Impaired visual search in patients with unilateral neglect: an oculographic analysis

Using augmented reality to assess spatial neglect: The Free Exploration Test (FET)

BACKGROUND

To capture the distortion of exploratory activity typical of patients with spatial neglect, traditional diagnostic methods and new virtual reality applications use confined workspaces that limit patients' exploration behavior to a predefined area. Our aim was to overcome these limitations and enable the recording of patients' biased activity in real, unconfined space.

METHODS

We developed the Free Exploration Test (FET) based on augmented reality technology. Using a live stream via the back camera on a tablet, patients search for a (non-existent) virtual target in their environment, while their exploration movements are recorded for 30 s. We tested 20 neglect patients and 20 healthy participants and compared the performance of the FET with traditional neglect tests.

RESULTS

In contrast to controls, neglect patients exhibited a significant rightward bias in exploratory movements. The FET had a high discriminative power (area under the curve = 0.89) and correlated positively with traditional tests of spatial neglect (Letter Cancellation, Bells Test, Copying Task, Line Bisection). An optimal cut-off point of the averaged bias of exploratory activity was at 9.0° on the right; it distinguished neglect patients from controls with 85% sensitivity.

DISCUSSION

FET offers time-efficient (execution time: ∼3 min), easy-to-apply, and gamified assessment of free exploratory activity. It supplements traditional neglect tests, providing unrestricted recording of exploration in the real, unconfined space surrounding the patient.

Preserved recognition of basic visual features despite lack of awareness of shape: Evidence from a case of neglect

Human visual experience of objects comprises a combination of visual features, such as color, position, and shape. Spatial attention is thought to play a role in creating a coherent perceptual experience, integrating visual information coming from a given location, but the mechanisms underlying this process are not fully understood. Deficits of spatial attention in which this integration process does not occur normally, such as neglect, can provide insights regarding the mechanisms of spatial attention in visual object recognition. In this study, we describe a series of experiments conducted with an individual with neglect, DH. DH presents characteristic lack of awareness of the left side of individual objects, evidenced by poor object and face recognition, and impaired word reading. However, he exhibits intact recognition of color within the boundaries of the same objects he fails to recognize. Furthermore, he can also report the orientation and location of a colored region on the neglected left side despite lack of awareness of the shape of the region. Overall, DH shows selective lack of awareness of shape despite intact processing of basic visual features in the same spatial location. DH's performance raises intriguing questions and challenges about the role of spatial attention in the formation of coherent object percepts and visual awareness.

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.

A systematic review on visual scanning behaviour in hemianopia considering task specificity, performance improvement, spontaneous and training-induced adaptations

PURPOSE

People with homonymous hemianopia (HH) benefit from applying compensatory scanning behaviour that limits the consequences of HH in a specific task. The aim of the study is to (i) review the current literature on task-specific scanning behaviour that improves performance and (ii) identify differences between this performance-enhancing scanning behaviour and scanning behaviour that is spontaneously adopted or acquired through training.

MATERIALS AND METHODS

The databases PsycInfo, Medline, and Web of Science were searched for articles on scanning behaviour in people with HH.

RESULTS

The final sample contained 60 articles, reporting on three main tasks, i.e., search (N = 17), reading (N = 16) and mobility (N = 14), and other tasks (N = 18). Five articles reported on two different tasks. Specific scanning behaviour related to task performance in search, reading, and mobility tasks. In search and reading tasks, spontaneous adaptations differed from this performance-enhancing scanning behaviour. Training could induce adaptations in scanning behaviour, enhancing performance in these two tasks. For mobility tasks, limited to no information was found on spontaneous and training-induced adaptations to scanning behaviour.

CONCLUSIONS

Performance-enhancing scanning behaviour is mainly task-specific. Spontaneous development of such scanning behaviour is rare. Luckily, current compensatory scanning training programs can induce such scanning behaviour, which confirms that providing scanning training is important.IMPLICATIONS FOR REHABILITATIONScanning behaviour that improves performance in people with homonymous hemianopia (HH) is task-specific.Most people with HH do not spontaneously adopt scanning behaviour that improves performance.Compensatory scanning training can induce performance-enhancing scanning behaviour.

Seeing without a Scene: Neurological Observations on the Origin and Function of the Dorsal Visual Stream

In all vertebrates, visual signals from each visual field project to the opposite midbrain tectum (called the superior colliculus in mammals). The tectum/colliculus computes visual salience to select targets for context-contingent visually guided behavior: a frog will orient toward a small, moving stimulus (insect prey) but away from a large, looming stimulus (a predator). In mammals, visual signals competing for behavioral salience are also transmitted to the visual cortex, where they are integrated with collicular signals and then projected via the dorsal visual stream to the parietal and frontal cortices. To control visually guided behavior, visual signals must be encoded in body-centered (egocentric) coordinates, and so visual signals must be integrated with information encoding eye position in the orbit-where the individual is looking. Eye position information is derived from copies of eye movement signals transmitted from the colliculus to the frontal and parietal cortices. In the intraparietal cortex of the dorsal stream, eye movement signals from the colliculus are used to predict the sensory consequences of action. These eye position signals are integrated with retinotopic visual signals to generate scaffolding for a visual scene that contains goal-relevant objects that are seen to have spatial relationships with each other and with the observer. Patients with degeneration of the superior colliculus, although they can see, behave as though they are blind. Bilateral damage to the intraparietal cortex of the dorsal stream causes the visual scene to disappear, leaving awareness of only one object that is lost in space. This tutorial considers what we have learned from patients with damage to the colliculus, or to the intraparietal cortex, about how the phylogenetically older midbrain and the newer mammalian dorsal cortical visual stream jointly coordinate the experience of a spatially and temporally coherent visual scene.

Assessing the allocation of attention during visual search using digit-tracking, a calibration-free alternative to eye tracking

Digit-tracking, a simple, calibration-free technique, has proven to be a good alternative to eye tracking in vision science. Participants view stimuli superimposed by Gaussian blur on a touchscreen interface and slide a finger across the display to locally sharpen an area the size of the foveal region just at the finger's position. Finger movements are recorded as an indicator of eye movements and attentional focus. Because of its simplicity and portability, this system has many potential applications in basic and applied research. Here we used digit-tracking to investigate visual search and replicated several known effects observed using different types of search arrays. Exploration patterns measured with digit-tracking during visual search of natural scenes were comparable to those previously reported for eye-tracking and constrained by similar saliency. Therefore, our results provide further evidence for the validity and relevance of digit-tracking for basic and applied research on vision and attention.

Gaze-contingent display technology can help to reduce the ipsilesional attention bias in hemispatial neglect following stroke

Background

Hemispatial neglect results from unilateral brain damage and represents a disabling unawareness for objects in the hemispace opposite the brain lesion (contralesional). The patients’ attentional bias for ipsilesional hemispace represents a hallmark of neglect, which results from an imbalanced attentional priority map in the brain. The aim of this study was to investigate whether gaze-contingent display (GCD) technology, reducing the visual salience of objects in ipsilesional hemispace, is able to rebalance this map and increase awareness and exploration of objects in the neglected contralesional hemispace.

Methods

Using remote eye-tracking, we recorded gaze positions in 19 patients with left hemispatial neglect following right-hemisphere stroke and 22 healthy control subjects, while they were watching static naturalistic scenes. There were two task conditions, free viewing (FV) or goal-directed visual search (VS), and four modification conditions including the unmodified original picture, a purely static modification and two differently strong modifications with an additional gaze-contingent mask (GC-LOW, GC-HIGH), that continuously reduced color saturation and contrast of objects in the right hemispace.

Results

The patients’ median gaze position (Center of Fixation) in the original pictures was markedly deviated to the right in both tasks (FV: 6.8° ± 0.8; VS: 5.5° ± 0.7), reflecting the neglect-typical ipsilesional attention bias. GC modification significantly reduced this bias in FV (GC-HIGH: d = − 3.2 ± 0.4°; p < 0.001). Furthermore, in FV and VS, GC modification increased the likelihood to start visual exploration in the (neglected) left hemifield by about 20%. This alleviation of the ipsilesional fixation bias was not associated with an improvement in detecting left-side targets, in contrast, the GC mask even decreased and slowed the detection of right-side targets. Subjectively, patients found the intervention pleasant and most of the patients did not notice any modification.

Conclusions

GCD technology can be used to positively influence visual exploration patterns in patients with hemispatial neglect. Despite an alleviation of the neglect-related ipsilesional fixation bias, a concomitant functional benefit (improved detection of contralesional targets) was not achieved. Future studies may investigate individualized GCD-based modifications as augmented reality applications during the activities of daily living.

Machine learning algorithms on eye tracking trajectories to classify patients with spatial neglect

BACKGROUND AND OBJECTIVE

Eye-movement trajectories are rich behavioral data, providing a window on how the brain processes information. We address the challenge of characterizing signs of visuo-spatial neglect from saccadic eye trajectories recorded in brain-damaged patients with spatial neglect as well as in healthy controls during a visual search task.

METHODS

We establish a standardized pre-processing pipeline adaptable to other task-based eye-tracker measurements. We use traditional machine learning algorithms together with deep convolutional networks (both 1D and 2D) to automatically analyze eye trajectories.

RESULTS

Our top-performing machine learning models classified neglect patients vs. healthy individuals with an Area Under the ROC curve (AUC) ranging from 0.83 to 0.86. Moreover, the 1D convolutional neural network scores correlated with the degree of severity of neglect behavior as estimated with standardized paper-and-pencil tests and with the integrity of white matter tracts measured from Diffusion Tensor Imaging (DTI). Interestingly, the latter showed a clear correlation with the third branch of the superior longitudinal fasciculus (SLF), especially damaged in neglect.

CONCLUSIONS

The study introduces new methods for both the pre-processing and the classification of eye-movement trajectories in patients with neglect syndrome. The proposed methods can likely be applied to other types of neurological diseases opening the possibility of new computer-aided, precise, sensitive and non-invasive diagnostic tools.

Effect of motor tasks with left monocular eyeglasses on visual search and line-bisection performance in people with left unilateral spatial neglect

Training with an eyepatch or eyeglasses is one of the effective approaches for unilateral spatial neglect (USN), and it usually uses a device that covers the right side. However, few approaches are available for the left side. In this study, we examine the effect of motor tasks with left/right monocular eyeglasses on visual search and line-bisection performance in people with left USN. Seven participants with left USN admitted to convalescent hospitals were included. We conducted the Bells test, line-crossing test, and line-bisection test of the behavioral inattention test before/after the motor task. Our analyses focused on the improvement or decline in these assessment scores and the achievement/errors/non-smoothness scores of the motor task. When using the left monocular eyeglasses, the percentages of participants categorized as "improvement," "unchanged," and "decline" were 71.4%, 28.6%, and 0%, respectively (when using the right one they were 14.3%, 85.7%, and 0%). In the motor task, when using the left monocular eyeglasses, total achievement scores in five of seven participants were greater than those when using the right one, and they performed efficiently with fewer movement errors. These results suggest that training with left monocular eyeglasses might improve visual search performance in people with left USN.

Adaptive integration of self-motion and goals in posterior parietal cortex

Rats readily switch between foraging and more complex navigational behaviors such as pursuit of other rats or prey. These tasks require vastly different tracking of multiple behaviorally significant variables including self-motion state. To explore whether navigational context modulates self-motion tracking, we examined self-motion tuning in posterior parietal cortex neurons during foraging versus visual target pursuit. Animals performing the pursuit task demonstrate predictive processing of target trajectories by anticipating and intercepting them. Relative to foraging, pursuit yields multiplicative gain modulation of self-motion tuning and enhances self-motion state decoding. Self-motion sensitivity in parietal cortex neurons is, on average, history dependent regardless of behavioral context, but the temporal window of self-motion integration extends during target pursuit. Finally, many self-motion-sensitive neurons conjunctively track the visual target position relative to the animal. Thus, posterior parietal cortex functions to integrate the location of navigationally relevant target stimuli into an ongoing representation of past, present, and future locomotor trajectories.

Psychiatric sequelae of stroke affecting the non-dominant cerebral hemisphere

There are a plethora of cognitive sequelae in addition to neglect and extinction that arise with unilateral right hemispheric stroke (RHS). Cognitive deficits following non-dominant (right) hemisphere stroke are common with unilateral neglect and extinction being the most recognized examples. The severity of RHS is usually underestimated by the National Institutes of Health Stroke Scale (NIHSS), which in terms of lateralized right hemisphere cognitive deficits, tests only for visual inattention/extinction. They account for 2 out of 42 total possible points. Additional neuropsychiatric sequelae include but are not limited to deficiencies in affective prosody comprehension and production (aprosodias), understanding and expressing facial emotions, empathy, recognition of familiar faces, anxiety, mania, apathy, and psychosis. These sequelae have a profound impact on patients' quality of life; affecting communication, interpersonal relationships, and the ability to fulfill social roles. They also pose additional challenges to recovery. There is presently a gap in the literature regarding a cohesive overview of the significant cognitive sequelae following RHS. This paper serves as a narrative survey of the current understanding of the subject, with particular emphasis on neuropsychiatric poststroke syndromes not predominantly associated with left hemisphere lesions (LHL), bilateral lesions, hemiplegia, or paralysis. A more comprehensive understanding of the neuropsychological consequences of RHS extending beyond the typical associations of unilateral neglect and extinction may have important implications for clinical practice, including the ways in which clinicians approach diagnostics, treatment, and rehabilitation.

Sources of variation in search and foraging: A theoretical perspective

Search-the problem of exploring a space of alternatives to identify target goals-is a fundamental behaviour for many species. Although its foundation lies in foraging, most studies of human search behaviour have been directed towards understanding the attentional mechanisms that underlie the efficient visual exploration of two-dimensional (2D) scenes. With this review, we aim to characterise how search behaviour can be explained across a wide range of contexts, environments, spatial scales, and populations, both typical and atypical. We first consider the generality of search processes across psychological domains. We then review studies of interspecies differences in search. Finally, we explore in detail the individual and contextual variables that affect visual search and related behaviours in established experimental psychology paradigms. Despite the heterogeneity of the findings discussed, we identify that variations in control processes, along with the ability to regulate behaviour as a function of the structure of search space and the sampling processes adopted, to be central to explanations of variations in search behaviour. We propose a tentative theoretical model aimed at integrating these notions and close by exploring questions that remain unaddressed.

Congruent movement training as a rehabilitation method to ameliorate symptoms of neglect-proof of concept

Stroke patients with visuospatial neglect (VSN) have difficulties responding to visual information located in the contralesional hemifield, affecting many daily life activities (ADL) such as eating, reading and mobility. Visual Scanning Therapy (VST) is widely used in clinical practice to ameliorate symptoms of VSN. Yet, not all patients benefit from this training and many training sessions are needed in order to achieve stable results. One potentially promising improvement to the VST is based on the theory that different effectors of the motor systems (e.g., eyes, hands) independently allocate attention during the programming of the movement (i.e., Pre Motor Theory of Attention (PMT)). Here, we studied this direct implementation of the PMT and tested whether a congruent movement training (CMT: congruent -i.e., executed at the same time to the same location-eye and pointing movements) is more effective to attenuate symptoms of neglect compared to VST. This study can be seen as a proof of concept. Attenuation of neglect symptoms was found in the CMT group after just 5 h of training in the subacute phase of neglect. In contrast, no training effects were found in the VST group. These findings indicate the potential of CMT which is a minimal -yet crucial-upgrade of the standard VST protocol that can be easily implemented in the clinic.

Bálint syndrome

This chapter starts by reviewing the various interpretations of Bálint syndrome over time. We then develop a novel integrative view in which we propose that the various symptoms, historically reported and labeled by various authors, result from a core mislocalization deficit. This idea is in accordance with our previous proposal that the core deficit of Bálint syndrome is attentional (Pisella et al., 2009, 2013, 2017) since covert attention improves spatial resolution in visual periphery (Yeshurun and Carrasco, 1998); a deficit of covert attention would thus increase spatial uncertainty and thereby impair both visual object identification and visuomotor accuracy. In peripheral vision, we perceive the intrinsic characteristics of the perceptual elements surrounding us, but not their precise localization (Rosenholtz et al., 2012a,b), such that without covert attention we cannot organize them to their respective and recognizable objects; this explains why perceptual symptoms (simultanagnosia, neglect) could result from visual mislocalization. The visuomotor symptoms (optic ataxia) can be accounted for by both visual and proprioceptive mislocalizations in an oculocentric reference frame, leading to field and hand effects, respectively. This new pathophysiological account is presented along with a model of posterior parietal cortex organization in which the superior part is devoted to covert attention, while the right inferior part is involved in visual remapping. When the right inferior parietal cortex is damaged, additional representational mislocalizations across saccades worsen the clinical picture of peripheral mislocalizations due to an impairment of covert attention.

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.

Non-Spatial Impairments Affect False-Positive Neglect Diagnosis Based on Cancellation Tasks

OBJECTIVE

To diagnose egocentric neglect after stroke, the spatial bias of performance on cancellation tasks is typically compared to a single cutoff. This standard procedure relies on the assumption that the measurement error of cancellation performance does not depend on non-spatial impairments affecting the total number of cancelled targets. Here we assessed the impact of this assumption on false-positive diagnoses.

METHOD

We estimated false positives by simulating cancellation data using a binomial model. Performance was summarised by the difference in left and right cancelled targets (R-L) and the Centre of Cancellation (CoC). Diagnosis was based on a fixed cutoff versus cutoffs adjusted for the total number of cancelled targets and on single test performance versus unanimous or proportional agreement across multiple tests. Finally, we compared the simulation findings to empirical cancellation data acquired from 651 stroke patients.

RESULTS

Using a fixed cutoff, the rate of false positives depended on the total number of cancelled targets and ranged from 10% to 30% for R-L scores and from 10% to 90% for CoC scores. The rate of false positives increased even further when diagnosis was based on proportional agreement across multiple tests. Adjusted cutoffs and unanimous agreement across multiple tests were effective at controlling false positives. For empirical data, fixed versus adjusted cutoffs differ in estimation of neglect prevalence by 13%, and this difference was largest for patients with non-spatial impairments.

CONCLUSIONS

Our findings demonstrate the importance of considering non-spatial impairments when diagnosing neglect based on cancellation performance.

Primate Amygdalo-Nigral Pathway for Boosting Oculomotor Action in Motivating Situations

A primary function of the primate amygdala is to modulate behavior based on emotional cues. To study the underlying neural mechanism, we first inactivated the amygdala locally and temporarily by injecting a GABA agonist. Then, saccadic eye movements and gaze were suppressed only on the contralateral side. Next, we performed optogenetic activation after injecting a viral vector into the amygdala. Optical stimulation in the amygdala excited amygdala neurons, whereas optical stimulation of axon terminals in the substantia nigra pars reticulata inhibited nigra neurons. Optical stimulation in either structure facilitated saccades to the contralateral side. These data suggest that the amygdala controls saccades and gaze through the basal ganglia output to the superior colliculus. Importantly, this amygdala-derived circuit mediates emotional context information, whereas the internal basal ganglia circuit mediates object value information. This finding demonstrates a basic mechanism whereby basal ganglia output can be modulated by other areas conveying distinct information.

Unbalancing the Attentional Priority Map via Gaze-Contingent Displays Induces Neglect-Like Visual Exploration

Selective spatial attention is a crucial cognitive process that guides us to the behaviorally relevant objects in a complex visual world by using exploratory eye movements. The spatial location of objects, their (bottom-up) saliency and (top-down) relevance is assumed to be encoded in one “attentional priority map” in the brain, using different egocentric (eye-, head- and trunk-centered) spatial reference frames. In patients with hemispatial neglect, this map is supposed to be imbalanced, leading to a spatially biased exploration of the visual environment. As a proof of concept, we altered the visual saliency (and thereby attentional priority) of objects in a naturalistic scene along a left-right spatial gradient and investigated whether this can induce a bias in the exploratory eye movements of healthy humans (n = 28; all right-handed; mean age: 23 years, range 19–48). We developed a computerized mask, using high-end “gaze-contingent display (GCD)” technology, that immediately and continuously reduced the saliency of objects on the left—“left” with respect to the head (body-centered) and the current position on the retina (eye-centered). In both experimental conditions, task-free viewing and goal-driven visual search, this modification induced a mild but significant bias in visual exploration similar to hemispatial neglect. Accordingly, global eye movement parameters changed (reduced number and increased duration of fixations) and the spatial distribution of fixations indicated an attentional bias towards the right (rightward shift of first orienting, fixations favoring the scene’s outmost right over left). Our results support the concept of an attentional priority map in the brain as an interface between perception and behavior and as one pathophysiological ground of hemispatial neglect.

The relationship between visuospatial neglect, spatial working memory and search behavior

Visuospatial neglect (VSN) is characterized by a lateralized attentional deficit in the visual domain. In addition, patients with VSN might have an impairment in the temporary storage of spatial information in working memory (spatial working memory; SWM) that, like VSN, could impair systematic searching behavior. Several studies have demonstrated either SWM impairments or impaired searching behavior in VSN patients. Here, we related SWM performance to search behavior in patients with and without VSN. We assessed SWM using a novel task in a group of 182 stroke patients (24 with VSN, 158 without) and 65 healthy controls. We related SWM performance to available stroke-related and cognitive data. Patients with VSN exhibited lower SWM performance than patients without VSN and healthy controls. Additional control analyses indicated that differences in SWM performance are specific to visuospatial processing, instead of e.g. verbal working memory or the general level of physical disability. Last, we related SWM performance to visual search performance on cancellation tasks, one where their cancellation markings remained visible and another one where their prior cancellations markings were invisible to the patient and therefore patients had to remember which targets they had canceled. SWM performance correlated with search organization. Together, these results from a large sample of stroke patients corroborate the findings of earlier studies, while excluding several alternative explanations: SWM impairment is a part of the neglect syndrome, and SWM impairments are related to search behavior.

Visuospatial Neglect - a Theory-Informed Overview of Current and Emerging Strategies and a Systematic Review on the Therapeutic Use of Non-invasive Brain Stimulation

Visuospatial neglect constitutes a supramodal cognitive deficit characterized by reduction or loss of spatial awareness for the contralesional space. It occurs in over 40% of right- and 20% of left-brain-lesioned stroke patients with lesions located mostly in parietal, frontal and subcortical brain areas. Visuospatial neglect is a multifaceted syndrome - symptoms can be divided into sensory, motor and representational neglect - and therefore requires an individually adapted diagnostic and therapeutic approach. Several models try to explain the origins of visuospatial neglect, of which the "interhemispheric rivalry model" is strongly supported by animal and human research. This model proposes that allocation of spatial attention is balanced by transcallosal inhibition and both hemispheres compete to direct attention to the contralateral hemi-space. Accordingly, a brain lesion causes an interhemispheric imbalance, which may be re-installed by activation of lesioned, or deactivation of unlesioned (over-activated) brain areas through noninvasive brain stimulation. Research in larger patient samples is needed to confirm whether noninvasive brain stimulation can improve long-term outcomes and whether these also affect activities of daily living and discharge destination.

Fixated in unfamiliar territory: Mapping estimates across typical and atypical number lines

Adults (N = 72) estimated the location of target numbers on number lines that varied in numerical range (i.e., typical range 0-10,000 or atypical range 0-7,000) and spatial orientation (i.e., the 0 endpoint on the left [traditional] or on the right [reversed]). Eye-tracking data were used to assess strategy use. Participants made meaningful first fixations on the line, with fixations occurring around the origin for low target numbers and around the midpoint and endpoint for high target numbers. On traditional direction number lines, participants used left-to-right scanning and showed a leftward bias; these effects were reduced for the reverse direction number lines. Participants made fixations around the midpoint for both ranges but were less accurate when estimating target numbers around the midpoint on the 7,000-range number line. Thus, participants are using the internal benchmark (i.e., midpoint) to guide estimates on atypical range number lines, but they have difficulty calculating the midpoint, leading to less accurate estimates. In summary, both range and direction influenced strategy use and accuracy, suggesting that both numerical and spatial processes influence number line estimation.

Peripheral Prisms Improve Obstacle Detection during Simulated Walking for Patients with Left Hemispatial Neglect and Hemianopia

SIGNIFICANCE

The first report on the use of peripheral prisms (p-prisms) for patients with left neglect and homonymous visual field defects (HVFDs).

PURPOSE

The purpose of this study was to investigate if patients with left hemispatial neglect and HVFDs benefit from p-prisms to expand the visual field and improve obstacle detection.

METHODS

Patients (24 with HVFDs, 10 of whom had left neglect) viewed an animated, virtual, shopping mall corridor and reported if they would have collided with a human obstacle that appeared at various offsets up to 13.5° from their simulated walking path. There were 40 obstacle presentations on each side, with and without p-prisms. No training with p-prisms was provided, and gaze was fixed at the center of expansion.

RESULTS

Detection on the side of the HVFD improved significantly with p-prisms in both groups, from 26 to 92% in the left-neglect group and 43 to 98% in the non-neglect group (both P < .001). There was a tendency for greater improvement in the neglect patients with p-prisms. For collision judgments, both groups exhibited a large increase in perceived collisions on the side of the HVFD with the prisms (P < .001), with no difference between the groups (P = .93). Increased perceived collisions represent a wider perceived safety margin on the side of the HVFD.

CONCLUSIONS

Within the controlled conditions of this simulated, collision judgment task, patients with left neglect responded well to initial application of p-prisms exhibiting improved detection and wider safety margins on the side of the HVFD that did not differ from non-neglect patients. Further study of p-prisms for neglect patients in free-gaze conditions after extended wear and in real-world mobility tasks is clearly warranted.

The Scanpaths of Subjects with Developmental Prosopagnosia during a Face Memory Task

The scanpaths of healthy subjects show biases towards the upper face, the eyes and the center of the face, which suggests that their fixations are guided by a feature hierarchy towards the regions most informative for face identification. However, subjects with developmental prosopagnosia have a lifelong impairment in face processing. Whether this is reflected in the loss of normal face-scanning strategies is not known. The goal of this study was to determine if subjects with developmental prosopagnosia showed anomalous scanning biases as they processed the identity of faces. We recorded the fixations of 10 subjects with developmental prosopagnosia as they performed a face memorization and recognition task, for comparison with 8 subjects with acquired prosopagnosia (four with anterior temporal lesions and four with occipitotemporal lesions) and 20 control subjects. The scanning of healthy subjects confirmed a bias to fixate the upper over the lower face, the eyes over the mouth, and the central over the peripheral face. Subjects with acquired prosopagnosia from occipitotemporal lesions had more dispersed fixations and a trend to fixate less informative facial regions. Subjects with developmental prosopagnosia did not differ from the controls. At a single-subject level, some developmental subjects performed abnormally, but none consistently across all metrics. Scanning distributions were not related to scores on perceptual or memory tests for faces. We conclude that despite lifelong difficulty with faces, subjects with developmental prosopagnosia still have an internal facial schema that guides their scanning behavior.

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.

Culturally influenced performance on tasks of line bisection and symbol cancellation in Arabs

The objective of this study was to administer line bisection (LB) and symbol cancellation (SC) tasks on a sample of healthy Arabs in Saudi Arabia, to determine if normative performance would differ from that of the Western population. A total of 136 healthy individuals were enrolled. Deviation direction from the veridical center and percentage deviation scores (PDS) were determined for LB. The overall performance on SC was calculated. Differences according to gender, education and age were measured. Out of the 2,287 times lines were bisected, 1025 (44.82%) deviated rightward (p < 0.0001). Mean (SD) PDS showed a rightward bias 1.57(3.4), (p < 0.0001). Rightward deviation odds modestly increased with age (OR 1.04, P 0.038). In SC, 63% started searching from the left and 67.5% used a horizontal strategy. The mean (SD) performance score was 0.468 (0.248) with no significant cancellation asymmetry. Female gender, education, and age significantly associated with performance. No correlation was found between the two tasks (p = 0.09). Line bisection error biases in Arabs are opposite of Western biases. Scanning for symbols started on the left side; however, this was smaller than that seen in existing Western reports. Normative performances are different from Western studies, but similarly influenced by the same demographic variables.

Association between prism adaptation and auditory cues on spatial navigation in individuals with unilateral neglect

BACKGROUND

Unilateral neglect is common among right-hemispheric stroke individuals and also concerns the auditory modality. Prism adaptation can improve auditory extinction during a dichotic listening task, but its effect during an ecological task has not been studied.

OBJECTIVE

The main objective was to evaluate whether lateralized cueing before and after prism adaptation improved virtual spatial navigation of stroke individuals with visual and auditory unilateral neglect. Secondary objectives were to assess spatial memory and obtain a better understanding of the mechanism of the cueing treatment by using an eye-tracker.

METHODS

We included 22 stroke individuals with left visual and auditory neglect, 14 individuals without neglect, and 12 healthy controls. After a familiarization task, participants underwent 3 evaluation sessions. Participants were first passively shown a path that they had then to actively reproduce by using a joystick. A path with lateralized beeping sounds indicating direction and a path without any sounds were followed in a randomized order. After prism adaptation, the participants followed a third path with lateralized beeping sounds. The time of navigation and number of trajectory mistakes were recorded. After navigation, spatial memory was assessed. Additionally, an eye-tracker was used during the navigation period.

RESULTS

The navigational performance of participants with neglect was significantly better with than without auditory cues, especially after prism adaptation. With auditory cues, participants without neglect reached the navigational performance of healthy controls. The spatial memory of individuals with neglect was significantly lower with auditory cues. Eye-tracking analyses showed that participants with neglect made more saccades and looked longer at the right-square angles in the absence of auditory cues.

CONCLUSIONS

This study demonstrates the positive effect of auditory cues in virtual spatial navigation of individuals with visual and auditory neglect and the potentiation of the help of cues after prism adaptation.

Ipsilesional Impairments of Visual Awareness After Right-Hemispheric Stroke

Unilateral brain damage following stroke frequently hampers the processing of contralesional space. Whether and how it also affects the processing of stimuli appearing on the same side of the lesion is still poorly understood. Three main alternative hypotheses have been proposed, namely that ipsilesional processing is functionally (i) hyperefficient, (ii) impaired, or (iii) spared. Here, we investigated ipsilesional space awareness through a computerized paradigm that exploits a manipulation of concurrent information processing demands (i.e., multitasking). Twelve chronic right-hemisphere stroke patients with a total lack of awareness for the contralesional side of space were administered a task that required the spatial monitoring of two locations within the ipsilesional hemispace. Targets were presented immediately to the right of a central fixation point (3° eccentricity), or farther to the right toward the screen edge (17° eccentricity), or on both locations. Response to target position occurred either in isolation or while performing a concurrent visual or auditory task. Results showed that most errors occurred when two targets were simultaneously presented and patients were faced with additional task demands (in the visual or auditory modalities). In the context of concurrent visual load, ipsilesional targets presented at the rightmost location were omitted more frequently than those presented closer to fixation. This pattern qualifies ipsilesional processing in right-hemisphere stroke patients as functionally impaired, arguing against the notion of ipsilesional hyperperformance, especially when under visual load.

Update on the Clinical Approach to Spatial Neglect

PURPOSE OF REVIEW

Spatial neglect is asymmetric orienting and action after a brain lesion, causing functional disability. It is common after a stroke; however, it is vastly underdocumented and undertreated. This article addresses the implementation gap in identifying and treating spatial neglect, to reduce disability and improve healthcare costs and burden.

RECENT FINDINGS

Professional organizations published recommendations to implement spatial neglect care. Physicians can lead an interdisciplinary team: functionally relevant spatial neglect assessment, evidence-based spatial retraining, and integrated spatial and vision interventions can optimize outcomes. Research also strongly suggests spatial neglect adversely affects motor systems. Spatial neglect therapy might thus "kick-start" rehabilitation and improve paralysis recovery. Clinicians can implement new techniques to detect spatial neglect and lead interdisciplinary teams to promote better, integrated spatial neglect care. Future studies of brain imaging biomarkers to detect spatial neglect, and real-world applicability of prism adaptation treatment, are needed.

Unilateral neglect post stroke: Eye movement frequencies indicate directional hypokinesia while fixation distributions suggest compensational mechanism

INTRODUCTION

Eye movements and spatial attention are closely related, and eye-tracking can provide valuable information in research on visual attention. We investigated the pathology of overt attention in right hemisphere (RH) stroke patients differing in their severity of neglect symptoms by using eye-tracking during a dynamic attention task.

METHODS

Eye movements were recorded in 26 RH stroke patients (13 with and 13 without unilateral spatial neglect, and a matched group of 26 healthy controls during a Multiple Object Tracking task. We assessed the frequency and spatial distributions of fixations, as well as frequencies of eye movements to the left and to the right side of visual space so as to investigate individuals' efficiency of visual processing, distribution of attentional processing resources, and oculomotoric orienting mechanisms.

RESULTS

Both patient groups showed increased fixation frequencies compared to controls. A spatial bias was found in neglect patients' fixation distribution, depending on neglect severity (indexed by scores on the Behavioral Inattention Test). Patients with more severe neglect had more fixations within the right field, while patients with less severe neglect had more fixations within their left field. Eye movement frequencies were dependent on direction in the neglect patient group, as they made more eye movements toward the right than toward the left.

CONCLUSION

The patient groups' higher fixation rates suggest that patients are generally less efficient in visual processing. The spatial bias in fixation distribution, dependent on neglect severity, suggested that patients with less severe neglect were able to use compensational mechanisms in their contralesional space. The observed relation between eye movement rates and directions observed in neglect patients provides a measure of the degree of difficulty these patients may encounter during dynamic situations in daily life and supports the idea that directional oculomotor hypokinesia may be a relevant component in this syndrome.

Task set induces dynamic reallocation of resources in visual short-term memory

Successful interaction with the environment requires the ability to flexibly allocate resources to different locations in the visual field. Recent evidence suggests that visual short-term memory (VSTM) resources are distributed asymmetrically across the visual field based upon task demands. Here, we propose that context, rather than the stimulus itself, determines asymmetrical distribution of VSTM resources. To test whether context modulates the reallocation of resources to the right visual field, task set, defined by memory-load, was manipulated to influence visual short-term memory performance. Performance was measured for single-feature objects embedded within predominantly single- or two-feature memory blocks. Therefore, context was varied to determine whether task set directly predicts changes in visual field biases. In accord with the dynamic reallocation of resources hypothesis, task set, rather than aspects of the physical stimulus, drove improvements in performance in the right- visual field. Our results show, for the first time, that preparation for upcoming memory demands directly determines how resources are allocated across the visual field.

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.

Nocebo and pseudo-neglect: Paradoxical effects detected with eye-tracking

The knowledge about effects of placebos and nocebos on specific visual attention processes is still very limited. In the present eye-tracking study, it was analyzed if a nocebo (sham transcranial magnetic stimulation) is able to elicit left-sided attentional deficits (pseudo-neglect). Fifty-two healthy participants performed a search task on the computer, once with and once without the nocebo. Indicators of left-biased search behavior (e.g. fixation count, reaction times for left vs. right-sided target detection) and affective state (e.g., valence, arousal) were assessed. The sample was divided into two groups (nocebo responder, non-responder) based on the experienced effectiveness of the nocebo. The nocebo treatment was associated with a positive and calm affective state. Contrary to the verbal suggestion, the nocebo increased the number of fixations and the dwell time on the left side of the computer screen. Moreover, the nocebo decreased the detection time for targets on the left side. These paradoxical nocebo effects were restricted to nocebo responders. Possible implications of nocebo-related compensatory behaviors for neuropsychological therapy are discussed.

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.

Here, there and everywhere: higher visual function and the dorsal visual stream

The dorsal visual stream, often referred to as the 'where' stream, represents the pathway taken by visual information from the primary visual cortex to the posterior parietal lobe and onwards. It partners the ventral or 'what' stream, the subject of a previous review and largely a temporal-based system. Here, we consider the dorsal stream disorders of perception (simultanagnosia, akinetopsia) along with their consequences on action (eg, optic ataxia and oculomotor apraxia, along with Balint's syndrome). The role of the dorsal stream in blindsight and hemispatial neglect is also considered.

The Role of Right Inferior Parietal Cortex in Auditory Spatial Attention: A Repetitive Transcranial Magnetic Stimulation Study

Behavioral studies support the concept of an auditory spatial attention gradient by demonstrating that attentional benefits progressively diminish as distance increases from an attended location. Damage to the right inferior parietal cortex can induce a rightward attention bias, which implicates this region in the construction of attention gradients. This study used event-related potentials (ERPs) to define attention-related gradients before and after repetitive transcranial magnetic stimulation (rTMS) to the right inferior parietal cortex. Subjects (n = 16) listened to noise bursts at five azimuth locations (left to right: -90°, -45°, 0° midline, +45°, +90°) and responded to stimuli at one target location (-90°, +90°, separate blocks). ERPs as a function of non-target location were examined before (baseline) and after 0.9 Hz rTMS. Results showed that ERP attention gradients were observed in three time windows (frontal 230–340, parietal 400–460, frontal 550–750 ms). Significant transient rTMS effects were seen in the first and third windows. The first window had a voltage decrease at the farthest location when attending to either the left or right side. The third window had on overall increase in positivity, but only when attending to the left side. These findings suggest that rTMS induced a small contraction in spatial attention gradients within the first time window. The asymmetric effect of attended location on gradients in the third time window may relate to neglect of the left hemispace after right parietal injury. Together, these results highlight the role of the right inferior parietal cortex in modulating frontal lobe attention network activity.

Asymmetry in the Collision Judgments of People With Homonymous Field Defects and Left Hemispatial Neglect

PURPOSE

Although the impact of homonymous visual field defects (HFDs) on mobility has been investigated previously, the emphasis has been on obstacle detection. Relatively little is known about HFD patients' ability to judge collisions once an obstacle is detected. We investigated this using a walking simulator.

METHODS

Patients with HFDs (n = 29) and subjects with normal vision (NV; n = 21) were seated in front of a large screen on which a visual simulation of walking was displayed. They made collision judgments for a human figure that appeared for 1 second at lateral offsets from the virtual walking path. A perceived-collision threshold was calculated for right and left sides.

RESULTS

Symmetrical collision thresholds (same on left and right sides) were measured for participants with NV (n = 21), and right (n = 9) and left (n = 7) HFD without hemispatial neglect. Participants with left neglect (n = 10) showed significant asymmetry with thresholds smaller (compared to the NV group and other HFD groups) on the blind (P < 0.001) and larger on the seeing (P = 0.05) sides. Despite the asymmetry, the overall width of the zone of perceived collision risk was not different, suggesting a relatively uniform rightward deviation in judgments of the left neglect group.

CONCLUSIONS

Left neglect was associated with rightward asymmetry in collision judgments, which may cause collisions on the left side even when an obstacle is detected. These behaviors may represent the spatial misperceptions in body midline described previously in patients with left neglect.

The 20/20 patient who can't read

To understand how reading can be disrupted in patients with good acuity, it is important to realize the complexities that underlie this task, which normally seems so effortless. The process of reading is an interplay among vision, eye movements, attention, and linguistic processing, and impairments in any of these functions can result in reduced reading efficiency. The goal of this review is to provide a systematic review of these functions that can help clinicians generate a logical and useful differential diagnosis of impaired reading in the patient with 20/20 vision.

Spatial and temporal dynamics of visual search tasks distinguish subtypes of unilateral spatial neglect: Comparison of two cases with viewer-centered and stimulus-centered neglect

We developed a computerised test to evaluate unilateral spatial neglect (USN) using a touchscreen display, and estimated the spatial and temporal patterns of visual search in USN patients. The results between a viewer-centered USN patient and a stimulus-centered USN patient were compared. Two right-brain-damaged patients with USN, a patient without USN, and 16 healthy subjects performed a simple cancellation test, the circle test, a visuomotor search test, and a visual search test. According to the results of the circle test, one USN patient had stimulus-centered neglect and a one had viewer-centered neglect. The spatial and temporal patterns of these two USN patients were compared. The spatial and temporal patterns of cancellation were different in the stimulus-centered USN patient and the viewer-centered USN patient. The viewer-centered USN patient completed the simple cancellation task, but paused when transferring from the right side to the left side of the display. Unexpectedly, this patient did not exhibit rightward attention bias on the visuomotor and visual search tests, but the stimulus-centered USN patient did. The computer-based assessment system provided information on the dynamic visual search strategy of patients with USN. The spatial and temporal pattern of cancellation and visual search were different across the two patients with different subtypes of neglect.

Impaired oculo-motor behaviour affects both reading and scene perception in neglect patients

Unilateral spatial neglect (USN) is a common neuropsychological disorder following a right-sided brain lesion. Although USN is mostly characterized by symptoms involving the left hemispace, other symptoms are not left lateralized. Recently, it was shown that patients with neglect dyslexia, a reading disturbance that affects about 40% of USN patients, manifest a non-lateralized impairment of eye movement behaviour in association with their reading deficit when they read aloud and perform non-verbal saccadic tasks (Primativo et al., 2013). In the present paper, we aimed to demonstrate that the eye movement impairment shown by some USN patients reflects a more general oculo-motor disorder that is not confined to orthographic material, the horizontal axis or constrained saccadic tasks. We conjectured that inaccurate oculo-motor behaviour in USN patients indicates the presence of a reading deficit. With this aim we evaluated 20 patients, i.e., 10 right-sided brain-damaged patients without neglect and 10 patients affected by USN. On the basis of the patients' eye movement patterns during a scene exploration task, we found that 4 out of the 10 USN patients presented an abnormal oculo-motor pattern. These same four patients (but not the others) also failed in performing 5 different saccadic tasks and produced neglect dyslexia reading errors in both single words and texts. First, we show that a large proportion of USN patients have inaccurate eye movement behaviour in non-reading tasks. Second, we demonstrate that this exploratory deficit is predictive of the reading impairment. Thus, we conclude that the eye movement deficit prevents reading and impairs the performance on many other perceptual tests, including scene exploration. The large percentage of patients with impaired eye-movement pattern suggests that particular attention should be paid to eye movement behaviour during the diagnostic phase in order to program the best rehabilitation strategy for each patient.

Reading direction shifts visuospatial attention: an Interactive Account of attentional biases

A growing amount of evidence confirms the influence of reading and writing habits on visuospatial processing, although this phenomenon has been so far testified mainly as a lateralized shift of a single behavioral sign (e.g., line bisection), with lack of proof from pure right-to-left readers. The present study contributed to this issue by analyzing multiple attentional and motor indexes in monolingual Italian (i.e., reading from left-to-right), and monolingual (i.e., reading from right-to-left) and bilingual Israeli (i.e., reading from right-to-left in Hebrew but also from left-to-right in English) participants' visuospatial performance. Subjects were administered a computerized standard star cancellation task and a modified version in which English letters and words were replaced by Hebrew ones. Tasks were presented on a graphics tablet, allowing recording of both chronometric and spatial parameters (i.e., measured in (x, y) vector coordinates). Results showed that reading direction modulated the on-line visuomotor performance (i.e., left-to-right vs. right-to-left shifts) from the beginning (i.e., first mark) to the end of the task (i.e., spatial distribution of omissions and subjective epicenter). Additionally, the spatial bias observed in a computerized line bisection task was also related to the participants' habitual reading direction. Overall, the results favor the proposal of an Interactive Account of visuospatial asymmetries, according to which both cultural factors, such as the directional scanning associated with language processing, and biological factors, such as hemispheric specialization, modulate visuospatial processing. Results are discussed in light of recent behavioral and neuroanatomical findings.

Extra-powerful on the visuo-perceptual space, but variable on the number space: Different effects of optokinetic stimulation in neglect patients

We studied the effects of optokinetic stimulation (OKS; leftward, rightward, control) on the visuo-perceptual and number space, in the same sample, during line bisection and mental number interval bisection tasks. To this end, we tested six patients with right-hemisphere damage and neglect, six patients with right-hemisphere damage but without neglect, and six neurologically healthy participants. In patients with neglect, we found a strong effect of leftward OKS on line bisection, but not on mental number interval bisection. We suggest that OKS influences the number space only under specific conditions.

Far-space neglect in conjunction but not feature search following transcranial magnetic stimulation over right posterior parietal cortex

Near- and far-space coding in the human brain is a dynamic process. Areas in dorsal, as well as ventral visual association cortex, including right posterior parietal cortex (rPPC), right frontal eye field (rFEF), and right ventral occipital cortex (rVO), have been shown to be important in visuospatial processing, but the involvement of these areas when the information is in near or far space remains unclear. There is a need for investigations of these representations to help explain the pathophysiology of hemispatial neglect, and the role of near and far space is crucial to this. We used a conjunction visual search task using an elliptical array to investigate the effects of transcranial magnetic stimulation delivered over rFEF, rPPC, and rVO on the processing of targets in near and far space and at a range of horizontal eccentricities. As in previous studies, we found that rVO was involved in far-space search, and rFEF was involved regardless of the distance to the array. It was found that rPPC was involved in search only in far space, with a neglect-like effect when the target was located in the most eccentric locations. No effects were seen for any site for a feature search task. As the search arrays had higher predictability with respect to target location than is often the case, these data may form a basis for clarifying both the role of PPC in visual search and its contribution to neglect, as well as the importance of near and far space in these.

Neglect dyslexia: a matter of "good looking"

Brain-damaged patients with right-sided unilateral spatial neglect (USN) often make left-sided errors in reading single words or pseudowords (neglect dyslexia, ND). We propose that both left neglect and low fixation accuracy account for reading errors in neglect dyslexia. Eye movements were recorded in USN patients with (ND+) and without (ND-) neglect dyslexia and in a matched control group of right brain-damaged patients without neglect (USN-). Unlike ND- and controls, ND+ patients showed left lateralized omission errors and a distorted eye movement pattern in both a reading aloud task and a non-verbal saccadic task. During reading, the total number of fixations was larger in these patients independent of visual hemispace, and most fixations were inaccurate. Similarly, in the saccadic task only ND+ patients were unable to reach the moving dot. A third experiment addressed the nature of the left lateralization in reading error distribution by simulating neglect dyslexia in ND- patients. ND- and USN- patients had to perform a speeded reading-at-threshold task that did not allow for eye movements. When stimulus exploration was prevented, ND- patients, but not controls, produced a pattern of errors similar to that of ND+ with unlimited exposure time (e.g., left-sided errors). We conclude that neglect dyslexia reading errors may arise in USN patients as a consequence of an additional and independent deficit unrelated to the orthographic material. In particular, the presence of an altered oculo-motor pattern, preventing the automatic execution of the fine saccadic eye movements involved in reading, uncovers, in USN patients, the attentional bias also in reading single centrally presented words.

Spatial working memory deficits represent a core challenge for rehabilitating neglect

Left neglect following right hemisphere injury is a debilitating disorder that has proven extremely difficult to rehabilitate. Traditional models of neglect have focused on impaired spatial attention as the core deficit and as such, most rehabilitation methods have tried to improve attentional processes. However, many of these techniques (e.g., visual scanning training, caloric stimulation, neck muscle vibration) produce only short-lived effects, or are too uncomfortable to use as a routine treatment. More recently, many investigators have begun examining the beneficial effects of prism adaptation for the treatment of neglect. Although prism adaptation has been shown to have some beneficial effects on both overt and covert spatial attention, it does not reliably alter many of the perceptual biases evident in neglect. One of the challenges of neglect rehabilitation may lie in the heterogeneous nature of the deficits. Most notably, a number of researchers have shown that neglect patients present with severe deficits in spatial working memory (SWM) in addition to their attentional impairments. Given that SWM can be seen as a foundational cognitive mechanism, critical for a wide range of other functions, any deficit in SWM memory will undoubtedly have severe consequences. In the current review we examine the evidence for SWM deficits in neglect and propose that it constitutes a core component of the syndrome. We present preliminary data which suggest that at least one current rehabilitation method (prism adaptation) has no effect on SWM deficits in neglect. Finally, we end by reviewing recent work that examines the effectiveness of SWM training and how SWM training may prove to be a useful avenue for future rehabilitative efforts in patients with neglect.