Distinct processes in line bisection according to severity of left unilateral spatial neglect

Full-field input generated from right visual field information for healthy participants reproduces performance simulating left unilateral spatial neglect in line bisection

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre when bisecting a horizontal line. This pathological phenomenon may be explained as a result of greater dependence on the right endpoint in the external reference frame (Koyama et al., Brain Cogn, 35, 1997, 271; McIntosh et al., Cogn Brain Res, 25, 2005, 833). Ishiai et al. (Brain, 112, 1989, 1485) reported that once patients with USN fixated on a certain point on the right part of the presented line, they persisted with this point and marked the subjective midpoint there without leftward searches. Ishiai et al.'s interpretation was that the patients saw a totalised line representation that extended equidistantly to the right and left sides, based on the information of the attended rightward extent from the subjective midpoint. Accordingly, we used virtual reality goggles (VRG) and devised a mirror-image viewing (MV) condition that showed a full-field view based on the right visual field information to test whether healthy participants would thereby show neglect-like bisection performance. The participants were 30 healthy adults (22-37 years old; 15 women and 15 men). In this condition, 96.7% (29/30) of participants were judged to exhibit USN-like performance of line bisection, indicating the effectiveness of MV condition to simulate USN. The novelty of the present study lies in the use of a task-specific intervention of neglect-like visuospatial processing during line bisection without attempting to modify the direction of spatial attention. This approach may contribute to the understanding of the pathological visuospatial processing of USN.

Endpoints and viewpoints on spatial neglect

In this issue of the Journal of Neuropsychology, Abe and Ishiai (2022) report an experiment designed to probe the subjective experience of line bisection in neglect. A re-analysis of their data can also offer insights into how best to characterise neglect performance for this and other tasks. We show that sensitive measures of neglect can be obtained by quantifying the difference in the influence (or 'weighting') that each endpoint has on the response. The right endpoint is dramatically more influential than the left in people with neglect performing line bisection and endpoint reproduction tasks. This supports the view that neglect may limit the ability to simultaneously represent two locations, so that the response is determined primarily with respect to the right endpoint. We also discuss Abe and Ishiai's conclusion that bisection responses in neglect are accompanied by the subjective experience of a complete line extending equally to either side of the chosen midpoint.

Mental representation of a line when patients with left unilateral spatial neglect bisect it: A study with an endpoint reproduction task

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre. Based on the previous findings (e.g., Ishiai et al. 1989, Brain, 112, 1485), we hypothesized that the patients with left USN may see the representational image of a line that extends equally towards either side of the subjective midpoint depending not upon the information about the leftward extent. The present study tested whether patients with left USN would place the subjective midpoint at the centre of their mental representation of the line. The participants were 10 patients with left USN and 10 neurologically healthy controls. We devised a new 'endpoint reproduction task' using a computer display with a touch panel to seek the representational image when patients with left USN bisect lines and asked the participants to reproduce the location of the right or left endpoint after bisecting lines. The results showed that the representational image of the bisected line depends primarily on the location of the objective right endpoint, not on the location of the objective left endpoint in space. The analyses of the estimated right and left representational extents confirmed our hypotheses that patients with left USN would bisect a line seeing the representational line image that centred across their subjective midpoint. We believe that the findings of the present study with the use of the endpoint reproduction task will contribute to a better understanding of the visuospatial process underlying line bisection of patients with left USN.

Keeping an eye on visual search patterns in visuospatial neglect: A systematic review

Patients with visuospatial neglect exhibit a failure to detect, respond, or orient towards information located in the side of space opposite to their brain lesion. To extend our understanding of the underlying cognitive processes involved in neglect, some studies have used eye movement measurements to complement behavioural data. We provide a qualitative synthesis of studies that have used eye-tracking in patients with neglect, with a focus on highlighting the utility of examining eye movements and reporting what eye-tracking has revealed about visual search patterns in these patients. This systematic review includes twenty studies that met the eligibility criteria. We extracted information pertaining to patient characteristics (e.g., age, type of stroke, time since stroke), neglect test(s) used, type of stimuli (e.g., static, dynamic), eye-tracker specifications (e.g., temporal and spatial resolution), and eye movement measurements (e.g., saccade amplitude, fixation duration). Five key themes were identified. First, eye-tracking is a useful tool to complement pen-and-paper neglect tests. Second, the lateral asymmetrical bias in eye movement patterns observed during active exploration also occurred while at rest. Third, the lateral asymmetrical bias was evident not only in the horizontal plane but also in the vertical plane. Fourth, eye movement patterns were modulated by stimulus- and task-related factors (e.g., visual salience, local perceptual features, image content, stimulus duration, presence of distractors). Fifth, measuring eye movements in patients with neglect is useful for determining and understanding other cognitive impairments, such as spatial working memory. To develop a fuller, and a more accurate, picture of neglect, future research would benefit from eye movement measurements.

Weight and see: Line bisection in neglect reliably measures the allocation of attention, but not the perception of length

Line bisection has long been a routine test for unilateral neglect, along with a range of tests requiring cancellation, copying or drawing. However, several studies have reported that line bisection, as classically administered, correlates relatively poorly with the other tests of neglect, to the extent that some authors have questioned its status as a valid test of neglect. In this article, we re-examine this issue, employing a novel method for administering and analysing line bisection proposed by McIntosh et al. (2005). We report that the measure of attentional bias yielded by this new method (EWB) correlates significantly more highly with cancellation, copying and drawing measures than the classical line bisection error measure in a sample of 50 right-brain damaged patients. Furthermore when EWB was combined with a second measure that emerges from the new analysis (EWS), even higher correlations were obtained. A Principal Components Analysis found that EWB loaded highly on a major factor representing neglect asymmetry, while EWS loaded on a second factor which we propose may measure overall attentional investment. Finally, we found that tests of horizontal length and size perception were related poorly to other measures of neglect in our group. We conclude that this novel approach to interpreting line bisection behaviour provides a promising way forward for understanding the nature of neglect.

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We used novel measures of attentional allocation to study line bisection behaviour in 50 right-brain damaged patients.

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These measures were more sensitive to neglect than was directional bisection error, and they correlated more highly with other core tests of neglect.

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We propose that one measure (EWB) reflects a lateral bias of attention, and the other measure (EWS) reflects overall attention.

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Perceptual biases on size-matching and landmark tasks did not correlate highly with line bisection, or any other core tests of neglect.

The end of the line: Antagonistic attentional weightings in unilateral neglect

The line bisection task is widely used in the study of neglect. Some years ago, McIntosh, Schindler, Birchall, & Milner (2005) proposed a radical reframing of this ubiquitous task. Rather than using the traditional measure of directional bisection error, they quantified the sensitivities of the response to the changing locations of the left and right endpoints of the line, expressing these as 'endpoint weightings'. A novel prediction generated from their analysis was that manipulations increasing attention to the left end of the line should cause an increase in the left endpoint weighting and a corresponding reduction in the right endpoint weighting. The present study fulfilled this prediction, using a forced-report cueing method in a group of 12 patients with left neglect. The data confirm an antagonistic relationship between endpoint weightings, consistent with the idea that they represent the sharing of a finite resource. It is argued that the endpoint weightings model of line bisection offers a sensitive and uniquely useful framework for studying competitive lateral biases of attention in neglect, and may also provide insight into non-lateralised attentional impairments.

Line Bisection and Rebisection: The Crossover Effect of Space Location

Objective. To investigate the relationship between the bisection test and the severity of behavioral hemineglect and to verify if this test can predict the behavioral hemineglect. Methods. Thirty stroke patients with left hemiparesis were divided into 4 groups according to the Catherine Bergego Scale, which assessed the behavioral hemineglect: severe unilateral neglect (UN), moderate UN, mild UN, and lack of UN. Eleven healthy subjects served as age-matched control subjects. In the bisection test, 18 lines were presented on the left, middle, and right of an A4 paper, respectively. The subjects were asked to place a short cross mark in the exact middle point of each line on the paper using their right hand. The middle 6 lines in the above bisection test were extracted on another sheet of A4 paper for the rebisection test. The subjects were asked to divide a line into 4 segments by successive bisections. The proportion of the right part to the length of line for bisecting was calculated. Results. In the bisection test, the main effect of space was significant in every group except the mild neglect group. The crossover effect of space location was found in the severe UN group, the group without UN, and the controls. In the severe UN group, the patients bisected the left and middle lines with rightward bias (<50%) but bisected the right lines with leftward bias (>50%). In the group without UN and the controls, the subjects bisected the left lines with leftward bias (>50%) but bisected the middle and right lines with rightward bias (<50%). Almost the same results were seen in the rebisection test. Conclusions. This study showed that if the spatial crossover effect occurred in the right space condition, it was strongly supported that this patient had moderate to severe behavioral hemineglect. The crossover effect of the space location was explained by a new model.

Understanding the parietal lobe syndrome from a neurophysiological and evolutionary perspective

In human and nonhuman primates parietal cortex is formed by a multiplicity of areas. For those of the superior parietal lobule (SPL) there exists a certain homology between man and macaques. As a consequence, optic ataxia, a disturbed visual control of hand reaching, has similar features in man and monkeys. Establishing such correspondence has proven difficult for the areas of the inferior parietal lobule (IPL). This difficulty depends on many factors. First, no physiological information is available in man on the dynamic properties of cells in the IPL. Second, the number of IPL areas identified in the monkey is paradoxically higher than that so far described in man, although this issue will probably be reconsidered in future years, thanks to comparative imaging studies. Third, the consequences of parietal lesions in monkeys do not always match those observed in humans. This is another paradox if one considers that, in certain cases, the functional properties of neurons in the monkey's IPL would predict the presence of behavioral skills, such as construction capacity, that however do not seem to emerge in the wild. Therefore, constructional apraxia, which is well characterized in man, has never been described in monkeys and apes. Finally, only certain aspects, i.e. hand directional hypokinesia and gaze apraxia (Balint's psychic paralysis of gaze), of the multifaceted syndrome hemispatial neglect have been described in monkeys. These similarities, differences and paradoxes, among many others, make the study of the evolution and function of parietal cortex a challenging case.

The eyes have it: Oculomotor exploration and line bisection in neglect

In this issue of Cortex, Ishiai et al. (2006) report the eye movements of patients with left neglect during the bisection of lines of different lengths. This is the latest in a series of papers from Ishiai's group, which form an important corpus of data on the oculomotor behaviour of neglect patients during line bisection and related tasks. In this article, I argue that these data should critically constrain theoretical models of bisection errors in neglect, but that these constraints have been applied rarely in practice. First, I briefly introduce bisection behaviour in neglect and describe some of the models proposed to account for its character. I then consider the implications for these models of Ishiai and colleagues' observations. Finally, I outline a novel view of the bisection task that is more compatible with their observations.

Approaches to Subjective Midpoint of Horizontal Lines in Unilateral Spatial Neglect

Patients with unilateral spatial neglect usually bisect longer lines with greater rightward errors, while they sometimes err leftward for very short lines (e.g., 25 mm). We analysed movements of eye fixation from the time before line presentation to elucidate whether patients with neglect approach the subjective midpoint differently for lines of various lengths. Four patients with left neglect bisected 200 mm, 100 mm, and 25 mm lines that appeared across the centre of a liquid crystal display (LCD) monitor. The fixation immediately before line presentation was located on average near the centre of the lines. Three of the patients approached the subjective midpoint point directly from the left side in more than 70% of the 200 mm and 100 mm trials. The subjective midpoint frequently deviated leftward on the "attended" segment between the leftmost point of fixation and the right endpoint, while it was displaced rightward on the total extent. The three patients initially explored the 25 mm lines searching for the left endpoint. They thereafter bisected the same lines with leftward errors approaching the subjective midpoint from the left side. The remaining patient searched beyond the right endpoint and in turn approached the subjective midpoint from the right side in about half of the trials and independently of line length. In the 200 mm and 100 mm trials, the subjective midpoint divided the attended right segment nearer to the right endpoint. On the attended right extent of a line, patients with neglect may place the subjective midpoint toward the side from which they approached that point. In the bisection of very short lines, approaches from the left endpoint may cause leftward errors of the subjective midpoint. For longer lines, however, approaches from the left side may result in rightward error of bisection for the total length, as the leftward extent from the fixation immediately before line presentation is hardly explored.

Weights and measures: A new look at bisection behaviour in neglect

Horizontal line bisection is a ubiquitous task in the investigation of visual neglect. Patients with left neglect typically make rightward errors that increase with line length and for lines at more leftward positions. For short lines, or for lines presented in right space, these errors may 'cross over' to become leftward. We have taken a new approach to these phenomena by employing a different set of dependent and independent variables for their description. Rather than recording bisection error, we record the lateral position of the response within the workspace. We have studied how this varies when the locations of the left and right endpoints are manipulated independently. Across 30 patients with left neglect, we have observed a characteristic asymmetry between the 'weightings' accorded to the two endpoints, such that responses are less affected by changes in the location of the left endpoint than by changes in the location of the right. We show that a simple endpoint weightings analysis accounts readily for the effects of line length and spatial position, including cross-over effects, and leads to an index of neglect that is more sensitive than the standard measure. We argue that this novel approach is more parsimonious than the standard model and yields fresh insights into the nature of neglect impairment.

Significance of paradoxical leftward error of line bisection in left unilateral spatial neglect

We intended to determine if leftward error of line bisection means "right" or "left" neglect in a patient with left unilateral spatial neglect. The patient placed the subjective midpoint to the left of the true center when bisecting lines without cueing. By contrast, when cued to the left endpoint, he showed typical rightward errors that became greater as longer lines were presented. Cueing to the right endpoint increased leftward errors compared with the bisections without cueing. The results suggest that paradoxical leftward error of line bisection is a form of "left" unilateral spatial neglect in that the shortness of the left extent is ignored.

Line versus representational bisections in unilateral spatial neglect

OBJECTIVES

To clarify the mechanisms of left unilateral spatial neglect found in the bisection of lines after cueing to the left end point and to determine whether neglect occurs for the mental representation of a line.

METHODS

A new representational bisection task was developed to eliminate the influence of the right segment of the physical line that would attract attention. Eight patients with typical left unilateral spatial neglect underwent line and representational bisection tasks on a computer display with a touch panel. In the line bisection with cueing, they bisected a line after touching the left end point. In the representational bisection, the patients were presented with a line until they touched the left end point. On the blank display, they pointed to the subjective midpoint of the erased line. The performances of the two bisection tasks were compared when the length and position of stimulus lines were varied.

RESULTS

The rightward errors in the representational bisection were greater than or equivalent to those in the line bisection with cueing. The effect of line length in which the errors became greater for the longer lines was equally found in the line bisection with cueing and the representational bisection. This was confirmed in the condition where the right end point was placed at a fixed position and the line length was varied.

CONCLUSIONS

After cueing to the left end point, rightward bisection errors of patients with neglect are not caused by overattention to the right segment of the physical line. Left neglect occurs mainly for the mental representation formed at the time of cueing or seeing the whole extent of a line.

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.

Line bisection and neglect severity

The relationship between (horizontal) line length and bisection accuracy continues to be of theoretical interest in the study of visuospatial neglect. In a recent paper, Koyama, Ishiai, Seki and Nakayama (1997) claim that line bisection performance by patients with severe neglect is "not only quantitatively but also qualitatively different" from that of patients with moderate or mild neglect. In particular, they argue that line length does not control bisection displacements in severe neglect. Contrary to that position, I first demonstrate that the conclusion of Koyama et al. (1997) does not follow from their own data; second, I describe empirical results showing that bisection displacement in severe neglect is exquisitely sensitive to line length. The standard psychophysical models of line bisection in visuospatial neglect are not falsified by the results of Koyama et al.