Visual neglect associated with frontal lobe infarction

Processing of irrelevant visual motion during performance of an auditory attention task

The extent to which irrelevant perception of visual motion distractors can be modulated by manipulating auditory load in a relevant task was assessed with Positron Emission Tomography (PET) and behavioural experiments. Subjects performed an auditory task and ignored an irrelevant visual motion stimulus, under two conditions. In a low load condition, subjects were asked to detect words spoken in a loud voice among words spoken in a quiet voice, while in a high load condition they attempted to detect bisyllabic words among monosyllabic and trisyllabic words. We found that motion-related visual areas were strongly activated by the irrelevant motion stimulus, compared to a static stimulus, under both conditions of load in the auditory task. In a second behavioural experiment, the duration of the motion after-effect was similarly unaffected by adaptation under low or high auditory load. These results are in clear contrast with the strong modulation of irrelevant motion processing by visual load, as reflected in the duration of the motion after effect (Section 6) and neural responses in motion-related visual areas (Rees et al., Science, (1997) 278, 338). These findings support the claim that attentional capacity is restricted within but not between sensory modalities, and indicate that processing of visual distractors may occur whenever there is sufficient visual capacity to process them, despite being task- and modality-irrelevant.

Extrapersonal visual unilateral spatial neglect and its neuroanatomy

The neural correlates of left extrapersonal visual unilateral spatial neglect (VUSN), the more extensively investigated component of the neglect syndrome, are reviewed. Damage to a number of right-hemisphere regions brings about VUSN: the posterior parietal cortex (inferior parietal lobule) and, although less frequently, the premotor cortex and subcortical structures, such as the thalamus and the basal ganglia, and white matter fiber tracts. In recent years, a number of studies have investigated the possible association of specific components of left VUSN with damage to specific brain regions within the right hemisphere. The putative distinction most extensively investigated from an anatomical perspective concerns the perceptual vs premotor components of VUSN. In addition, a fine-grain componential analysis of the behavioral tasks used to investigate VUSN is providing more specific insight into the pathological mechanisms underlying the variety of its manifestations. The emerging pattern is that USN is a multifarious disorder, in which specific deficits are associated with damage localized in discrete brain regions and neural circuits. These data concur with evidence from other domains (functional neuroimaging, neurophysiology) to suggest a highly multicomponential neural and functional architecture of spatial cognition.

Do neck-proprioceptive and caloric-vestibular stimulation influence covert visual attention in normals, as they influence visual neglect?

Neck-proprioceptive and caloric-vestibular stimulation have been shown to ameliorate the spatial bias exhibited by patients suffering from unilateral visual neglect. These interventions might in principle have their effect by biasing covert attention towards the neglected side. If so, the same interventions should also modulate covert attention in neurologically-intact subjects. However, we demonstrate here that neither neck-proprioception (vibration of left neck muscles) nor caloric-vestibular stimulation (injection of iced water into the left ear) affect covert visual attention in healthy individuals. These results from normals may distinguish between different accounts for unilateral neglect in patients. In particular, they argue against explanations of neglect solely in terms of a pathological misperception of body orientation within an otherwise normal neural representation of space.

Perceptual awareness and its loss in unilateral neglect and extinction

We review recent evidence from studies of patients with unilateral neglect and/or extinction, who suffer from a loss of awareness for stimuli towards the affected side of space. We contrast their deficit with the effects of damage to primary sensory areas, noting that such areas can remain structurally intact in neglect, with lesions typically centred on the right inferior parietal lobe. In keeping with preservation of initial sensory pathways, many recent studies have shown that considerable residual processing can still take place for neglected or extinguished stimuli, yet without reaching the patient's awareness. This ranges from preserved visual grouping processes through to activation of identity, semantics and emotional significance. Similarly to 'preattentive' processing in normals, such residual processing can modulate what will enter the patient's awareness. Recent studies have used measures such as ERPs and fMRI to determine the neural correlates of conscious versus unconscious perception in the patients, which in turn can be related to the anatomy of their lesions. We relate the patient findings to neurophysiological data from areas in the monkey parietal lobe, which indicate that these serve as cross-modal and sensorimotor interfaces highlighting currently relevant locations as targets for intentional action. We speculate on the special role such brain regions may play in perceptual awareness, seeking to explain how damage to a system which appears primarily to code space could eliminate awareness even for non-spatial stimulus properties at affected locations. This may relate to the extreme nature of 'winner-takes-all' functions within the parietal lobe, and their correspondingly strong influence on other brain areas.

Spatial hemineglect in humans

The paper reviews the main findings of studies of hemispatial neglect after acquired brain lesions in people. The behavioral consequences of experimentally induced lesions in animals and electrophysiological studies, which shed light on the nature of the disorder, are briefly considered. Neglect is behaviorally defined as a deficit in processing or responding to sensory stimuli in the contralateral hemispace, a part of the own body, the part of an imagined scene, or may include the failure to act with the contralesional limbs despite intact motor functions. Neglect in humans is frequently encountered after right parieto-temporal lesions and leads to a multicomponent syndrome of sensory, motor and representational deficits. Relevant findings relating to neglect, extinction and unawareness are reviewed and include the following topics: etiological and anatomical basis, recovery; allocentric, egocentric, object-centered and representational neglect; motor neglect and directional hypokinesia; elementary sensorimotor and associated disorders; subdivisions of space and frames of reference; extinction versus neglect; covert processing of information; unawareness of deficits; human and animal models; effects of sensory stimulation and rehabilitation techniques.

Electrophysiological correlates of visual impairments after traumatic brain injury

Our aims were to investigate: (i) the VEP correlates of functional visual impairments following traumatic brain injury (TBI), in particular of the reduced spatial form perception; and (ii) the VEP correlates of visual sustained arousal in TBI patients. We used two approaches: (i) the analysis of latency and amplitude of the peaks; and (ii) the study of the correlations among the latencies of the peaks as a label of temporal synchronization. Thirty-five severe TBI outcome inpatients and 35 matching controls were studied. Pattern-reversal VEPs were recorded at Oz-Fz and Cz-A1, first without counting, then with counting of the reversals. Seven peaks of the waveform at Oz and eight peaks at Cz were measured. We found several differences in amplitude and latency between patients and controls, and between nocount/count. The temporal binding of the peaks within each channel and between the two channels was calculated by correlation matrices, and tested by factor analysis. Results indicated that the synchronization of the peaks within each channel did not differ between patients and controls. The temporal covariation between peaks occurring at Oz and Cz, however, was highly significantly altered in patients. This suggests that visual impairments in TBI patients may be due to a deranged synchronization of the activity of different brain regions.

Processing of illusion of length in spatial hemineglect: a study of line bisection

Bisection of horizontal lines and of the Brentano form of the Müller-Lyer illusion was investigated in six right brain-damaged patients with left spatial hemineglect, and in six control subjects. Patients bisected the lines to the right of the objective mid-point. Comparable illusory effects on line bisection were however found in both patients and control subjects. Relative to the baseline condition, in both groups the subjective midpoint was displaced towards the side expanded by the illusion, both leftwards and rightwards. By contrast, line length and spatial position of the stimulus had differential effects. In neglect patients, the rightward bisection error increased disproportionately with line length, and when the stimulus was located in the left, neglected, side of egocentric space. Control subjects showed no such effects. The suggestion is made that the visual, non-egocentric, processes underlying these illusory effects of length may be spared in patients with left spatial neglect. The possible neural basis of this dissociation is discussed.

"Near" and "far" in language and perception

A major interest in cognitive science is the relationship between linguistic and perceptual representations of space. One approach to exploring this relationship has been to investigate aspects of the linguistic encoding of space that correspond closely to aspects of the visual system. Another approach, which does not contradict the first but rather complements it, is to investigate ways in which linguistic and visual representations of space are different. This paper pursues the second approach by arguing that the distinction between proximal and distal demonstratives (e.g. this vs. that, here vs. there) does not correspond to an independently established distinction between near and far space in the visual system but is instead based on language-internal factors. Recent neuropsychological and neurophysiological studies suggest that the brain contains separate mechanisms for representing, on the one hand, near or peripersonal space which extends roughly to the perimeter of arm's reach and, on the other hand, far or extrapersonal space which expands outward from that boundary. In addition, crosslinguistic research suggests that it is very common for languages to have two basic types of demonstrative terms - proximal and distal. This parallelism raises the possibility that the linguistic distinction may derive from the perceptual distinction. However, several arguments support the contrary view that the two distinctions are independent of one another. A substantial proportion of languages in the world have demonstrative systems that divide space into three or more egocentrically-grounded regions, thereby violating the two-way perceptual contrast. Even more importantly, empirical studies of how demonstratives are used in ongoing discourse in different languages suggest that they do not encode quantitative spatial information such as within vs. beyond arm's reach; instead, they specify abstract semantic notions that, when combined with the unique pragmatic features of communicative contexts, allow speakers to make a virtually unlimited range of spatial distance contrasts. Thus, demonstratives constitute an interesting case of divergence between linguistic and perceptual representations of space.

Interhemispheric asymmetries in the perception of unimanual and bimanual cutaneous stimuli. A study using transcranial magnetic stimulation

Previous studies have shown that transcranial magnetic stimulation (TMS) of the sensorimotor cortex can induce a suppression of cutaneous perception from the fingers of the contralateral hand. In this work, 17 normal subjects were submitted to focal TMS of frontal and parietal scalp sites of each hemisphere. TMS was delivered at two interstimulus intervals (20 and 40 ms) following a cutaneous electrical stimulation of the first, third and fifth digits of either hand or both hands near the subjective threshold of perception. The aim of our study was to investigate whether TMS could detect an asymmetrical hemispheric specialization in the sensory perception of unimanual and bimanual, ipsilateral and contralateral sensory stimuli. At each interpulse interval, the right parietal cortex was significantly more sensitive to TMS interference with stimulus detection for both contralateral and ipsilateral stimuli compared with the left parietal cortex. These effects were mainly evident during bimanual discrimination tasks. Our results are indicative of an interhemispheric difference in the detection of cutaneous sensation, showing right hemispheric prevalence in the perception of contralateral as well as of ipsilateral stimuli. They provide neurophysiological support in normal humans to the clinical evidence which indicates that right hemisphere lesions can indeed produce deficits in the perception of ipsilateral sensory stimuli.

Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events

The syndrome of contralesional neglect reflects a lateralized disruption of spatial attention. In the human, the left hemisphere shifts attention predominantly in the contralateral hemispace and in a contraversive direction whereas the right hemisphere distributes attention more evenly, in both hemispaces and both directions. As a consequence of this asymmetry, severe contralesional neglect occurs almost exclusively after right hemisphere lesions. Patients with left neglect experience a loss of salience in the mental representation and conscious perception of the left side and display a reluctance to direct orientating and exploratory behaviours to the left. Neglect is distributed according to egocentric, allocentric, world-centred, and object-centred frames of reference. Neglected events can continue to exert an implicit influence on behaviour, indicating that the attentional filtering occurs at the level of an internalized representation rather than at the level of peripheral sensory input. The unilateral neglect syndrome is caused by a dysfunction of a large-scale neurocognitive network, the cortical epicentres of which are located in posterior parietal cortex, the frontal eye fields, and the cingulate gyrus. This network coordinates all aspects of spatial attention, regardless of the modality of input or output. It helps to compile a mental representation of extrapersonal events in terms of their motivational salience, and to generate 'kinetic strategies' so that the attentional focus can shift from one target to another.

Misrepresentation of horizontal space in left unilateral neglect: role of hemianopia

BACKGROUND

Right-brain-damaged patients with left unilateral neglect are reported to misperceive the horizontal extension of contralesional stimuli as being shorter than that of ipsilesional stimuli.

OBJECTIVE

To investigate the functional and anatomic correlates of horizontal space misrepresentation.

METHODS

Eight right-brain-damaged patients with contralesional neglect and complete hemianopia (N+H+), nine right-brain-damaged patients with contralesional neglect and no visual field defect (N+H-), and five unilateral brain-damaged patients with contralesional complete hemianopia and no neglect (N-H+) reproduced a horizontal distance (10 cm) in the contralesional and ipsilesional hemispace.

RESULTS

N+H+ patients overextended the distance contralesionally and underextended the same distance ipsilesionally. N+H- and N-H+ patients reproduced equivalent distances contralesionally and ipsilesionally. Compared with N+H- patients, N+H+ patients had a greater ipsilesional shift when bisecting horizontal lines; however, these two groups of patients had comparable neglect severity on multiple-item cancellation tasks. In the N+H+ group the area of maximal overlapping of the lesion was in the posterior cerebral lobes.

CONCLUSION

Complete contralesional hemianopia after posterior brain damage is an important factor in determining misrepresentation of horizontal space in patients with left unilateral neglect.

Cortical areas activated by bilateral galvanic vestibular stimulation

The brain areas activated by bilateral galvanic vestibular stimulation (GVS) were studied using functional magnetic resonance imaging. In six human volunteers, GVS led to activation in the region of the temporoparietal junction, the central sulcus, and the anterior interior intraparietal sulcus, which may correspond to macaque areas PIVC, 3aV, and 2v, respectively. In addition, activation was found in premotor regions of the frontal lobe, presumably analogous to areas 6pa and 8a in the monkey. Since these areas were not detected in previous studies using caloric vestibular stimulation, they could be related to the modulation of otolith afferent activity by GVS. However, the simple paradigm used did not allow separation of the otolithic and semicircular canal effects of GVS. Further studies must be performed to clarify the question of cortical representation of the otolithic information in the human and monkey brain.

Covariation of activity in visual and prefrontal cortex associated with subjective visual perception

Visual areas of the occipitotemporal pathway are thought to be essential for the conscious perception of objects, but the contribution of other cortical regions and the neural mechanisms leading to the awareness of a visual stimulus remain unclear. By using functional MRI in humans exposed to bistable viewing conditions, subjective visual perception was related to covariation of activity in multiple extrastriate ventral, parietal, and prefrontal cortical areas. The coordination of activity among these regions was not linked to external sensory or motor events; rather, it reflected internal changes in perception and varied in strength with the frequency of perceptual events, suggesting that functional interactions between visual and prefrontal cortex may contribute to conscious vision. Because similar cortical systems have been implicated in short-term memory and motor planning, the results also imply that related neural processes may underlie visual awareness and the organization of voluntary behavior contingent on sensory cues.

Saccadic eye movement and working memory deficits following damage to human prefrontal cortex

A patient with a lesion confined largely to the right inferior frontal gyrus was found to be impaired on tests of spatial working memory and executive functioning. By contrast, his pattern recognition was good. The patient's selective impairments are consistent with the view that prefrontal cortex contributes to processes involved in spatial working memory. The patient was also tested on a range of oculomotor paradigms, some of which required the temporary suppression of a saccadic response. He was unable to suppress making contra- or ipsilesional reflexive glances to peripheral stimuli on the "anti-saccade" paradigm, but his performance improved on delayed saccade, memory-guided saccade and fixation tasks. Although reflexive glances were observed under these conditions they occurred more frequently in response to contralesional stimuli than ipsilesional ones. Furthermore, the patient had no difficulty in performing anti-point movements with his ipsilesional hand. Thus, his inability to suppress reflexive glances on the anti-saccade task is not due to a generalised problem of "distractibility". The patient's deficits are discussed in terms of models of anti-saccade generation and are related to recent findings regarding the role of prefrontal cortex in working memory and visual attention.

Functional MRI of galvanic vestibular stimulation

The cortical processing of vestibular information is not hierarchically organized as the processing of signals in the visual and auditory modalities. Anatomic and electrophysiological studies in the monkey revealed the existence of multiple interconnected areas in which vestibular signals converge with visual and/or somatosensory inputs. Although recent functional imaging studies using caloric vestibular stimulation (CVS) suggest that vestibular signals in the human cerebral cortex may be similarly distributed, some areas that apparently form essential constituents of the monkey cortical vestibular system have not yet been identified in humans. Galvanic vestibular stimulation (GVS) has been used for almost 200 years for the exploration of the vestibular system. By contrast with CVS, which mediates its effects mainly via the semicircular canals (SCC), GVS has been shown to act equally on SCC and otolith afferents. Because galvanic stimuli can be controlled precisely, GVS is suited ideally for the investigation of the vestibular cortex by means of functional imaging techniques. We studied the brain areas activated by sinusoidal GVS using functional magnetic resonance imaging (fMRI). An adapted set-up including LC filters tuned for resonance at the Larmor frequency protected the volunteers against burns through radio-frequency pickup by the stimulation electrodes. Control experiments ensured that potentially harmful effects or degradation of the functional images did not occur. Six male, right-handed volunteers participated in the study. In all of them, GVS induced clear perceptions of body movement and moderate cutaneous sensations at the electrode sites. Comparison with anatomic data on the primate cortical vestibular system and with imaging studies using somatosensory stimulation indicated that most activation foci could be related to the vestibular component of the stimulus. Activation appeared in the region of the temporo-parietal junction, the central sulcus, and the intraparietal sulcus. These areas may be analogous to areas PIVC, 3aV, and 2v, respectively, which form in the monkey brain, the "inner vestibular circle". Activation also occurred in premotor regions of the frontal lobe. Although undetected in previous imaging-studies using CVS, involvement of these areas could be predicted from anatomic data showing projections from the anterior ventral part of area 6 to the inner vestibular circle and the vestibular nuclei. Using a simple paradigm, we showed that GVS can be implemented safely in the fMRI environment. Manipulating stimulus waveforms and thus the GVS-induced subjective vestibular sensations in future imaging studies may yield further insights into the cortical processing of vestibular signals.

Neural correlates of perceptual rivalry in the human brain

When dissimilar images are presented to the two eyes, perception alternates spontaneously between each monocular view, a phenomenon called binocular rivalry. Functional brain imaging in humans was used to study the neural basis of these subjective perceptual changes. Cortical regions whose activity reflected perceptual transitions included extrastriate areas of the ventral visual pathway, and parietal and frontal regions that have been implicated in spatial attention; whereas the extrastriate areas were also engaged by nonrivalrous perceptual changes, activity in the frontoparietal cortex was specifically associated with perceptual alternation only during rivalry. These results suggest that frontoparietal areas play a central role in conscious perception, biasing the content of visual awareness toward abstract internal representations of visual scenes, rather than simply toward space.

Spatial maps for the control of movement

Neurons in the ventral premotor cortex of the monkey encode the locations of visual, tactile, auditory and remembered stimuli. Some of these neurons encode the locations of stimuli with respect to the arm, and may be useful for guiding movements of the arm. Others encode the locations of stimuli with respect to the head, and may be useful for guiding movements of the head. We suggest that a general principle of sensory-motor integration is that the space surrounding the body is represented in body-part-centered coordinates. That is, there are multiple coordinate systems used to guide movement, each one attached to a different part of the body. This and other recent evidence from both monkeys and humans suggest that the formation of spatial maps in the brain and the guidance of limb and body movements do not proceed in separate stages but are closely integrated in both the parietal and frontal lobes.

Motor role of human inferior parietal lobe revealed in unilateral neglect patients

The exact role of the parietal lobe in spatial cognition is controversial. One influential hypothesis proposes that it subserves spatial perception, whereas other accounts suggest that its primary role is to direct spatial movement. For humans, it has been suggested that these functions may be divided between inferior and superior parietal lobes, respectively. In apparent support of a purely perceptual function for the inferior parietal lobe (IPL), patients with lesions to this structure, particularly in the right hemisphere, exhibit unilateral spatial neglect (deficient awareness for the side of space opposite to that of their lesion). Here we show that patients with right IPL lesions also have a specific difficulty in initiating leftward movements towards visual targets on the left side of space. This motor impairment was not found in neglect patients with frontal lesions, contrary to previous proposals that motor aspects of neglect are particularly associated with anterior damage. Our results suggest that the human IPL operates as a sensorimotor interface, rather than subserving only perceptual functions.

Spatial frames of reference and somatosensory processing: a neuropsychological perspective

In patients with lesions in the right hemisphere, frequently involving the posterior parietal regions, left-sided somatosensory (and visual and motor) deficits not only reflect a disorder of primary sensory processes, but also have a higher-order component related to a defective spatial representation of the body. This additional factor, related to right brain damage, is clinically relevant: contralesional hemianaesthesia (and hemianopia and hemiplegia) is more frequent in right brain-damaged patients than in patients with damage to the left side of the brain. Three main lines of investigation suggest the existence of this higher-order pathological factor. (i) Right brain-damaged patients with left hemineglect may show physiological evidence of preserved processing of somatosensory stimuli, of which they are not aware. Similar results have been obtained in the visual domain. (ii) Direction-specific vestibular, visual optokinetic and somatosensory or proprioceptive stimulations may displace spatial frames of reference in right brain-damaged patients with left hemineglect, reducing or increasing the extent of the patients' ipsilesional rightward directional error, and bring about similar directional effects in normal subjects. These stimulations, which may improve or worsen a number of manifestations of the neglect syndrome (such as extrapersonal and personal hemineglect), have similar effects on the severity of left somatosensory deficits (defective detection of tactile stimuli, position sense disorders). However, visuospatial hemineglect and the somatosensory deficits improved by these stimulations are independent, albeit related, disorders. (iii) The severity of left somatosensory deficits is affected by the spatial position of body segments, with reference to the midsagittal plane of the trunk. A general implication of these observations is that spatial (non-somatotopic) levels of representation contribute to corporeal awareness. The neural basis of these spatial frames includes the posterior parietal and the premotor frontal regions. These spatial representations could provide perceptual-premotor interfaces for the organization of movements (e.g. pointing, locomotion) directed towards targets in personal and extrapersonal space. In line with this view, there is evidence that the sensory stimulations that modulate left somatosensory deficits affect left motor disorders in a similar, direction-specific, fashion.

Distractor-dependent frontal neglect

The effect of distractor load on visual search was examined in a patient with visual neglect following infarction of the right frontal lobe. The spatial extent of his left-sided neglect was modified greatly by changing stimulus attributes. When targets were highly discriminable compared to distractors, or distractor density was low, or when the subject was asked to cancel distractors as well as targets, he was able to direct his search to the extreme left of search arrays and there was little or no evidence of neglect. By contrast, similar changes in distractor load had little or no effect on the neglect of a patient with a fronto-parietal lesion. These findings suggest that distractability towards ipsilesional stimuli may be an important component of neglect in individuals with only frontal lobe injury.

Abnormal temporal dynamics of visual attention in spatial neglect patients

When we identify a visual object such as a word or letter, our ability to detect a second object is impaired if it appears within 400ms of the first. This phenomenon has been termed the attentional blink or dwell time and is a measure of our ability to allocate attention over time (temporal attention). Patients with unilateral visual neglect are unaware of people or objects contralateral to their lesion. They are considered to have a disorder of attending to a particular location in space (spatial attention). Here we examined the non-spatial temporal dynamics of attention in patients, using a protocol for assessing the attentional blink. Neglect patients with right parietal, frontal or basal ganglia strokes had an abnormally severe and protracted attentional blink When they identified a letter, their awareness of a subsequent letter was significantly diminished for a length of time that was three times as long as for individuals without neglect. Our results demonstrate for the first time that visual neglect is a disorder of directing attention in time, as well as space.

Visuomotor functions of the lateral pre-motor cortex

Recent studies have provided new insights into the visuomotor functions of the dorsal and ventral regions of the lateral pre-motor cortex. Anatomical and physiological investigations in non-human primates have demonstrated that these regions have differing patterns of cortical connectivity and distinctive neuronal responses. Brain-imaging techniques and lesion studies have begun to probe the functions of homologous regions in humans.