Re-fixation and perseveration patterns in neglect patients during free visual exploration

Comparison of uni- and multimodal motion stimulation on visual neglect: A proof-of-concept study

Spatial neglect is characterized by the failure to attend stimuli presented in the contralesional space. Typically, the visual modality is more severely impaired than the auditory one. This dissociation offers the possibility of cross-modal interactions, whereby auditory stimuli may have beneficial effects on the visual modality. A new auditory motion stimulation method with music dynamically moving from the right to the left hemispace has recently been shown to improve visual neglect. The aim of the present study was twofold: a) to compare the effects of unimodal auditory against visual motion stimulation, i.e., smooth pursuit training, which is an established therapeutical approach in neglect therapy and b) to explore whether a combination of auditory + visual motion stimulation, i.e., multimodal motion stimulation, would be more effective than unimodal auditory or visual motion stimulation. 28 patients with left-sided neglect due to a first-ever, right-hemispheric subacute stroke were included. Patients either received auditory, visual, or multimodal motion stimulation. The between-group effect of each motion stimulation condition as well as a control group without motion stimulation was investigated by means of a one-way ANOVA with the patient's visual exploration behaviour as an outcome variable. Our results showed that unimodal auditory motion stimulation is equally effective as unimodal visual motion stimulation: both interventions significantly improved neglect compared to the control group. Multimodal motion stimulation also significantly improved neglect, however, did not show greater improvement than unimodal auditory or visual motion stimulation alone. Besides the established visual motion stimulation, this proof-of-concept study suggests that auditory motion stimulation seems to be an alternative promising therapeutic approach to improve visual attention in neglect patients. Multimodal motion stimulation does not lead to any additional therapeutic gain. In neurorehabilitation, the implementation of either auditory or visual motion stimulation seems therefore reasonable.

Immersive virtual reality gameplay detects visuospatial atypicality, including unilateral spatial neglect, following brain injury: a pilot study

BACKGROUND

In neurorehabilitation, problems with visuospatial attention, including unilateral spatial neglect, are prevalent and routinely assessed by pen-and-paper tests, which are limited in accuracy and sensitivity. Immersive virtual reality (VR), which motivates a much wider (more intuitive) spatial behaviour, promises new futures for identifying visuospatial atypicality in multiple measures, which reflects cognitive and motor diversity across individuals with brain injuries.

METHODS

In this pilot study, we had 9 clinician controls (mean age 43 years; 4 males) and 13 neurorehabilitation inpatients (mean age 59 years; 9 males) recruited a mean of 41 days post-injury play a VR visual search game. Primary injuries included 7 stroke, 4 traumatic brain injury, 2 other acquired brain injury. Three patients were identified as having left sided neglect prior to taking part in the VR. Response accuracy, reaction time, and headset and controller raycast orientation quantified gameplay. Normative modelling identified the typical gameplay bounds, and visuospatial atypicality was defined as gameplay beyond these bounds.

RESULTS

The study found VR to be feasible, with only minor instances of motion sickness, positive user experiences, and satisfactory system usability. Crucially, the analytical method, which emphasized identifying 'visuospatial atypicality,' proved effective. Visuospatial atypicality was more commonly observed in patients compared to controls and was prevalent in both groups of patients-those with and without neglect.

CONCLUSION

Our research indicates that normative modelling of VR gameplay is a promising tool for identifying visuospatial atypicality after acute brain injury. This approach holds potential for a detailed examination of neglect.

Increased scene complexity during free visual exploration reveals residual unilateral neglect in recovered stroke patients

Unilateral neglect is a common cognitive syndrome after stroke, which is defined as a spatially specific unawareness of the contralesional space. The syndrome is caused by disruptions of attentional networks in the brain, which impair the patients' ability to direct attention towards the contralesional space. During recovery, patients often learn to compensate by voluntarily directing their attention to the neglected side at the expense of cognitive resources. In this study, we examined the impact of the complexity of visual input on free visual exploration behavior of unilateral neglect and apparently recovered patients. We asked whether increasing scene complexity would allow the detection of residual unilateral neglect in recovered patients by increasing the amount of cognitive resources needed for visual processing and limiting capacities for compensation. Using virtual reality, we analyzed the spatial distribution of gaze of unilateral neglect patients, patients who had, according to conventional diagnostics, recovered from the syndrome, stroke patients with no history of unilateral neglect, and age-matched healthy controls. We manipulated the complexity of an immersive virtual scene presented on head mounted displays. We identified the orientation bias towards the ipsilesional side as a sensitive and specific marker of unilateral neglect, which was present in unilateral neglect and recovered patients but absent in stroke patients with no history of unilateral neglect and controls. Increasing scene complexity exacerbated the orientation shift in unilateral neglect patients and revealed that three out of nine (33%) recovered patients had a high probability of suffering from residual unilateral neglect as estimated by a generalized linear model using the median horizontal gaze position as a predictor.

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

Background

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

Methods

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

Results

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

Conclusions

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

A systematic review of transcranial direct current stimulation on eye movements and associated psychological function

The last decades have seen a rise in the use of transcranial direct current stimulation (tDCS) approaches to modulate brain activity and associated behavior. Concurrently, eye tracking (ET) technology has improved to allow more precise quantitative measurement of gaze behavior, offering a window into the mechanisms of vision and cognition. When combined, tDCS and ET provide a powerful system to probe brain function and measure the impact on visual function, leading to an increasing number of studies that utilize these techniques together. The current pre-registered, systematic review seeks to describe the literature that integrates these approaches with the goal of changing brain activity with tDCS and measuring associated changes in eye movements with ET. The literature search identified 26 articles that combined ET and tDCS in a probe-and-measure model and are systematically reviewed here. All studies implemented controlled interventional designs to address topics related to oculomotor control, cognitive processing, emotion regulation, or cravings in healthy volunteers and patient populations. Across these studies, active stimulation typically led to changes in the number, duration, and timing of fixations compared to control stimulation. Notably, half the studies addressed emotion regulation, each showing hypothesized effects of tDCS on ET metrics, while tDCS targeting the frontal cortex was widely used and also generally produced expected modulation of ET. This review reveals promising evidence of the impact of tDCS on eye movements and associated psychological function, offering a framework for effective designs with recommendations for future studies.

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

In everyday life, information from different cognitive domains - such as visuospatial attention, alertness, and inhibition - needs to be integrated between different brain regions. Early models suggested that completely segregated brain networks control these three cognitive domains. However, more recent accounts, mainly based on neuroimaging data in healthy participants, indicate that different tasks lead to specific patterns of activation within the same, higher-order and "multiple-demand" network. If so, then a lesion to critical substrates of this common network should determine a concomitant impairment in all three cognitive domains. The aim of the present study was to critically investigate this hypothesis, i.e., to identify focal stroke lesions within the network that can concomitantly impact visuospatial attention, alertness and inhibition. We studied an unselected sample of 60 first-ever right-hemispheric, subacute stroke patients using a data-driven, bottom-up approach. Patients performed 12 standardized neuropsychological and oculomotor tests, four per cognitive domain. Principal component analyses revealed a strong relationship between all three cognitive domains: 10 of 12 tests loaded on a first, Common Component. Analysis of the neuroanatomical lesion correlates using different approaches (i.e., Voxel-Based and Tractwise Lesion-Symptom Mapping, Disconnectome maps) provided convergent evidence on the association between severe impairment of this Common Component and lesions at the intersection of Superior Longitudinal Fasciculus II and III, Frontal Aslant Tract and, to a lesser extent, the Putamen and Inferior Fronto-Occipital Fasciculus. Moreover, patients with a lesion involving this region were significantly more impaired in daily living cognition, which provides an ecological validation of our results. A probabilistic functional atlas of the multiple-demand network was performed to confirm the potential relationship between patients' lesion substrates and observed cognitive impairments as a function of the MD-network connectivity disruption. These findings show, for the first time, that a lesion to a specific white matter crossroad can determine a concurrent breakdown in all three considered cognitive domains. Our results support the multiple-demand network model, proposing that different cognitive operations depend on specific collaborators and their interaction, within the same underlying neural network. Our findings also extend this hypothesis by showing (1) the contribution of SLF and FAT to the multiple-demand network, and (2) a critical neuroanatomical intersection, crossed by a vast amount of long-range white matter tracts, many of which interconnect cortical areas of the multiple-demand network. The vulnerability of this crossroad to stroke has specific cognitive and clinical consequences; this has the potential to influence future rehabilitative approaches.

Virtual Reality and Eye-Tracking Assessment, and Treatment of Unilateral Spatial Neglect: Systematic Review and Future Prospects

Unilateral spatial neglect (USN) is a disorder characterized by the failure to report, respond to, or orient toward the contralateral side of space to a brain lesion. Current assessment methods often fail to discover milder forms, cannot differentiate between unilateral spatial neglect subtypes and lack ecological validity. There is also a need for treatment methods that target subtypes. Immersive virtual reality (VR) systems in combination with eye-tracking (ET) have the potential to overcome these shortcomings, by providing more naturalistic environments and tasks, with sensitive and detailed measures. This systematic review examines the state of the art of research on these technologies as applied in the assessment and treatment of USN. As we found no studies that combined immersive VR and ET, we reviewed these approaches individually. The review of VR included seven articles, the ET review twelve. The reviews revealed promising results. (1) All included studies found significant group-level differences for several USN measures. In addition, several studies found asymmetric behavior in VR and ET tasks for patients who did not show signs of USN in conventional tests. Particularly promising features were multitasking in complex VR environments and detailed eye-movement analysis. (2) No VR and only a few ET studies attempted to differentiate USN subtypes, although the technologies appeared appropriate. One ET study grouped USN participants using individual heatmaps, and another differentiated between subtypes on drawing tasks. Regarding (3) ecological validity, although no studies tested the prognostic validity of their assessment methods, VR and ET studies utilized naturalistic tasks and stimuli reflecting everyday situations. Technological characteristics, such as the field of view and refresh rate of the head-mounted displays, could be improved, though, to improve ecological validity. We found (4) no studies that utilized VR or ET technologies for USN treatment up until the search date of the 26th of February 2020. In conclusion, VR-ET-based systems show great potential for USN assessment. VR-ET holds great promise for treatment, for example, by monitoring behavior and adapting and tailoring to the individual person's needs and abilities. Future research should consider developing methods for individual subtypes and differential diagnostics to inform individual treatment programs.

Visual Neglect after PICA Stroke-A Case Study

After cerebellar stroke, cognition can be impaired, as described within the framework of the so-called Cerebellar Cognitive Affective Syndrome (CCAS). However, it remains unclear whether visual neglect can also be part of CCAS. We describe the case of a patient with a subacute cerebellar stroke after thrombosis of the left posterior inferior cerebellar artery (PICA), who showed a left-sided visual neglect, indicating that the cerebellum also has a modulatory function on visual attention. The neglect, however, was mild and only detectable when using the sensitive neuro-psychological Five-Point Test as well as video-oculography assessment, yet remained unnoticed when evaluated with common neglect-specific paper-pencil tests. Three weeks later, follow-up assessments revealed an amelioration of neglect symptoms. Therefore, these findings suggest that visual neglect may be a part of CCAS, but that the choice of neglect assessments and the time delay since stroke onset may be crucial. Although the exact underlying pathophysiological mechanisms remain unclear, we propose cerebellar-cerebral diaschisis as a possible explanation of why neglect can occur on the ipsilateral side. Further research applying sensitive assessment tools at different post-stroke stages is needed to investigate the incidence, lesion correlates, and pathophysiology of neglect after cerebellar lesions.

Conventional and HD-tDCS May (or May Not) Modulate Overt Attentional Orienting: An Integrated Spatio-Temporal Approach and Methodological Reflections

Transcranial Direct Current Stimulation (tDCS) has been employed to modulate visuo-spatial attentional asymmetries, however, further investigation is needed to characterize tDCS-associated variability in more ecological settings. In the present research, we tested the effects of offline, anodal conventional tDCS (Experiment 1) and HD-tDCS (Experiment 2) delivered over the posterior parietal cortex (PPC) and Frontal Eye Field (FEF) of the right hemisphere in healthy participants. Attentional asymmetries were measured by means of an eye tracking-based, ecological paradigm, that is, a Free Visual Exploration task of naturalistic pictures. Data were analyzed from a spatiotemporal perspective. In Experiment 1, a pre-post linear mixed model (LMM) indicated a leftward attentional shift after PPC tDCS; this effect was not confirmed when the individual baseline performance was considered. In Experiment 2, FEF HD-tDCS was shown to induce a significant leftward shift of gaze position, which emerged after 6 s of picture exploration and lasted for 200 ms. The present results do not allow us to conclude on a clear efficacy of offline conventional tDCS and HD-tDCS in modulating overt visuospatial attention in an ecological setting. Nonetheless, our findings highlight a complex relationship among stimulated area, focality of stimulation, spatiotemporal aspects of deployment of attention, and the role of individual baseline performance in shaping the effects of tDCS.

Spatial Neglect Midline Diagnostics From Virtual Reality and Eye Tracking in a Free-Viewing Environment

Purpose: Virtual reality (VR) and eye tracking may provide detailed insights into spatial cognition. We hypothesized that virtual reality and eye tracking may be used to assess sub-types of spatial neglect in stroke patients not readily available from conventional assessments.

Method: Eighteen stroke patients with spatial neglect and 16 age and gender matched healthy subjects wearing VR headsets were asked to look around freely in a symmetric 3D museum scene with three pictures. Asymmetry of performance was analyzed to reveal group-level differences and possible neglect sub-types on an individual level.

Results: Four out of six VR and eye tracking measures revealed significant differences between patients and controls in this free-viewing task. Gaze-asymmetry between-pictures (including fixation time and count) and head orientation were most sensitive to spatial neglect behavior on a group level analysis. Gaze-asymmetry and head orientation each identified 10 out of 18 (56%), compared to 12 out of 18 (67%) for the best conventional test. Two neglect patients without deviant performance on conventional measures were captured by the VR and eyetracking measures. On the individual level, five stroke patients revealed deviant gaze-asymmetry within-pictures and six patients revealed deviant eye orientation in either direction that were not captured by the group-level analysis.

Conclusion: This study is a first step in using VR in combination with eye tracking measures as individual differential neglect subtype diagnostics. This may pave the way for more sensitive and elaborate sub-type diagnostics of spatial neglect that may respond differently to various treatment approaches.

Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study

BACKGROUND

Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity.

OBJECTIVE

This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals.

METHODS

In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures.

RESULTS

In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity.

CONCLUSIONS

The developed iVR serious game, "bird search task," was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task.

Video-Oculography During Free Visual Exploration to Detect Right Spatial Neglect in Left-Hemispheric Stroke Patients With Aphasia: A Feasibility Study

Spatial neglect has been shown to occur in 17–65% of patients after acute left-hemispheric stroke. One reason for this varying incidence values might be that left-hemispheric stroke is often accompanied by aphasia, which raises difficulties in assessing attention deficits with conventional neuropsychological tests entailing verbal instructions. Video-oculography during free visual exploration (FVE) requires only little understanding of simple non-verbal instruction and has been shown to be a sensitive and reliable tool to detect spatial neglect in patients with right-hemispheric stroke. In the present study, we aimed to investigate the feasibility of FVE to detect neglect in 10 left-hemispheric stroke patients with mild to severe aphasia as assessed by means of the Token Test, Boston Naming Test and Aachener Aphasie Test. The patient’s individual deviation between eye movement calibration and validation was recorded and compared to 20 age-matched healthy controls. Furthermore, typical FVE parameters such as the landing point of the first fixation, the mean gaze position (in ° of visual angle), the number and duration of visual fixations and the mean visual exploration area were compared between groups. In addition, to evaluate for neglect, the Bells cancellation test was performed and neglect severity in daily living was measured by means of the Catherine Bergego Scale (CBS). Our results showed that the deviation between calibration and validation did not differ between aphasia patients and healthy controls highlighting its feasibility. Furthermore, FVE revealed the typical neglect pattern with a significant leftward shift in visual exploration bahaviour, which highly correlated with neglect severity as assessed with CBS. The present study provides evidence that FVE has the potential to be used as a neglect screening tool in left-hemispheric stroke patients with aphasia in which compliance with verbal test instructions may be compromised by language deficits.

Test-Retest-Reliability of Video-Oculography During Free Visual Exploration in Right-Hemispheric Stroke Patients With Neglect

The Mean gaze position during free visual exploration (FVE) is a sensitive tool to detect neglect in patients after a right-hemispheric stroke. Here we investigated the test-retest-reliability of mean gaze position during FVE in 23 patients with left-sided neglect after a first-ever sub-acute right-hemispheric stroke. We analyzed the reliability between different test sets administered within 11 days (test sets A and B, each including different images and their mirrored versions), and between repeated measures using the same test set administered three times within 2 days (test set C, including the same images and their mirrored versions). The intra-class correlation coefficient (ICC) showed good reliability between the two different test sets (test sets A and B; ICC = 0.819), and excellent reliability for the repeated measures with the same test set C (ICC = 0.964). FVE can therefore be recommended for the longitudinal assessments of patients’ neglect severity during neurorehabilitation as well as in treatment trials.

Evidence of inverted gravity-driven variation in predictive sensorimotor function

We move our eyes to place the fovea into the part of a viewed scene currently of interest. Recent evidence suggests that each human has signature patterns of eye movements like handwriting which depend on their sensitivity, allocation of attention and experience. Use of implicit knowledge of how earth's gravity influences object motion has been shown to aid dynamic perception. We used a projected ball-tracking task with a plain background offering no context cues to probe the effect of acquired experience about physical laws of gravitation on performance differences of 44 participants under a simulated gravity and an atypical (upward) antigravity condition. Performance measured by the unsigned difference between instantaneous eye and stimulus positions (RMSE) was consistently worse in the antigravity condition. In the vertical RMSE, participants took about 200 ms longer to improve to the best performance for antigravity compared to gravity trials. The antigravity condition produced a divergence of individual performance which was correlated with levels of questionnaire-based quantified traits of schizotypy but not control traits. Grouping participants by high or low traits revealed a negative relationship between schizotypy trait level and both initiation and maintenance of tracking, a result consistent with trait-related impoverished sensory prediction. The findings confirm for the first time that where cues enabling exact estimation of acceleration are unavailable, knowledge of gravity contributes to dynamic prediction improving motion processing. With acceleration expectations violated, we demonstrate that antigravity tracking could act as a multivariate diagnostic window into predictive brain function.

Keeping an eye on visual search patterns in visuospatial neglect: A systematic review

Patients with visuospatial neglect exhibit a failure to detect, respond, or orient towards information located in the side of space opposite to their brain lesion. To extend our understanding of the underlying cognitive processes involved in neglect, some studies have used eye movement measurements to complement behavioural data. We provide a qualitative synthesis of studies that have used eye-tracking in patients with neglect, with a focus on highlighting the utility of examining eye movements and reporting what eye-tracking has revealed about visual search patterns in these patients. This systematic review includes twenty studies that met the eligibility criteria. We extracted information pertaining to patient characteristics (e.g., age, type of stroke, time since stroke), neglect test(s) used, type of stimuli (e.g., static, dynamic), eye-tracker specifications (e.g., temporal and spatial resolution), and eye movement measurements (e.g., saccade amplitude, fixation duration). Five key themes were identified. First, eye-tracking is a useful tool to complement pen-and-paper neglect tests. Second, the lateral asymmetrical bias in eye movement patterns observed during active exploration also occurred while at rest. Third, the lateral asymmetrical bias was evident not only in the horizontal plane but also in the vertical plane. Fourth, eye movement patterns were modulated by stimulus- and task-related factors (e.g., visual salience, local perceptual features, image content, stimulus duration, presence of distractors). Fifth, measuring eye movements in patients with neglect is useful for determining and understanding other cognitive impairments, such as spatial working memory. To develop a fuller, and a more accurate, picture of neglect, future research would benefit from eye movement measurements.

Visual Exploration Area in Neglect: A New Analysis Method for Video-Oculography Data Based on Foveal Vision

Video-oculography during free visual exploration (FVE) is a valuable tool to evaluate visual attention spatial allocation in neglect patients after right-hemispheric stroke. In conventional FVE analyses, the position of a visual fixation is conceived as a single point in space. Here, we describe a new complementary method to analyze FVE data based on foveal vision, leading to an accurate estimate of the portion of the picture that was effectively explored. In 15 neglect patients and 20 healthy controls, visual exploration areas (i.e., considering 1° visual angle around every single fixation) were computed. Furthermore, the proportion of single and overlapping fixations was analyzed. Overlapping fixations were further categorized into capture fixations (successive overlapping fixation, putatively reflecting problem of disengagement) and re-capture fixations (temporally distant overlapping fixations, putatively reflecting spatial working memory deficits). The results of this new analysis approach were compared to the ones of conventional approaches. Conventional analyses showed the typical visual attention deficits in neglect patients versus healthy controls: significantly less fixations and time spent within the left and significantly more fixations and time spent within the right screen half. According to the results of our new approach, patients showed a significantly smaller visual exploration area within the left screen half. However, the right visual exploration area did not differ between groups. Furthermore, in neglect patients, the proportion of overlapping fixations within the right screen half was significantly higher than within the left screen half, as well as significantly higher than in healthy controls within either screen halves. Whereas neglect patients showed significantly more capture fixations than healthy controls, the number of re-capture fixations did not differ between groups. These results suggest that, in neglect patients, the efficiency of visual exploration is also reduced within the right screen half and that impaired disengagement might be an important mechanism leading to overlapping fixations. Our new analysis of the visual exploration area, based on foveal vision, may be a promising additional approach in visual attention research. It allows to accurately measure the portion of the picture that was effectively explored, disentangle single from overlapping fixations, and distinguish between capture and re-capture fixations.

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

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