The neurological basis of visual neglect

Peripheral and bimanual reaching in a stroke survivor with left visual neglect and extinction

Whether attentional deficits are accompanied by visuomotor impairments following posterior parietal lesions has been debated for quite some time. This single-case study investigated reaching in a stroke survivor (E.B.) with left visual neglect and visual extinction following right temporo-parietal-frontal strokes. Unlike most neglect patients, E.B. did not present left hemiparesis, homonymous hemianopia nor show evidence of motor neglect or extinction allowing us to examine, for the first time, if lateralised attentional deficits co-occur with deficits in peripheral and bimanual reaching. First, we found a classic optic ataxia field effect: E.B.'s accuracy was impaired when reaching to peripheral targets in her neglected left visual field (regardless of the hand used). Second, we found a larger bimanual cost for movement time in E.B. than controls when both hands reached to incongruent locations. E.B.'s visuomotor profile is similar to the one of patients with optic ataxia showing that attentional deficits are accompanied by visuomotor deficits in the affected field.

Combined optokinetic stimulation and cueing-assisted reading therapy to treat hemispatial neglect: A randomized controlled crossover trial

BACKGROUND

Hemispatial neglect is a disabling cognitive disorder following stroke and effective therapies are required.

OBJECTIVES

To evaluate the effects of combined optokinetic stimulation (OKS) and cueing-assisted reading therapy (READ) on the remission of hemispatial neglect following stroke.

METHODS

Randomized, controlled, two-period, crossover trial conducted at a German neurorehabilitation center. Twenty participants with left neglect following right hemispheric stroke (mean age 66 years (SD 11), mean time since stroke 50 days (SD 33)) finished the trial (12 received OKSREAD first, 8 CONTROL first). The intervention consisted of 15 daily sessions of OKS (20 min) and text reading assisted by a therapist providing cues (20 min). The control treatment was a same-number, same-length neuropsychological treatment not targeting visuospatial attention. Primary outcomes were the change in performance of a customized neuropsychological test battery for neglect (0% worst - 100% best) and a test of neglect-related functional disability (Catherine Bergego Scale, 0 no impairment - 30 severest impairment), assessed before and after each treatment period. Secondary outcomes were performance in the 6 single tests composing the battery (e.g., omissions in text reading, center of cancellation in the Bells test, spatial bias of fixations when freely viewing photographs) and a clinical test of anosognosia.

RESULTS

Overall performance in the neglect test battery improved slightly more after OKSREAD than after CONTROL (d=6%; p=0.002). The remission of neglect-related functional disability did not differ between treatments (d=-2; p=0.291). Ipsilesional fixation bias during free viewing was the only secondary outcome that was improved by OKSREAD as compared to CONTROL (d= -2.8°; p=0.005).

CONCLUSION

At the applied intensity, the combined OKSREAD intervention slightly attenuated the ipsilesional attention bias in persons with neglect, but it did not improve neglect-related functional disability, anosognosia, or other neglect symptoms to a clinically meaningful degree.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT04273620.

Effects of Prism Adaptation on Unilateral Neglect After Stroke: An Updated Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to investigate the effects of prism adaptation (PA) on unilateral neglect after stroke.

METHODS

Randomized clinical trials, published up to January 31, 2020, comparing PA with neutral goggles or no goggles were systematically searched and included. Two independent reviewers performed data extraction and assessed the quality of studies using the Physiotherapy Evidence Database scale.

RESULTS

A total of seven randomized trials, involving 211 participants, satisfied the inclusion criteria. There was no significant immediate benefit of PA as measured by Behavioral Inattention Test (BIT) (weighted mean difference [WMD], 5.10; [95% confidence interval (CI), -6.68 to 16.88]), behavioral subset (BIT-B; WMD, 3.40 [95% CI, -3.97 to 10.76), conventional subset (BIT-C; WMD, 9.98 [95% CI, -0.42 to 20.38]), and Catherine Bergego Scale (WMD, -0.52 [95% CI, -1.98 to 0.93]). No statistical difference was observed between PA and control on the long-term effect (BIT: WMD, 1.92 [95% CI, -9.34 to 13.18]; BIT-B: WMD, -3.28 [95% CI, -11.89 to 5.34]; BIT-C: WMD, 2.66 [95% CI, -10.35 to 11.67]; Catherine Bergego Scale: WMD, -1.22 [95% CI, -3.05 to 0.62]).

CONCLUSIONS

PA did not show a greater improvement on neglect symptoms in post-stroke patients with unilateral neglect, compared with placebo or no treatment. These findings do not support the routine use of PA in patients with unilateral neglect after stroke.

The role of transcranial magnetic stimulation in understanding attention-related networks in single subjects

Attention is a cognitive mechanism that has been studied through several methodological viewpoints, including animal models, MRI in stroke patients, and fMRI in healthy subjects. Activation-based fMRI research has also pointed to specific networks that activate during attention tasks. Most recently, network neuroscience has been used to study the functional connectivity of large-scale networks for attention to reveal how strongly correlated networks are to each other when engaged in specific behaviors. While neuroimaging has revealed important information about the neural correlates of attention, it is crucial to better understand how these processes are organized and executed in the brain in single subjects to guide theories and treatments for attention. Noninvasive brain stimulation is an effective tool to causally manipulate neural activity to detect the causal roles of circuits in behavior. We describe how combining transcranial magnetic stimulation (TMS) with modern precision network analysis in single-subject neuroimaging could test the roles of regions, circuits, and networks in regulating attention as a pathway to improve treatment effect magnitudes and specificity.

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Though studied for over 100 years, the brain basis of attention is still queried.

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Complexity in frameworks for attention makes brain mapping difficult.

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Relevant brain networks vary significantly across subjects, challenging progress.

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Single-subject neuroimaging with TMS can improve our understanding of attention.

Recovery of contralesional saccade choice and reaction time deficits after a unilateral endothelin-1-induced lesion in the macaque caudal prefrontal cortex

The caudal primate prefrontal cortex (PFC) is involved in target selection and visually guided saccades through both covert attention and overt orienting eye movements. Unilateral damage to the caudal PFC often leads to decreased awareness of a contralesional target alone, referred to as “neglect,” or when it is presented simultaneously with an ipsilesional target, referred to as “extinction.” In the current study, we examined whether deficits in contralesional target selection were due to contralesional oculomotor deficits, such as slower reaction times. We experimentally induced a focal ischemic lesion in the right caudal PFC of 4 male macaque monkeys using the vasoconstrictor endothelin-1 and measured saccade choice and reaction times on double-stimulus free-choice tasks and single-stimulus trials before and after the lesion. We found that 1) endothelin-1-induced lesions in the caudal PFC produced contralesional target selection deficits that varied in severity and duration based on lesion volume and location; 2) contralesional neglect-like deficits were transient and recovered by week 4 postlesion; 3) contralesional extinction-like deficits were longer lasting and recovered by weeks 8–16 postlesion; 4) contralesional reaction time returned to baseline well before the contralesional choice deficit had recovered; and 5) neither the mean reaction times nor the reaction time distributions could account for the degree of contralesional extinction on the free-choice task throughout recovery. These findings demonstrate that the saccade choice bias observed after a right caudal PFC lesion is not exclusively due to contralesional motor deficits, but instead reflects a combination of impaired motor and attentional processing.

NEW & NOTEWORTHY Unilateral damage to the caudal prefrontal cortex in macaque monkeys results in impaired contralesional target selection during the simultaneous presentation of an ipsilesional target. We show that the recovery of contralesional target selection cannot be explained by the recovery of prolonged contralesional saccadic reaction times alone. This indicates that an impairment in contralesional attentional processing contributes to the magnitude of the saccade choice bias in the weeks following a unilateral caudal prefrontal cortex lesion.

Perceiving animacy purely from visual motion cues involves intraparietal sulcus

Distinguishing animate from inanimate objects is fundamental for social perception in humans and animals. Visual motion cues indicative of self-propelled object motion are useful for animacy perception: they can be detected over a wide expanse of visual field, at distance and in low visibility conditions, can attract attention and provide clues about object behaviour. However, the neural correlates of animacy perception evoked exclusively by visual motion cues, i.e. not relying on form, background or visual context, are unclear. We aimed to address this question in four psychophysical experiments in humans, two of which performed during neuroimaging. The stimulus was a single dot with constant form that moved on a blank background and evoked controlled degrees of perceived animacy through parametric variations of self-propelled motion cues. BOLD signals reflecting perceived animacy in a graded manner irrespective of eye movements were found in one intraparietal region. Additional whole-brain and region-of-interest analyses revealed no comparable effects in brain regions associated with social processing or other areas. Our study shows that animacy perception evoked solely by visual motion cues, a basic perceptual process in social cognition, engages brain regions not primarily associated with social cognition.

Spatial Attention Deficits Are Causally Linked to an Area in Macaque Temporal Cortex

Spatial neglect is a common clinical syndrome involving disruption of the brain's attention-related circuitry, including the dorsocaudal temporal cortex. In macaques, the attention deficits associated with neglect can be readily modeled, but the absence of evidence for temporal cortex involvement has suggested a fundamental difference from humans. To map the neurological expression of neglect-like attention deficits in macaques, we measured attention-related fMRI activity across the cerebral cortex during experimental induction of neglect through reversible inactivation of the superior colliculus and frontal eye fields. During inactivation, monkeys exhibited hallmark attentional deficits of neglect in tasks using either motion or non-motion stimuli. The behavioral deficits were accompanied by marked reductions in fMRI attentional modulation that were strongest in a small region on the floor of the superior temporal sulcus; smaller reductions were also found in frontal eye fields and dorsal parietal cortex. Notably, direct inactivation of the mid-superior temporal sulcus (STS) cortical region identified by fMRI caused similar neglect-like spatial attention deficits. These results identify a putative macaque homolog to temporal cortex structures known to play a central role in human neglect.

Development of Visuospatial Attention in Typically Developing Children

The aim of the present study is to investigate the development of visuospatial attention in typically developing children and to propose reference values for children for the following six visuospatial attention tests: star cancellation, Ogden figure, reading test, line bisection, proprioceptive pointing and visuo-proprioceptive pointing. Data of 159 children attending primary or secondary school in the Fédération Wallonie Bruxelles (Belgium) were analyzed. Results showed that the children's performance on star cancellation, Ogden figure and reading test improved until the age of 13 years, whereas their performance on proprioceptive pointing, visuo-proprioceptive pointing and line bisection was stable with increasing age. These results suggest that the execution of different types of visuospatial attention tasks are not following the same developmental trajectories. This dissociation is strengthened by the lack of correlation observed between tests assessing egocentric and allocentric visuospatial attention, except for the star cancellation test (egocentric) and the Ogden figure copy (ego- and allocentric). Reference values are proposed that may be useful to examine children with clinical disorders of visuospatial attention.

Rehabilitation of visuospatial neglect by prism adaptation: effects of a mild treatment regime. A randomised controlled trial

Closely examining the effects, optimal regime and time window of prism adaptation (PA) promotes guidelines for effective rehabilitation practice. The effects of short-term repetitive PA on spatial neglect manifestations were evaluated in patients with heterogeneous post-stroke delays, using a digital Visuospatial Neglect Test Battery. Subsequently, potential differences in PA effects between acute, subacute or chronic neglect were explored. A multicentre randomised controlled trial was conducted in 43 right-hemisphere neglect patients. They were treated with a mild PA regime: seven sessions of experimental or placebo prism training over 7-12 days. The outcome measures were diverse neglect variables related to peripersonal navigation, visual extinction, visuospatial memory, bisection, cancellation, drawing and visual search. The treatment effects were assessed after a short and a long time interval. Two to 24 hours after PA, conventional effects were found for drawing and centred bisection, and novel effects for peripersonal visuospatial navigation, visual extinction, and non-motor memory (with caution). No effects were found for visual search times and cancellation. The assessments after three months were still indicative of PA benefits for navigational, drawing and memory functions. PA did not prove to be more effective in acute, subacute or chronic patients. The extension of effects is theoretically framed within the debate about the levels of cognitive processing that are impacted by PA. Clinical suggestions are formulated regarding PA implementation in neglect treatment.

Capturing peripersonal spatial neglect: an electronic method to quantify visuospatial processes

Computerized as well as paper-and-pencil tasks are applied in mapping visuospatial neglect in experimental research and clinical practice. This article presents a new kind of computer-based assessment method, using an electronic pen display and user-friendly software. The approach is tailored to specific spatial processes and highlights the usefulness of a pen display in neglect patients. The advantages of the introduced method are illustrated by a recently designed battery of classic, as well as new, types of tests. The development of the appropriate stimuli and the assorted scoring systems is addressed, as well as the resulting types of task implementation and data generation. The diagnostic value of the different visuospatial neglect tests is demonstrated by comparative analyses between a neglect group and a control group. Among the benefits of the proposed assessment method are (1) the opportunity to perform standardized repeated measurements to quantify recovery, (2) online performance monitoring, (3) flexible employment, (4) the collection of exact data over a short period, and (5) the easy availability of more refined quantitative as well as interesting qualitative information, especially as compared to classic or paper-and-pencil tasks. To indicate that this method also lends itself well to measures for treatment procedures, an illustration is given with respect to specific measurements during prism adaptation. The tasks of the Visuospatial Neglect Test Battery and the prism adaptation measures are illustrated by a case study. The outlined applications are discussed with respect to experimental as well as clinical purposes.

Visual attention: Linking prefrontal sources to neuronal and behavioral correlates

Attention is a means of flexibly selecting and enhancing a subset of sensory input based on the current behavioral goals. Numerous signatures of attention have been identified throughout the brain, and now experimenters are seeking to determine which of these signatures are causally related to the behavioral benefits of attention, and the source of these modulations within the brain. Here, we review the neural signatures of attention throughout the brain, their theoretical benefits for visual processing, and their experimental correlations with behavioral performance. We discuss the importance of measuring cue benefits as a way to distinguish between impairments on an attention task, which may instead be visual or motor impairments, and true attentional deficits. We examine evidence for various areas proposed as sources of attentional modulation within the brain, with a focus on the prefrontal cortex. Lastly, we look at studies that aim to link sources of attention to its neuronal signatures elsewhere in the brain.

The time course for visual extinction after a 'virtual' lesion of right posterior parietal cortex

Our understanding of the attentional networks in the human brain largely relies on neuropsychological studies in patients with lesions to the posterior parietal cortex (PPC), particularly in the right hemisphere, that may cause severe disruptions of attentional functions. However, lesion studies only capture a point in time when the dysfunctions caused by the damage have triggered a chain of adaptive responses in the brain. To disentangle deficits and ensuing cortical plasticity, here we examined the time course for one's ability to detect objects in the visual periphery after an inhibitory continuous theta-burst stimulation (cTBS) protocol to the left or right PPC. Our results showed that cTBS of right PPC caused participants to be less sensitive to objects appearing on the left side as well as to objects appearing on both sides at the same time, consistent with an overall shift of attention to the right side of space. In addition, we found that participants missed more objects during bilateral presentations similar to patients with visual extinction. Critically, extinction evolved over time; that is, visual extinction for ipsilateral objects improved after 10 min whereas contralateral extinction peaked around 15-25 min after cTBS. Our findings suggest that lesions to the PPC impair competition between the two visual hemifields, resulting in contralateral extinction as a secondary response, arguably due to ensuing disruptions in interhemispheric balance.

Italian standardization of the Apples Cancellation Test

Hemispatial neglect due to right parieto-temporo-frontal lesions has a negative impact on the success of rehabilitation, resulting in poor functional gain. Recent research has shown that different types of neglect can impact in a different way on rehabilitation outcomes. The availability of a sensitive test, useful for distinguishing egocentric and allocentric forms of neglect, may be clinically important as all current clinical instruments fail to distinguish between these forms of disturbance, yet they differentially predict outcome. The Apples Test is a new instrument useful to evaluate both egocentric and allocentric forms of neglect. In order to establish Italian norms for this diagnostic instrument the test was administered to a sample of 412 healthy people of both genders (201 M and 211 F), aged from 20 to 80 years enrolled from 14 different rehabilitation centers in Italy. Based on the data, we established pathological performance cut-offs for the accuracy score (total omission errors), the asymmetry score for egocentric neglect (omission error difference), the asymmetry score for allocentric neglect (commission error difference) and execution time. The usefulness of the Apples Test for diagnostic purposes is illustrated by presenting three patients with different forms of neglect (egocentric, allocentric and mixed neglect).

The hybrid model of attentional control: New insights into hemispheric asymmetries inferred from TMS research

Several competing theories on the mechanisms underlying attentional control have emerged over the years that, despite their substantial differences, all emphasize the importance of hemispheric asymmetries. Transcranial magnetic stimulation (TMS) has proven particularly successful in teasing them apart by selective perturbation of the dorsal and ventral fronto-parietal network. We here critically review the TMS literature and show that hemispheric asymmetries within the dorsal attention network differ between parietal and frontal cortex. Specifically, posterior parietal cortex seems to be characterized by a contralateral bias of each hemisphere and competition between them. In contrast, the right frontal eye field seems to be involved in shifting attention toward both hemifields, whereas left frontal eye field is only involved on shifting attention toward the contralateral hemifield. In the light of presented evidence, we propose to revise the functional-anatomical model originally proposed by Corbetta and Shulman (2011, 2002) and introduce a hybrid model of hemispheric asymmetries in attentional control.

Relationship between visuospatial neglect and kinesthetic deficits after stroke

BACKGROUND

After stroke, visuospatial and kinesthetic (sense of limb motion) deficits are common, occurring in approximately 30% and 60% of individuals, respectively. Although both types of deficits affect aspects of spatial processing necessary for daily function, few studies have investigated the relationship between these 2 deficits after stroke.

OBJECTIVE

We aimed to characterize the relationship between visuospatial and kinesthetic deficits after stroke using the Behavioral Inattention Test (BIT) and a robotic measure of kinesthetic function.

METHODS

Visuospatial attention (using the BIT) and kinesthesia (using robotics) were measured in 158 individuals an average of 18 days after stroke. In the kinesthetic matching task, the robot moved the participant's stroke-affected arm at a preset direction, speed, and magnitude. Participants mirror-matched the robotic movement with the less/unaffected arm as soon as they felt movement in their stroke affected arm.

RESULTS

We found that participants with visuospatial inattention (neglect) had impaired kinesthesia 100% of the time, whereas only 59% of participants without neglect were impaired. For those without neglect, we observed that a higher percentage of participants with lower but passing BIT scores displayed impaired kinesthetic behavior (78%) compared with those participants who scored perfect or nearly perfect on the BIT (49%).

CONCLUSIONS

The presence of visuospatial neglect after stroke is highly predictive of the presence of kinesthetic deficits. However, the presence of kinesthetic deficits does not necessarily always indicate the presence of visuospatial neglect. Our findings highlight the importance of assessment and treatment of kinesthetic deficits after stroke, especially in patients with visuospatial neglect.

Gaze direction affects visuo-spatial short-term memory

Hemispheric asymmetries were investigated by changing the horizontal position of stimuli that had to be remembered in a visuo-spatial short-term memory task. Observers looked at matrices containing a variable number of filled squares on the left or right side of the screen center. At stimulus offset, participants reproduced the positions of the filled squares in an empty response matrix. Stimulus and response matrices were presented in the same quadrant. We observed that memory performance was better when the matrices were shown on the left side of the screen. We distinguished between recall strategies that relied on visual or non-visual (verbal) cues and found that the effect of gaze position occurred more reliably in participants using visual recall strategies. Overall, the results show that there is a solid enhancement of visuo-spatial short-term memory when observers look to the left. In contrast, vertical position had no influence on performance. We suggest that unilateral gaze to the left activates centers in the right hemisphere contributing to visuo-spatial memory.

Look where you're going! Perceptual attention constrains the online guidance of action

Action guidance, like perceptual discrimination, requires selective attention. Perception is enhanced at the target of a reaching movement, but it is not known whether selecting an object for perception reciprocally prioritises it for action. Two theoretical frameworks, the premotor theory and the Visual Attention Model, predict that this reciprocal relation should hold. We tested the influence of perceptual attention on the online control of reaching. In Experiment 1, participants attended covertly to a flanker on one or other side of a fixated target, prior to reaching for that target, which occasionally jumped, after reach onset, to the attended or non-attended side. Participants corrected their reaches for almost all target jumps. In Experiment 2, we required covert monitoring of the flanker during reaching. This concurrent perceptual task globally reduced correction behaviour, indicating that perception and action share a common attentional resource. Corrections were especially unlikely toward the attended side. This is explained by assuming that perceptual attention primed an action toward the attended location and that the participant inhibited this primed action. The data thus imply that perceptual selection constrains online action guidance, as predicted by the premotor theory and the VAM. We further argue that the fact that participants can inhibit a location within the action system but simultaneously maintain its prioritisation for perceptual monitoring, is easier to reconcile with the VAM than with the premotor theory.

Benefits of occupational therapy in stroke rehabilitation

Stroke is the largest single cause of severe physical disability and rehabilitation to reduce functional deficits is the most effective treatment. Occupational therapists play a central role in rehabilitation as members of a multidisciplinary team. Occupational therapy is a client-centered profession that uses meaningful activities across the spectrum of physical and mental domains to reduce limitations after stroke. Where remediation is not possible, occupational therapists implement compensatory strategies to promote independence. Rehabilitation is based on the concept of brain plasticity, which implies that it is possible to modulate or facilitate cerebral reorganization by external inputs. Occupational therapy activities are specifically geared to promote this re-education process and encourage the development of lost skills while accommodating for specific physical, cognitive or affective impairments. Principles of motor, sensory, cognitive and affective rehabilitation are incorporated into effective task-specific activities and environments are adapted to create the optimum conditions for successful rehabilitation. Several promising new rehabilitation approaches, based on neuropsychology and technological advances, have been developed to complement therapy inputs and exploit the brain's capacity to recover from stroke.

Prism adaptation in the healthy brain: the shift in line bisection judgments is long lasting and fluctuates

Rightward prism adaptation has been shown to ameliorate visuospatial biases in right brain-damaged patients with neglect, and a single session of prism adaptation can lead to improvements that last up to several hours. Leftward prism adaptation in neurologically healthy individuals induces neglect-like biases in visuospatial tasks. The duration of these effects in healthy individuals, typically assumed to be ephemeral, has never been investigated. Here we assessed the time-course of the adaptation-induced modifications in a classical perceptual line bisection task that was repeatedly administered for approximately 40min after a single session of adaptation to either a leftward or rightward prismatic deviation. Consistent with previous reports, only adaptation to leftward-deviating prisms induced a visuospatial shift on perceptual line bisection judgments. The typical pattern of pseudoneglect was counteracted by a rightward shift in midline judgments, which became significant between 5 and 10 min after adaptation, fluctuated between being significant or not several times in the 40 min following adaptation, and was present as late as 35 min. In contrast, the sensorimotor aftereffect was present immediately after adaptation to both rightward and leftward deviating prisms, decayed initially then remained stable until 40 min. These results demonstrate that both the sensorimotor and visuospatial effects last for at least 35 min, but that the visuospatial shift needs time to fully develop and fluctuates. By showing that the effects of prism adaptation in the undamaged brain are not ephemeral, these findings reveal the presence of another, so-far neglected dimension in the domain of the cognitive effects induced by prism adaptation, namely time. The prolonged duration of the induced visuospatial shift, previously considered to be a feature of prism adaptation unique to brain-damaged subjects, also applies to the normal brain.

Tonal cues modulate line bisection performance: preliminary evidence for a new rehabilitation prospect?

The effect of the presentation of two different auditory pitches (high and low) on manual line-bisection performance was studied to investigate the relationship between space and magnitude representations underlying motor acts. Participants were asked to mark the midpoint of a given line with a pen while they were listening a pitch via headphones. In healthy participants, the effect of the presentation order (blocked or alternative way) of auditory stimuli was tested (Experiment 1). The results showed no biasing effect of pitch in blocked-order presentation, whereas the alternative presentation modulated the line-bisection. Lower pitch produced leftward or downward bisection biases whereas higher pitch produced rightward or upward biases, suggesting that visuomotor processing can be spatially modulated by irrelevant auditory cues. In Experiment 2, the effect of such alternative stimulations in line bisection in right brain damaged patients with a unilateral neglect and without a neglect was tested. Similar biasing effects caused by auditory cues were observed although the white noise presentation also affected the patient's performance. Additionally, the effect of pitch difference was larger for the neglect patient than for the no-neglect patient as well as for healthy participants. The neglect patient's bisection performance gradually improved during the experiment and was maintained even after 1 week. It is therefore, concluded that auditory cues, characterized by both the pitch difference and the dynamic alternation, influence spatial representations. The larger biasing effect seen in the neglect patient compared to the no-neglect patient and healthy participants suggests that auditory cues could modulate the direction of the attentional bias that is characteristic of neglect patients. Thus, the alternative presentation of auditory cues could be used as rehabilitation for neglect patients. The space-pitch associations are discussed in terms of a generalized magnitude system.

Disturbed resting functional inter-hemispherical connectivity of the ventral attentional network in alpha band is associated with unilateral spatial neglect

Unilateral spatial neglect (USN) is one of the most common symptoms of right hemisphere damage; its classical symptom is that patients fail to respond to information on their left side. It has been postulated that disturbance of 2 separate attentional networks relates to the occurrence of USN. However, little is known about the underlying mechanism and neuronal substrates. In this study, we measured spontaneous neural activity by means of magnetoencephalography in 13 patients with brain damage and 5 control subjects. To study the relationship between functional connectivity at rest and severity of USN symptoms, we determined the imaginary coherence values relating to the inter-hemispherical ventral and dorsal attentional networks, as well as the clinical severity of USN using neuropsychological tests and behavioral rating scales. The present results showed that inter-hemispherical connectivity in the ventral attentional network, especially between the left and right angular gyri, detected in the alpha band is associated with the severity of USN symptoms. This may suggest that connectivity of inter-hemispherical homologous regions of the ventral attentional network in the alpha band could be one of the biomarkers of attentional network imbalance occurring in patients with USN.

Visual search in spatial neglect studied with a preview paradigm

Impaired visual search is a hallmark of spatial neglect. When searching for an unique feature (e.g., color) neglect patients often show only slight visual field asymmetries. In contrast, when the target is defined by a combination of features (e.g., color and form) they exhibit a severe deficit of contralesional search. This finding suggests a selective impairment of the serial deployment of spatial attention. Here, we examined this deficit with a preview paradigm. Neglect patients searched for a target defined by the conjunction of shape and color, presented together with varying numbers of distracters. The presentation time was varied such that on some trials participants previewed the target together with same-shape/different-color distracters, for 300 or 600 ms prior to the appearance of additional different-shape/same-color distracters. On the remaining trials the target and all distracters were shown simultaneously. Healthy participants exhibited a serial search strategy only when all items were presented simultaneously, whereas in both preview conditions a pop-out effect was observed. Neglect patients showed a similar pattern when the target was presented in the right hemifield. In contrast, when searching for a target in the left hemifield they showed serial search in the no-preview condition, as well as with a preview of 300 ms, and partly even at 600 ms. A control experiment suggested that the failure to fully benefit from item preview was probably independent of accurate perception of time. Our results, when viewed in the context of existing literature, lead us to conclude that the visual search deficit in neglect reflects two additive factors: a biased representation of attentional priority in favor of ipsilesional information and exaggerated capture of attention by ipsilesional abrupt onsets.

Neglect: a multisensory deficit?

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

Seeing your error alters my pointing: observing systematic pointing errors induces sensori-motor after-effects

During the procedure of prism adaptation, subjects execute pointing movements to visual targets under a lateral optical displacement: As consequence of the discrepancy between visual and proprioceptive inputs, their visuo-motor activity is characterized by pointing errors. The perception of such final errors triggers error-correction processes that eventually result into sensori-motor compensation, opposite to the prismatic displacement (i.e., after-effects). Here we tested whether the mere observation of erroneous pointing movements, similar to those executed during prism adaptation, is sufficient to produce adaptation-like after-effects. Neurotypical participants observed, from a first-person perspective, the examiner's arm making incorrect pointing movements that systematically overshot visual targets location to the right, thus simulating a rightward optical deviation. Three classical after-effect measures (proprioceptive, visual and visual-proprioceptive shift) were recorded before and after first-person's perspective observation of pointing errors. Results showed that mere visual exposure to an arm that systematically points on the right-side of a target (i.e., without error correction) produces a leftward after-effect, which mostly affects the observer's proprioceptive estimation of her body midline. In addition, being exposed to such a constant visual error induced in the observer the illusion “to feel” the seen movement. These findings indicate that it is possible to elicit sensori-motor after-effects by mere observation of movement errors.

The frontoparietal attention network of the human brain: action, saliency, and a priority map of the environment

The dorsal convexity of the human frontal and parietal lobes forms a network that is crucially involved in the selection of sensory contents by attention. This network comprehends cortex along the intraparietal sulcus, the inferior parietal lobe, and dorsal premotor cortex, including the frontal eye field. These regions are richly interconnected with recurrent fibers passing through the superior longitudinal fasciculus. The posterior parietal cortex has several functional characteristics-such as feature-independent coding, enhancement of activity by attention, representation of task-related signals, and access to multiple reference frames-that point to a central role of this region in the computation of a feature- and modality-independent priority map of the environment. The priority map integrates feature information elaborated in sensory cortex and top-down representations of behavioral goals and expectations originating in the dorsolateral prefrontal and premotor cortex. This review presents converging evidence from single-unit studies of the primate brain, functional neuroimaging, and investigations of neuropsychological disorders such as Bálint syndrome and spatial neglect for a decisive role of the frontoparietal attention network in the selection of relevant environmental information.

A virtual reality test battery for assessment and screening of spatial neglect

BACKGROUND

There is a need for improved screening methods for spatial neglect.

AIM

To construct a VR-test battery and evaluate its accuracy and usability in patients with acute stroke.

METHOD

VR-DiSTRO consists of a standard desktop computer, a CRT monitor and eye shutter stereoscopic glasses, a force feedback interface, and software, developed to create an interactive and immersive 3D experience. VR-tests were developed and validated to the conventional Star Cancellation test, Line bisection, Baking Tray Task (BTT), and Visual Extinction test. A construct validation to The Rivermead Behavioral Inattention Test, used as criterion of visuospatial neglect, was made. Usability was assessed according to ISO 9241-11.

RESULTS

Thirty-one patients with stroke were included, 9/31 patients had neglect. The sensitivity was 100% and the specificity 82% for the VR-DiSTRO to correctly identify neglect. VR-BTT and VR-Extinction had the highest correlation (r² = 0.64 and 0.78), as well as high sensitivity and specificity. The kappa values describing the agreement between traditional neglect tests and the corresponding virtual reality test were between 0.47-0.85. Usability was assessed by a questionnaire; 77% reported that the VR-DiSTRO was 'easy' to use. Eighty-eight percent reported that they felt 'focused', 'pleased' or 'alert'. No patient had adverse symptoms. The test session took 15 min.

CONCLUSIONS

The VR-DiSTRO quickly and with a high accuracy identified visuospatial neglect in patients with stroke in this construct validation. The usability among elderly patients with stroke was high. This VR-test battery has the potential to become an important screening instrument for neglect and a valuable adjunct to the neuropsychological assessment.

Proprioceptive pathways to posterior parietal areas MIP and LIPv from the dorsal column nuclei and the postcentral somatosensory cortex

The posterior parietal cortex (PPC) serves as an interface between sensory and motor cortices by integrating multisensory signals with motor-related information. Sensorimotor transformation of somatosensory signals is crucial for the generation and updating of body representations and movement plans. Using retrograde transneuronal transfer of rabies virus in combination with a conventional tracer, we identified direct and polysynaptic somatosensory pathways to two posterior parietal areas, the ventral lateral intraparietal area (LIPv) and the rostral part of the medial intraparietal area (MIP) in macaque monkeys. In addition to direct projections from somatosensory areas 2v and 3a, respectively, we found that LIPv and MIP receive disynaptic inputs from the dorsal column nuclei as directly as these somatosensory areas, via a parallel channel. LIPv is the target of minor neck muscle-related projections from the cuneate (Cu) and the external cuneate nuclei (ECu), and direct projections from area 2v, that likely carry kinesthetic/vestibular/optokinetic-related signals. In contrast, MIP receives major arm and shoulder proprioceptive inputs disynaptically from the rostral Cu and ECu, and trisynaptically (via area 3a) from caudal portions of these nuclei. These findings have important implications for the understanding of the influence of proprioceptive information on movement control operations of the PPC and the formation of body representations. They also contribute to explain the specific deficits of proprioceptive guidance of movement associated to optic ataxia.

Cerebellar inputs to intraparietal cortex areas LIP and MIP: functional frameworks for adaptive control of eye movements, reaching, and arm/eye/head movement coordination

Using retrograde transneuronal transfer of rabies virus in combination with a conventional tracer (cholera toxin B), we studied simultaneously direct (thalamocortical) and polysynaptic inputs to the ventral lateral intraparietal area (LIPv) and the medial intraparietal area (MIP) in nonhuman primates. We found that these areas receive major disynaptic inputs from specific portions of the cerebellar nuclei, the ventral dentate (D), and ventrolateral interpositus posterior (IP). Area LIPv receives inputs from oculomotor domains of the caudal D and IP. Area MIP is the target of projections from the ventral D (mainly middle third), and gaze- and arm-related domains of IP involved in reaching and arm/eye/head coordination. We also showed that cerebellar cortical "output channels" to MIP predominantly stem from posterior cerebellar areas (paramedian lobe/Crus II posterior, dorsal paraflocculus) that have the required connectivity for adaptive control of visual and proprioceptive guidance of reaching, arm/eye/head coordination, and prism adaptation. These findings provide important insight about the interplay between the posterior parietal cortex and the cerebellum regarding visuospatial adaptation mechanisms and visual and proprioceptive guidance of movement. They also have potential implications for clinical approaches to optic ataxia and neglect rehabilitation.

Integration of goal- and stimulus-related visual signals revealed by damage to human parietal cortex

Where we look is determined both by our current intentions and by the tendency of visually salient items to "catch our eye." After damage to parietal cortex, the normal process of directing attention is often profoundly impaired. Here, we tracked parietal patients' eye movements during visual search to separately map impairments in goal-directed orienting to targets versus stimulus-driven gaze shifts to salient but task-irrelevant probes. Deficits in these two distinct types of attentional selection are shown to be identical in both magnitude and spatial distribution, consistent with damage to a "priority map" that integrates goal- and stimulus-related signals to select visual targets. When goal-relevant and visually salient items compete for attention, the outcome depends on a biased competition in which the priority of contralesional targets is undervalued. On the basis of these findings, we further demonstrate that parietal patients' spatial bias (neglect) in goal-directed visual exploration can be corrected and even reversed by systematically manipulating the spatial distribution of stimulus salience in the visual array.

Effect of prism adaptation on left dichotic listening deficit in neglect patients: glasses to hear better?

Unilateral neglect is a disabling syndrome frequently observed following right hemisphere brain damage. Symptoms range from visuo-motor impairments through to deficient visuo-spatial imagery, but impairment can also affect the auditory modality. A short period of adaptation to a rightward prismatic shift of the visual field is known to improve a wide range of hemispatial neglect symptoms, including visuo-manual tasks, mental imagery, postural imbalance, visuo-verbal measures and number bisection. The aim of the present study was to assess whether the beneficial effects of prism adaptation may generalize to auditory manifestations of neglect. Auditory extinction, whose clinical manifestations are independent of the sensory modalities engaged in visuo-manual adaptation, was examined in neglect patients before and after prism adaptation. Two separate groups of neglect patients (all of whom exhibited left auditory extinction) underwent prism adaptation: one group (n = 6) received a classical prism treatment ('Prism' group), the other group (n = 6) was submitted to the same procedure, but wore neutral glasses creating no optical shift (placebo 'Control' group). Auditory extinction was assessed by means of a dichotic listening task performed three times: prior to prism exposure (pre-test), upon prism removal (0 h post-test) and 2 h later (2 h post-test). The total number of correct responses, the lateralization index (detection asymmetry between the two ears) and the number of left-right fusion errors were analysed. Our results demonstrate that prism adaptation can improve left auditory extinction, thus revealing transfer of benefit to a sensory modality that is orthogonal to the visual, proprioceptive and motor modalities directly implicated in the visuo-motor adaptive process. The observed benefit was specific to the detection asymmetry between the two ears and did not affect the total number of responses. This indicates a specific effect of prism adaptation on lateralized processes rather than on general arousal. Our results suggest that the effects of prism adaptation can extend to unexposed sensory systems. The bottom-up approach of visuo-motor adaptation appears to interact with higher order brain functions related to multisensory integration and can have beneficial effects on sensory processing in different modalities. These findings should stimulate the development of therapeutic approaches aimed at bypassing the affected sensory processing modality by adapting other sensory modalities.