Effects of a robot intervention on visuospatial hemineglect in postacute stroke patients: a randomized controlled trial

OBJECTIVE

To evaluate the effects of an intervention using the robot device PARO on visuospatial hemineglect and activities of daily living, and its acceptance during stroke rehabilitation. PARO is an interactive robotic toy with the appearance of a baby seal, which can move, produce sounds, and react to speech and touch.

DESIGN

A randomized controlled trial.

SETTING

Hospital for neurorehabilitation.

SUBJECTS

Patients above 60 years old who have suffered their first stroke within the previous three months with left hemineglect (n = 39).

INTERVENTIONS

The PARO group (n = 21) was exposed to PARO over a period of two weeks, three times per week. The participants of the control group (n = 18) were read to aloud.

OUTCOME MEASURE

Visuospatial hemineglect was measured by a cancellation test and a Line Bisection Test, and independence in the activities of daily living was assessed by Scores of Independence Index for Neurological and Geriatric Rehabilitation (SINGER) test. The acceptance of PARO was also evaluated. Data were collected blinded at three times: baseline (T0), after two weeks of interventions (T1), and after additional two weeks as follow-up (T2).

RESULTS

Improvement of hemineglect at T1 and T2 was significantly higher in the PARO group (T1: mean (SD) = 6.23 (3.81); T2: mean (SD) = 7.85 (3.68)) compared to the control group (T1: mean (SD) = 2.66 (4.19); T2: mean (SD) = 3.33 (4.16)) (T1: P < 0.05; T2: P < 0.05).

CONCLUSION

The study showed that the use of the PARO is well accepted and can help to improve neglect symptoms in patients with subacute stroke.

[Auditory agnosia associated with bilateral putaminal hemorrhage: A case report of clinical course of recovery]

A 45-year-old right-handed man with a past history (10 years) of putaminal hemorrage presented with auditory agnosia associated with left putaminal hemorrhage. It was suspected that the auditory agnosia was due to bilateral damage in the acoustic radiations. Generalized auditory agnosia, verbal and non-verbal (music and environmental), was diagnosed by neuropsychological examinations. It improved 4 months after the onset. However, the clinical assessment of attention remained poor. The cognition for speech sounds improved slowly, but once it started to improve, the progress of improvement was rapid. Subsequently, the cognition for music sounds also improved, while the recovery of the cognition for environmental sounds remained delayed. There was a dissociation in recovery between these cognitions. He was able to return to work a year after the onset. We also reviewed the literature for cases with auditory agnosia and discuss their course of recovery in this report.

A Framework for Ethical Decision Making in the Rehabilitation of Patients with Anosognosia

Currently, the number of patients diagnosed with impaired self-awareness of their own deficits after brain injury-anosognosia-is increasing. One reason is a growing understanding of this multifaceted phenomenon. Another is the development and accessibility of alternative measurements that allow more detailed diagnoses. Anosognosia can adversely affect successful rehabilitation, as often patients lack confidence in the need for treatment. Planning such treatment can become a complex process full of ethical dilemmas. To date, there is no systematic way to deal with different aspects of anosognosia rehabilitation planning. This is the first article to present a framework for ethical decision making in establishing rehabilitation plans that are focused on increasing patients' self-awareness of their own deficits after brain injury. It concentrates especially on addressing the ethical dilemmas that may arise, and describes stepwise procedures that can be applied to distinct theoretical approaches, as well as diagnostic and rehabilitation methods. To show the flexibility of the use of this framework, alternative approaches are discussed.

Use of prism adaptation in children with unilateral brain lesion: Is it feasible?

INTRODUCTION

Unilateral visuospatial deficits have been observed in children with brain damage. While the effectiveness of prism adaptation for treating unilateral neglect in adult stroke patients has been demonstrated previously, the usefulness of prism adaptation in a pediatric population is still unknown. The present study aims at evaluating the feasibility of prism adaptation in children with unilateral brain lesion and comparing the validity of a game procedure designed for child-friendly paediatric intervention, with the ecological task used for prism adaptation in adult patients.

METHODS

Twenty-one children with unilateral brain lesion randomly were assigned to a prism group wearing prismatic glasses, or a control group wearing neutral glasses during a bimanual task intervention. All children performed two different bimanual tasks on randomly assigned consecutive days: ecological tasks or game tasks. The efficacy of prism adaptation was measured by assessing its after-effects with visual open loop pointing (visuoproprioceptive test) and subjective straight-ahead pointing (proprioceptive test).

RESULTS

Game tasks and ecological tasks produced similar after-effects. Prismatic glasses elicited a significant shift of visuospatial coordinates which was not observed in the control group.

CONCLUSION

Prism adaptation performed with game tasks seems an effective procedure to obtain after-effects in children with unilateral brain lesion. The usefulness of repetitive prism adaptation sessions as a therapeutic intervention in children with visuospatial deficits and/or neglect, should be investigated in future studies.

[Recognition and rehabilitation of impaired awareness of illness, i.e. anosognosia in a patient with cerebrovascular disease]

The prevalence of anosognosia after stroke is approximately 30%. Anosognosia refers to the lack of awareness of illness or specific symptom of illness in patients with neurological diseases. Because stroke patients with anosognosia are not properly comprehending the nature of their medical situation, they may not seek treatment in time, which weakens patients' commitment to treatment and rehabilitation. Anosognosia also exposes patients to dangerous situations in daily life. Anosognosia is associated with poor functional outcome after stroke, which makes the early neuropsychological identification and treatment of anosognosia important.

[Unawareness in brain disorders: a complex and multifaceted phenomenon]

Unawareness of the diseases or its consequences can be a protective mechanism against a traumatic event. However, it can also result in dangerous behaviors and hamper the care management. Still not well understood, unawareness is a very complex and multidimensional construct involving neurological, neuropsychological, psychopathological and psychosocial dimensions. Sometimes considered to be a categorical phenomenon, unawareness is actually partial and dimensional. Nevertheless, no or only weak correlation are found between the results of various methods used to its assessment. We propose that the usual opposition between neurological (anosognosia) and psychopathological (denial) conceptions should be replaced by an integrative approach of the various dimensions involved in unawareness to allow a better adaptation of the care management.

Recovery from unilateral neglect after right-hemisphere stroke

PURPOSE

To show the recovery process for different forms of unilateral neglect (UN)--including personal neglect and neglect of far space--in relationship to impairment, disability, cognition and mood.

METHOD

Patients were tested at 2-4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

RESULTS

Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

CONCLUSIONS

For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.

Prism adaptation in the rehabilitation of patients with visuo-spatial cognitive disorders

PURPOSE OF REVIEW

The traditional focus of neurorehabilitaion has been on the patients' attention on their deficit, such that they should become aware of their problems and gain intentional control of compensatory strategies (descending approach). We review prism adaptation as one of the approaches that emphasize ascending rather than descending strategies to the rehabilitation of visuo-spatial disorders. The clinical outcome of prism adaptation highlights the need for a theoretical reconsideration of some previous stances to neurological rehabilitation.

RECENT FINDINGS

Recent years have given rise to a growing body of experimental studies showing that the descending strategy is not always optimal, especially when higher-level cognition is affected by the patients' condition. Ascending approaches have, for example, used visuo-manual adaptation for the rehabilitation of visuo-spatial deficits. A simple task of pointing to visual targets while wearing prismatic goggles can produce remarkable improvements of various aspects of unilateral neglect.

SUMMARY

The neural mechanisms underpinning visuo-manual plasticity can be viewed as a powerful rehabilitation tool that produces straightforward effects not only on visual and motor parameters, but on visuo-spatial, attentional and higher cognitive neurological functions. The use of prism adaptation therapy in neglect and other visuo-spatial disorders has just started to reveal its potential, both at a practical and theoretical level.

Concurrent visuomotor behaviour improves form discrimination in a patient with visual form agnosia

It is now well established that the visual brain is divided into two visual streams, the ventral and the dorsal stream. Milner and Goodale have suggested that the ventral stream is dedicated for processing vision for perception and the dorsal stream vision for action [A.D. Milner & M.A. Goodale (1995) The Visual Brain in Action, Oxford University Press, Oxford]. However, it is possible that ongoing processes in the visuomotor stream will nevertheless have an effect on perceptual processes. This possibility was examined in the present study. We have examined the visual form-discrimination performance of the form-agnosic patient D.F. with and without a concurrent visuomotor task, and found that her performance was significantly improved in the former condition. This suggests that the visuomotor behaviour provides cues that enhance her ability to recognize the form of the target object. In control experiments we have ruled out proprioceptive and efferent cues, and therefore propose that D.F. can, to a significant degree, access the object's visuomotor representation in the dorsal stream. Moreover, we show that the grasping-induced perceptual improvement disappears if the target objects only differ with respect to their shape but not their width. This suggests that shape information per se is not used for this grasping task.

Behavioral change and its neural correlates in visual agnosia after expertise training

Agnosia, the impairment in object and face recognition despite intact vision and intelligence, is one of the most intriguing and debilitating neuropsychological deficits. The goal of this study was to determine whether S.M., an individual with longstanding visual agnosia and concomitant prosopagnosia, can be retrained to perform visual object recognition and, if so, what neural substrates mediate this reacquisition. Additionally, of interest is the extent to which training on one type of visual stimulus generalizes to other visual stimuli, as this informs our understanding of the organization of ventral visual cortex. Greebles were chosen as the stimuli for retraining given that, in neurologically normal individuals, these stimuli can engage the fusiform face area. Posttraining, S.M. showed significant improvement in recognizing Greebles, although he did not attain normal levels of performance. He was also able to recognize untrained Greebles and showed improvement in recognizing common objects. Surprisingly, his performance on face recognition, albeit poor initially, was even more impaired following training. A comparison of pre- and postintervention functional neuroimaging data mirrored the behavioral findings: Face-selective voxels in the fusiform gyrus prior to training were no longer so and were, in fact, more Greeble-selective. The findings indicate potential for experience-dependent dynamic reorganization in agnosia with the possibility that residual neural tissue, with limited capacity, will compete for representations.

Clinical management of agnosia

Agnosia is a neurological recognition deficit that affects a single modality. Visual agnosias include pure object agnosia, prosopagnosia, akinetopsia, and pure alexia. Auditory agnosias include pure word deafness, phonagnosia, and pure sound agnosia. New neuroimaging tools have permitted scientists to better understand the loci of lesions that cause various agnosias and from that knowledge to develop theories about the processing networks that contribute to perception and recognition in each modality. These research data, in turn, inform the rehabilitation process. By utilizing current knowledge about neuroprocessing networks, clinical professionals can differentially diagnose agnosias from aphasia and other cognitive deficits. Practical approaches to treatment of agnosia will follow once the diagnosis is established.

Balint's syndrome in a 10-year-old male

A 10-year-old male was referred with difficulties at school. He had particular difficulty with reading long words, following the sequence of text down a page, writing words in the correct order, writing words in line, and copying from the blackboard. He had a history of infective endocarditis complicated by intracerebral haemorrhage at the age of three years. Detailed history taking revealed symptoms typical of 'dorsal stream' pathology, namely a deficit of 'vision for action'. This included a spatial disorder of attention (simultanagnosia), defective hand and foot movements under visual control (optic ataxia), and acquired oculomotor apraxia which are consistent with Balint's syndrome. Strategies were suggested for coping with the symptoms and one year later a distinct improvement in adapting to the disability was found.

1 Hz repetitive transcranial magnetic stimulation of the unaffected hemisphere ameliorates contralesional visuospatial neglect in humans

The aim of the study was to investigate whether low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere can ameliorate visuospatial neglect. We treated three right brain damaged patients with left neglect. 900 pulses (1 Hz frequency) were given over left posterior parietal cortex every other day for 2 weeks. Patients performed a computerized task requiring length judgement of prebisected lines, tachistoscopically presented for 150 ms. With respect to rTMS the task was given 15 days before, at the beginning, at the end and 15 days after. At these times patients performed also line bisection and clock drawing tasks. rTMS induced a significant improvement of visuo-spatial performance that remained quite unchanged 15 days after. Patients performance at Time 3 and 4 improved also as concerns line bisection and clock drawing tasks.

Anosognosia for hemiplegia in stroke rehabilitation

OBJECTIVE

The purpose of this study was to investigate anosognosia for hemiplegia (AHP) in the rehabilitation phase after onset of stroke.

METHODS

Forty-six hemiplegic stroke patients, 29 with right hemisphere damage (RHD) and 17 with left hemisphere damage (LHD) were evaluated approximately 1 month after onset of stroke. Anosognosia was evaluated with an implicit measure designed to assess anosognosic behaviors (choosing between unimanual and bimanual tasks), in addition to a traditional explicit verbal measure.

RESULTS

AHP was found in 28% of the RHD and 24% of the LHD group. The majority of patients with AHP in the RHD group had large lesions involving the frontal, parietal, or temporal lobes and had coexisting sensory deficits and unilateral spatial neglect, whereas the LHD patients with AHP had predominantly small subcortical lesions and no sensory or attentional deficits. The functional outcomes of AHP patients in both hemisphere groups revealed their inability to retain safety measures at discharge from rehabilitation (p < 0.036) and their need for assistance in basic and instrumental activities of daily living at follow-up.

CONCLUSIONS

AHP presents a significant risk for negative functional outcome in stroke rehabilitation. The underlying mechanisms of AHP may be different for left and right hemisphere patients, therefore requiring different intervention approaches.

Long-lasting amelioration of visuospatial neglect by prism adaptation

It has been shown that unilateral left neglect can be significantly improved for a short time after a short period of adaptation to a prismatic shift of the visual field to the right. In neuropsychological studies, however, there is no evidence demonstrating long-lasting effects following treatment by prism adaptation (PA). The first aim of the present study was to find out whether the short-term amelioration found after prismatic adaptation could be converted into long-term therapeutic improvement. Secondly, we investigated whether the improvement of neglect in standard tests could be generalized to ecological visuospatial tests. Thirdly, the effects of prism adaptation on different spatial domains (far, near and personal space) were evaluated. Fourthly, the influence of PA on high-order visuospatial functions, such as spatial representation, and on a low-order factor, i.e. sensory--motor bias, was investigated. Finally, we investigated the possible correlation between neglect amelioration, the adaptation effect and the visuomotor after-effect, as assessed by a pointing task during and after PA. Seven patients with right hemisphere lesion and left visuospatial neglect were treated with prismatic lenses in twice-daily sessions over a period of 2 weeks. In each training session, patients were required to perform a pointing task wearing base-left wedge prisms inducing a shift of the visual field to the right by 10. The presence of visual neglect and the duration of the amelioration achieved were assessed before the treatment and 2 days, 1 week and 5 weeks after treatment by using a standardized battery that included a series of behavioural and ecological visuospatial tests. Six control, untreated patients, matched to the experimental group for gravity and duration of illness, were submitted to the same tests at the same intervals as the experimental patients. The results showed an improvement in the experimental patients' performance after PA, which was maintained during the 5-week period after treatment. The amelioration of neglect was found in standard as well as in behavioural tests and in all spatial domains. In contrast, control patients did not show any improvement in neglect. The amelioration of neglect occurred only in patients who showed the adaptation effect and the after-effect in the pointing task. Neglect amelioration did not occur in one patient who did not show the adaptation effect and had an unstable after-effect. In conclusion, these findings show that prism adaptation is a productive way of achieving long-lasting improvements in neglect treatment.

Predictors of discharge to home during the first year after right hemisphere stroke

OBJECTIVES

The aim of this study was to explore predictive factors of the length of hospital stay at the acute stage of right hemisphere stroke. Special attention was paid to the possible role of anosognosia for hemiparesis and anosognosia for neglect in this prediction.

PATIENTS AND METHODS

A consecutive series of 57 patients having their first right hemisphere stroke were examined at the acute phase. Forty-nine patients were included in this study and followed-up for 12 months. The examinations were conducted within 2 weeks of onset. The outcome variable was the time (days) from stroke to discharge to home. The predictors were age, gender, size of infarct, neglect, hemiparesis, verbal memory, unawareness of illness, anosognosia for neglect, anosognosia for hemiparesis and presence of a relative at home.

RESULTS

Hemiparesis and unawareness of illness lengthened the duration of the hospital stay, the presence of a relative reduced it. Neglect was the best single predictor of poor outcome, but it had no additional value in the combination of the three predictors above. Neither anosognosia for hemiparesis nor anosognosia for neglect were important predictors.

CONCLUSION

Hemiparesis, unawareness of illness and presence of a relative at home were the best predictors of the time from right hemisphere stroke to discharge to home.

[What is a "left"?]

OBJECTIVE

Patients with right hemisphere syndrome may be labeled as "gauche" by the rehabilitation staff. This term corresponds to a variety of oddities in behavior or discourse. The aim of this study is to understand the coherence of these oddities with the classical elements of right hemisphere syndrome.

MATERIAL

In this article, we present a detailed study of the discourse and the relation with others of a patient with severe left hemineglect, who was followed up for twelve months and did not exhibited any significant change in his symptomatology.

METHODS

This study relies on the data from neuropsychological examination, on notes written after rehabilitation session by the therapists and on data from weekly non-directive interviews.

RESULTS

This follow-up revealed disturbances of time sense, reduplication for places, misidentification of therapists, pseudo hallucinations, and showed that the transferential relation was "floating". The non-directive interviews permitted the patient to express his own interpretation of his troubles. He described them in terms of gaps in his body "carapace" and disorganization of the oral drive.

CONCLUSION

We propose to consider the symptomatology of this patient in relation with the subjective effects of the breaking up of his body image and the concomitant intrusion of the oral object (in the psychoanalytic sense of this term) in his psychic reality.

Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect

OBJECTIVE

To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke.

DESIGN

Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up.

SETTING

Urban, acute inpatient rehabilitation facility.

PATIENTS

Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan.

MAIN OUTCOME MEASURES

The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R).

RESULTS

Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing.

CONCLUSIONS

Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.

[Case report. Therapeutic intervention using a "particular interest" of an autistic child with visual agnosia]

Although special education under its diverse forms is consensually recognized as the privileged area of pervasive developmental delay, there is little studies on re-education intervention for autistic persons of normal intelligence. This article presents a psychoeducative intervention with a three year old autistic boy in a pedopsychiatric day care centre. The interest of this observation is double. On the one hand, this child, aside from autism, is carrier of an exceptional ailment: visual agnosia. On the other hand, his "restrictive autistic interest", namely perceptive attraction and his questioning of a particular class of objects or a particular parameter of these objects were used as lever to bring him to improve his capacities of communication and social interactions.

Balint's syndrome arising from bilateral posterior cortical atrophy or infarction: rehabilitation strategies and their limitation

Balint's syndrome is characterized by faulty visual scanning, dysmetria secondary to a visual perceptual deficit, and an inability to recognize more than one object at a time. We report three cases of Balint's syndrome and the individualized rehabilitation they received. One patient developed symptoms of Balint's syndrome caused by bilateral occipitoparietal infarcts. In the two other cases the symptoms arose secondary to posterior cortical atrophy, a slowly progressive dementia with alexia and agraphia. All three patients initially responded to a multicontext treatment approach with intensive verbal cueing and organizational strategies with subsequent improvement in visual recognition, reaching and scanning. Continued deterioration from posterior cortical atrophy or a second infarction resulted in worsening dementia in two patients. Cognitive remediation was required as visual perceptual rehabilitation became ineffective. Clinicians should be familiar with Balint's syndrome and its various aetiologies. Lack of awareness of this syndrome may lead to a misdiagnosis and resulting inappropriate or inadequate treatment.

[Rehabilitation of hemiplegia patients]

The indications for a specific rehabilitation training programme for elderly stroke patients are discussed. Special symptomatology, such as hemi-anesthesia as a result of a damaged perceptual process, apraxia including apraxia of dressing, communication disorders and affective disorders are presented. The measures to be taken for effective rehabilitation in hospital, in an institution for the elderly or in the home care situation are indicated. In addition, the physician has to have marked ability for empathic comportment.

[Neurocognitive rehabilitation of hemi-inattention in patients with a right hemispheric lesion]

The incapacity to focus attention in the direction contralateral to cerebral lesion (hemi-inattention) significantly affects the patient's day-to-day behaviour. Recent studies have demonstrated that although spontaneous recovery may occur during the weeks immediately after ictus, a significant number of patients continue to suffer from this disorder in a chronic manner. The paper describes a rehabilitation programme which has proved to be selectively effective in reducing hemi-inattention in the majority of patients persistently affected by the disorder. The results indicate a) that improvements are not confined to laboratory situations but extend to the patient's day-to-day behaviour in general, and b) that they are still present at a follow-up carried out several months after the end of therapy. Given the dramatic impact of this disorder on adult social relations it is important that rehabilitation centres dedicate time to this particular aspect.

Behavioral assessment and treatment of acquired visuoperceptual disorders

Visuoperceptual deficits are common sequelae of damage to either hemisphere of the brain, but are typically more pronounced following injuries involving the right cerebral hemisphere. Common visuoperceptual disorders include visual field cuts, hemi-inattention and hemi-spatial neglect, hemi-perceptual deficits, and gaze and visual pursuit disturbances. A number of behavioral interventions have been developed to teach patients to compensate for acquired visual deficits. Studies addressing assessment and treatment issues in this area are reviewed, and future directions for research are outlined.

Word deafness in head injury: implications for coma assessment and rehabilitation

Pure word deafness, usually involving left hemisphere focal lesions that destroy Heschl's gyrus and/or isolate auditory association cortex, may be rare, but cases with additional perceptual or cognitive symptoms may not be. Word deafness can be transient or evolving, and has been seen in various conditions without identifiable focal lesions. Only two closed head injury cases with focal contusions have been reported; we report two more, with diffuse damage and no focal signs. One patient's symptoms evolved soon after they were recognized. The other patient's unresponsiveness to spoken verbal stimuli persisted despite relatively preserved reading and speech, in a context of poor initiation and moderately severe cognitive impairment. Unrecognized, word deafness following head injury could lead to overestimation of coma duration if transient, and impede rehabilitation if chronic.

Unilateral neglect: suggestions for research by occupational therapists

This paper reviews the research literature pertinent to the evaluation of and therapy for patients having unilateral neglect. Emphasis is on areas in need of research by occupational therapists. Specific suggestions are made for studies to relate evaluation tools to functional criteria, to adapt the environment, and to investigate the effectiveness of compensatory or neurologically based treatment.

[The disorder of space analysis as a key to understanding anosognosia in right-sided cerebral infarct]

The dextrocerebral stroke is often underestimated as a result of its deficits--in contrary to the left cerebral stroke with the aphasia--because the patient's neglect of the plegic side is transferred to the therapist. A key to understanding this is the hypothesis that the anosognosia results in a loss of spatial analysis. After a survey of the different functions of the left and right hemispheres the author demonstrates the symptoms, diagnosis and therapeutic prognoses. The therapy needs to be continued for several months. In addition, the patient's social environment is important.

[A case of regressive prosopagnosia (author's transl)]

After bilateral cranial trauma a 20 year-old male patient presented severe prosopagnosia which regressed after five months before disappearing completely. Referring to this exceptional case of regressive prosopagnosia the authors discuss the influence of rehabilitation, and review the literature concerning this disorder. They stress its association with other neuropsychological deficiencies connected with right hemispheric lesions, such as topagnosia and disturbance of visual perception.