The influence of distracters, stimulus duration and hemianopia on first saccade in patients with unilateral neglect

The influence of clinical characteristics on prism adaptation training in visuospatial neglect: A post-hoc analysis of a randomized controlled trial

Previous studies indicate that the effect of prism adaptation training (PAT) on unilateral neglect may depend on clinical characteristics. In this explorative work, we re-analyzed data from a previously conducted randomized controlled trial (N = 23) to investigate whether age, etiology, severity of motor impairments, and visual field deficits affect the efficacy of PAT. Additionally, we reviewed PAT studies that reported lesion maps and distinguished responders from non-responders. We transferred these maps into a common standard brain and added data from 12 patients from our study. We found patients suffering from subarachnoid bleeding appeared to show stronger functional recovery than those with intracranial hemorrhage or cortical infarction. Furthermore, patients with visual field deficits and those with more severe contralateral motor impairments had larger after-effect sizes but did not differ in treatment effects. In addition, patients with parietal lesions showed reduced recovery, whereas patients with lesions in the basal ganglia recovered better. We conclude that PAT (in its current form) is effective when fronto-subcortical areas are involved but it may not be the best choice when parietal regions are affected. Overall, the present work adds to the understanding on the effects of clinical characteristics on PAT.

Some historical notes orienting towards brain mechanisms that could underlie hemispheric asymmetries

The first minor aim of this synthetical historical survey consisted in showing that the discovery of the internal organization of language within the left hemisphere has been mainly determined by theoretical models and cultural factors, whereas the discovery of the left lateralisation of language and of the right lateralization of emotions and of other cognitive and perceptual functions has been mainly determined by empirical observations. A second more relevant aim of the survey consisted in discussing historical and more recent data suggesting that the different lateralisation of language and emotions has influenced not only the asymmetrical representation of other cognitive, affective and perceptual functions, but also (thank to the shaping influence of language on human cognition) of asymmetries regarding more general aspects of thought (such as the distinctions between 'propositional vs automatic' and 'conscious vs unconscious' ways of functioning). In the last part of the review, these data will be included in a more general discussion, concerning the brain functions that could be subsumed by the right hemisphere for three main reasons: (a) to avoid conflicts with the language mediated activities of the left hemisphere; (b) because of unconscious and automatic aspects of its non-verbal organisation or (c) due to the competition for cortical space determined by the development of language within the left hemisphere.

Virtual Reality and Eye-Tracking Assessment, and Treatment of Unilateral Spatial Neglect: Systematic Review and Future Prospects

Unilateral spatial neglect (USN) is a disorder characterized by the failure to report, respond to, or orient toward the contralateral side of space to a brain lesion. Current assessment methods often fail to discover milder forms, cannot differentiate between unilateral spatial neglect subtypes and lack ecological validity. There is also a need for treatment methods that target subtypes. Immersive virtual reality (VR) systems in combination with eye-tracking (ET) have the potential to overcome these shortcomings, by providing more naturalistic environments and tasks, with sensitive and detailed measures. This systematic review examines the state of the art of research on these technologies as applied in the assessment and treatment of USN. As we found no studies that combined immersive VR and ET, we reviewed these approaches individually. The review of VR included seven articles, the ET review twelve. The reviews revealed promising results. (1) All included studies found significant group-level differences for several USN measures. In addition, several studies found asymmetric behavior in VR and ET tasks for patients who did not show signs of USN in conventional tests. Particularly promising features were multitasking in complex VR environments and detailed eye-movement analysis. (2) No VR and only a few ET studies attempted to differentiate USN subtypes, although the technologies appeared appropriate. One ET study grouped USN participants using individual heatmaps, and another differentiated between subtypes on drawing tasks. Regarding (3) ecological validity, although no studies tested the prognostic validity of their assessment methods, VR and ET studies utilized naturalistic tasks and stimuli reflecting everyday situations. Technological characteristics, such as the field of view and refresh rate of the head-mounted displays, could be improved, though, to improve ecological validity. We found (4) no studies that utilized VR or ET technologies for USN treatment up until the search date of the 26th of February 2020. In conclusion, VR-ET-based systems show great potential for USN assessment. VR-ET holds great promise for treatment, for example, by monitoring behavior and adapting and tailoring to the individual person's needs and abilities. Future research should consider developing methods for individual subtypes and differential diagnostics to inform individual treatment programs.

Is There a Causal Link between the Left Lateralization of Language and Other Brain Asymmetries? A Review of Data Gathered in Patients with Focal Brain Lesions

This review evaluated if the hypothesis of a causal link between the left lateralization of language and other brain asymmetries could be supported by a careful review of data gathered in patients with unilateral brain lesions. In a short introduction a distinction was made between brain activities that could: (a) benefit from the shaping influences of language (such as the capacity to solve non-verbal cognitive tasks and the increased levels of consciousness and of intentionality); (b) be incompatible with the properties and the shaping activities of language (e.g., the relations between language and the automatic orienting of visual-spatial attention or between cognition and emotion) and (c) be more represented on the right hemisphere due to competition for cortical space. The correspondence between predictions based on the theoretical impact of language on other brain functions and data obtained in patients with lesions of the right and left hemisphere was then assessed. The reviewed data suggest that different kinds of hemispheric asymmetries observed in patients with unilateral brain lesions could be subsumed by common mechanisms, more or less directly linked to the left lateralization of language.

Investigating the Characteristics of Covert Unilateral Spatial Neglect Using the Modified Posner Task: A Single-subject Design Study

Objectives:

Patients identified as asymptomatic for unilateral spatial neglect (USN) based on paper-and-pen tests nonetheless often collide with objects to their left while walking. This study aimed to investigate chronic USN in subjects who experienced collisions while walking.

Methods:

Two patients with chronic USN who experienced collisions while walking were evaluated using the Behavioral Inattention Test-conventional (BIT-c). Additionally, the modified Posner task (MPT) was used to evaluate the left and right reaction times. MPT targets randomly appeared either on the side indicated by the cue (valid condition) or on the opposite side (invalid condition). This study used an alternating treatments single-case design. The valid and invalid conditions of the MPT alternated rapidly and randomly to determine differences in reaction time. Statistical analysis compared left and right reaction times using a one-tailed randomization test to study valid and invalid conditions.

Results:

The total BIT-c score was in the normal range for both subjects, whereas MPT reaction times were higher on the left side than on the right side for the invalid condition. However, for the valid condition, only Case B had increased reaction times on the left side.

Conclusions:

The MPT valid condition evaluates voluntary attention, whereas the invalid condition evaluates the reorientation of attention. Consequently, for Case A, a left reorientation of attention deficit was observed, whereas, for Case B, left voluntary attention and left reorientation of attention deficits were observed. The MPT results revealed the characteristics of covert neglect signs. USN evaluation would benefit from additional research using MPT.

Pupil dilation during orienting of attention and conscious detection of visual targets in patients with left spatial neglect

Right Brain-Damaged patients (RBD) with left spatial neglect (N+), are characterised by deficits in orienting and re-orienting attention to stimuli in the contralesional left side of space. In a recent ERPs study with visual stimuli (Lasaponara et al., 2018) we have pointed out that the pathological attentional bias of N+ is matched with exaggerated novelty reaction and contextual updating of targets in the right ipsilesional space and reduced novelty reaction and contextual updating of targets in the left contralesional space. To characterise further the attentional performance of N+, here we measured Pupil Dilation (PDil), which is a reliable marker of noradrenergic-locus coeruleus activity and response to unexpected events/rewards. Compared to Neutral and Valid targets, N+ patients displayed a pathological reduction of PDil in response to infrequent Invalid targets in the left side of space, while in Healthy Controls (HC) and RBD without neglect (N-) the same targets enhanced PDil with respect to Neutral and frequent Valid targets. Invalid targets in the right side of space enhanced PDil in all experimental groups. Interestingly, both N- and N+ showed a consistent number of target omissions both in the left and right side of space. With respect to seen targets, N- showed reduced PDil in response to unseen targets both in the left and right side of space. In contrast, N+ had reduced PDil in response to unseen targets in the left side of space though not in the right side, where seen and unseen targets evoked comparable levels of PDil. These results disclose, for the first time, the PDil correlates of spatial attention in left spatial neglect and suggest that the pathological attentional bias suffered by N+ might enhance the autonomic responses reflected in PDil to unseen ipsilesional stimuli. This enhancement can contribute to biasing contextual updating and predictive coding of stimuli in the ipsilesional space, thus worsening the pathological attentional bias of N+.

How does the number of targets affect visual search performance in visuospatial neglect?

INTRODUCTION

Impairments in visual search are a common symptom in visuospatial neglect (VSN). The severity of the lateralized attention bias in visual search tasks can vary depending on the number of distractors: the more distractors, the more targets are missed. However, little is known about how the number of targets affect search performance in VSN. The aim of the current study was to examine the effect of the number of targets on hit rate in VSN.

METHODS

We included 23 stroke patients with right-brain damage and VSN, 55 with right-brain damage without VSN, and 49 with left-brain damage without VSN, all admitted for inpatient rehabilitation. In a visual search task, patients had to find and tap targets, presented along with non-targets. The location and number of targets varied from trial to trial, allowing the evaluation of the effects of number and location of targets on hit rate.

RESULTS

VSN patients detected a lower percentage of targets when more targets were present. For patients with right-brain damage without VSN, adding targets only reduced the hit rate of the most contralesional target. No effect of number of targets on hit rate was seen in patients with left-brain damage. Additionally, VSN patients found less contralesional targets than ipsilesional targets, made more delayed revisits, and had an initial rightward bias when compared to the other groups. There were no differences in search time, search consistency, or immediate revisits between groups. There was a moderate positive relation between the hit rate asymmetry score in our search task and conventional paper-and-pencil VSN tasks, and neglect behavior in daily life.

CONCLUSIONS

In VSN patients, a higher number of targets reduces the hit rate. The reduced hit rate in visual search evoked by additional targets should be taken into account when assessing visual search in VSN.

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.

Concomitant recovery from left spatial neglect and inflammatory dysfunction of white-matter pathways in a case of acute disseminated encephalo-myelitis (ADEM)

Spatial neglect is an invalidating neuropsychological syndrome characterized by the inability of paying attention to the side of space contralateral to a unilateral brain damage. Recent studies have suggested that lesion of white-matter pathways plays an important role in producing spatial neglect by causing a widespread functional breakdown of the network of cortical and subcortical structures that regulates orienting of spatial attention. Nonetheless, this conclusion is largely based on the study of patients who suffer combined grey and white matter damage and should be better corroborated by the study of cases with selective or predominant white matter dysfunction. Here, we describe the clinical and MRI follow-up of a patient who suffered left spatial neglect due to inflammatory Acute Disseminated Encephalo-Myelitis (ADEM) that affected the white matter. Recovery from neglect was matched with recovery from inflammatory white-matter dysfunction, despite a concomitant and progressive increase in cortical atrophy and ventricular dilatation. These findings confirm the role of white matter lesion/dysfunction in the pathogenesis of left spatial neglect.

The Hemispheric Distribution of α-Band EEG Activity During Orienting of Attention in Patients with Reduced Awareness of the Left Side of Space (Spatial Neglect)

EEG studies in healthy humans have highlighted that alpha-band activity is relatively reduced over the occipital-parietal areas of the hemisphere contralateral to the direction of spatial attention. Here, we investigated the hemispheric distribution of alpha during orienting of attention in male and female right brain-damaged patients with left spatial neglect. Temporal spectral evolution showed that in patients with neglect alpha oscillations over the damaged hemisphere were pathologically enhanced both during the baseline-fixation period that preceded cued orienting (capturing tonic alpha changes) and during orienting with leftward, rightward, or neutral-bilateral spatial cues (reflecting phasic alpha changes). Patients without neglect showed a similar though significantly less enhanced hemispheric asymmetry. Healthy control subjects displayed a conventional decrease of alpha activity over the hemisphere contralateral to the direction of orienting. In right-brain-damaged patients, neglect severity in the line bisection task was significantly correlated both with tonic alpha asymmetry during the baseline period and with phasic asymmetries during orienting of attention with neutral-bilateral and leftward cues. Asymmetries with neutral-bilateral and leftward cues were correlated with lesion of white matter tracts linking frontal with parietal-occipital areas. These findings show that disruption of rostrocaudal white matter connectivity in the right hemisphere interferes with the maintenance of optimal baseline tonic levels of alpha and the phasic modulation of alpha activity during shifts of attention. The hemispheric distribution of alpha activity can be used as a diagnostic tool for acquired pathological biases of spatial attention due to unilateral brain damage.SIGNIFICANCE STATEMENT Alpha desynchronization over the hemisphere contralateral to the attended side of space is a reliable marker of attentional orienting in the healthy human brain: can the same marker be used to spot and quantify acquired disturbances of spatial attention after unilateral brain injuries? Are pathological modifications in the hemispheric distribution of alpha specifically linked to attentional neglect for one side of space? We show that in patients with right brain damage the pathological enhancement of alpha oscillations over the parietal and occipital areas of the injured hemisphere is correlated with reduced awareness for the left side of space and with the lesion of white matter pathways that subserve frontal modulation of alpha activity in posterior brain areas.

Multiple left-to-right spatial representations of number magnitudes? Evidence from left spatial neglect

The SNARC effect reflects the observation that when healthy observers with left-to-right reading habits are asked to compare the magnitude or to judge the parity of numbers, they provide faster reaction times (RT) to small numbers with left-sided responses and faster RTs to large numbers with right-sided responses. In magnitude comparison (MC), right brain damaged patients with left-sided neglect typically show a pathologically enlarged SNARC for large numbers and selective slowing to numbers that are immediately lower than the numerical reference (e.g. 4 for reference 5). This asymmetry has been taken as evidence that small numbers are mentally positioned to the left of the reference and, therefore, are processed less efficiently by patients neglecting the left side of space. In parity judgement (PJ), on the other hand, the size of the SNARC effect is unaffected by neglect. This dissociation is typically attributed to the disturbed explicit processing of number magnitude in MC and preserved implicit processing of magnitude in PJ. Before accepting this interpretation, however, it remains to be investigated whether neglect patients show the same RT pattern that characterizes the performance of healthy participants (i.e. left-side RTs that increase linearly as a function of number magnitude and right-side RTs that decrease linearly as a function of magnitude). Clarifying this point is crucial, because an equally sized SNARC can originate from different RT patterns. Here we demonstrate that the RT pattern of neglect patients during PJ is entirely comparable to those of patients without neglect and healthy controls, while the same neglect patients show selective slowing to numbers that are immediately lower than the numerical reference in MC. These findings suggest the existence of multiple left-to-right spatial representations of number magnitude and provides an explanation of the functional dissociation between MC and PJ tasks.

The Number Interval Position Effect (NIPE) in the mental bisection of numerical intervals might reflect the influence of the decimal-number system on the Gaussian representations of numerosities: A combined developmental and computational-modeling study

Healthy adults show typical error biases when they mentally bisect number intervals without exact calculations. For a given number interval length, the bisection bias is in fact modulated by the position that the interval occupies within a ten. For intervals positioned at the beginning of tens the error bias is directed toward values that are higher than those of the true interval midpoint whereas for intervals at the end of tens the direction of the error bias is reversed toward values that are lower than that of the true midpoint (Doricchi et al., 2009; Rotondaro et al., 2015). This effect has been defined Number Interval Position Effect (NIPE). The NIPE recurs over consecutive tens and it is not found when intervals are bisected through exact calculations. For this reasons we have hypothesized that the NIPE reflects the influence that the habit of counting in tens has on the neural representations of numerosities that humans share with other species. Here, in a developmental study we demonstrate that children from preschool to fifth-grade display a NIPE that is comparable to that of healthy adults. Then, through a computational-modeling study we investigated whether the NIPE might reflect specific patterns in the Gaussian representations of numerosities that are found in the parietal and pre-frontal neuronal populations of macaque monkeys and that underlie approximate numerosity estimations also in humans. The findings of computational simulations suggest that the NIPE might reflect the influence that the learning and use of the decimal numerical system has on the phylogenetically and ontogenetically older representation of numerosities that humans share with other species. These changes in the representation of numerosities have an influence on approximate numerical estimations even when these, like in the case of the mental bisection of number intervals, are elicited by numerical symbols or words.

Occurrence and Recovery of Different Neglect-Related Symptoms in Right Hemisphere Infarct Patients during a 1-Year Follow-Up

OBJECTIVES

To examine the occurrence of and recovery from visual neglect-related symptoms with the focus on neglect laterality, ipsilateral orienting bias, and slowed processing speed in right hemisphere (RH) infarct patients during a 1-year follow-up. Furthermore, to propose guidelines for assessing processing speed alongside the Behavioural Inattention Test (BIT).

METHODS

We studied three RH patient groups: neglect (N+), mild left inattention (MLI+), and non-neglect (N-) patients, and healthy controls. The BIT with some additional analyses was conducted at the acute phase and at 6 and 12 months.

RESULTS

The N+ group's BIT score increased and originally lateralized omissions became more evenly distributed during the follow-up. The N+ and MLI+ groups' starting points were more rightward located than the healthy group's at the acute phase and at 6, and partly at 12 months. Patient groups were slower than the controls in performing cancellation tests at the acute phase. The N+ and MLI+ groups remained slower than the controls throughout the follow-up.

CONCLUSIONS

During the first year after RH infarct, originally left-sided manifestation of neglect shifted toward milder non-lateralized attentional deficit. Ipsilateral orienting bias and slowed processing speed appeared to be rather persistent neglect-related symptoms both in neglect patients and patients with initially milder inattention. We propose some effortless, tentative ways of examining processing speed and ipsilateral orienting bias alongside the BIT to better recognize these neglect-related symptoms, and highlight the need to assess and treat patients with initially milder inattention, who have been under-recognized and under-treated in clinical work. (JINS, 2018, 24, 617-628).

Visual search in unilateral spatial neglect: The effects of distractors on a dynamic visual search task

The objective of this study was to examine visual scanning performance in patients with Unilateral Spatial Neglect (USN) in a visual search task. Thirty-one right hemisphere stroke patients with USN were recruited. They performed a dynamic visual search task with two conditions, with and without distractors, while eye movements were monitored with an eye-tracker. The main goal of the task was to select target stimuli that appeared from the top of the screen and moved vertically downward. Target detection and visual scanning percentage were assessed over two hemispaces (right, left) on two conditions (distractor, no distractor). Most Scanned Regions (MSR) were calculated to analyze the areas of the screen where most points of fixation were directed to. Higher target detection rate and visual scanning percentages were found on the right hemispace on both conditions. From the MSRs we found that participants with a center of attention further to the right of the screen also presented smaller overall MSRs. Right hemisphere stroke patients with USN presented not only a significant rightward bias but reduced overall search areas, implying hyperattention does not only restrict search on the horizontal (right-left) axis but the vertical axis (top-bottom) too.

Prevalence and association of visual functional deficits with lesion characteristics and functional neurological deficits in patients with stroke

BACKGROUND

Stroke frequently induces visual problems, which impair activities of daily living, lead to falls, and require rehabilitation. However, visual dysfunction has not been well characterized in stroke.

OBJECTIVE

The purpose of this study was to characterize visual function in patients with stroke and the association of these characteristics with neurological dysfunction and lesion hemisphere.

METHODS

In 40 patients with stroke and 321 control subjects, we carried out an assessment of a broad panel of visual and neurological functional metrics to identify risk factors for specific visual impairments in stroke.

RESULTS

Patients with stroke exhibited a significantly higher rate of occurrence for impairments in all visual metrics assessed, when compared to healthy controls. Risk for particular visual deficits varied according to lesion side (right versus left hemisphere) and specific types of neurological dysfunction.

CONCLUSIONS

Detailed assessment of visual function in patients with stroke can help to clarify the risk of various types of visual impairment. Moreover, as visual function assessment in patients with stroke is difficult, knowledge of the correlation of visual impairments with different neurological dysfunctions observed in stroke and lesion side will help predict vision problems and inform optimal corrective measures in treating patients with stroke.

Rehabilitation of spatial neglect by prism adaptation: a peculiar expansion of sensorimotor after-effects to spatial cognition

Unilateral neglect is a neurological condition responsible for many debilitating effects on everyday life, poor functional recovery, and decreased ability to benefit from treatment. Prism adaptation (PA) to a right lateral displacement of the visual field is classically known to directionally bias visuo-motor and sensory-motor correspondences. One longstanding issue about this visuo-motor plasticity is about its specificity to the exposure condition. In contrast to very poor transfer to unexposed effectors classically described in healthy subjects, therapeutic results obtained in neglect patients suggested that PA can generate unexpected "expansion". Prism adaptation affects numerous levels of neglect symptomatology, suggesting that its effects somehow expand to unexposed sensory, motor and cognitive systems. The available body of evidence in support for this expansion raises important questions about the mechanisms involved in producing unexpected cognitive effects following a simple and moderate visuo-motor adaptation. We further develop here the idea that prism adaptation expansion to spatial cognition involves a cerebello-cortical network and review support for this model. Building on the basic, therapeutical and pathophysiological knowledge accumulated over the last 15 years, we also provide guidelines for the optimal use of prism adaptation in the clinic. Although further research and clinical trials are required to precisely define the ideal regime for routine applications, the current state of the art allows us to outline practical recommendations for therapeutical use of prisms.

Neglect: a multisensory deficit?

Neglect is a neurological syndrome characterised by a lack of conscious perception of events localised in the contralesional side of space. Here, we consider the possible multisensory nature of this disorder, critically reviewing the literature devoted to multisensory manifestations and processing in neglect. Although its most striking manifestations have been observed in the visual domain, a number of studies demonstrate that neglect can affect virtually any sensory modality, in particular touch and audition. Furthermore, a few recent studies have reported a correlation in severity between visual and non-visual neglect-related deficits evaluated in the same patients, providing some preliminary support for a multisensory conception of neglect. Sensory stimulation and sensorimotor adaptation techniques, aimed at alleviating neglect, have also been shown to affect several sensory modalities, including some that were not directly affected by the intervention. Finally, in some cases neglect can bias multisensory interactions known to occur in healthy individuals, leading to abnormal behaviour or uncovering multisensory compensation mechanisms. This evidence, together with neurophysiological and neuroimaging data revealing the multisensory role played by the areas that are most commonly damaged in neglect patients, seems to speak in favour of neglect as a multisensory disorder. However, since most previous studies were not conducted with the specific purpose of systematically investigating the multisensory nature of neglect, we conclude that more research is needed to appropriately assess this question, and suggest some methodological guidelines that we hope will help clarify this issue. At present, the conception of neglect as a multisensory disorder remains a promising working hypothesis that may help define the pathophysiology of this syndrome.

Current tests and trends in single-case neuropsychology

In this issue of Cortex, Crawford, Garthwaite and Ryan publish bayesian statistical tests that will enable researchers to take account of covariates when comparing single patients to control samples. In this article, we provide some context for this development, from an audit of the Cortex archives. We suggest that single-case research is alive and well, and more rigorous than ever, and that current practice has been shaped considerably by Crawford and colleagues' statistical refinements over the past 12 years. However, there is scope for further tightening and standardisation of statistical methods and reporting standards. The advantages offered by the new bayesian tests should promote the even wider use of appropriate statistical methods, with benefits for the validity of individual studies, and for cross-comparability in the single-case literature.

Perceptual grouping operates independently of attentional selection: evidence from hemispatial neglect

To what extent can human observers process visual information that is not currently the focus of attention? We evaluated the extent to which unattended visual information (i.e., that which appears on the neglected side of space in individuals with hemispatial neglect) is perceptually organized and influences the perceptual processing of information on the attended side. To examine this, patients (and matched controls) judged whether successive, complex checkerboard stimuli (targets), presented entirely to their intact side of space, were the same or different. Concurrent with this demanding task, irrelevant distractor elements appeared on the unattended side and either changed or retained their perceptual grouping on successive displays, independently of changes in the ipsilesional task-relevant target. Changes in the grouping of the unattended task-irrelevant distractor elements produced congruency effects on the attended target-change judgment to the same extent in the neglect patients as in the control participants, and this was true even in those patients with severe attentional deficits. These results suggest that some perceptual processes, such as grouping, can operate in the absence of attention.