Visual neglect as a disconnection syndrome? A confirmatory case report

The role of white matter variability in TMS neuromodulatory effects

BACKGROUND

Transcranial Magnetic Stimulation (TMS) is a widely used tool to explore the causal role of focal brain regions in cognitive processing. TMS effects over attentional processes are consistent and replicable, while at the same time subjected to individual variability. This individual variability needs to be understood to better comprehend TMS effects, and most importantly, its clinical applications.

OBJECTIVE

/Hypothesis: This study aimed to explore the role of white matter variability in TMS neuromodulatory effects on behavior in healthy participants (N=50).

METHODS

Participants completed an attentional task in which orienting and alerting cues preceded near-threshold targets. Continuous Theta Burst Stimulation (cTBS) was applied over the left frontal eye field (FEF) or an active vertex condition. White matter was explored with diffusion-weighted imaging tractography and Tract-Based Spatial Statistics (TBSS).

RESULTS

Behaviourally, TMS over the left FEF slowed down reaction times (especially in the alerting task), impaired accuracy in the objective task, and reduced the proportion of seen targets (as compared to the vertex condition). Attentional effects increased, overall, when TMS was applied to the left FEF as compared to the vertex condition. Correlations between white matter and TMS effects showed i) reduced TMS effects associated with the microstructural properties of long-range white matter pathways such as the superior longitudinal fasciculus (SLF), and interhemispheric fibers of the corpus callosum (CC), and ii) increased TMS effects in participants with high integrity of the CC connecting the stimulated region with the opposite hemisphere. Additionally, variability in attentional effects was also related to white matter, showing iii) increased alerting effects in participants with low integrity of association, commissural, and projection fibers, and iv) increased orienting effects in participants with high integrity of the right SLF III.

CONCLUSION

All these observations highlight the importance of taking into account individual variability in white matter for the understanding of cognitive processing and brain neuromodulation effects.

Integrating brain function and structure in the study of the human attentional networks: a functionnectome study

Attention is a heterogeneous function theoretically divided into different systems. While functional magnetic resonance imaging (fMRI) has extensively characterized their functioning, the role of white matter in cognitive function has gained recent interest due to diffusion-weighted imaging advancements. However, most evidence relies on correlations between white matter properties and behavioral or cognitive measures. This study used a new method that combines the signal from distant voxels of fMRI images using the probability of structural connection given by high-resolution normative tractography. We analyzed three fMRI datasets with a visual perceptual task and three attentional manipulations: phasic alerting, spatial orienting, and executive attention. The phasic alerting network engaged temporal areas and their communication with frontal and parietal regions, with left hemisphere dominance. The orienting network involved bilateral fronto-parietal and midline regions communicating by association tracts and interhemispheric fibers. The executive attention network engaged a broad set of brain regions and white matter tracts connecting them, with a particular involvement of frontal areas and their connections with the rest of the brain. These results partially confirm and extend previous knowledge on the neural substrates of the attentional system, offering a more comprehensive understanding through the integration of structure and function.

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

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

Connectivity of Frontoparietal Regions Reveals Executive Attention and Consciousness Interactions

The executive control network is involved in the voluntary control of novel and complex situations. Solving conflict situations or detecting errors have demonstrated to impair conscious perception of near-threshold stimuli. The aim of this study was to explore the neural mechanisms underlying executive control and its interaction with conscious perception using functional magnetic resonance imaging and diffusion-weighted imaging. To this end, we used a dual-task paradigm involving Stroop and conscious detection tasks with near-threshold stimuli. A set of prefrontal and frontoparietal regions were more strongly engaged for incongruent than congruent trials while a distributed set of frontoparietal regions showed stronger activation for consciously than nonconsciously perceived trials. Functional connectivity analysis revealed an interaction between executive control and conscious perception in frontal and parietal nodes. The microstructural properties of the middle branch of the superior longitudinal fasciculus were associated with neural measures of the interaction between executive control and consciousness. These results demonstrate that conscious perception and executive control share neural resources in frontoparietal networks, as proposed by some influential models.

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.

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

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

Computational Neuropsychology and Bayesian Inference

Computational theories of brain function have become very influential in neuroscience. They have facilitated the growth of formal approaches to disease, particularly in psychiatric research. In this paper, we provide a narrative review of the body of computational research addressing neuropsychological syndromes, and focus on those that employ Bayesian frameworks. Bayesian approaches to understanding brain function formulate perception and action as inferential processes. These inferences combine ‘prior’ beliefs with a generative (predictive) model to explain the causes of sensations. Under this view, neuropsychological deficits can be thought of as false inferences that arise due to aberrant prior beliefs (that are poor fits to the real world). This draws upon the notion of a Bayes optimal pathology – optimal inference with suboptimal priors – and provides a means for computational phenotyping. In principle, any given neuropsychological disorder could be characterized by the set of prior beliefs that would make a patient’s behavior appear Bayes optimal. We start with an overview of some key theoretical constructs and use these to motivate a form of computational neuropsychology that relates anatomical structures in the brain to the computations they perform. Throughout, we draw upon computational accounts of neuropsychological syndromes. These are selected to emphasize the key features of a Bayesian approach, and the possible types of pathological prior that may be present. They range from visual neglect through hallucinations to autism. Through these illustrative examples, we review the use of Bayesian approaches to understand the link between biology and computation that is at the heart of neuropsychology.

The allocentric neglect due to injury of the inferior fronto-occipital fasciculus in a stroke patient: A case report

RATIONALE

We report on a patient who developed allocentric neglect due to injury of the inferior fronto-occipital fasciculus (IFOF) following intracranial hemorrhage, diagnosed using diffusion tensor tractography (DTT).

PATIENT CONCERNS

Her cognition seemed normal (A 17-year-old, right-handed female patient). However, in spite of a normal visual field, her perception was missing on the left side, and she had no awareness of her deficit. She was unable to perceive the left side in each of 2 objects, regardless of position of the 2 objects, and failed at detail exploration of the left side of 1 object. In addition, the line bisection test, the most representative neglect test, did not reveal any abnormality.

DIAGNOSES

She was diagnosed with an intracerebral hemorrhage (right thalamus), intraventricular hemorrhage, and subarachnoid hemorrhage due to arteriovenous malformation in the right thalamus.

INTERVENTIONS

Seven weeks after onset, she began rehabilitation. Consequently, the apple cancellation test to discriminate between allocentric and egocentric neglect was performed, with the result of severe allocentric neglect.

OUTCOMES

The right superior longitudinal fasciculus and inferior longitudinal fasciculus were well-reconstructed without definite injury compared with those of the left side. However, the right IFOF was discontinued in the anterior portion around the frontal lobe.

LESSONS

Allocentric neglect due to injury of IFOF was demonstrated in a stroke patient using DTT. It appears that DTT would be helpful in demonstrating the neglect type and pathway in patients with neglect.

White matter microstructure of attentional networks predicts attention and consciousness functional interactions

Attention is considered as one of the pre-requisites of conscious perception. Phasic alerting and exogenous orienting improve conscious perception of near-threshold information through segregated brain networks. Using a multimodal neuroimaging approach, combining data from functional MRI (fMRI) and diffusion-weighted imaging (DWI), we investigated the influence of white matter properties of the ventral branch of superior longitudinal fasciculus (SLF III) in functional interactions between attentional systems and conscious perception. Results revealed that (1) reduced integrity of the left hemisphere SLF III was predictive of the neural interactions observed between exogenous orienting and conscious perception, and (2) increased integrity of the left hemisphere SLF III was predictive of the neural interactions observed between phasic alerting and conscious perception. Our results combining fMRI and DWI data demonstrate that structural properties of the white matter organization determine attentional modulations over conscious perception.

The active construction of the visual world

What we see is fundamentally dependent on where we look. Despite this seemingly obvious statement, many accounts of the neurobiology underpinning visual perception fail to consider the active nature of how we sample our sensory world. This review offers an overview of the neurobiology of visual perception, which begins with the control of saccadic eye movements. Starting from here, we can follow the anatomy backwards, to try to understand the functional architecture of neuronal networks that support the interrogation of a visual scene. Many of the principles encountered in this exercise are equally applicable to other perceptual modalities. For example, the somatosensory system, like the visual system, requires the sampling of data through mobile receptive epithelia. Analysis of a somatosensory scene depends on what is palpated, in much the same way that visual analysis relies on what is foveated. The discussion here is structured around the anatomical systems involved in active vision and visual scene construction, but will use these systems to introduce some general theoretical considerations. We will additionally highlight points of contact between the biology and the pathophysiology that has been proposed to cause a clinical disorder of scene construction - spatial hemineglect.

Cortico-thalamic disconnection in a patient with supernumerary phantom limb

Supernumerary phantom limb (SPL) designates the experience of an illusory additional limb occurring after brain damage. Functional neuroimaging during SPL movements documented increased response in the ipsilesional supplementary motor area (SMA), premotor cortex (PMC), thalamus and caudate. This suggested that motor circuits are important for bodily related cognition, but anatomical evidence is sparse. Here, we tested this hypothesis by studying an extremely rare patient with chronic SPL, still present 3 years after a vascular stroke affecting cortical and subcortical right-hemisphere structures. Anatomical analysis included an advanced in vivo reconstruction of white matter tracts using diffusion-based spherical deconvolution. This reconstruction demonstrated a massive and relatively selective disconnection between anatomically preserved SMA/PMC and the thalamus. Our results provide strong anatomical support for the hypothesis that cortico-thalamic loops involving motor-related circuits are crucial to integrate sensorimotor processing with bodily self-awareness.

Differential white matter involvement associated with distinct visuospatial deficits after right hemisphere stroke

Visuospatial attention depends on the integration of multiple processes, and people with right hemisphere lesions after a stroke may exhibit severe or no visuospatial deficits. The anatomy of core components of visuospatial attention is an area of intense interest. Here we examine the relationship between the disruption of core components of attention and lesion distribution in a heterogeneous group (N = 70) of patients with right hemisphere strokes regardless of the presence of clinical neglect. Deficits of lateralized spatial orienting, measured as the difference in reaction times for responding to visual targets in the contralesional or ipsilesional visual field, and deficits in re-orienting attention, as measured by the difference in reaction times for invalidly versus validly cued targets, were measured using a computerized spatial orienting task. Both measures were related through logistic regression and a novel ridge regression method to anatomical damage measured with magnetic resonance imaging. While many regions were common to both deficit maps, a deficit in lateralized spatial orienting was more associated with lesions in the white matter underlying the posterior parietal cortex, and middle and inferior frontal gyri. A deficit in re-orienting of attention toward unattended locations was associated with lesions in the white matter of the posterior parietal cortex, insular cortex and less so with white matter involvement of the anterior frontal lobe. An hodological analysis also supports this partial dissociation between the white matter tracts that are damaged in lateralized spatial biases versus impaired re-orienting. Our results underscore that the integrity of fronto-parietal white matter tracts is crucial for visuospatial attention and that different attention components are mediated by partially distinct neuronal substrates.

Botallo's error, or the quandaries of the universality assumption

One of the founding principles of human cognitive neuroscience is the so-called universality assumption, the postulate that neurocognitive mechanisms do not show major differences among individuals. Without negating the importance of the universality assumption for the development of cognitive neuroscience, or the importance of single-case studies, here we aim at stressing the potential dangers of interpreting the pattern of performance of single patients as conclusive evidence concerning the architecture of the intact neurocognitive system. We take example from the case of Leonardo Botallo, an Italian surgeon of the Renaissance period, who claimed to have discovered a new anatomical structure of the adult human heart. Unfortunately, Botallo's discovery was erroneous, because what he saw in the few samples he examined was in fact the anomalous persistence of a fetal structure. Botallo's error is a reminder of the necessity to always strive for replication, despite the major hindrance of a publication system heavily biased towards novelty. In the present paper, we briefly discuss variations and anomalies in human brain anatomy and introduce the issue of variability in cognitive neuroscience. We then review some examples of the impact on cognition of individual variations in (1) brain structure, (2) brain functional organization and (3) brain damage. We finally discuss the importance and limits of single case studies in the neuroimaging era, outline potential ways to deal with individual variability, and draw some general conclusions.

White matter lesional predictors of chronic visual neglect: a longitudinal study

Chronic visual neglect prevents brain-damaged patients from returning to an independent and active life. Detecting predictors of persistent neglect as early as possible after the stroke is therefore crucial to plan the relevant interventions. Neglect signs do not only depend on focal brain lesions, but also on dysfunction of large-scale brain networks connected by white matter bundles. We explored the relationship between markers of axonal degeneration occurring after the stroke and visual neglect chronicity. A group of 45 patients with unilateral strokes in the right hemisphere underwent cognitive testing for neglect twice, first at the subacute phase (<3 months after onset) and then at the chronic phase (>1 year). For each patient, magnetic resonance imaging including diffusion sequences was performed at least 4 months after the stroke. After masking each patient's lesion, we used tract-based spatial statistics to obtain a voxel-wise statistical analysis of the fractional anisotropy data. Twenty-seven patients had signs of visual neglect at initial testing. Only 10 of these patients had recovered from neglect at follow-up. When compared with patients without neglect, the group including all subacute neglect patients had decreased fractional anisotropy in the second (II) and third (III) branches of the right superior longitudinal fasciculus, as well as in the splenium of the corpus callosum. The subgroup of chronic patients showed reduced fractional anisotropy in a portion the splenium, the forceps major, which provides interhemispheric communication between regions of the occipital lobe and of the superior parietal lobules. The severity of neglect correlated with fractional anisotropy values in superior longitudinal fasciculus II/III for subacute patients and in its caudal portion for chronic patients. Our results confirm a key role of fronto-parietal disconnection in the emergence and chronic persistence of neglect, and demonstrate an implication of caudal interhemispheric disconnection in chronic neglect. Splenial disconnection may prevent fronto-parietal networks in the left hemisphere from resolving the activity imbalance with their right hemisphere counterparts, thus leading to persistent neglect.

Effector-dependent neglect and splenial disconnection: a spherical deconvolution tractography study

We present the case of a patient with left homonymous hemianopia and chronic left neglect consequent to a stroke in the occipito-temporal regions of the right hemisphere. When the patient performed cancellation tasks with her right (dominant) hand, she had severe and persistent left neglect at retest 7 and 8 years after onset. However, her performance on line bisection was invariably within normal limits. Strikingly, performance on cancellation tests reverted to normal when the patient used her left hand. White matter tractography using spherical deconvolution demonstrated damage to the splenium of the corpus callosum, as well as a relative preservation of the right fronto-parietal network. Effector-dependent neglect may occur because splenial disconnection deprives the right fronto-parietal network from visual information processed by the left hemisphere. Consequently, spatial exploration reverts to normal when the patient uses her left hand, thus involving more directly the fronto-parietal attentional networks in the right-hemisphere.

Cerebral correlates of visuospatial neglect: a direct cerebral stimulation study

OBJECTIVE

To assess the role of the superior longitudinal fascicle, the inferior fronto-occipital fascicle, and the posterior parietal lobe in visuospatial attention in humans during awake brain surgery.

EXPERIMENTAL DESIGN

Seven patients with hemispheric gliomas (six in the right hemisphere) entered the study. During surgery in asleep/awake anesthesia, guided by Diffusion Tensor Imaging Fiber Tractography, visuospatial neglect was assessed during direct electrical stimulation by computerized line bisection.

PRINCIPAL OBSERVATIONS

A rightward deviation, indicating left visuospatial neglect, was induced in six of seven patients by stimulation of the parietofrontal connections, in a location consistent with the trajectory of the second branch of the superior longitudinal fascicle. Stimulation of the medial and dorsal white matter of the superior parietal lobule (corresponding to the first branch of the superior longitudinal fascicle), of the ventral and lateral white matter of the supramarginal gyrus (corresponding to the third branch of the superior longitudinal fascicle), and of the inferior occipitofrontal fasciculus, was largely ineffective. Stimulation of the superior parietal lobule (Brodmann's area 7) caused a marked rightward deviation in all of the six assessed patients, while stimulation of Brodmann's areas 5 and 19 was ineffective.

CONCLUSIONS

The parietofrontal connections of the dorso-lateral fibers of the superior longitudinal fascicle (i.e., the second branch of the fascicle), and the posterior superior parietal lobe (Brodmann's area 7) are involved in the orientation of spatial attention. Spatial neglect should be assessed systematically during awake brain surgery, particularly when the right parietal lobe may be involved by the neurosurgical procedure.

Brain networks of visuospatial attention and their disruption in visual neglect

Visual neglect is a multi-component syndrome including prominent attentional disorders. Research on the functional mechanisms of neglect is now moving from the description of dissociations in patients' performance to the identification of the possible component deficits and of their interaction with compensatory strategies. In recent years, the dissection of attentional deficits in neglect has progressed in parallel with increasing comprehension of the anatomy and function of large-scale brain networks implicated in attentional processes. This review focuses on the anatomy and putative functions of attentional circuits in the brain, mainly subserved by fronto-parietal networks, with a peculiar although not yet completely elucidated role for the right hemisphere. Recent results are discussed concerning the influence of a non-spatial attentional function, phasic alertness, on conscious perception in normal participants and on conflict resolution in neglect patients. The rapid rate of expansion of our knowledge of these systems raises hopes for the development of effective strategies to improve the functioning of the attentional networks in brain-damaged patients.