the minimum threshold is for how large the scan should be. Using driving simulation, we evaluated thresholds (criteria) for gaze and head scan magnitudes that best predict detection safety.

Methods

Seventeen participants with complete HFL and 15 with normal vision (NV) drove through 4 routes in a virtual city while their eyes and head were tracked. Participants pressed the horn as soon as they detected a motorcycle (10 per drive) that appeared 54 degrees eccentricity on cross-streets and approached toward the driver.

Results

Those with HFL detected fewer motorcycles than those with NV and had worse detection on the blind side than the seeing side. On the blind side, both safe detections and early detections (detections before the hazard entered the intersection) could be predicted with both gaze (safe 18.5 degrees and early 33.8 degrees) and head (safe 19.3 degrees and early 27 degrees) scans. However, on the seeing side, only early detections could be classified with gaze (25.3 degrees) and head (9.0 degrees).

Conclusions

Both head and gaze scan magnitude were significant predictors of detection on the blind side, but less predictive on the seeing side, which was likely driven by the ability to use peripheral vision. Interestingly, head scans were as predictive as gaze scans.

Translational Relevance

The minimum scan magnitude could be a useful criterion for scanning training or for developing assistive technologies to improve scanning.

Influence of Static Magnetic Field Stimulation on the Accuracy of Tachystoscopically Presented Line Bisection

Transcranial static magnetic stimulation (tSMS) has been known to reduce human cortical excitability. Here, we investigated whether tSMS would modulate visuo-spatial cognition in healthy humans. Subjects performed a visuo-spatial task requiring judgements about the symmetry of pre-bisected lines. Visual stimuli consisted of symmetrically or asymmetrically transected lines, tachystoscopically presented for 150 ms on a computer monitor. Task performance was examined before, immediately after, and 10 min after tSMS/sham stimulation of 20 min over the posterior parietal cortex (PPC: P4 from the international 10-20 system) or superior temporal gyrus (STG: C6). Nine out of 16 subjects misjudged pre-bisected lines by consistently underestimating the length of the right-side segment (judging lines to be exactly pre-bisected when the transector was located to the left of the midpoint, or judging the left-side segment to be longer when the transector was located at the midpoint). In these subjects showing a leftward bias, tSMS over the right STG reduced the magnitude of the leftward bias. This did not occur with tSMS over the right PPC or sham stimulation. In the remaining right-biased subjects, no intervention effect was observed with any stimulation. Our findings indicate that application of tSMS over the right STG modulates visuo-spatial cognition in healthy adults.

Evaluating the Measurement Properties of the ScanCourse, a Dual-Task Assessment of Visual Scanning

IMPORTANCE

The ScanCourse is used by occupational therapists to evaluate visual scanning ability during locomotion. Its measurement properties have not been examined.

OBJECTIVE

To assess the interrater reliability, test-retest reliability, and construct validity of the ScanCourse.

DESIGN

This study involved data collection at two time points. To assess test-retest reliability, the ScanCourse was administered twice within a 2-week period. To assess interrater reliability, a second rater was present for one session. To assess level of agreement, a Bland-Altman plot was created. To assess absolute reliability, the standard error of measurement was calculated. To evaluate construct validity, the results of the ScanCourse were compared with results of the Bells Test and Trail Making Test A and B.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Forty-one patients with neurological impairments.

OUTCOMES AND MEASURES

The ScanCourse (participants identify numbered cards placed on both sides of a hallway at various heights during locomotion).

RESULTS

The ScanCourse was found to have excellent interrater reliability (intraclass correlation coefficient [ICC] [1,1] = .998; 95% confidence interval [CI] [.996-.999]), test-retest reliability (ICC [1,1] = .912; 95% CI [.811-.959]), a high level of agreement, and a low standard error of measurement (.503), and it was found to be significantly correlated with Trails A (r_s = -.436, p = .009) and B (r_s = -.364, p = .029).

CONCLUSIONS AND RELEVANCE

The assessment was found to have strong measurement properties, and it is therefore an appropriate tool for assessing dual-task visual scanning among those with neurological impairments.

WHAT THIS ARTICLE ADDS

This research demonstrates that the ScanCourse is reliable between raters and over time and that scores on the measure vary as anticipated with scores on a related measure, which provides evidence of its validity. These findings support its use in practice.

The Effects of Hemianopia on Perception of Mutual Gaze

SIGNIFICANCE

Individuals with left hemianopic field loss (HFL), especially with neglect history, may have greater difficulties than individuals with right HFL in judging the direction of another person's gaze.

PURPOSE

Individuals with HFL often show a spatial bias in laboratory-based perceptual tasks. We investigated whether such biases also manifest in a more real-world task, perception of mutual gaze direction, an important, nonverbal communication cue in social interactions.

METHODS

Participants adjusted the eye position of a life-size virtual head on a monitor at a 1-m distance until (1) the eyes appeared to be looking straight at them, or (2) the eyes were perceived to be no longer looking at them (to the right and left).

RESULTS

Participants with right HFL (n = 8) demonstrated a rightward error in line bisection but made gaze judgments within the range of normally sighted controls (n = 17). Participants with left HFL without neglect history (n = 6) made leftward errors in line bisection and had more variable gaze judgments; three had estimates of gaze direction outside the reference range. Four participants with left HFL and neglect history made estimates of gaze direction that were to the right of the reference range.

CONCLUSIONS

Our results suggest that individuals with left HFL, especially with neglect history, may have greater difficulties than individuals with right HFL in compensating for low-level spatial biases (as manifested in line bisection) when performing the more complex, higher-level task of judging gaze direction.

Robot Diagnosis Test for Egocentric and Allocentric Hemineglect

OBJECTIVE

Patients with hemineglect fail to respond to egocentric stimuli or allocentric parts of stimuli contralateral to the brain lesion. The clinical diagnosis of hemineglect mainly involves evaluation of the egocentric form, while less sensitive standardized tests exist for other forms. Our global aim is to develop an innovative integrative robot measure, the MonAmour test, combining the assessment of egocentric, allocentric and motor hemineglect. Here, we present the egocentric and allocentric evaluations.

METHODS

Thirty-five first stroke patients (25 hemineglect) and 56 age-matched healthy controls were assessed on the index test (MonAmour) and on three reference standard tests (Bells test, Apples test and Neglect subtest of the Test for Attentional Performance). Based on controls' performance, normative data were created. Validity was evaluated between the MonAmour and the reference standard tests through correlations and test sensitivity/specificity. Reliability of the MonAmour was measured with test-retest and minimal detectable change.

RESULTS

Results demonstrated moderate to strong correlations between the MonAmour and the reference standard tests (r = .40-.88, p < .001 - p = .016). The sensitivity was high (50%-96%), with accurate diagnosis of patients with hemineglect, and reliability was excellent (Intraclass Correlation Coefficient = .79-.95, p < .001).

CONCLUSIONS

The MonAmour robot test is a valid, sensitive and reliable tool that can diagnose egocentric and allocentric hemineglect. Future studies will deepen the assessment and understanding of the different forms of hemineglect by testing the motor component of the test in order to use this accurate and integrative measure in daily clinical routine.

REGISTRATION

ClinicalTrials.gov(NCT02543424).

A New Standardization of the Bells Test: An Italian Multi-Center Normative Study

Objective: The Bells Test is a cancelation task that is widely used for the diagnosis of unilateral spatial neglect (USN). With the aim of fostering more reliable use of this instrument, we set out to develop new norms adjusted for the possible influence of age, gender and education. We worked on the original version of the test.

Methods: Normative data were collected from 401 healthy participants aged between 20 and 80 years. Individual factors that could affect performance (i.e., gender, age, and years of education) were considered. We computed several indices on the Bells Test including an asymmetry score, an accuracy score and execution time. Multiple regression analyses (for time measures) and generalized linear models (for accuracy measures) were used to check for the influence of individual predictors of performance on the Bells Test.

Results: Data indicated a significant influence of age on the accuracy score and execution time variables and a marginally significant effect of education on the accuracy score variable. Wherever appropriate, cut-offs are provided for the three dependent scores on the Bells Test corrected for age and education.

Conclusion: Based on a large normative sample, the present study provides new normative data on the Bells Test, which could lead to its reliable use in the diagnosis of USN.

Evaluating the Measurement Properties of the ScanCourse, a Dual-Task Assessment of Visual Scanning

IMPORTANCE

The ScanCourse is used by occupational therapists to evaluate visual scanning ability during locomotion. Its measurement properties have not been examined.

OBJECTIVE

To assess the interrater reliability, test-retest reliability, and construct validity of the ScanCourse.

DESIGN

This study involved data collection at two time points. To assess test-retest reliability, the ScanCourse was administered twice within a 2-week period. To assess interrater reliability, a second rater was present for one session. To assess level of agreement, a Bland-Altman plot was created. To assess absolute reliability, the standard error of measurement was calculated. To evaluate construct validity, the results of the ScanCourse were compared with results of the Bells Test and Trail Making Test A and B.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Forty-one patients with neurological impairments. Outcomes and Measures: The ScanCourse (participants identify numbered cards placed on both sides of a hallway at various heights during locomotion).

RESULTS

The ScanCourse was found to have excellent interrater reliability (intraclass correlation coefficient [ICC] [1,1] = .998; 95% confidence interval [CI] [.996-.999]), test-retest reliability (ICC [1,1] = .912; 95% CI [.811-.959]), a high level of agreement, and a low standard error of measurement (.503), and it was found to be significantly correlated with Trails A (rs = -.436, p = .009) and B (rs = -.364, p = .029).

CONCLUSIONS AND RELEVANCE

The assessment was found to have strong measurement properties, and it is therefore an appropriate tool for assessing dual-task visual scanning among those with neurological impairments. What This Article Adds: This research demonstrates that the ScanCourse is reliable between raters and over time and that scores on the measure vary as anticipated with scores on a related measure, which provides evidence of its validity. These findings support its use in practice.

Measuring the Difficulty Watching Video With Hemianopia and an Initial Test of a Rehabilitation Approach

PURPOSE

If you cannot follow the story when watching a video, then the viewing experience is degraded. We measured the difficulty of following the story, defined as the ability to acquire visual information, which is experienced by people with homonymous hemianopia (HH). Further, we proposed and tested a novel rehabilitation aid.

METHODS

Participants watched 30-second directed video clips. Following each video clip, subjects described the visual content of the clip. An objective score of information acquisition (IA) was derived by comparing each new response to a control database of descriptions of the same clip using natural language processing. Study 1 compared 60 participants with normal vision (NV) to 24 participants with HH to test the hypothesis that participants with HH would score lower than NV participants, consistent with reports from people with HH that describe difficulties in video watching. In the second study, 21 participants with HH viewed clips with or without a superimposed dynamic cue that we called a content guide. We hypothesized that IA scores would increase using this content guide.

RESULTS

The HH group had a significantly lower IA score, with an average of 2.8, compared with 4.3 shared words of the NV group (mixed-effects regression, P < 0.001). Presence of the content guide significantly increased the IA score by 0.5 shared words (P = 0.03).

CONCLUSIONS

Participants with HH had more difficulty acquiring information from a video, which was objectively demonstrated (reduced IA score). The content guide improved information acquisition, but not to the level of people with NV.

TRANSLATIONAL RELEVANCE

The value as a possible rehabilitation aid of the content guide warrants further study that involves an extended period of content-guide use and a randomized controlled trial.

Noninvasive Brain Stimulations for Unilateral Spatial Neglect after Stroke: A Systematic Review and Meta-Analysis of Randomized and Nonrandomized Controlled Trials

Background

Unilateral spatial neglect (USN) is the most frequent perceptual disorder after stroke. Noninvasive brain stimulation (NIBS) is a tool that has been used in the rehabilitation process to modify cortical excitability and improve perception and functional capacity.

Objective

To assess the impact of NIBS on USN after stroke.

Methods

An extensive search was conducted up to July 2016. Studies were selected if they were controlled and noncontrolled trials examining transcranial direct current stimulation (tDCS), repetitive transcranial magnetic stimulation (rTMS), and theta burst stimulation (TBS) in USN after stroke, with outcomes measured by standardized USN and functional tests.

Results

Twelve RCTs (273 participants) and 4 non-RCTs (94 participants) proved eligible. We observed a benefit in overall USN measured by the line bisection test with NIBS in comparison to sham (SMD -2.35, 95% CI -3.72, -0.98; p = 0.0001); the rTMS yielded results that were consistent with the overall meta-analysis (SMD -2.82, 95% CI -3.66, -1.98; p = 0.09). The rTMS compared with sham also suggested a benefit in overall USN measured by Motor-Free Visual Perception Test at both 1 Hz (SMD 1.46, 95% CI 0.73, 2.20; p < 0.0001) and 10 Hz (SMD 1.19, 95% CI 0.48, 1.89; p = 0.54). There was also a benefit in overall USN measured by Albert's test and the line crossing test with 1 Hz rTMS compared to sham (SMD 2.04, 95% CI 1.14, 2.95; p < 0.0001).

Conclusions

The results suggest a benefit of NIBS on overall USN, and we conclude that rTMS is more efficacious compared to sham for USN after stroke.

Unilateral spatial neglect in the acute phase of ischemic stroke can predict long-term disability and functional capacity

OBJECTIVE

The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence.

METHODS

This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors.

RESULTS

We studied 60 patients with a median age of 68 (34-89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03-1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13-2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78-0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48-0.92], p=0.017).

CONCLUSION

The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.

Peri- and intraoperative cognitive and language assessment for surgical resection in brain eloquent structures

Neuropsychological care of patients suffering from an infiltrative glioma and candidates for a neurosurgery under awake condition with intraoperative functional mapping is a critical and mandatory stage in therapeutic management. It enables to estimate the functional impact of the tumor and, consequently, the efficacy of functional reorganization typically observed in these patients, not only to better predict surgery outcomes and select appropriate tasks for intraoperative functional mapping, but also to plan efficient and individualized postoperative cognitive rehabilitation strategies. Neuropsychological care management also enables patients to benefit from a solid psychological preparation both to the surgery and its associated transitory functional consequences, as well as provide a personalized psychological and emotional long-term support. Based on their solid experience in the peri-operative care of diffuse low-grade glioma patients, the authors thoroughly describe the different stages of neuropsychological management. Cognitive, emotional and language assessments typically used by the authors around and during surgery are reported, and different possible avenues of improvement are further discussed.

Motor Free Visual Perceptual Test: Impact of Vertical Answer Cards Position on Performance of Adults with Hemispatial Visual Neglect

Patients who have hemispatial visual neglect (HVN) have difficulty directing their attention toward the visual field contralateral to the side of the lesion. This affects their performance on perceptual assessment tests and masks related visual perceptual deficits. The aim of this study was to verify whether a vertical position of the answer cards of the Motor Free Visual Perceptual Test (MVPT) could overcome this problem. Three groups of subjects were involved in the study: 15 healthy subjects, 15 subjects who had right brain damage without HVN, and 9 subjects who had right brain damage with HVN. The presence of HVN was established by positive test results for at least one of the two tests used, the Albert Test and the Bells Test. The subjects performed the MVPT twice—once in its standard version, and once in a modified version in which the answer cards were presented in a vertical position. The equivalence between the two forms was confirmed with healthy subjects and subjects with right brain damage without HVN. Tor the subjects who had HVN, the vertical positioning of the answer cards caused significantly less interference (p < .05). The test-retest reliability coefficient for the two versions of the MVPT was 0.92–0.94.

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.

Peripheral prism glasses: effects of moving and stationary backgrounds

PURPOSE

Unilateral peripheral prisms for homonymous hemianopia (HH) expand the visual field through peripheral binocular visual confusion, a stimulus for binocular rivalry that could lead to reduced predominance and partial suppression of the prism image, thereby limiting device functionality. Using natural-scene images and motion videos, we evaluated whether detection was reduced in binocular compared with monocular viewing.

METHODS

Detection rates of nine participants with HH or quadranopia and normal binocularity wearing peripheral prisms were determined for static checkerboard perimetry targets briefly presented in the prism expansion area and the seeing hemifield. Perimetry was conducted under monocular and binocular viewing with targets presented over videos of real-world driving scenes and still frame images derived from those videos.

RESULTS

With unilateral prisms, detection rates in the prism expansion area were significantly lower in binocular than in monocular (prism eye) viewing on the motion background (medians, 13 and 58%, respectively, p = 0.008) but not the still frame background (medians, 63 and 68%, p = 0.123). When the stimulus for binocular rivalry was reduced by fitting prisms bilaterally in one HH and one normally sighted subject with simulated HH, prism-area detection rates on the motion background were not significantly different (p > 0.6) in binocular and monocular viewing.

CONCLUSIONS

Conflicting binocular motion appears to be a stimulus for reduced predominance of the prism image in binocular viewing when using unilateral peripheral prisms. However, the effect was only found for relatively small targets. Further testing is needed to determine the extent to which this phenomenon might affect the functionality of unilateral peripheral prisms in more real-world situations.

Evaluating Unilateral Spatial Neglect Post Stroke: Working Your Way Through the Maze of Assessment Choices

This study identified, using a comprehensive review of the literature, 62 standardized and nonstandardized assessment tools that exist to evaluate unilateral spatial neglect (USN). Each standardized tool was critically appraised according to its purpose (hemispace assessed), psychometric properties, and client appropriateness. The findings on the 28 standardized tools were compiled into a USN Assessment Summary Guide to facilitate clinical decision-making regarding the standardized USN assessments that are appropriate for specific clients at different phases of their recovery post stroke.

Target-to-Distractor Ratio Effects on Decision Time in the Orderly Array Shape Cancellation Task

The cancellation task is a paper-and-pencil test commonly used to assess attention or planning. This study investigated whether the decision time performance on the task was influenced by the number of targets and distractors. This study reduced the demand of planning and used an index of the decision time, an estimate of the time taken to decide whether to mark a stimulus. Forty healthy adults ( M age = 21.3 yr., SD = 1.5) performed five cancellation tasks. Four tasks were conducted with instructions to mark a detected target. The target-to-distractor ratio varied from 35/15,40/10,45/5, and 50/0, and one task with instructions to mark all stimuli (50/0), to measure the motor time to mark targets. One-way analysis of variance indicated statistically significant differences between conditions. There was a linear relationship between decision time and target-to-distractor ratio; the decision time increased as the proportion of distractors increased. The results suggested the decision time reflects the frequency of switches between responses to targets and distractors or attention modulation of processing to targets and distractors.

Selection of intraoperative tasks for awake mapping based on relationships between tumor location and functional networks

Intraoperative electrical brain mapping is currently the most reliable method to identify eloquent cortical and subcortical structures at the individual level and to optimize the extent of resection of intrinsic brain tumors. The technique allows the preservation of quality of life, not only allowing avoidance of severe neurological deficits but also facilitating preservation of high neurocognitive functions. To accomplish this goal, however, it is crucial to optimize the selection of appropriate intraoperative tasks, given the limited intrasurgical awake time frame. In this review, the authors' aim was to propose specific parameters that could be used to build a personalized protocol for each patient. They have focused on lesion location and relationships with functional networks to guide selection of intrasurgical tasks in an effort to increase reproducibility among neurooncological centers.

Clinical Utility of Cancellation on the WISC-IV

This study examined empirical evidence for clinical utility of the Wechsler Intelligence Scale for Children, fourth edition (WISC-IV) cancellation subtest by comparing data from 597 clinical and 597 matched control children. The results of dependent t and sequential logistic regression analyses demonstrated that (a) children with intellectual disabilities, motor impairments, head injuries, Autistic/Aszperger’s disorder, ADHD and learning disabilities, and mathematics disorder showed significant deficits on the cancellation subtest; (b) children with intellectual disabilities and Asperger’s disorder benefited when stimuli were randomly aligned, but children with ADHD benefited from structured conditions; (c) beyond the full-scaled IQ (FSIQ) and General Ability Index (GAI)–Cognitive Proficiency Index (CPI) discrepancy scores, the cancellation subtest added unique diagnostic power to identify children with reading disorders, mild intellectual disabilities, closed head injuries, and motor impairments. These results suggest the utility of the cancellation subtest in clinical assessment.

Influence of hemianopic visual field loss on visual motor control

BACKGROUND

Homonymous hemianopia (HH) is an anisotropic visual impairment characterized by the binocular inability to see one side of the visual field. Patients with HH often misperceive visual space. Here we investigated how HH affects visual motor control.

METHODS AND FINDINGS

Seven patients with complete HH and no neglect or cognitive decline and seven gender- and age-matched controls viewed displays in which a target moved randomly along the horizontal or the vertical axis. They used a joystick to control the target movement to keep it at the center of the screen. We found that the mean deviation of the target position from the center of the screen along the horizontal axis was biased toward the blind side for five out of seven HH patients. More importantly, while the normal vision controls showed more precise control and larger response amplitudes when the target moved along the horizontal rather than the vertical axis, the control performance of the HH patients was not different between these two target motion experimental conditions.

CONCLUSIONS

Compared with normal vision controls, HH affected patients' control performance when the target moved horizontally (i.e., along the axis of their visual impairment) rather than vertically. We conclude that hemianopia affects the use of visual information for online control of a moving target specific to the axis of visual impairment. The implications of the findings for driving in hemianopic patients are discussed.

A pilot evaluation of on-road detection performance by drivers with hemianopia using oblique peripheral prisms

Aims. Homonymous hemianopia (HH), a severe visual consequence of stroke, causes difficulties in detecting obstacles on the nonseeing (blind) side. We conducted a pilot study to evaluate the effects of oblique peripheral prisms, a novel development in optical treatments for HH, on detection of unexpected hazards when driving. Methods. Twelve people with complete HH (median 49 years, range 29-68) completed road tests with sham oblique prism glasses (SP) and real oblique prism glasses (RP). A masked evaluator rated driving performance along the 25 km routes on busy streets in Ghent, Belgium. Results. The proportion of satisfactory responses to unexpected hazards on the blind side was higher in the RP than the SP drive (80% versus 30%; P = 0.001), but similar for unexpected hazards on the seeing side. Conclusions. These pilot data suggest that oblique peripheral prisms may improve responses of people with HH to blindside hazards when driving and provide the basis for a future, larger-sample clinical trial. Testing responses to unexpected hazards in areas of heavy vehicle and pedestrian traffic appears promising as a real-world outcome measure for future evaluations of HH rehabilitation interventions aimed at improving detection when driving.

Diferenças quanto à escolaridade em adultos no desempenho no teste de cancelamento dos sinos

O papel de variáveis sociodemográficas na cognição humana, em especial da escolaridade, vem sendo estudado em indivíduos saudáveis. Esta pesquisa objetivou verificar se há diferenças entre grupos de diferentes níveis educacionais no processamento atencional visual avaliado pelo Teste de Cancelamento dos Sinos. Participaram 124 adultos jovens, distribuídos em três grupos, 5-8, 9-11 e 12 ou mais anos de educação formal, emparelhados por idade. As variáveis de acurácia e tempo, assim como os resultados qualitativos de estratégias utilizadas, foram comparados entre grupos (ANCOVA One-Way e Qui-quadrado). Observou-se uma discrepância entre dados quantitativos e qualitativos. Os grupos de diferentes escolaridades não se diferenciaram entre si quanto a acurácia e tempo; houve, porém, diferenças significativas quanto à distribuição de participantes por coluna em que o primeiro sino foi cancelado e pelas estratégias de cancelamento utilizadas. Novos estudos são relevantes com grupos de diferentes idades e com populações clínicas neurológicas e/ou psiquiátricas.

Visual Puzzles, Figure Weights, and Cancellation: Some Preliminary Hypotheses on the Functional and Neural Substrates of These Three New WAIS-IV Subtests

In this study, five consecutive patients with focal strokes and/or cortical excisions were examined with the Wechsler Adult Intelligence Scale and Wechsler Memory Scale-Fourth Editions along with a comprehensive battery of other neuropsychological tasks. All five of the lesions were large and typically involved frontal, temporal, and/or parietal lobes and were lateralized to one hemisphere. The clinical case method was used to determine the cognitive neuropsychological correlates of mental rotation (Visual Puzzles), Piagetian balance beam (Figure Weights), and visual search (Cancellation) tasks. The pattern of results on Visual Puzzles and Figure Weights suggested that both subtests involve predominately right frontoparietal networks involved in visual working memory. It appeared that Visual Puzzles could also critically rely on the integrity of the left temporoparietal junction. The left temporoparietal junction could be involved in temporal ordering and integration of local elements into a nonverbal gestalt. In contrast, the Figure Weights task appears to critically involve the right temporoparietal junction involved in numerical magnitude estimation. Cancellation was sensitive to left frontotemporal lesions and not right posterior parietal lesions typical of other visual search tasks. In addition, the Cancellation subtest was sensitive to verbal search strategies and perhaps object-based attention demands, thereby constituting a unique task in comparison with previous visual search tasks.

[Neuropsychological evaluation as a part of the neurological examination]

A systematic evaluation of cognitive function is an integral part of the neurological examination. Behavioral measures could detect functional impairment that is too subtle to be detected by current neurological procedures. Neuropsychological examination should cover both general and specific cognitive processes. The level of general attention or emotional change may affect variety of cognitive processes. Impairment of a functional system due to a focal cerebral damage results in a specific cognitive dysfunction such as aphasia, apraxia, agnosia, etc. Simplified but systematic methods to assess basic neuropsychological functions are suitable for everyday clinical examination by neurologists. A relatively short form of the cognitive status examination was devised, which covers general attention, language, calculation, praxis, visuospatial ability, directional attention and memory. Not only quantitative but also qualitative assessment of patients' performance would give clinicians valuable clues for the neuronal bases of cognitive functions.

Task-related modulation of visual neglect in cancellation tasks

Unilateral neglect involves deficits of spatial exploration and awareness that do not always affect a fixed portion of extrapersonal space, but may vary with current stimulation and possibly with task demands. Here, we assessed any 'top-down', task-related influences on visual neglect, with novel experimental variants of the cancellation test. Many different versions of the cancellation test are used clinically, and can differ in the extent of neglect revealed, though the exact factors determining this are not fully understood. Few cancellation studies have isolated the influence of top-down factors, as typically the stimuli are changed also when comparing different tests. Within each of three cancellation studies here, we manipulated task factors, while keeping visual displays identical across conditions to equate purely bottom-up factors. Our results show that top-down task demands can significantly modulate neglect as revealed by cancellation on the same displays. Varying the target/non-target discrimination required for identical displays has a significant impact. Varying the judgement required can also have an impact on neglect even when all items are targets, so that non-targets no longer need filtering out. Requiring local versus global aspects of shape to be judged for the same displays also has a substantial impact, but the nature of discrimination required by the task still matters even when local/global level is held constant (e.g. for different colour discriminations on the same stimuli). Finally, an exploratory analysis of lesions among our neglect patients suggested that top-down task-related influences on neglect, as revealed by the new cancellation experiments here, might potentially depend on right superior temporal gyrus surviving the lesion.

A new account of face apraxia based on a longitudinal study

The aim of this paper is to provide an interpretation of face apraxia which accounts also for the role of right hemisphere lesions. Thirty-one patients with left hemisphere (L/pts) and 31 patients with right hemisphere (R/pts) lesions entered a cross-sectional study to identify those presenting with either lower or upper face apraxia. The 16L/pts and 8R/pts who presented with face apraxia in the acute stage and could be retested 4 months later, were followed up longitudinally. The degree of recovery did not differ between the two groups of patients. The traditional hypothesis of face apraxia based on the presence of a left-sided praxis centre could not account for these findings. A new trade-off model of face praxis resources distributed across the two hemispheres is presented. This model, based on individual differences in the healthy brain, accounts for the presence and persistence of face apraxia in a proportion of R/pts.

Is judgement of line orientation selectively impaired in right brain damaged patients?

The judgement of line orientation test (JLOT) is widely used to assess visuo-spatial processing. Most neuropsychological studies have shown that on this task right hemisphere damaged (RHD) patients are significantly more impaired than left hemisphere damaged (LHD) patients, suggesting a dominant role of the right hemisphere in discriminating line orientation. To investigate whether other factors can affect performance on JLOT, a modified version of the test, consisting of the 30 original test items and their mirror images, was employed. In Experiment 1 normal participants were more accurate in discriminating the left lines of the original items, and the right lines of the mirror-reversed items, thus indicating that in original JLOT the stimulus arrays comprise lines on the left side that are easier to judge than lines on the right. In Experiment 2, RHD patients with visual neglect were significantly more impaired than patients without neglect, who performed similarly independently from the side of the lesion. Among patients without neglect, however, LHD patients were more accurate than RHD patients without neglect with the original items, but produced more errors than RHD patients without neglect when faced with the mirror-reversed items. Overall, the results of the present study suggest that the greater impairment on standard JLOT shown by RHD patients has to be interpreted as the by-product of the presence of visual neglect, which is more frequent following right hemisphere damage, and of the uneven distribution of the stimulus lines, which are easier to discriminate in the left space. The clinical and theoretical implications of the results are discussed.

The predictive value of longitudinal neuropsychologic assessment in the early detection of brain tumor recurrence

BACKGROUND

Neuropsychologic tests are widely used to predict the course of progressive neurologic diseases, and recent research has demonstrated the specificity of cognitive measures, even in relatively diffuse diseases. However, the cognitive effects of brain tumors of similar histology and location are known to be highly variable. The authors used the specificity of cognitive function principle to compare two models for the early detection of low-grade brain tumor recurrence prior to detection with clinically scheduled neuroimaging.

METHODS

To test the feasibility of these prediction models, 34 patients with supratentorial, low-grade brain tumors prospectively were administered serial comprehensive neuropsychologic examinations; 11 patients developed recurrent tumors during the series and 23 patients did not. A general model based on tests sensitive to malignancy and white matter disease was compared with a tumor-specific model based on indices related to each patient's tumor locus. A Cox proportional hazards model was used to identify the predictor variables that significantly changed immediately prior to recurrence.

RESULTS

Only the tumor-specific model achieved statistical significance (P < 0.02). A tumor-specific index decline of 1 standard deviation indicated a 5-fold increase in the probability of tumor recurrence.

CONCLUSIONS

Although this method needs to be tested with more frequent and regular observations and with a larger sample, these results provide evidence of the feasibility of the subject-specific model as a predictor of recurrence. The evidence of the predictive value of a tumor-specific model is consistent with studies that identify only limited, brain structure-specific cognitive decline from broad neuropsychologic batteries.

Grey scales uncover similar attentional effects in homonymous hemianopia and visual hemi-neglect

Multi-component models of visual hemi-neglect have postulated that visual hemi-neglect is characterised by various attentional deficits. A grey scales task has been developed to quantify the early, automatic, (perhaps obligatory) ipsilesional orienting of visual attention, frequently assumed as the first of these attentional deficits. Explanations for this attentional imbalance are up until now mainly formulated in terms of right hemisphere activation. This lateral attentional bias has also been demonstrated in controls, in whom it is expressed as a leftward perceptual asymmetry. We reproduced previous literature findings on a grey scales task, considering controls and neglect patients. Three patients with neglect showed an extreme ipsilesional lateral bias. This bias did not change during or after cognitive rehabilitation. Additionally, we presented this grey scale task to 32 patients with left- and right-sided homonymous hemianopia (HP). HP is the loss of sight in one visual hemi-field. The HH patients had no clinical signs of impaired lateralised attention. Results revealed that HH patients showed a similar ipsilesional bias, albeit to a lesser degree than in neglect. Left-sided HH patients presented a quantitatively similar, but qualitatively opposite bias than the right-sided HH patients. We suggest that sensory effects can be an alternative source of attentional imbalance, which can interact with the previously proposed (right) hemispheric effects. This suggests that the perceptual asymmetry in the grey scales task is not necessarily an indicator of impaired right hemisphere attention. It rather suggests a pattern of functional cerebral asymmetry, which can also be caused by asymmetric sensory input.

The effect of visual field defects on eye movements and practical fitness to drive

Eye movements of subjects with visual field defects due to ocular pathology were monitored while performing a dot counting task and a visual search task. Subjects with peripheral field defects required more fixations, longer search times, made more errors, and had shorter fixation durations than control subjects. Subjects with central field defects performed less well than control subjects although no specific impairment could be pinpointed. In both groups a monotonous relationship was observed between the visual field impairment and eye movement parameters. The use of eye movement parameters to predict viewing behavior in a complex task (e.g. driving) was limited.

Effects of upper limb unilateral isometric efforts on postural stabilization in subjects with hemiparesis

OBJECTIVE

To characterize postural stabilization during a progressive unilateral isometric abduction of the upper limb in a seated position in healthy subjects and subjects with hemiparesis.

DESIGN

Convenience sample.

SETTING

University secondary care rehabilitation center.

PATIENTS

Twelve patients with hemiparesis and 12 subjects without neurologic disorder.

INTERVENTIONS

Subjects were seated on a forceplate, with forearms fixed in cuffs mounted on a force transducer. Two trials per side of isometric abduction of arm were conducted. The orthogonal force and torque exerted was measured for each arm.

MAIN OUTCOME MEASURES

Forces at the upper limbs and at the seat, global motor performance, spasticity of upper limb, grip force, and dexterity.

RESULTS

Results of analyses of variance showed differences in the magnitude of the contralateral limb forces generated by subjects with hemiparesis and healthy subjects (p <.05). Normalized contralateral forces in the nonparetic upper limb associated with paretic isometric efforts were higher than those associated with nonparetic efforts and higher than those associated with efforts in healthy subjects.

CONCLUSION

These results suggest that postural stabilization during isometric efforts is impaired in subjects with hemiparesis.

Diagonal neglect on cancellation

Patients with right hemisphere injury frequently neglect to cancel targets primarily in the left part of the page nearest the body. Since this region is diagonally opposite the area from where such patients usually begin cancelling, near left ('diagonal') neglect may be consequent to stimulus order effects ('fatigue'). We evaluated the persistence of near left neglect in nine stroke patients when they had to cancel either the near or the far half of the page before proceeding to the other half. Our results showed that near left neglect on the page was largely unaffected by cancellation order. Furthermore, a near left gradient of omissions was established within both radial (near and far) halves of the page, as well as for the entire page. Our findings suggest that diagonal cancellation neglect is unrelated to fatigue and reflects a consistent, two-dimensional disorder of spatial attention. Such neglect may be related to the extent of the visible stimulus array, as well as to the array's location in egocentric space.

Two-dimensional cancellation neglect a review and suggested method of analysis

Directional bias on cancellation has thus far not been standardized. While cancellation tasks are primarily used to assess lateral performance asymmetries, they may also reveal two-dimensional (i.e., combined lateral and radial) neglect patterns. We propose a method to evaluate and report cancellation neglect regardless of whether the neglect pattern is strictly unilateral or two-dimensional. Our method establishes the location of the geographic center of all neglected stimuli relative to the page center by averaging their Cartesian coordinates. This "neglect center" is reported in polar coordinates to indicate its distance and direction from the page center. We apply our method to published examples of two-dimensional neglect. We find that neglect centers from different cancellation performances may not be statistically distinct even though they may occupy different quadrants. In addition, the net direction of neglect found by the coordinate method may differ from that inferred from measuring differences in quadrant omission totals. The suitability of the coordinate vs. the quadrant method will depend on the mechanism hypothesized for visuospatial exploration under particular test conditions. Using both approaches may detect different attentional biases operating during the same task. The coordinate method is appropriate for conventional cancellation testing. By incorporating the precise locations of all neglected stimuli and determining the net neglect direction in two dimensions, the technique may stimulate more comprehensive explanations for directional bias.

Ignoring left and far: an investigation of tactile neglect

The aims of this paper were to identify patients with tactile neglect, to corroborate its independence from visual neglect, to ascertain its presence along the radial dimension of space and to detect a gradient of performance, as recently reported for visual neglect. To this end eight patients with vascular right cerebral lesions and 28 healthy controls have been tested with a modified version of the tactile maze test of De Renzi et al. [Cortex, vol. 6, pp. 191-203, 1970] and a seven-test clinical battery to detect the presence of visual USN. Four patients presenting tactile USN were selected: two showed left tactile neglect while the other two showed tactile neglect for far space. The distribution of omissions showed a clear spatial gradient. Since our patients were blindfolded, neglect behaviour in the tactile domain cannot be attributed to the attractive power of visual information. However, 25% of the normal subjects were also significantly faster in the 'near' space pointing towards the possibility that neglect for 'far' space can reflect the exaggeration of a normal asymmetry.