Common brain networks for distinct deficits in visual neglect. A combined structural and tractography MRI approach

Same, Same but Different? A Multi-Method Review of the Processes Underlying Executive Control

Attention, working memory, and executive control are commonly considered distinct cognitive functions with important reciprocal interactions. Yet, longstanding evidence from lesion studies has demonstrated both overlap and dissociation in their behavioural expression and anatomical underpinnings, suggesting that a lower dimensional framework could be employed to further identify processes supporting goal-directed behaviour. Here, we describe the anatomical and functional correspondence between attention, working memory, and executive control by providing an overview of cognitive models, as well as recent data from lesion studies, invasive and non-invasive multimodal neuroimaging and brain stimulation. We emphasize the benefits of considering converging evidence from multiple methodologies centred on the identification of brain mechanisms supporting goal-driven behaviour. We propose that expanding on this approach should enable the construction of a comprehensive anatomo-functional framework with testable new hypotheses, and aid clinical neuroscience to intervene on impairments of executive functions.

Spontaneous unilateral spatial neglect recovery after brain tumour resection: A multimodal diffusion and rs-fMRI case report

Patients with unilateral spatial neglect (USN) are unable to explore or to report stimuli presented in the left personal and extra-personal space. USN is usually caused by lesion of the right parietal lobe: nowadays, it is also clear the key role of structural connections (the second and the third branch of the right Superior Longitudinal Fasciculus, respectively, SLF II and III) and functional networks (Dorsal and Ventral Attention Network, respectively, DAN and VAN) in USN. In this multimodal case report, we have merged those structural and functional information derived from a patient with a right parietal lobe tumour and USN before surgery. Functional, structural and neuropsychological data were also collected 6 months after surgery, when the USN was spontaneously recovered. Diffusion metrics and Functional Connectivity (FC) of the right SLF and DAN, before and after surgery, were compared with the same data of a patient with a tumour in a similar location, but without USN, and with a control sample. Results indicate an impairment in the right SLF III and a reduction of FC of the right DAN in patients with USN before surgery compared to controls; after surgery, when USN was recovered, patient's diffusion metrics and FC showed no differences compared to the controls. This single case and its multimodal approach reinforce the crucial role of the right SLF III and DAN in the development and recovery of egocentric and allocentric extra-personal USN, highlighting the need to preserve these structural and functional areas during brain surgery.

Comprehensive voxel-wise, tract-based, and network lesion mapping reveals unique architectures of right and left visuospatial neglect

Visuospatial neglect is a common, post-stroke cognitive impairment which is widely considered to be a disconnection syndrome. However, the patterns of disconnectivity associated with visuospatial neglect remain unclear. Here, we had 480 acute stroke survivors [age = 72.8 (SD = 13.3), 44.3% female, 7.5 days post-stroke (SD = 11.3)] undertake routine clinical imaging and standardised visuospatial neglect testing. The data were used to conduct voxel-wise, tract-level, and network-level lesion-mapping analyses aimed at localising the neural correlates of left and right egocentric (body-centred) and allocentric (object-centred) visuospatial neglect. Only minimal anatomical homogeneity was present between the correlates of right and left egocentric neglect across all analysis types. This finding challenges previous work suggesting that right and left visuospatial neglect are anatomically homologous, and instead suggests that egocentric neglect may involve damage to a shared, but hemispherically asymmetric attention network. By contrast, egocentric and allocentric neglect was associated with disconnectivity in a distinct but overlapping set of network edges, with both deficits related to damage across the dorsal and ventral attention networks. Critically, this finding suggests that the distinction between egocentric and allocentric neglect is unlikely to reflect a simple dichotomy between dorsal versus ventral networks dysfunction, as is commonly asserted. Taken together, the current findings provide a fresh perspective on the neural circuitry involved in regulating visuospatial attention, and provide important clues to understanding the cognitive and perceptual processes involved in this common and debilitating neuropsychological syndrome.

Joint impact on attention, alertness and inhibition of lesions at a frontal white matter crossroad

In everyday life, information from different cognitive domains-such as visuospatial attention, alertness and inhibition-needs to be integrated between different brain regions. Early models suggested that completely segregated brain networks control these three cognitive domains. However, more recent accounts, mainly based on neuroimaging data in healthy participants, indicate that different tasks lead to specific patterns of activation within the same, higher-order and 'multiple-demand' network. If so, then a lesion to critical substrates of this common network should determine a concomitant impairment in all three cognitive domains. The aim of the present study was to critically investigate this hypothesis, i.e. to identify focal stroke lesions within the network that can concomitantly affect visuospatial attention, alertness and inhibition. We studied an unselected sample of 60 first-ever right-hemispheric, subacute stroke patients using a data-driven, bottom-up approach. Patients performed 12 standardized neuropsychological and oculomotor tests, four per cognitive domain. A principal component analysis revealed a strong relationship between all three cognitive domains: 10 of 12 tests loaded on a first, common component. Analysis of the neuroanatomical lesion correlates using different approaches (i.e. voxel-based and tractwise lesion-symptom mapping, disconnectome maps) provided convergent evidence on the association between severe impairment of this common component and lesions at the intersection of superior longitudinal fasciculus II and III, frontal aslant tract and, to a lesser extent, the putamen and inferior fronto-occipital fasciculus. Moreover, patients with a lesion involving this region were significantly more impaired in daily living cognition, which provides an ecological validation of our results. A probabilistic functional atlas of the multiple-demand network was performed to confirm the potential relationship between patients' lesion substrates and observed cognitive impairments as a function of the multiple-demand network connectivity disruption. These findings show, for the first time, that a lesion to a specific white matter crossroad can determine a concurrent breakdown in all three considered cognitive domains. Our results support the multiple-demand network model, proposing that different cognitive operations depend on specific collaborators and their interaction, within the same underlying neural network. Our findings also extend this hypothesis by showing (i) the contribution of superior longitudinal fasciculus and frontal aslant tract to the multiple-demand network; and (ii) a critical neuroanatomical intersection, crossed by a vast amount of long-range white matter tracts, many of which interconnect cortical areas of the multiple-demand network. The vulnerability of this crossroad to stroke has specific cognitive and clinical consequences; this has the potential to influence future rehabilitative approaches.

A narrative review of the anatomy and function of the white matter tracts in language production and comprehension

Much is known about the role of cortical areas in language processing. The shift towards network approaches in recent years has highlighted the importance of uncovering the role of white matter in connecting these areas. However, despite a large body of research, many of these tracts' functions are not well-understood. We present a comprehensive review of the empirical evidence on the role of eight major tracts that are hypothesized to be involved in language processing (inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, uncinate fasciculus, extreme capsule, middle longitudinal fasciculus, superior longitudinal fasciculus, arcuate fasciculus, and frontal aslant tract). For each tract, we hypothesize its role based on the function of the cortical regions it connects. We then evaluate these hypotheses with data from three sources: studies in neurotypical individuals, neuropsychological data, and intraoperative stimulation studies. Finally, we summarize the conclusions supported by the data and highlight the areas needing further investigation.

Disconnectomics to unravel the network underlying deficits of spatial exploration and attention

Spatial attention and exploration are related to a predominantly right hemispheric network structure. However, the areas of the brain involved and their exact role is still debated. Spatial neglect following right hemispheric stroke lesions has been frequently viewed as a model to study these processes in humans. Previous investigations on the anatomical basis on spatial neglect predominantly focused on focal brain damage and lesion-behaviour mapping analyses. This approach might not be suited to detect remote areas structurally spared but which might contribute to the behavioural deficit. In the present study of a sample of 203 right hemispheric stroke patients, we combined connectome lesion-symptom mapping with multivariate support vector regression to unravel the complex and disconnected network structure in spatial neglect. We delineated three central nodes that were extensively disconnected from other intrahemispheric areas, namely the right superior parietal lobule, the insula, and the temporal pole. Additionally, the analysis allocated central roles within this network to the inferior frontal gyrus (pars triangularis and opercularis), right middle temporal gyrus, right temporal pole and left and right orbitofrontal cortices, including interhemispheric disconnection. Our results suggest that these structures-although not necessarily directly damaged-might play a role within the network underlying spatial neglect in humans.

Noninvasive neuromodulation for unilateral neglect after stroke: a systematic review and network meta-analysis

OBJECTIVE

To systematically evaluate the effect of noninvasive neuromodulation (NINM) on unilateral neglect (UN) after stroke and compare the effects of different NINMs.

METHODS

Randomized controlled trials (RCTs) on the effect of NINM on UN after stroke were retrieved from the PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM databases from inception to January 2022. The risk of bias and quality of the trials were assessed following the Cochrane Handbook of Systematic Reviews and the physiotherapy evidence database PEDro Scale. Statistical analysis was conducted with Stata 16.0 and R 4.0.2. This study was registered on PROSPERO (No. CRD42021295336).

RESULTS

A total of 12 RCTs involving 291 patients were included. Meta-analysis showed that NINM could reduce the line bisection test (LBT) score (SMD =  - 1.56, 95% CI - 2.10 ~  - 1.03, P < 0.05), the line cancellation test score (SMD =  - 1.83, 95% CI - 2.39 ~  - 1.27, P < 0.05), and the star cancellation test score (SMD =  - 2.85, 95% CI - 4.93 ~  - 0.76, P < 0.05). Network meta-analysis showed that the best probabilistic ranking of the effects of different NINMs on the LBT score was theta-burst stimulation (TBS) (P = 0.915) > repetitive transcranial magnetic stimulation (P = 0.068) > transcranial direct current stimulation (P = 0.018).

CONCLUSION

Existing evidence showed that NINM could improve UN after stroke and that TBS was best. Due to the number of included studies and sample size, more large-sample, multicenter, double-blinded, high-quality clinical RCTs are still needed in the future to further confirm the results of this research.

Right-side spatial neglect and white matter disconnection after left-hemisphere strokes

Spatial neglect usually concerns left-sided events after right-hemisphere damage. Its anatomical correlates are debated, with evidence suggesting an important role for fronto-parietal white matter disconnections in the right hemisphere. Here, we describe the less frequent occurrence of neglect for right-sided events, observed in three right-handed patients after a focal stroke in the left hemisphere. Patients were tested 1 month and 3 months after stroke. They performed a standardized paper-and-pencil neglect battery and underwent brain MRI with both structural and diffusion tensor (DT) sequences, in order to assess both grey matter and white matter tracts metrics. Lesions were manually reconstructed for each patient. Patients presented signs of mild right-sided neglect during visual search and line bisection. One patient also showed pathological performance in everyday life. Structural MRI demonstrated left parietal strokes in two patients, in the region extending from the postcentral gyrus to the temporo-parietal junction. One of these two patients also had had a previous occipital stroke. The remaining patient had a left frontal stroke, affecting the precentral, the postcentral gyri and the basal ganglia. DT MRI tractography showed disconnections in the fronto-parietal regions, concerning principally the superior longitudinal fasciculus (SLF). These results suggest an important role for left SLF disconnection in right-side neglect, which complements analogous evidence for right SLF disconnection in left-side neglect.

Distinct roles of right temporoparietal cortex in pentagon copying test

Pentagon Copying Test (PCT) is commonly used to assess visuospatial deficits, but the neural substrates underlying pentagon copying are not well understood. The Qualitative Scoring Pentagon Test (QSPT), an optimized scoring system, classifies five categories of errors patients make in pentagons copying and grades them depending on the errors' severity. To determine the strategic brain regions involved in the PCT, we applied the QSPT system to evaluate the visuospatial impairment of 136 acute ischemic stroke patients on the PCT and used Support Vector Regression Lesion-Symptom Mapping to investigate relevant brain regions. The total QSPT score was correlated with the right supramarginal gyrus. The angle number errors and closure errors were principally associated with lesions of the posterior temporoparietal cortex, including the right middle occipital gyrus and middle temporal gyrus, while the intersection errors and rotation errors were related to the more anterior part of the right temporoparietal lobe with the additional frontal cortex. In conclusion, the right temporoparietal cortex is the strategic region for pentagon copying tasks. The angle number and closure represent the visuospatial processing of within-object features, while intersection and rotation require between-object manipulation. The posterior-anterior distinction in the right temporoparietal region underlies the differences of within-object and between-object processing.

Visual mental imagery: Inside the mind's eyes

What are mental images needed for? A variety of everyday situations calls for us to plan ahead; one of the clever ways our mind prepares and strategizes our next move is through mental simulation. A powerful tool in running these simulations is visual mental imagery, which can be conceived as a way to activate and maintain an internal representation of the to-be-imagined object, giving rise to predictions. Therefore, under normal conditions imagination is primarily an endogenous process, and only more rarely can mental images be activated exogenously, for example, by means of intracerebral stimulation. A large debate is still ongoing regarding the neural substrates supporting mental imagery, with the neuropsychological and neuroimaging literature agreeing in some cases, but not others. This chapter reviews the neuroscientific literature on mental imagery, and attempts to reappraise the neuropsychological and neuroimaging evidence by drawing a model of mental imagery informed by both structural and functional brain data. Overall, the role of regions in the ventral temporal cortex, especially of the left hemisphere, stands out unequivocally as a key substrate in mental imagery.

Neural Mechanisms of Prism Adaptation in Healthy Adults and Individuals with Spatial Neglect after Unilateral Stroke: A Review of fMRI Studies

Functional disability due to spatial neglect hinders recovery in up to 30% of stroke survivors. Prism adaptation treatment (PAT) may alleviate the disabling consequences of spatial neglect, but we do not yet know why some individuals show much better outcomes following PAT than others. The goal of this scoping review and meta-analysis was to investigate the neural mechanisms underlying prism adaptation (PA). We conducted both quantitative and qualitative analyses across fMRI studies investigating brain activity before, during, and after PA, in healthy individuals and patients with right or left brain damage (RBD or LBD) due to stroke. In healthy adults, PA was linked with activity in posterior parietal and cerebellar clusters, reduced bilateral parieto-frontal connectivity, and increased fronto-limbic and sensorimotor network connectivity. In contrast, RBD individuals with spatial neglect relied on different circuits, including an activity cluster in the intact left occipital cortex. This finding is consistent with a shift in hemispheric dominance in spatial processing to the left hemisphere. However, more studies are needed to clarify the contribution of lesion location and load on the circuits involved in PA after unilateral brain damage. Future studies are also needed to clarify the relationship of decreasing resting state functional connectivity (rsFC) to visuomotor function.

The Visuospatial and Sensorimotor Functions of Posterior Parietal Cortex in Drawing Tasks: A Review

Drawing is a comprehensive skill that primarily involves visuospatial processing, eye-hand coordination, and other higher-order cognitive functions. Various drawing tasks are widely used to assess brain function. The neuropsychological basis of drawing is extremely sophisticated. Previous work has addressed the critical role of the posterior parietal cortex (PPC) in drawing, but the specific functions of the PPC in drawing remain unclear. Functional magnetic resonance imaging and electrophysiological studies found that drawing activates the PPC. Lesion-symptom mapping studies have shown an association between PPC injury and drawing deficits in patients with global and focal cerebral pathology. These findings depicted a core framework of the fronto-parietal network in drawing tasks. Here, we review neuroimaging and electrophysiological studies applying drawing paradigms and discuss the specific functions of the PPC in visuospatial and sensorimotor aspects. Ultimately, we proposed a hypothetical model based on the dorsal stream. It demonstrates the organization of a PPC-centered network for drawing and provides systematic insights into drawing for future neuropsychological research.

From competition to cooperation: Visual neglect across the hemispheres

Visuospatial neglect is a frequent and disabling consequence of injuries to the right hemisphere. Patients with neglect show signs of impaired attention for left-sided events, which depends on dysfunction of fronto-parietal networks. After unilateral injury, such as stroke, these networks and their contralateral homologs can reorganize following multiple potential trajectories, which can be either adaptive or maladaptive. This article presents possible factors influencing the profile of evolution of neglect towards recovery or chronicity, and highlights potential mechanisms that may constrain these processes in time and space. The integrity of white matter pathways within and between the hemisphere appears to pose crucial connectivity constraints for compensatory brain plasticity from remote brain regions. Specifically, the availability of a sufficient degree of inter-hemispheric connectivity might be critical to shift the role of the undamaged left hemisphere in spatial neglect, from exerting maladaptive effects, to promoting compensatory activity.

The inferior fronto-occipital fascicle: a century of controversies from anatomy theaters to operative neurosurgery

INTRODUCTION

Since its first description in the early 19th century, the inferior frontooccipital fascicle (IFOF) and its anatomo-functional features were neglected in the neuroscientific literature for the last century. In the last decade, the rapid development of in vivo imaging for the reconstruction of white matter (WM) connectivity (i.e., tractography) and the consequent interest in more traditional ex vivo methods (postmortem dissection) have allowed a renewed debate about course, termination territories, anatomical relationships, and functional roles of this fascicle.

EVIDENCE ACQUISITION

We reviewed the main current knowledge concerning the structural and functional anatomy of the IFOF and possible implications in neurosurgical practice.

EVIDENCE SYNTHESIS

The IFOF connects the occipital cortex, the temporo-basal areas, the superior parietal lobule, and the pre-cuneus to the frontal lobe, passing through the ventral third of subinsular WM of the external capsule. This wide distribution of cortical terminations provides multimodal integration between several functional networks, including language, non-verbal semantic processing, object identification, visuo-spatial processing and planning, reading, facial expression recognition, memory and conceptualization, emotional and neuropsychological behavior. This anatomo-functional organization has important implication also in neurosurgical practice, especially when approaching the frontal, insular, temporo-parieto-occipital regions and the ventricular system.

CONCLUSIONS

The IFOF is the most extensive associative bundle of the human connectome. Its multi-layer organization reflects important implications in many aspects of brain functional processing. Accurate awareness of IFOF functional anatomy and integration between multimodal datasets coming from different sources has crucial implications for both neuroscientific knowledge and quality of neurosurgical treatments.

The superior longitudinal fascicle: reconsidering the fronto-parietal neural network based on anatomy and function

Due primarily to the extensive disposition of fibers and secondarily to the methodological preferences of researchers, the superior longitudinal fasciculus (SLF) subdivisions have multiple names, complicating SLF research. Here, we collected and reassessed existing knowledge regarding the SLF, which we used to propose a four-term classification of the SLF based mainly on function: dorsal SLF, ventral SLF, posterior SLF, and arcuate fasciculus (AF); these correspond to the traditional SLF II, SLF III or anterior AF, temporoparietal segment of the SLF or posterior AF, and AF or AF long segment, respectively. Each segment has a distinct functional role. The dorsal SLF is involved in visuospatial attention and motor control, while the ventral SLF is associated with language-related networks, auditory comprehension, and articulatory processing in the left hemisphere. The posterior SLF is involved in language-related processing, including auditory comprehension, reading, and lexical access, while the AF is associated with language-related activities, such as phonological processing; the right AF plays a role in social cognition and visuospatial attention. This simple proposed classification permits a better understanding of the SLF and may comprise a convenient classification for use in research and clinical practice relating to brain function.

Lesion Quantification Toolkit: A MATLAB software tool for estimating grey matter damage and white matter disconnections in patients with focal brain lesions

Lesion studies are an important tool for cognitive neuroscientists and neurologists. However, while brain lesion studies have traditionally aimed to localize neurological symptoms to specific anatomical loci, a growing body of evidence indicates that neurological diseases such as stroke are best conceptualized as brain network disorders. While researchers in the fields of neuroscience and neurology are therefore increasingly interested in quantifying the effects of focal brain lesions on the white matter connections that form the brain's structural connectome, few dedicated tools exist to facilitate this endeavor. Here, we present the Lesion Quantification Toolkit, a publicly available MATLAB software package for quantifying the structural impacts of focal brain lesions. The Lesion Quantification Toolkit uses atlas-based approaches to estimate parcel-level grey matter lesion loads and multiple measures of white matter disconnection severity that include tract-level disconnection measures, voxel-wise disconnection maps, and parcel-wise disconnection matrices. The toolkit also estimates lesion-induced increases in the lengths of the shortest structural paths between parcel pairs, which provide information about changes in higher-order structural network topology. We describe in detail each of the different measures produced by the toolkit, discuss their applications and considerations relevant to their use, and perform example analyses using real behavioral data collected from sub-acute stroke patients. We show that analyses performed using the different measures produced by the toolkit produce results that are highly consistent with results that have been reported in the prior literature, and we demonstrate the consistency of results obtained from analyses conducted using the different disconnection measures produced by the toolkit. We anticipate that the Lesion Quantification Toolkit will empower researchers to address research questions that would be difficult or impossible to address using traditional lesion analyses alone, and ultimately, lead to advances in our understanding of how white matter disconnections contribute to the cognitive, behavioral, and physiological consequences of focal brain lesions.

Quantitative Assessment of Motor Neglect

[Figure: see text].

Visual and motor neglect: Clinical and neurocognitive aspects

Attention allows us to prioritize the processing of external information according to our goals, but also to cope with sudden, unforeseen events. Attention processes rely on the coordinated activity of large-scale brain networks. At the cortical level, these systems are mainly organized in fronto-parietal networks, with functional and anatomical asymmetries in favor of the right hemisphere. Dysfunction of these right-lateralized networks often produce severe deficit of spatial attention, such as visual neglect. Other brain-damaged patients avoid moving the limbs contralateral to their brain lesion, even in the absence of sensorimotor deficits (motor neglect). This paper first summarizes past and current evidence on brain networks of attention; then, it presents clinical and experimental findings on visual and motor neglect, and on the possible mechanisms of clinical recovery.

Neural substrates of subcortical aphasia in subacute stroke: Voxel-based lesion symptom mapping study

Subcortical aphasia develops as a result of damage to subcortical brain areas without loss of cortical functions. Although earlier voxel-based lesion-symptom mapping (VLSM) studies have shown possible neural correlates for aphasia, it remains to be clarified which brain regions are associated with subcortical aphasia. The aim of this study was to investigate the neural substrates associated with subcortical aphasia in patients with stroke using VLSM and atlas-based analyses to explore the involvement of white matter tracts and subcortical structures. Fifty patients with subacute subcortical stroke without cortical involvement were retrospectively enrolled: 24 with and 26 without aphasia. We performed VLSM and atlas-based analyses of the patients' fluid-attenuated inversion recovery images and found that the left perisylvian white matter, left fronto-occipital fasciculus, uncinate fasciculus, and forceps minor were significantly more greatly affected in the aphasia than in the non-aphasia group. The left anterior thalamic radiation, cingulum (cingulate gyrus), and superior longitudinal fasciculus also showed higher involvement in this group (marginal significance). Among the subcortical regions, the left caudate and putamen were more greatly involved in the aphasia group. Our findings confirm language processing as one of the integrated sensory-motor processes that occur in the region around the left sylvian fissure. Our atlas-based analysis approach can be used to complement VLSM analyses.

Disconnection somewhere down the line: Multivariate lesion-symptom mapping of the line bisection error

Line Bisection is a simple task frequently used in stroke patients to diagnose disorders of spatial perception characterized by a directional bisection bias to the ipsilesional side. However, previous anatomical and behavioural findings are contradictory, and the diagnostic validity of the line bisection task has been challenged. We hereby aimed to re-analyse the anatomical basis of pathological line bisection by using multivariate lesion-symptom mapping and disconnection-symptom mapping based on support vector regression in a sample of 163 right hemispheric acute stroke patients. In line with some previous studies, we observed that pathological line bisection was related to more than a single focal lesion location. Cortical damage primarily to right parietal areas, particularly the inferior parietal lobe, including the angular gyrus, as well as damage to the right basal ganglia contributed to the pathology. In contrast to some previous studies, an involvement of frontal cortical brain areas in the line bisection task was not observed. Subcortically, damage to the right superior longitudinal fasciculus (I, II and III) and arcuate fasciculus as well as the internal capsule was associated with line bisection errors. Moreover, white matter damage of interhemispheric fibre bundles, such as the anterior commissure and posterior parts of the corpus callosum projecting into the left hemisphere, was predictive of pathological deviation in the line bisection task.

Revisiting 'brain modes' in a new computational era: approaches for the characterization of brain-behavioural associations

The study of brain-function relationships is undergoing a conceptual and methodological transformation due to the emergence of network neuroscience and the development of multivariate methods for lesion-deficit inferences. Anticipating this process, in 1998 Godefroy and co-workers conceptualized the potential of four elementary typologies of brain-behaviour relationships named 'brain modes' (unicity, equivalence, association, summation) as building blocks able to describe the association between intact or lesioned brain regions and cognitive processes or neurological deficits. In the light of new multivariate lesion inference and network approaches, we critically revisit and update the original theoretical notion of brain modes, and provide real-life clinical examples that support their existence. To improve the characterization of elementary units of brain-behavioural relationships further, we extend such conceptualization with a fifth brain mode (mutual inhibition/masking summation). We critically assess the ability of these five brain modes to account for any type of brain-function relationship, and discuss past versus future contributions in redefining the anatomical basis of human cognition. We also address the potential of brain modes for predicting the behavioural consequences of lesions and their future role in the design of cognitive neurorehabilitation therapies.

Game theoretical mapping of white matter contributions to visuospatial attention in stroke patients with hemineglect

White matter bundles linking gray matter nodes are key anatomical players to fully characterize associations between brain systems and cognitive functions. Here we used a multivariate lesion inference approach grounded in coalitional game theory (multiperturbation Shapley value analysis, MSA) to infer causal contributions of white matter bundles to visuospatial orienting of attention. Our work is based on the characterization of the lesion patterns of 25 right hemisphere stroke patients and the causal analysis of their impact on three neuropsychological tasks: line bisection, letter cancellation, and bells cancellation. We report that, out of the 11 white matter bundles included in our MSA coalitions, the optic radiations, the inferior fronto-occipital fasciculus and the anterior cingulum were the only tracts to display task-invariant contributions (positive, positive, and negative, respectively) to the tasks. We also report task-dependent influences for the branches of the superior longitudinal fasciculus and the posterior cingulum. By extending prior findings to white matter tracts linking key gray matter nodes, we further characterize from a network perspective the anatomical basis of visual and attentional orienting processes. The knowledge about interactions patterns mediated by white matter tracts linking cortical nodes of attention orienting networks, consolidated by further studies, may help develop and customize brain stimulation approaches for the rehabilitation of visuospatial neglect.

Fluency and rule breaking behaviour in the frontal cortex

Design (DF) and phonemic fluency tests (FAS; D-KEFS, 2001) are commonly used to investigate voluntary generation. Despite this, several important issues remain poorly investigated. In a sizeable sample of patients with focal left or right frontal lesion we established that voluntary generation performance cannot be accounted for by fluid intelligence. For DF we found patients performed significantly worse than healthy controls (HC) only on the switch condition. However, no significant difference between left and right frontal patients was found. In contrast, left frontal patients were significantly impaired when compared with HC and right frontal patients on FAS. These lateralization findings were complemented, for the first time, by three neuroimaging; investigations. A traditional frontal subgrouping method found significant differences on FAS between patients with or without Left Inferior Frontal Gyrus lesions involving BA 44 and/or 45. Parcel Based Lesion Symptom Mapping (PLSM) found lower scores on FAS were significantly associated with damage to posterior Left Middle Frontal Gyrus. An increase in rule break errors, so far only anecdotally reported, was associated with damage to the left dorsal anterior cingulate and left body of the corpus callosum, supporting the idea that conflict resolution and monitoring impairments may play a role. Tractwise statistical analysis (TSA) revealed that patients with disconnection; in the left anterior thalamic projections, frontal aslant tract, frontal; orbitopolar tract, pons, superior longitudinal fasciculus I and II performed significantly worse than patients without disconnection in these tracts on FAS. In contrast, PLSM and TSA analyses did not reveal any significant relationship between lesion location and performance on the DF switch condition. Overall, these findings suggest DF may have limited utility as a tool in detecting lateralized frontal executive dysfunction, whereas FAS and rule break behavior appears to be linked to a set of well localized left frontal grey matter regions and white matter tracts.

Behavioral deficits in left hemispatial neglect are related to a reduction of spontaneous neuronal activity in the right superior parietal lobule

Focal brain lesions may induce dysfunctions in distant brain regions leading to behavioral impairments. Based on this concept of 'diaschisis', spatial neglect following stroke has been related to structural damage of the right-lateralized ventral attention network (VAN) and disrupted inter-hemispheric functional connectivity (FC) in the bilateral dorsal attention network (DAN). We questioned whether neglect-related behavioral deficits may be determined by local dysfunction of a specific region within these brain networks. We investigated acute right-hemisphere stroke patients with left hemispatial neglect using resting-state functional MRI, neuropsychological tests of spatial attention and clinical assessment of neglect-related functional disability. In addition to conventional FC analyses between different cortical regions of interest (ROIs) in the DAN/VAN, we extracted the fractional amplitude of low frequency fluctuations (fALFF) from each ROI as a marker of regional spontaneous neuronal activity. Although DAN regions (as opposed to the VAN regions) were largely spared from structural brain damage, they exhibited a significant reduction of inter-hemispheric FC. However, significant fMRI-behavior correlations were revealed specifically for the fALFF of one DAN-ROI in the right superior parietal lobule (SPL): the smaller the fALFF in the right posterior intraparietal sulcus, the more severe the patient's pathological attention bias and neglect-related functional impairment. In line with 'diaschisis', our findings confirm a crucial role of the non-lesioned but dysfunctional right SPL for the emergence of spatial neglect and its behavioral consequences. They further support targeting the SPL dysfunction by non-invasive brain stimulation in neglect rehabilitation.

Using machine learning-based lesion behavior mapping to identify anatomical networks of cognitive dysfunction: Spatial neglect and attention

Previous lesion behavior studies primarily used univariate lesion behavior mapping techniques to map the anatomical basis of spatial neglect after right brain damage. These studies led to inconsistent results and lively controversies. Given these inconsistencies, the idea of a wide-spread network that might underlie spatial orientation and neglect has been pushed forward. In such case, univariate lesion behavior mapping methods might have been inherently limited in detecting the presumed network due to limited statistical power. By comparing various univariate analyses with multivariate lesion-mapping based on support vector regression, we aimed to validate the network hypothesis directly in a large sample of 203 newly recruited right brain damaged patients. If the exact same correction factors and parameter combinations (FDR correction and dTLVC for lesion size control) were used, both univariate as well as multivariate approaches uncovered the same complex network pattern underlying spatial neglect. At the cortical level, lesion location dominantly affected the temporal cortex and its borders into inferior parietal and occipital cortices. Beyond, frontal and subcortical gray matter regions as well as white matter tracts connecting these regions were affected. Our findings underline the importance of a right network in spatial exploration and attention and specifically in the emergence of the core symptoms of spatial neglect.

Musical Neglect Training for Chronic Persistent Unilateral Visual Neglect Post-stroke

Unilateral visual neglect from right hemispheric stroke is a condition that reduces a person's ability to attend to and process stimuli in their left visual field, resulting in neglect and inattention to the left side of their environment. This perceptual processing deficit can negatively affect individuals' daily living which in turn reduces functional independence. Musical Neglect Training (MNT) has been developed based on previous research evidence to improve left visual field processing. Two individuals with persistent chronic unilateral visual neglect participated in this study. Participants underwent six individual MNT sessions. Active MNT was used involving exercises on musical equipment (tone bars) to complete musical patterns emphasizing attentional focus toward the neglect visual field. Two standardized assessments (Albert's and Line Bisection Test) were used. The assessments were administered immediately before and after each of the 6 MNT sessions to assess the within-session effect of MNT. Follow-up testing was done 1 week after their 6th session to examine the longer-lasting effects of MNT. Paired t-test and Wilcoxon signed rank test were used to examine results. Both participants showed significant improvement pre vs. posttest on the Albert's Test but not on the Line Bisection Test. The current study presents the positive potential of MNT for patients with chronic persistent visual neglect. In particular, effects were shown for exploratory visuomotor neglect (Albert's test), but not for egocentric perceptive neglect (Line Bisection Test), and substantiated for within-session effects only. The predictable auditory stimulus patterns associated with object sequences (tone bars) to provide feedback, direct spatial attention and orientation, and initiate intention for movement into the neglect field may offer specific advantages to reduce persistent perceptual attention deficits.

Perturbation-driven paradoxical facilitation of visuo-spatial function: Revisiting the 'Sprague effect'

The 'Sprague Effect' described in the seminal paper of James Sprague (Science 153:1544-1547, 1966a) is an unexpected paradoxical effect in which a second brain lesion reversed functional deficits induced by an earlier lesion. It was observed initially in the cat where severe and permanent contralateral visually guided attentional deficits generated by the ablation of large areas of the visual cortex were reversed by the subsequent removal of the superior colliculus (SC) opposite to the cortical lesion or by the splitting of the collicular commissure. Physiologically, this effect has been explained in several ways-most notably by the reduction of the functional inhibition of the ipsilateral SC by the contralateral SC, and the restoration of normal interactions between cortical and midbrain structures after ablation. In the present review, we aim at reappraising the 'Sprague Effect' by critically analyzing studies that have been conducted in the feline and human brain. Moreover, we assess applications of the 'Sprague Effect' in the rehabilitation of visually guided attentional impairments by using non-invasive therapeutic approaches such as transcranial magnetic stimulation (TMS) and transcranial direct-current stimulation (tDCS). We also review theoretical models of the effect that emphasize the inhibition and balancing between the two hemispheres and show implications for lesion inference approaches. Last, we critically review whether the resulting inter-hemispheric rivalry theories lead toward an efficient rehabilitation of stroke in humans. We conclude by emphasizing key challenges in the field of 'Sprague Effect' applications in order to design better therapies for brain-damaged patients.

Eye-Tracking Provides a Sensitive Measure of Exploration Deficits After Acute Right MCA Stroke

The eye-tracking study aimed at assessing spatial biases in visual exploration in patients after acute right MCA (middle cerebral artery) stroke. Patients affected by unilateral neglect show less functional recovery and experience severe difficulties in everyday life. Thus, accurate diagnosis is essential, and specific treatment is required. Early assessment is of high importance as rehabilitative interventions are more effective when applied soon after stroke. Previous research has shown that deficits may be overlooked when classical paper-and-pencil tasks are used for diagnosis. Conversely, eye-tracking allows direct monitoring of visual exploration patterns. We hypothesized that the analysis of eye-tracking provides more sensitive measures for spatial exploration deficits after right middle cerebral artery stroke. Twenty-two patients with right MCA stroke (median 5 days after stroke) and 28 healthy controls were included. Lesions were confirmed by MRI/CCT. Groups performed comparably in the Mini-Mental State Examination (patients and controls median 29) and in a screening of executive functions. Eleven patients scored at ceiling in neglect screening tasks, 11 showed minimal to severe signs of unilateral visual neglect. An overlap plot based on MRI and CCT imaging showed lesions in the temporo-parieto-frontal cortex, basal ganglia, and adjacent white matter tracts. Visual exploration was evaluated in two eye-tracking tasks, one assessing free visual exploration of photographs, the other visual search using symbols and letters. An index of fixation asymmetries proved to be a sensitive measure of spatial exploration deficits. Both patient groups showed a marked exploration bias to the right when looking at complex photographs. A single case analysis confirmed that also most of those patients who showed no neglect in screening tasks performed outside the range of controls in free exploration. The analysis of patients' scoring at ceiling in neglect screening tasks is of special interest, as possible deficits may be overlooked and thus remain untreated. Our findings are in line with other studies suggesting considerable limitations of laboratory screening procedures to fully appreciate the occurrence of neglect symptoms. Future investigations are needed to explore the predictive value of the eye-tracking index and its validity in everyday situations.