Anosognosia for hemiplegia: somatosensory evoked potential studies

Is Anosognosia for Left-Sided Hemiplegia Due to a Specific Self-Awareness Defect or to a Poorly Conscious Working Mode Typical of the Right Hemisphere?

This review aimed to evaluate whether the association between 'anosognosia for hemiplegia' and lesions of the right hemisphere points to a special self-awareness role of the right side of the brain, or could instead be due to a working mode typical of the right hemisphere. This latter viewpoint is consistent with a recently proposed model of human brain asymmetries that assumes that language lateralization in the left hemisphere might have increased the left hemisphere's level of consciousness and intentionality in comparison with the right hemisphere's less conscious and more automatic functioning. To assess these alternatives, I tried to ascertain whether anosognosia is greater for left-sided hemiplegia than for other disorders provoked by right brain lesions, or whether unawareness prevails in tasks more clearly related to the disruption of the right hemisphere's more automatic (and less conscious) functioning. Data consistent with the first alternative would support the existence of a specific link between anosognosia for hemiplegia and self-awareness, whereas data supporting the second option would confirm the model linking anosognosia to a poorly conscious working mode typical of the right hemisphere. Analysis results showed that the incidence of anosognosia of the highly automatic syndrome of unilateral neglect was greater than that concerning the unawareness of left hemiplegia, suggesting that anosognosia for left-sided hemiplegia might be due to the poorly conscious working mode typical of the right hemisphere.

The dynamic opponent relativity model: an integration and extension of capacity theory and existing theoretical perspectives on the neuropsychology of arousal and emotion

Arousal theory as discussed within the present paper refers to those mechanisms and neural systems involved in central nervous system activation and more specifically the systems involved in cortical activation. Historical progress in the evolution of arousal theory has led to a better understanding of the functional neural systems involved in arousal or activation processes and ultimately contributed much to our current theories of emotion. Despite evidence for the dynamic interplay between the left and right cerebral hemispheres, the concepts of cerebral balance and dynamic activation have been emphasized in the neuropsychological literature. A conceptual model is proposed herein that incorporates the unique contributions from multiple neuropsychological theories of arousal and emotion. It is argued that the cerebral hemispheres may play oppositional roles in emotion partially due to the differences in their functional specializations and in their persistence upon activation. In the presence of a threat or provocation, the right hemisphere may activate survival relevant responses partially derived from hemispheric specializations in arousal and emotional processing, including the mobilization of sympathetic drive to promote heightened blood pressure, heart rate, glucose mobilization and respiratory support necessary for the challenge. Oppositional processes and mechanisms are discussed, which may be relevant to the regulatory control over the survival response; however, the capacity of these systems is necessarily limited. A limited capacity mechanism is proposed, which is familiar within other physiological systems, including that providing for the prevention of muscular damage under exceptional demand. This capacity theory is proposed, wherein a link may be expected between exceptional stress within a neural system and damage to the neural system. These mechanisms are proposed to be relevant to emotion and emotional disorders. Discussion is provided on the possible role of currently applied therapeutic interventions for emotional disorders.

Bimanual simultaneous movements and hemispheric dominance: Timing of events reveals hard-wired circuitry for action, speech, and imagination

The evidence that speech is the marker of hemisphere of action is overwhelming. Thus, contrary to the commonly accepted belief, the evidence indicates that both sides of the body are under the same command (major hemisphere) and that the nondominant side of the body is a callosum-width farther from the major hemisphere. Substantial controversy exists, however, as to the best method for determining the laterality of motor control in an individual case. According to the new understanding, ie, the one-way callosal traffic circuitry underpinning laterality of motor control, the larger excursions of effectors located opposite (contralateral to) the command center while performing bimanual simultaneous drawing tasks provides the best noninvasive and inexpensive approach for demonstrating the laterality of the major hemisphere of a person (who is able to perform such tasks). Here, it is documented pictorially that bimanual simultaneous drawing of geometrical designs or straight lines, as well as moving the arms simultaneously from side to side (or up and down) while noting the difference of speed of the two arms (represented by the distance between the two index fingers), both provide a reliable indication of the laterality of a person’s major hemisphere. In all these maneuvers the nondominant side of the body (even the diaphragms) lags behind the dominant side by an interval equal to the interhemispheric transfer time (IHTT). This lagging behind of the nondominant side of the body in bimanual simultaneous movements is the footprint of directionality of callosal traffic underpinning the laterality of motor control evidenced by worsening of the delay of the nondominant side following callosotomy (uncoupling). Here, the historical precedence of a novel understanding in motor control together with its neurological implications in daily life as well as in laterality of seizure onset are briefly addressed, pointing out the deleterious effects of Sir Isaac Newton’s influence in neurological research on interhemispheric connectivity by suggesting symmetrical representation of visual sense of space in the human brain.

The anatomy of anosognosia for hemiplegia: a meta-analysis

Anosognosia for hemiplegia is the denial of the contralesional motor deficits that may follow brain damage. Although this disturbance has been reported in the neurological literature since the beginning of the last century, only few longitudinal studies have addressed the issue of the anatomical substrate of the disorder. Here we present a comprehensive review of the literature on anosognosia for hemiplegia from 1938 to 2001, taking into account some of its clinical, epidemiological and anatomical aspects. In particular, an attempt has been made to identify the intra-hemispheric lesion locations most frequently associated to the denial behaviour. Our review shows that anosognosia for hemiplegia most frequently occurs in association to unilateral right-sided or bilateral lesions of different brain areas (cortical and/or subcortical). It seems to be equally frequent when the damage is confined to frontal, parietal or temporal cortical structures, and may also emerge as a consequence of subcortical lesions. Interestingly, the probability of occurrence of anosognosia is highest when the lesion involves parietal and frontal structures in combination, if compared to other combinations of lesioned areas. This pattern of lesions suggests the existence of a complex cortico-subcortical circuit underlying awareness of motor acts that, if damaged, can give raise to the anosognosic symptoms.

Unawareness of deficits in neuropsychological syndromes

Damage to different regions of the brain can cause a variety of neuropsychological deficits, including specific disturbances of language, memory, perception and motor function. A significant number of brain-damaged patients are unaware of their deficits, even when they are profound and have debilitating effects on patients' performance. This article reviews clinical observations and experimental investigations concerning unawareness of deficits, considers methodological issues, and critically evaluates different interpretations of the phenomenon. An integrative theoretical framework is proposed to account for unawareness of deficits in diverse neuropsychological syndromes. Possible directions for future research are outlined.

Hemispheric lateralization of functions related to emotion

We have reviewed the evidence that processes and functions related to perception and expression of emotions are represented asymmetrically in the cerebral hemispheres. The literature describes three possible aspects of emotional lateralization: that emotions are better recognized by the right hemisphere; that control of emotional expression and related behaviors takes place principally in the right hemisphere; and that the right hemisphere is specialized for dealing with negative emotions, while the left is specialized for dealing with positive emotions. Evidence for the three hypotheses derives from methodologically diverse studies in unimpaired, brain-lesioned, and mood-disordered populations. Relatively little of the work has been precisely replicated, and conclusions rest on parallel lines of evidence from diverse sources. The present level of knowledge suggests a model of emotional control based on interactive inhibition between a right negatively biased and left positively biased hemisphere. However, the details of such a model, including the precise conditions under which emotion-related functions are lateralized, and the mechanisms of such lateralization have yet to be elucidated.

Confabulation and delusional denial: frontal lobe and lateralized influences

Various forms of confabulation, including denial of illness (e.g., paralysis, blindness), and conditions that often give rise to these disorders, such as cerebral disconnection, disinhibitory states, incomplete information reception, and "gap filling" are discussed. On the basis of clinical observation and a review of a number of studies, it appears that confabulatory states frequently are associated with cerebral damage that involves the right hemisphere, notably, the frontal (often bilaterally) and parietal lobes--areas intimately involved in arousal, attention, information regulation, and integration. With certain forms of injury, initially there appear disturbances in the organization, integration, and assimilation of ideas and associations, such that large gaps appear in the information transmitted to and received by the language axis of the left hemisphere. It is argued that in these instances, the language areas act so as to fill these "gaps" with information that, although inappropriate, is linked in some manner to the fragments received. In contrast, frontal lobe damage sometimes results in gross disinhibition and cortical overresponsiveness and, thus, speech release due to the flooding of the language axis (and other cortical regions) with tangential, fantastical, and grandiose associations. Other forms of confabulation also are reviewed briefly.

Remote effects of cerebrovascular accidents: visual evoked potentials and electrophysiological coupling

Performance on two electrophysiological tasks, EEG and VEP, of patients who had sustained either a right or left middle cerebral artery CVA was examined. The occurrence of a stroke disrupted electrophysiological functioning of brain regions beyond the ischemic focus of the CVA, and these remote effects persisted beyond the period of transient diaschisis. CVA reduced the electrophysiological concordance between brain regions as reflected in EEG coupling and VEP intercorrelation procedures, and the disruption was more severe if the CVA affected the right as opposed to left middle cerebral artery. Techniques for characterizing the abnormal event-related potentials of CVA subjects are reviewed, and some possible theoretical explanations of the functional communication and remote effects are offered.

Evoked potentials in the clinical neurosciences

The use of evoked potentials for the evaluation of disorders of the nervous system has become a most valuable aid to the neurosurgeon and neurologist, often providing information of critical value without recourse to invasive techniques. In order to employ these techniques, it is helpful to understand the principles of evoked potential electrogenesis and the methodology used for analysis of evoked potential clinical data. This article is aimed at providing the clinical neurosurgeon with this type of information and with a review of current clinical applications in this rapidly developing field.