Anosognosia for hemiplegia, neglect dyslexia, and drawing neglect: clinical findings and theoretical considerations

Does the right hemisphere retain functional characteristics typical of the emotional adaptive system? An evolutionary approach to the problem of brain asymmetries

The right and left hemispheres host two complementary adaptive systems with a right-sided prevalence of automatic and unconscious processing modes, typical of the 'emotional system', and a left-sided prevalence of propositional and conscious processing modes typical of the 'cognitive system' The principal right hemispheric syndromes (and the functioning modes typical of this hemisphere) are, indeed, characterized by automatic and unconscious processing modalities. Thus, the unilateral neglect syndrome discloses a defective automatic (and spared intentional) spatial orienting of attention; face and voice recognition disorders are due to disruption of mechanisms that automatically generate familiarity feelings and anosognosia seems due to the unconscious loss of personal significance attributed by the patient to the pathological event. Since emotions were the only adaptive system existing before the development of language (which is provided of a strong capacity to develop and shape cognition), the persistence in the right hemisphere of mechanisms typical of the emotional system strongly supports an evolutionary model of brain laterality. (160 words).

What I think she thinks about my paralysed body: Social inferences about disability-related content in anosognosia for hemiplegia

The neuropsychological disorder of anosognosia for hemiplegia (AHP) can offer unique insights into the neurocognitive processes of body consciousness and representation. Previous studies have found associations between selective social cognition deficits and anosognosia. In this study, we examined how such social cognition deficits may directly interact with representations of one's body as disabled in AHP. We used a modified set of previously validated Theory of Mind (ToM) stories to create disability-related content that was related to post-stroke paralysis and to investigate differences between right hemisphere damage patients with (n = 19) and without (n = 19) AHP. We expected AHP patients to perform worse than controls when trying to infer paralysis-related mental states in the paralysis-related ToM stories and explored whether such differences depended on the inference patients were asked to perform (e.g. self or other referent perspective-taking). Using an advanced structural neuroimaging technique, we expected selective social cognitive deficits to be associated with posterior parietal cortex lesions and deficits in self-referent perspective-taking in paralysis-related mentalising to be associated with frontoparietal disconnections. Group- and individual-level results revealed that AHP patients performed worse than HP controls when trying to infer paralysis-related mental states. Exploratory lesion analysis results revealed some of the hypothesised lesions, but also unexpected white matter disconnections in the posterior body and splenium of the corpus collosum associated with a self-referent perspective-taking in paralysis-related ToM stories. The study has implications for the multi-layered nature of body awareness, including abstract, social perspectives and beliefs about the body.

Is Anosognosia for Left-Sided Hemiplegia Due to a Specific Self-Awareness Defect or to a Poorly Conscious Working Mode Typical of the Right Hemisphere?

This review aimed to evaluate whether the association between 'anosognosia for hemiplegia' and lesions of the right hemisphere points to a special self-awareness role of the right side of the brain, or could instead be due to a working mode typical of the right hemisphere. This latter viewpoint is consistent with a recently proposed model of human brain asymmetries that assumes that language lateralization in the left hemisphere might have increased the left hemisphere's level of consciousness and intentionality in comparison with the right hemisphere's less conscious and more automatic functioning. To assess these alternatives, I tried to ascertain whether anosognosia is greater for left-sided hemiplegia than for other disorders provoked by right brain lesions, or whether unawareness prevails in tasks more clearly related to the disruption of the right hemisphere's more automatic (and less conscious) functioning. Data consistent with the first alternative would support the existence of a specific link between anosognosia for hemiplegia and self-awareness, whereas data supporting the second option would confirm the model linking anosognosia to a poorly conscious working mode typical of the right hemisphere. Analysis results showed that the incidence of anosognosia of the highly automatic syndrome of unilateral neglect was greater than that concerning the unawareness of left hemiplegia, suggesting that anosognosia for left-sided hemiplegia might be due to the poorly conscious working mode typical of the right hemisphere.

Key constructs of body awareness impairments post-stroke: a scoping review of assessment tools and interventions

PURPOSE

To summarise body awareness assessment tools and interventions relevant for stroke rehabilitation using a framework that categorises key body awareness constructs, disorders and impairments.

MATERIALS AND METHODS

Online electronic databases and trial registries were searched from inception until July 2021, in addition to hand searching reference lists of included studies and reviews. Study selection included any study design where the investigation involved assessing and/or intervening in body awareness following stroke. Data were extracted based on predefined criteria by two independent reviewers and mapped to the emergent framework.

RESULTS

The final analysis included 144 papers that reported 43 assessment tools and 8 types of interventions for body awareness. Consensus was reached on a synthesised body awareness framework. This comprised specific impairments and disorders, constructs, sub-categories and main categories leading to the overarching term of body awareness. Clinical and psychometric properties of the assessment tools were not reported or poorly evaluated, and the interventions lacked robust study designs and rigorous methods.

CONCLUSIONS

The framework produced will enable future research and clinical practice to be based on consistent concepts and definitions. Clinicians can also use this information to cautiously select assessment tools and/or interventions but are reminded of the limitations identified in this review.Implications for rehabilitationThere is limited understanding, compounded by inconsistent terminology and definitions regarding body awareness after stroke.A synthesized framework to define key constructs and definitions of body awareness is proposed.Assessment tools and interventions reported in the literature are mapped to the proposed framework.Psychometric properties of available tools are reported.Significant work remains to refine concepts of body awareness, develop and evaluate assessment tools and interventions.

Neural Correlates of Impaired Self-awareness of Deficits after Acquired Brain Injury: A Systematic Review

Self-awareness is essential for the process and outcome of rehabilitation but is often affected by acquired brain injury (ABI). While many studies investigated the psychological aspects of self-awareness deficits, the biological underpinnings are not well understood. The aim of this systematic review was to identify the neural correlates of self-awareness after ABI. Results indicate that anticipation of future problems is associated with lesions and decreased neural functioning in the right frontal lobe, as well as increased diffusivity throughout the white matter of the brain. Poor behavioral adjustment on implicit awareness tasks is associated with less functional connectivity of anterior cingulate cortex and right or middle inferior frontal gyri to the fronto-parietal control network, as well as more activation in the left insula and left parietal operculum during error processing. Recognition of mistakes is associated with internetwork connectivity of anterior or posterior default mode network to salience network. In conclusion, after ABI, different results in brain activation and connectivity are found depending on level of awareness measured. Future studies are necessary to confirm these findings.

Case report of anosognosia for hemiplegia: A fMRI study

OBJECTIVE

The aim of this study is to verify the functional activation in a patient with anosognosia for hemiplegia following left brain lesions.

METHODS

We report a case of a 53-year-old right-handed female patient. She came to our rehabilitative unit with a diagnosis of an ischemic major stroke in the left internal carotid artery and important hemiplegia to the right side. She underwent functional magnetic resonance imaging (fMRI), during which she performed a motor imagery task.

RESULTS

The fMRI assessment showed an ischemic lesion in the frontotemporal and insular left areas. In the fMRI experiment, we revealed activation of the residual neural patterns of both hemispheres.

CONCLUSION

We underlined an interest in the compensation mechanism that involved neural networks near brain lesions and some areas of the contro-lesional hemisphere, suggesting that the synaptic plasticity permitted an intra and inter-hemispheric reorganization of the cerebral system.

Rapid screening for neglect following stroke: A systematic search and European Academy of Neurology recommendations

Background and purpose

Unilateral neglect is a common cognitive disorder following stroke. Neglect has a significant impact on functional outcomes, so it is important to detect. However, there is no consensus on which are the best screening tests to administer to detect neglect in time‐limited clinical environments.

Methods

Members of the European Academy of Neurology Scientific Panel on Higher Cortical Functions, neuropsychologists, occupational therapists, and researchers produced recommendations for primary and secondary tests for bedside neglect testing based on a rigorous literature review, data extraction, online consensus meeting, and subsequent iterations.

Results

A total of 512 articles were screened, and 42 were included. These reported data from 3367 stroke survivors assessed using 62 neglect screens. Tests were grouped into cancellation, line bisection, copying, reading/writing, and behavioral. Cancellation tasks were most frequently used (97.6% of studies), followed by bisection, copying, behavioral, and reading/writing assessments. The panel recommended a cancellation test as the primary screening test if there is time to administer only one test. One of several cancellation tests might be used, depending on availability. If time permits, one or more of line bisection, figure copying, and baking tray task were recommended as secondary tests. Finally, if a functional and ecological test is feasible, the Catherine Bergego Scale was recommended. Overall, the literature suggests that no single test on its own is sufficient to exclude a diagnosis of neglect. Therefore, the panel recommended that multiple neglect tests should be used whenever possible.

Conclusions

This study provides consensus recommendations for rapid bedside detection of neglect in real‐world, clinical environments.

Prism Adaptation Treatment Improves Inpatient Rehabilitation Outcome in Individuals With Spatial Neglect: A Retrospective Matched Control Study

Objective

To determine whether prism adaptation treatment (PAT) integrated into the standard of care improves rehabilitation outcome in patients with spatial neglect (SN).

Design

Retrospective matched control study based on information extracted from June 2017-September 2019.

Setting

Inpatient rehabilitation.

Participants

Patients from 14 rehabilitation hospitals scoring >0 on the Catherine Bergego Scale (N=312). The median age was 69.5 years, including 152 (49%) female patients and 275 (88%) patients with stroke.

Interventions

Patients were matched 1:1 by age (±5 years), FIM score at admission (±2 points), and SN severity using the Catherine Bergego Scale (±2 points) and classified into 2 groups: treated (8-12 daily sessions of PAT) vs untreated (no PAT).

Main Outcome Measures

FIM and its minimal clinically important difference (MCID) were the primary outcome variables. Secondary outcome was home discharge.

Results

Analysis included the 312 matched patients (156 per group). FIM scores at discharge were analyzed using repeated-measures analyses of variance. The treated group showed reliably higher scores than the untreated group in Total FIM, F=5.57, P=.020, partial η²=0.035, and Cognitive FIM, F=19.20, P<.001, partial η²=0.110, but not Motor FIM, F=0.35, P=.553, partial η²=0.002. We used conditional logistic regression to examine the odds ratio of reaching MCID in each FIM score and of returning home after discharge. No reliable difference was found between groups in reaching MCID or home discharge.

Conclusions

Patients with SN receiving PAT had better functional and cognitive outcomes, suggesting that integrating PAT into the standard of care is beneficial. However, receiving PAT may not determine home discharge.

Updating beliefs beyond the here-and-now: the counter-factual self in anosognosia for hemiplegia

The syndrome of anosognosia for hemiplegia, or the lack of awareness for one’s paralysis following right hemisphere stroke, can provide unique insights into the neurocognitive mechanisms of self-awareness. Yet it remains unclear whether anosognosia for hemiplegia is a modality-specific deficit of sensorimotor monitoring, or whether domain-general processes of attention and belief-updating converge to cause anosognosia for hemiplegia. Using a Bayesian learning framework, we formalized and empirically investigated the hypothesis that failures to update anosognosic beliefs can be explained by abnormalities in the relative uncertainty (i.e. precision) ascribed to prior beliefs versus sensory information in different contexts. We designed a new motor belief-updating task that manipulated both the temporal (prospective and retrospective) and spatial (hemispace most affected by inattention and hemispace less affected by inattention) conditions in which beliefs had to be updated, and we validated its sensitivity to anosognosia for hemiplegia in 26 patients with right hemisphere stroke. We then computed and empirically tested two different Bayesian predictors of prospective beliefs using two proxies for precision in anosognosia for hemiplegia patients: (i) standardized, neuropsychological measures of objective attention abilities, i.e. visuospatial neglect scores and (ii) subjective uncertainty reports, i.e. confidence ratings. Our results suggest that while neglect does not affect local, sensorimotor error monitoring, it does seem to affect the degree to which observed errors are used to update more general, prospective beliefs about counterfactual motor abilities in anosognosia for hemiplegia. Difficulties in such ‘counterfactual’ belief-updating were associated with disruptions in tracts of the ventral attentional network (i.e. superior longitudinal fasciculus connecting the temporo-parietal junction and ventral frontal cortex) and associated lesions to the insula, inferior parietal cortex and superior temporal regions. These results suggest that self-awareness extends beyond local, retrospective monitoring, requiring also salience-based, convergence of beliefs about the self that go beyond the ‘here-and-now’ of sensorimotor experience.

The Phenomenology of Acute Anosognosia for Hemiplegia

OBJECTIVE

After attempting to move a plegic limb, patients with anosognosia for hemiplegia (AHP) may claim that limb movement occurred, even though the limb remained motionless. The authors investigated the characteristics, natural history, and anatomical basis of AHP phenomenology.

METHODS

Twenty-nine right-hemisphere stroke patients with acute anosognosia for hemiplegia (AHP) were prospectively assessed for the presence and characteristics of movement claims and observable behavior during movement attempts.

RESULTS

AHP was transient, with the condition resolving in 68% of patients by 1 week. Patients made movement claims during 31% of unilateral movement attempts and 50% of bilateral movement attempts. Movement claims were idiosyncratic, lacked internal consistency within individual patients, and even dissociated from explicit denial, as several patients made movement claims after they began to explicitly acknowledge hemiplegia. Observable behavior during movement attempts revealed allochiria (moving the right arm instead of the left) in 31% of patients, signs of implicit knowledge of weakness in 24%, and intact intention in 34%. Lesion analysis revealed that allochiria was associated with inferior right parietal lobe damage.

CONCLUSIONS

These results highlight that heterogeneity, phenomenological complexity, and transience are hallmarks of AHP. This advances clinical AHP assessment by showing that assessment of performance, rather than just verbal response, uncovers multiple dimensions of AHP. Allochiria emerges as an anatomically distinct subcomponent of the disorder. These findings also have theoretical implications, because they do not lend support to unitary pathogenic models proposing that illusions of movement or impaired intention form the basis of AHP. Most patients rapidly improve, which should invigorate the search for typical compensatory mechanisms underlying spontaneous recovery.

Barriers and Facilitators to Rehabilitation Care of Individuals With Spatial Neglect: A Qualitative Study of Professional Views

Objective

To identify barriers and facilitators to achieving optimal inpatient rehabilitation outcome among individuals with spatial neglect (SN).

Design

Cross-sectional, semistructured focus group discussions.

Setting

Rehabilitation hospitals.

Participants

A total of 15 occupational therapists and 14 physical therapists treating patients with SN on 3 campuses of a rehabilitation hospital system (N=29). Six focus group sessions were conducted and audio-recorded for transcription.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Participants identified several patient-related characteristics that posed barriers to treatment, including the symptoms of SN itself, cognitive issues, physical weakness, comorbidities, and reduced therapy engagement. Supportive family members were considered a key facilitator, but lack of preparedness to assume caregiving roles, poor understanding of SN and rehabilitation goals, and inadequate levels of involvement were family-related barriers to successful treatment. Participants expressed that having resources and technologies available at their center to support SN treatment facilitated positive outcomes and perceived limited staff knowledge and skills and poor interclinician communication as barriers to treatment. At the health care system level, barriers included a lack of responsive measures of SN progress and insurer-related issues. Strong continuity of care between transitions was considered an important factor for enabling effective treatment.

Conclusions

Barriers and facilitators to the current practice of SN care were identified from occupational and physical therapists’ point of view. Opportunities exist to promote identified facilitators and minimize barriers to improve SN rehabilitation. The present study makes a unique contribution in identifying specific needs for innovative interventions that involve family support and training, promotion of interdisciplinary collaboration, development of interprofessional vocabulary, and continuous treatment and follow-up assessment for SN through care transitions.

Auditory agnosia with anosognosia

A 66-year-old right-handed female medical doctor suffered two consecutive cardioembolic strokes, initially affecting the right frontal lobe and the right insula, followed by a lesion in the left temporal lobe. The patient presented with distinctive phenomenology of general auditory agnosia with anosognosia for the deficit. She did not understand verbal requests and her answers to oral questions were fluent but unrelated to the topic. However, she was able to correctly answer written questions, name objects, and fluently describe their purpose, which is characteristic for verbal auditory agnosia. She was also unable to recognise environmental sounds or to recognise and repeat any melody. These inabilities represent environmental sound agnosia and amusia, respectively. Surprisingly, she was not aware of the problem, not asking any questions regarding her symptoms, and avoiding discussing her inability to understand spoken language, which is indicative of anosognosia. The deficits in our patient followed a distinct pattern of recovery. The verbal auditory agnosia was the first to resolve, followed by environmental sound agnosia. Amusia persisted the longest. The patient was clinically assessed from the first day of symptom onset and the evolution of symptoms was video documented. We give a detailed account of the patient's behaviour and provide results of audiological and neuropsychological evaluations. We discuss the anatomy of auditory agnosia and anosognosia relevant to the case. This case study may serve to better understand auditory agnosia in clinical settings. It is important to distinguish auditory agnosia from Wernicke's aphasia, because use of written language may enable normal communication.

Prevalence of spatial neglect post-stroke: A systematic review

OBJECTIVE

Spatial neglect (SN) impedes stroke rehabilitation progress, slows functional recovery, and increases caregiver stress and burden. The estimation of SN prevalence varies widely across studies.

BACKGROUND

We aimed to establish the prevalence of SN based on the injured cerebral hemisphere, recovery stage post-stroke, and diagnostic methodology.

MATERIALS AND METHODS

All journal articles published up to February 27, 2019 from CINAHL, PsycINFO, PubMed and Web of Science were searched. We selected original research articles that described observational studies, included both individuals with left brain damage (LBD) and those with right brain damage (RBD) post-stroke, and reported specific diagnostic methods for SN. All authors reached consensus for the final selection of 41 articles. Time post-stroke, patient selection criteria, study setting, SN diagnostic methods were extracted.

RESULTS

A total of 6324 participants were included: 3411 (54%) with RBD and 2913 (46%) with LBD. Without considering time post-stroke or diagnostic methods, the occurrence rate of SN was 29% (38% after RBD and 18% after LBD). Using ecological assessments resulted in higher prevalence than using tests not directly related to daily life activities (53% vs. 24%). Using methods based on a single-cutoff criterion led to lower occurrence of SN than using multi-test methods (27% vs. 33%). The prevalence decreased from the acute to chronic stage post-stroke.

CONCLUSIONS

The estimated prevalence of SN after unilateral stroke is 30%. SN is more common after RBD than after LBD, but SN after LBD is still quite common. Using ecological assessments and multi-test methods to detect SN is preferred to using a single-cutoff criterion of a test that is not directly related to daily function. The decrease in SN prevalence over time is evident, but the exact prevalence in later stages cannot be estimated. More research is needed to better understand chronic SN.

Spatial exploration strategy training for spatial neglect: A pilot study

Spatial neglect is a syndrome due to impaired neural networks critical for spatial attention and related cognitive and motor functions. Affected individuals also have impaired self-awareness of their own neglect symptoms. The present randomized controlled study was the first proof-of-concept pilot examining the multi-context treatment approach using a protocol of spatial exploration strategy training in one brief session (20-30 minutes). The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. 40 patients with left-sided neglect after right brain stroke were included. The results showed that the treatment reduced lateralized bias toward the ipsilesional side of space but did not improve overall detection performance. Impaired general self-awareness of daily-life spatial difficulties was found independent of treatment outcome. This implies that judgment regarding responsiveness to treatment should not be made based on an awareness interview or the severity of neglect symptoms. Lastly, the treatment showed the potential of improving online contextual self-awareness of spatial abilities. A collaborative and interactive approach that focuses on helping the patient self-discover, monitor and self-manage their errors, appears to have a potential for decreasing neglect symptoms. Future studies are required to examine additional aspects of the multi-context treatment approach.

Multisensory stimulation for the rehabilitation of unilateral spatial neglect

Unilateral spatial neglect (USN) is a neuropsychological syndrome, typically caused by lesions of the right hemisphere, whose features are the defective report of events occurring in the left (contralesional) side of space and the inability to orient and set up actions leftwards. Multisensory integration mechanisms, largely spared in USN patients, may temporally modulate spatial orienting. In this pilot study, the effects of an intensive audio-visual Multisensory Stimulation (MS) on USN were assessed, and compared with those of a treatment that ameliorates USN, Prismatic Adaptation (PA). Twenty USN stroke patients received a 2-week treatment (20 sessions, twice per day) of MS or PA. The effects of MS and PA were assessed by a set of neuropsychological clinical tests (target cancellation, line bisection, sentence reading, personal neglect, complex drawing) and the Catherine Bergego Scale for functional disability. Results showed that MS brought about an amelioration of USN deficits overall comparable to that induced by PA; personal neglect was improved only by MS, not by PA. The clinical gains of the MS treatment were not influenced by duration of disease and lesion volume, and they persisted up to one month post-treatment. In conclusion, MS represents a novel and promising rehabilitation procedure for USN.

Multiple Network Disconnection in Anosognosia for Hemiplegia

Anosognosia for hemiplegia (AHP) is a complex syndrome whose neural correlates are still under investigation. One hypothesis, mainly based on lesion mapping studies, is that AHP reflects a breakdown of neural systems of the right hemisphere involved in motor function. However, more recent theories have suggested that AHP may represent a disorder of cognitive systems involved in belief updating, self-referential or body processing. Two recent studies, using a method to estimate the degree of white matter disconnection from lesions, have indeed shown that patients with AHP suffer from damage of several long-range white matter pathways in association cortex. Here, we use a similar indirect disconnection approach to study a group of patients with motor deficits without anosognosia (hemiparesis or hemiplegia, HP, n = 35), or motor deficits with AHP (n = 28). The HP lesions came from a database of stroke patients, while cases of AHP were selected from the published literature. Lesions were traced into an atlas from illustrations of the publications using a standard method. There was no region in the brain that was more damaged in AHP than HP. In terms of structural connectivity, AHP patients had a similar pattern of disconnection of motor pathways to HP patients. However, AHP patients also showed significant disconnection of the right temporo-parietal junction, right insula, right lateral and medial prefrontal cortex. These associative cortical regions were connected through several white matter tracts, including superior longitudinal fasciculus III, arcuate, fronto-insular, frontal inferior longitudinal, and frontal aslant. These tracts connected regions of different cognitive networks: default, ventral attention, and cingulo-opercular. These results were not controlled for clinical variables as concomitant symptoms and other disorders of body representation were not always available for co-variate analysis. In conclusion, we confirm recent studies of disconnection demonstrating that AHP is not limited to dysfunction of motor systems, but involves a much wider set of large-scale cortical networks.

Direct electrical stimulation of the premotor cortex shuts down awareness of voluntary actions

A challenge for neuroscience is to understand the conscious and unconscious processes underlying construction of willed actions. We investigated the neural substrate of human motor awareness during awake brain surgery. In a first experiment, awake patients performed a voluntary hand motor task and verbally monitored their real-time performance, while different brain areas were transiently impaired by direct electrical stimulation (DES). In a second experiment, awake patients retrospectively reported their motor performance after DES. Based on anatomo-clinical evidence from motor awareness disorders following brain damage, the premotor cortex (PMC) was selected as a target area and the primary somatosensory cortex (S1) as a control area. In both experiments, DES on both PMC and S1 interrupted movement execution, but only DES on PMC dramatically altered the patients’ motor awareness, making them unconscious of the motor arrest. These findings endorse PMC as a crucial hub in the anatomo-functional network of human motor awareness.

Here, using electrical stimulation on patients undergoing awake brain surgery, the authors show that disruption of the premotor cortex makes patients unconscious of motor arrest. This finding suggests the premotor cortex is crucial for motor awareness.

Hippocampal diaschisis contributes to anosognosia for hemiplegia: Evidence from lesion network-symptom-mapping

Anosognosia for hemiplegia (AHP) is known to be associated with lesions to the motor system combined with varying lesions to the right insula, premotor cortex, parietal lobe or hippocampus. Due to this widespread cortical lesion distribution, AHP can be understood best as a network disorder. We used lesion maps and behavioral data (n ​= ​49) from two previous studies on AHP and performed a lesion network-symptom-mapping (LNSM) analysis. This new approach permits the identification of relationships between behavior and regions connected to the lesion site based on normative functional connectome data. In a first step, using ordinary voxel-based lesion-symptom mapping, we found an association of AHP with lesions in the right posterior insula. This is in accordance with previous studies. Applying LNSM, we were able to additionally identify a region in the right posterior hippocampus where AHP was associated with significantly higher normative lesion connectivity. Notably, this region was spared by infarction in all patients. We therefore argue that remote neuronal dysfunction caused by disrupted functional connections between the lesion site and the hippocampus (i.e. diaschisis) contributed to the phenotype of AHP. An indirect affection of the hippocampus may lead to memory deficits which, in turn, impair the stable encoding of updated beliefs on the bodily state thus contributing to the multifactorial phenomenon of AHP.

"Sequential multimodality stimulation" for post-stroke-hemineglect: Feasibility and outcome in a pilot randomized controlled trial

OBJECTIVE

To test the feasibility and efficacy of multimodality stimulation combined with motor tasking as a corrective strategy for hemineglect following right hemispheric ischemic strokes.

MATERIAL AND METHODS

A prospective randomized controlled single blinded clinical trial was conducted over eighteen months from January 2017. All patients with right hemispheric ischemic strokes were screened for hemineglect and those fulfilling criteria were recruited and randomized. Patients under the therapy group (TG) received the intervention based on a structured protocol in addition to standard physiotherapy. The control group (CG) received standard physiotherapy alone. NIHSS, mRS and Neuropsychological test scores were recorded at different time points. The primary outcome measures (neuropsychological test scores) were compared between the two groups (Student's t-test to find out the difference in outcome measures) at one and three months post-stroke.

RESULTS

Of the 14 patients recruited, data from 12 were available for analysis, 5 patients in TG and 7 in CG. There was a trend for better hemineglect and functional outcomes in TG.

CONCLUSION

Multimodality stimulation, in addition to standard physiotherapy, is feasible and potentially results in better neurocognitive and functional recovery following right hemispheric ischemic strokes. However, larger studies are warranted to prove these preliminary observations beyond doubt.

Reduplicative paramnesia for places: A comprehensive review of the literature and a new case report

Reduplicative paramnesia for places (i.e., the delusional belief that a place has been duplicated or exists in two different locations) is a rare disorder observed in neurological patients. We review the existing literature on the topic, highlighting commonalities and differences among the 51 cases published since the first report in 1903. Our results highlight the combination of multiple factors in the pathogenesis of this monothematic spatial delusion. From a neurological perspective, a crucial role is played by damage to the right frontal and temporal lobe. Deficits of non-verbal memory and executive functions, along with topographical disorientation, appear to be the most common (but, not systematic) cognitive impairments. The clinical picture of the disorder is further complicated by often overlooked psychological and motivational factors. Consequently, the precise neuro-cognitive substrate of this disorder is yet to be described in detail. We stress the need for a more detailed and systematic approach exploiting neurological, neuroimaging, neuropsychological and psychopathological methods. To guide future investigations, we provide clinical- and research-oriented recommendations. Finally, we illustrate the interplay of all above-mentioned factors with a new case report.

The 'Neglected' Personal Neglect

A review of patients with brain injury showing personal neglect is presented. The aim is to shed light on this aspect of neglect often unresearched or only indirectly investigated, and to discuss recent findings concerning the methods used to assess personal neglect, its neural correlates and its association with the more often explored aspect of extrapersonal neglect. The review was performed using PubMed and PsychInfo databases to search for papers published in the last 123 years (until January 2018). We reviewed 81 papers describing either single or group studies for a total of 2247 patients. The results of this review showed that various aspects of personal neglect are still controversial and outcomes potentially contradictory. Despite the data reported in the present review suggest that personal neglect is more frequently associated with lesions of the right hemisphere, the left hemisphere may also play an important role. Not surprisingly, personal neglect and extrapersonal neglect seem to co-occur. However double dissociations of these two forms of neglect have been reported, and they seem to dissociate both from a functional and an anatomical perspective. More recent interpretations of personal neglect suggest that it may result from a disrupted body representation. The development of reliable psychometric tools with shared diagnostic criteria is essential to identify different degrees of personal neglect for different body parts and to better refine personal neglect in comparison to extrapersonal neglect and disorders related to distortions of personal domain.

Unawareness for Motor Impairment and Distorted Perception of Task Difficulty

OBJECTIVES

Anosognosia for motor impairment is a complex syndrome that can manifest itself under different forms, guiding patients' behavior and task decisions. However, current diagnostic tools tend to evaluate only more explicit aspects of anosognosia (asking the patients about their motor abilities) and fail to address more subtle features of awareness. We have developed a new assessment measure, the ECT (Errand Choice Test), where patients are asked to judge task difficulty rather than estimate their own impairment.

METHODS

We assessed awareness in a group of 73 unilateral left- and right-brain damaged (30 LBD and 43 RBD, respectively) patients by means of the VATAm, which explicitly requires them to evaluate their own motor abilities, and the ECT. A control group of 65 healthy volunteers was asked to perform the ECT under two conditions: Current condition (i.e., using both hands) and Simulated conditions (i.e., simulating hemiplegia).

RESULTS

A total of 27% of the patients showed different performance on the VATAm and ECT, 21% of the patients showing lack of awareness only on VATAm and 6% only on ECT. Moreover, despite the ECT identified a higher frequency of anosognosia after RBD (33.3%) than LBD (27.6%), this hemispheric asymmetry was not significant. Remarkably, anosognosic patients performed very similarly to controls in the "current condition", suggesting that anosognosic patients' ability to perceive the complexity of each task per se is not altered.

CONCLUSION

Different methods may be able to tackle different aspects of awareness and the ECT proved to be able to detect less evident forms of awareness. (JINS, 2018, 24, 45-56).

Unilateral spatial neglect after posterior parietal damage

Unilateral spatial neglect is a disabling neurologic deficit, most frequent and severe after right-hemispheric lesions. In most patients neglect involves the left side of space, contralateral to a right-hemispheric lesion. About 50% of stroke patients exhibit neglect in the acute phase. Patients fail to orient, respond to, and report sensory events occurring in the contralateral sides of space and of the body, to explore these portions of space through movements by action effectors (eye, limbs), and to move the contralateral limbs. Neglect is a multicomponent higher-level disorder of spatial awareness, cognition, and attention. Spatial neglect may occur independently of elementary sensory and motor neurologic deficits, but it can mimic and make them more severe. Diagnostic tests include: motor exploratory target cancellation; setting the midpoint of a horizontal line (bisection), that requires the estimation of lateral extent; drawing by copy and from memory; reading, assessing neglect dyslexia; and exploring the side of the body contralateral to the lesion. Activities of daily living scales are also used. Patients are typically not aware of neglect, although they may exhibit varying degrees of awareness toward different components of the deficit. The neural correlates include lesions to the inferior parietal lobule of the posterior parietal cortex, which was long considered the unique neuropathologic correlate of neglect, to the premotor and to the dorsolateral prefrontal cortices, to the posterior superior temporal gyrus, at the temporoparietal junction, to subcortical gray nuclei (thalamus, basal ganglia), and to parietofrontal white-matter fiber tracts, such as the superior longitudinal fascicle. Damage to the inferior parietal lobule of the posterior parietal cortex is specifically associated with the mainly egocentric, perceptual, and exploratory extrapersonal, and with the personal, bodily components of neglect. Productive manifestations, such as perseveration, are not a correlate of posterior parietal cortex damage.

Anosognosia, denial of illness and the right hemisphere dominance for emotions: Some historical and clinical notes

Poor disease awareness ('anosognosia') is often observed in patients with various disabilities caused by brain damage. The lack of disease awareness can be due to the disruption of specific cognitive mechanisms and the development of psychodynamic mechanisms of denial. The aim of this paper is to review how these phenomena were discovered and evolved over time and to consider the relationships between them and the right hemisphere dominance for emotions. It is not clear whether the term 'anosognosia' refers to a basic mechanism that can explain similar awareness defects in different behavioural domains or whether it must be viewed as a multifaceted phenomenon in which both the disruption of cognitive or sensorimotor mechanisms and the emergence of motivational factors can play different roles in various forms of disease unawareness and in different kinds of 'anosognosic' patients.

Reading the mind in the touch: Neurophysiological specificity in the communication of emotions by touch

Touch is central to interpersonal interactions. Touch conveys specific emotions about the touch provider, but it is not clear whether this is a purely socially learned function or whether it has neurophysiological specificity. In two experiments with healthy participants (N = 76 and 61) and one neuropsychological single case study, we investigated whether a type of touch characterised by peripheral and central neurophysiological specificity, namely the C tactile (CT) system, can communicate specific emotions and mental states. We examined the specificity of emotions elicited by touch delivered at CT-optimal (3 cm/s) and CT-suboptimal (18 cm/s) velocities (Experiment 1) at different body sites which contain (forearm) vs. do not contain (palm of the hand) CT fibres (Experiment 2). Blindfolded participants were touched without any contextual cues, and were asked to identify the touch provider's emotion and intention. Overall, CT-optimal touch (slow, gentle touch on the forearm) was significantly more likely than other types of touch to convey arousal, lust or desire. Affiliative emotions such as love and related intentions such as social support were instead reliably elicited by gentle touch, irrespective of CT-optimality, suggesting that other top-down factors contribute to these aspects of tactile social communication. To explore the neural basis of this communication, we also tested this paradigm in a stroke patient with right perisylvian damage, including the posterior insular cortex, which is considered as the primary cortical target of CT afferents, but excluding temporal cortex involvement that has been linked to more affiliative aspects of CT-optimal touch. His performance suggested an impairment in ‘reading’ emotions based on CT-optimal touch. Taken together, our results suggest that the CT system can add specificity to emotional and social communication, particularly with regards to feelings of desire and arousal. On the basis of these findings, we speculate that its primary functional role may be to enhance the ‘sensual salience’ of tactile interactions.

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Touch can convey specific emotions and intentions.

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Slow gentle touch communicates love and intimacy regardless of CT fibre activation.

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The CT system plays a specific role in mediating sensual touch.

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Insula activation might be necessary in the arousing function of the CT system.

Modulation of somatoparaphrenia following left-hemisphere damage

Somatoparaphrenic symptoms after left-hemisphere damage are rare. To verify the potential role of body-related sensory (proprioceptive, visual, and somatosensory) manipulation in patients experiencing sensations of hand disownership, the symptoms of a patient suffering from right-hand somatoparaphrenia were monitored and clinical and neuropsychological variables were controlled. Four types of manipulation were administered: changes in spatial position of the hand, multisensory stimulation, and self-observation using video or mirrors. Multisensory visuo-tactile stimulation was efficacious in terms of reducing somatoparaphrenia, and changes in the position of the hand produced some positive effects. Third-person perspective self-observation did not, however, result in any changes.

Ownership illusions in patients with body delusions: Different neural profiles of visual capture and disownership

The various neurocognitive processes contributing to the sense of body ownership have been investigated extensively in healthy participants, but studies in neurological patients can shed unique light into such phenomena. Here, we aimed to investigate whether visual capture by a fake hand (without any synchronous or asynchronous tactile stimulation) affects body ownership in a group of hemiplegic patients with or without disturbed sensation of limb ownership (DSO) following damage to the right hemisphere. We recruited 31 consecutive patients, including seven patients with DSO. The majority of our patients (64.5% overall and up to 86% of the patients with DSO) experienced strong feelings of ownership over a rubber hand within 15 sec following mere visual exposure, which correlated with the degree of proprioceptive deficits across groups and in the DSO group. Using voxel-based lesion-symptom mapping analysis, we were able to identify lesions associated with this pathological visual capture effect in a selective fronto-parietal network, including significant voxels (p < .05) in the frontal operculum and the inferior frontal gyrus. By contrast, lesions associated with DSO involved more posterior lesions, including the right temporoparietal junction and a large area of the supramarginal gyrus, and to a lesser degree the middle frontal gyrus. Thus, this study suggests that our sense of ownership includes dissociable mechanisms of multisensory integration.

For a Cognitive Model of Subjective Memory Awareness

The clinical challenge in subjective memory decline (SMD) is to identify which individuals will present memory deficits. Since its early description from Babinsky, who coined the term 'anosognosia' (i.e., the lack of awareness of deficit), the awareness of cognitive impairment is crucial in clinical neuropsychology. We propose a cognitive model in which SMD and anosognosia can be considered two opposite forms of distorted awareness of cognitive performance and can be accounted for within a model in which consciousness of memory performance can vary in a continuum from normal awareness of performance (preserved or impaired) to anosognosia through a disorder of consciousness related to SMD that we call "cognitive dysgnosia", i.e., awareness of normal performance as impaired. This model suggests that the neuropsychological assessment of memory performance should always be coupled with a deep evaluation of awareness of the subject's memory profile, which allow to better identify the disorder of consciousness with or without cognitive impairment. In this line, it seems necessary to develop more sensitive neuropsychological tools in order to discriminate, within the SMD, individuals who are likely to develop clinical Alzheimer's disease from those whose memory decline complaint is not associated with an underlying neurodegenerative pathology.

Understanding Motor Awareness Through Normal and Pathological Behavior

Data on patients with localized brain damage and on neurologically intact subjects show that normal motor control depends on the functionality of a chain of neurobiological events. These events, through the activation of internal representations of the desired, predicted, and actual condition of one's body with respect to the external world, contribute to the construction of conscious knowledge of voluntary actions and to self-awareness.

Mentalizing the body: spatial and social cognition in anosognosia for hemiplegia

Following right-hemisphere damage, a specific disorder of motor awareness can occur called anosognosia for hemiplegia, i.e. the denial of motor deficits contralateral to a brain lesion. The study of anosognosia can offer unique insights into the neurocognitive basis of awareness. Typically, however, awareness is assessed as a first person judgement and the ability of patients to think about their bodies in more 'objective' (third person) terms is not directly assessed. This may be important as right-hemisphere spatial abilities may underlie our ability to take third person perspectives. This possibility was assessed for the first time in the present study. We investigated third person perspective taking using both visuospatial and verbal tasks in right-hemisphere stroke patients with anosognosia (n = 15) and without anosognosia (n = 15), as well as neurologically healthy control subjects (n = 15). The anosognosic group performed worse than both control groups when having to perform the tasks from a third versus a first person perspective. Individual analysis further revealed a classical dissociation between most anosognosic patients and control subjects in mental (but not visuospatial) third person perspective taking abilities. Finally, the severity of unawareness in anosognosia patients was correlated to greater impairments in such third person, mental perspective taking abilities (but not visuospatial perspective taking). In voxel-based lesion mapping we also identified the lesion sites linked with such deficits, including some brain areas previously associated with inhibition, perspective taking and mentalizing, such as the inferior and middle frontal gyri, as well as the supramarginal and superior temporal gyri. These results suggest that neurocognitive deficits in mental perspective taking may contribute to anosognosia and provide novel insights regarding the relation between self-awareness and social cognition.

Imaging studies of functional neurologic disorders

Brain imaging techniques provide unprecedented opportunities to study the neural mechanisms underlying functional neurologic disorder (FND, or conversion disorder), which have long remained a mystery and clinical challenge for physicians, as they arise with no apparent underlying organic disease. One of the first questions addressed by imaging studies concerned whether motor conversion deficits (e.g., hysteric paralysis) represent a form of (perhaps unconscious) simulation, a mere absence of voluntary movement, or more specific disturbances in motor control (such as abnormal inhibition). Converging evidence from several studies using different techniques and paradigms has now demonstrated distinctive brain activation patterns associated with functional deficits, unlike those seen in actors simulating similar deficits. Thus, patients with motor FND show consistent hypoactivation of both cortical and subcortical motor pathways, with frequent increases in other brain areas within the limbic system, but no recruitment of prefrontal regions usually associated with voluntary motor inhibition. Other studies point to a dysfunction in sensorimotor integration and agency - related to parietal dysfunction - and abnormal motor planning related to supplementary motor area and prefrontal areas. These findings not only suggest that functional symptoms reflect a genuine brain dysfunction, but also give new insights into how they are produced. However, fewer studies attempted to understand why these symptoms are produced and linked to potential psychologic or emotional risk/triggering factors. Results from such studies point towards abnormal limbic regulation with heightened emotional arousal and amygdalar activity, potentially related to engagement of defense systems and stereotyped motor behaviors, mediated by medial prefrontal cortex and subcortical structures, including the periaqueductal gray area and basal ganglia. In addition, across different symptom domains, several studies reported abnormal recruitment of ventromedial prefrontal cortex (vmPFC), a region known to regulate emotion appraisal, memory retrieval, and self-reflective representations. The vmPFC might provide important modulatory signals to both cortical and subcortical sensorimotor, visual, and even memory circuits, promoting maladaptive self-protective behaviors based on personal affective appraisals of particular events. A better understanding of such a role of vmPFC in FND may help link how and why these symptoms are produced. Further research is also needed to determine brain activation patterns associated with FND across different types of deficits and different evolution stages (e.g., acute vs. chronic vs. recovered).

The affective modulation of motor awareness in anosognosia for hemiplegia: behavioural and lesion evidence

The possible role of emotion in anosognosia for hemiplegia (i.e., denial of motor deficits contralateral to a brain lesion), has long been debated between psychodynamic and neurocognitive theories. However, there are only a handful of case studies focussing on this topic, and the precise role of emotion in anosognosia for hemiplegia requires empirical investigation. In the present study, we aimed to investigate how negative and positive emotions influence motor awareness in anosognosia. Positive and negative emotions were induced under carefully-controlled experimental conditions in right-hemisphere stroke patients with anosognosia for hemiplegia (n = 11) and controls with clinically normal awareness (n = 10). Only the negative, emotion induction condition resulted in a significant improvement of motor awareness in anosognosic patients compared to controls; the positive emotion induction did not. Using lesion overlay and voxel-based lesion-symptom mapping approaches, we also investigated the brain lesions associated with the diagnosis of anosognosia, as well as with performance on the experimental task. Anatomical areas that are commonly damaged in AHP included the right-hemisphere motor and sensory cortices, the inferior frontal cortex, and the insula. Additionally, the insula, putamen and anterior periventricular white matter were associated with less awareness change following the negative emotion induction. This study suggests that motor unawareness and the observed lack of negative emotions about one's disabilities cannot be adequately explained by either purely motivational or neurocognitive accounts. Instead, we propose an integrative account in which insular and striatal lesions result in weak interoceptive and motivational signals. These deficits lead to faulty inferences about the self, involving a difficulty to personalise new sensorimotor information, and an abnormal adherence to premorbid beliefs about the body.

Action-monitoring impairment in anosognosia for hemiplegia

Every movement begins with action programming, and ends with a produced effect. Anosognosia for hemiplegia (AH), involving unawareness of motor deficits after brain damage, is a striking but also poorly understood symptom in clinical neurology. It has been suggested that it may result from a combination of cognitive and sensorimotor dysfunctions, including impairments in monitoring motor action and detecting the mismatch between intention and outcome. Here we investigated the relationship between motor action awareness and monitoring of self-produced movements by using a motor imaginary task, which was performed with either the intact or the affected limb. We tested 10 right brain-damaged patients, including 5 with AH, in comparison with 5 healthy controls. In a first phase, participants were asked to either realize or imagine a movement with their right or left arm. In a subsequent recognition phase, the participants had to recall whether the movement was a realized or imagined and which arm was used. AH patients performed significantly worse relative to no-AH patients and healthy controls for the left movements. Specifically, we found that AH patients believed they had realized movements with their (paralyzed) left arm even when they failed in the left execution condition. However, they also made more errors for movements actually realized with the right hand. These findings confirm that impaired action monitoring may contribute to AHP. Furthermore, our results support the notion of an action control system integrating "feedforward" signals through a comparison process between the intention and execution of movement, but also indicate that monitoring deficits in AHP are not strictly unilateral. Combined together, dysfunction of motor comparator processes and more general monitoring deficits may add up to lead to unawareness of paralysis.

Anosognosia for hemianaesthesia: a voxel-based lesion-symptom mapping study

Brain-damaged patients affected by hemianaesthesia (i.e., the loss of tactile sensibility on the contralesional side of the body) may deny their deficits (i.e., anosognosia for tactile deficits) even reporting tactile experience when stimuli are delivered on the impaired side. So far, descriptive analysis on small samples of patients reported that the insular cortex, the internal/external capsule, the basal ganglia and the periventricular white matter would subserve anosognosia for hemianaesthesia. Here, we aimed at examining in depth the anatomo-functional nature of anosognosia for hemianaesthesia by means of a voxelwise statistical analysis. We compared two groups of left hemiplegic patients due to right brain damages differing only for the presence/absence of anosognosia for left hemianaesthesia. Our findings showed a lesional cluster confined mainly to the anterior part of the putamen. According to the current anatomical evidence on the neural basis of sensory expectancies, we suggested that anosognosia for hemianaesthesia might be explained as a failure to detect the mismatch between expected and actual tactile stimulation.

Selective improvement of anosognosia for hemiplegia during transcranial direct current stimulation: a case report

Right brain damage patients may not complain of a left sided paralysis up to the point of denying it or even claiming of having just moved an otherwise paralyzed limb. This condition is known as anosognosia for hemiplegia (AHP). Recent behavioural experiments suggest that some residual intentionality might be preserved in patients with anosognosia and that the false belief of having moved originates from a failure to notice discrepancies between movement expectancies and the actual state of the motor system. This failure may be caused by a lack of afferent sensory information concerning the movement or alternatively by a direct dysfunction of the brain regions involved in actions' motor monitoring (i.e., the comparator system). Here we examined the effect of anodal transcranial direct current stimulation (tDCS) of the right premotor cortex in a patient with a bilateral lesion, involving predominantly the right hemisphere, and a dense unawareness for his left hemiplegia. During sham or anodal tDCS the patient was requested to judge his ability to perform simple motor actions (i) without actually executing the movement itself ("offline" condition) and after having performed a series of verbally cued finger opposition movements ("online" condition) with (i) eyes-closed or (ii) eyes-open. We found that anodal tDCS induces a significant remission of the false experience of movement only when the patient is requested to actually perform the movement with eyes open. Conversely, the patient's awareness does not improve in both the "offline" condition (in which the patient does not attempt to perform the movement) and in the "online" condition, when vision is precluded ("online" condition, eyes-closed). We conclude that the stimulation of the premotor cortex by tDCS activates brain regions involved in motor monitoring, temporary restoring the ability of the motor comparator system to correctly appreciate afferent information and build up a veridical motor awareness.

Anosognosia for hemiplegia: The contributory role of right inferior frontal gyrus

OBJECTIVE

Awareness of motor functioning is most likely a complex process that requires integration of sensory-motor feedback to constantly update the system on the functioning of the limb during motor behavior. Using lesion mapping procedures and behavioral measures, the current study aimed to evaluate neural correlates of anosognosia for hemiplegia (AHP) in the acute stage (first 48 hr) of right hemisphere stroke.

METHOD

Thirty-five individuals with right hemisphere stroke who presented to an urban medical center within 24 hr of symptom onset were included in the study. All 35 individuals had hemiplegia, and 8 of these individuals exhibited AHP.

RESULTS

Fisher's exact test statistical map of lesion-deficit association (range is between-log(p) 4 to 11) found maximal value of 10.9 located in pars orbitalis (Brodmann's Area 47; BA). In this selected location, 6 out of 8 patients with AHP had tissue abnormality, whereas none of the unaffected subjects had tissue abnormality in BA 47. Right BA 44/45 was also found to be lesioned more frequently in individuals with AHP (75%) than without AHP (11%).

CONCLUSIONS

The current study findings provide preliminary support for unique involvement of the right inferior frontal gyrus (IFG), pars orbitalis (BA 47) in AHP. The current data suggest that frontal operculum may play a key role in awareness of limb functioning.