Severity-Dependent Interhemispheric White Matter Connectivity Predicts Poststroke Neglect Recovery

Left-sided spatial neglect is a very common and challenging issue after right-hemispheric stroke, which strongly and negatively affects daily living behavior and recovery of stroke survivors. The mechanisms underlying recovery of spatial neglect remain controversial, particularly regarding the involvement of the intact, contralesional hemisphere, with potential contributions ranging from maladaptive to compensatory. In the present prospective, observational study, we assessed neglect severity in 54 right-hemispheric stroke patients (32 male; 22 female) at admission to and discharge from inpatient neurorehabilitation. We demonstrate that the interaction of initial neglect severity and spared white matter (dis)connectivity resulting from individual lesions (as assessed by diffusion tensor imaging, DTI) explains a significant portion of the variability of poststroke neglect recovery. In mildly impaired patients, spared structural connectivity within the lesioned hemisphere is sufficient to attain good recovery. Conversely, in patients with severe impairment, successful recovery critically depends on structural connectivity within the intact hemisphere and between hemispheres. These distinct patterns, mediated by their respective white matter connections, may help to reconcile the dichotomous perspectives regarding the role of the contralesional hemisphere as exclusively compensatory or not. Instead, they suggest a unified viewpoint wherein the contralesional hemisphere can - but must not necessarily - assume a compensatory role. This would depend on initial impairment severity and on the available, spared structural connectivity. In the future, our findings could serve as a prognostic biomarker for neglect recovery and guide patient-tailored therapeutic approaches.

Coherent activity within and between hemispheres: cortico-cortical connectivity revealed by rTMS of the right posterior parietal cortex

Introduction

Low frequency (1 Hz) repetitive transcranial stimulation (rTMS) applied over right posterior parietal cortex (rPPC) has been shown to reduce cortical excitability both of the stimulated area and of the interconnected contralateral homologous areas. In the present study, we investigated the whole pattern of intra- and inter-hemispheric cortico-cortical connectivity changes induced by rTMS over rPPC.

Methods

To do so, 14 healthy participants underwent resting state EEG recording before and after 30 min of rTMS at 1 Hz or sham stimulation over the rPPC (electrode position P6). Real stimulation was applied at 90% of motor threshold. Coherence values were computed on the electrodes nearby the stimulated site (i.e., P4, P8, and CP6) considering all possible inter- and intra-hemispheric combinations for the following frequency bands: delta (0.5-4 Hz), theta (4-8 Hz), alpha (8-12Hz), low beta (12-20 Hz), high beta (20-30 Hz), and gamma (30-50 Hz).

Results and discussion

Results revealed a significant increase in coherence in delta, theta, alpha and beta frequency bands between rPPC and the contralateral homologous sites. Moreover, an increase in coherence in theta, alpha, beta and gamma frequency bands was found between rPPC and right frontal sites, reflecting the activation of the fronto-parietal network within the right hemisphere. Summarizing, subthreshold rTMS over rPPC revealed cortico-cortical inter- and intra-hemispheric connectivity as measured by the increase in coherence among these areas. Moreover, the present results further confirm previous evidence indicating that the increase of coherence values is related to intra- and inter-hemispheric inhibitory effects of rTMS. These results can have implications for devising evidence-based rehabilitation protocols after stroke.

The enigma and implications of brain hemispheric asymmetry in neurodegenerative diseases

The lateralization of the human brain may provide clues into the pathogenesis and progression of neurodegenerative diseases. Though differing in their presentation and underlying pathologies, neurodegenerative diseases are all devastating and share an intriguing theme of asymmetrical pathology and clinical symptoms. Parkinson’s disease, with its distinctive onset of motor symptoms on one side of the body, stands out in this regard, but a review of the literature reveals asymmetries in several other neurodegenerative diseases. Here, we review the lateralization of the structure and function of the healthy human brain and the common genetic and epigenetic patterns contributing to the development of asymmetry in health and disease. We specifically examine the role of asymmetry in Parkinson’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis, and multiple sclerosis, and interrogate whether these imbalances may reveal meaningful clues about the origins of these diseases. We also propose several hypotheses for how lateralization may contribute to the distinctive and enigmatic features of asymmetry in neurodegenerative diseases, suggesting a role for asymmetry in the choroid plexus, neurochemistry, protein distribution, brain connectivity and the vagus nerve. Finally, we suggest how future studies may reveal novel insights into these diseases through the lens of asymmetry.

Transcranial electric stimulation optimizes the balance of visual attention across space

OBJECTIVE

Transcranial direct current stimulation (tDCS) provides a way to modulate spatial attention by enhancing the ratio of neural activity between the left and right hemispheres, with a potential benefit for the rehabilitation of visual neglect.

METHODS

We tested the effect of bilateral tDCS in healthy individuals performing a visual detection task. This protocol consists in the positioning of the anode and cathode on mirror positions over the left and right parietal areas. The stimulation was repeated over three days to maximize the chance to observe a bias to the hemispace controlateral to the anode.

RESULTS

Compared to a sham treatment, left anodal - right cathodal stimulation enhanced attention across the full range of space, since the first day with no build-up effect on the next days, and modified the balance of left-right omissions when stimuli appeared at the same time.

CONCLUSION

Bilateral tDCS improved detection in both visual fields, with no privileged processing of one side, except when concurrent stimuli were presented. The results provide partial support to the hemispheric rivalry hypothesis.

SIGNIFICANCE

The technique has the potential to boost attention in neglect patients but should be used as an adjuvant rather than as an alternative to functional rehabilitation.

Sensorimotor lateralization scaffolds cognitive specialization

In this chapter, we review hemispheric differences for sensorimotor function and cognitive abilities. Specifically, we examine the left-hemisphere specialization for visuomotor control and its interplay with language, executive function, and musical training. Similarly, we discuss right-hemisphere lateralization for haptic processing and its relationship to spatial and numerical processing. We propose that cerebral lateralization for sensorimotor functions served as a foundation for the development of higher cognitive abilities and their hemispheric functional specialization. We further suggest that sensorimotor and cognitive functions are inextricably linked. Based on the studies discussed in this chapter our view is that sensorimotor control serves as a loom upon which the fibers of language, executive function, spatial, and numerical processing are woven together to create the fabric of cognition.

What Do Spatial Distortions in Patients' Drawing After Right Brain Damage Teach Us About Space Representation in Art?

The right cerebral hemisphere plays a crucial rule in spatial cognition, spanning from perception of elementary features, such as location, color, line orientation or shape to representation of different spaces (3D space, allocentric, egocentric, face, personal, peri-personal, or imaginal). One important aspect of its contribution concerns the perception of space symmetry and the representation of objects and scenes, with reference to the midline or body axis. This representation results from a balance between spatial attention processes depending from the two hemispheres. Healthy participants tend to show a discrete deviation of the midline plane representation toward the left side, that is likely to result from the predominance of the activity of the right cerebral hemisphere, mainly oriented toward the contralateral side of space. The visuospatial abilities of the right hemisphere, especially for the representation of the midline plane are crucially engaged in painting and drawing processes in artists. Interestingly, the distortions created by painters of the Cubism period, characterized by an asymmetry of objects and body representations, a specific enlargement or reduction of parts of space, or even by complex distortions of 3D space are analogous to those classically reported in right-brain-damaged patients (unilateral spatial neglect, hyperschematia, constructional apraxia). Understanding the pathological mechanisms of these representation disorders provides meaningful information to apprehend visual artist creations and esthetic perception of space.

Adaptation to Leftward Shifting Prisms Alters Motor Interhemispheric Inhibition

Adaptation to rightward shifting prisms (rightward prism adaptation, RPA) ameliorates neglect symptoms in patients while adaptation to leftward shifting prisms (leftward prism adaptation, LPA) induces neglect-like behaviors in healthy subjects. It has been hypothesized that prism adaptation (PA) modulates interhemispheric balance between the parietal cortices by inhibiting the posterior parietal cortex (PPC) contralateral to the prismatic deviation, but PA's effects on interhemispheric inhibition (IHI) have not been directly investigated. Since there are hyper-excitable connections between the PPC and primary motor cortex (M1) in the left hemisphere of neglect patients, we reasoned that LPA might mimic right hemisphere lesions by reducing parietal IHI, hyper-exciting the left PPC and PPC-M1 connections, and in turn altering IHI at the motor level. Namely, we hypothesized that LPA would increase IHI from the left to the right M1. We examined changes in left-to-right and right-to-left IHI between the 2 M1s using the ipsilateral silent period (iSP) (Meyer et al. 1995) before and after either LPA or RPA. The iSP was significantly longer after LPA but only from left-to-right and it did not change at all after RPA. This is the first physiological demonstration that LPA alters IHI in the healthy brain.

Variation in left posterior parietal-motor cortex interhemispheric facilitation following right parietal continuous theta-burst stimulation in healthy adults

Spatial neglect is modeled on an imbalance of interhemispheric inhibition (IHI); however evidence is emerging that it may not explain neglect in all cases. The aim of this study was to investigate the IHI imbalance model of visual neglect in healthy adults, using paired pulse transcranial magnetic stimulation to probe excitability of projections from posterior parietal cortex (PPC) to contralateral primary motor cortex (M1) bilaterally. Motor-evoked potentials (MEPs) were recorded from the first dorsal interossei and facilitation was determined as ratio of conditioned to non-conditioned MEP amplitude. A laterality index reflecting the balance of excitability between the two hemispheres was calculated. A temporal order judgment task (TOJ) assessed visual attention. Continuous theta-burst stimulation was used to transiently suppress right parietal cortex activity and the effect on laterality and judgment task measured, along with associations between baseline and post stimulation measures. Stimulation had conflicting results on laterality, with most participants demonstrating an effect in the negative direction with no decrement in the TOJ task. Correlation analysis suggests a strong association between laterality direction and degree of facilitation of left PPC-to right M1 following stimulation (r=.902), with larger MEP facilitation at baseline demonstrating greater reduction (r=-.908). Findings indicate there was relative balance between the cortices at baseline but right PPC suppression did not evoke left PPC facilitation in most participants, contrary to the IHI imbalance model. Left M1 facilitation prior to stimulation may predict an individual's response to continuous theta-burst stimulation of right PPC.

Anticlockwise or clockwise? A dynamic Perception-Action-Laterality model for directionality bias in visuospatial functioning

Orientation bias and directionality bias are two fundamental functional characteristics of the visual system. Reviewing the relevant literature in visual psychophysics and visual neuroscience we propose here a three-stage model of directionality bias in visuospatial functioning. We call this model the 'Perception-Action-Laterality' (PAL) hypothesis. We analyzed the research findings for a wide range of visuospatial tasks, showing that there are two major directionality trends in perceptual preference: clockwise versus anticlockwise. It appears these preferences are combinatorial, such that a majority of people fall in the first category demonstrating a preference for stimuli/objects arranged from left-to-right rather than from right-to-left, while people in the second category show an opposite trend. These perceptual biases can guide sensorimotor integration and action, creating two corresponding turner groups in the population. In support of PAL, we propose another model explaining the origins of the biases - how the neurogenetic factors and the cultural factors interact in a biased competition framework to determine the direction and extent of biases. This dynamic model can explain not only the two major categories of biases in terms of direction and strength, but also the unbiased, unreliably biased or mildly biased cases in visuosptial functioning.

Multisensory integration in hemianopia and unilateral spatial neglect: Evidence from the sound induced flash illusion

Recent neuropsychological evidence suggests that acquired brain lesions can, in some instances, abolish the ability to integrate inputs from different sensory modalities, disrupting multisensory perception. We explored the ability to perceive multisensory events, in particular the integrity of audio-visual processing in the temporal domain, in brain-damaged patients with visual field defects (VFD), or with unilateral spatial neglect (USN), by assessing their sensitivity to the 'Sound-Induced Flash Illusion' (SIFI). The study yielded two key findings. Firstly, the 'fission' illusion (namely, seeing multiple flashes when a single flash is paired with multiple sounds) is reduced in both left- and right-brain-damaged patients with VFD, but not in right-brain-damaged patients with left USN. The disruption of the fission illusion is proportional to the extent of the occipital damage. Secondly, a reliable 'fusion' illusion (namely, seeing less flashes when a single sound is paired with multiple flashes) is evoked in USN patients, but neither in VFD patients nor in healthy participants. A control experiment showed that the fusion, but not the fission, illusion is lost in older participants (>50 year-old), as compared with younger healthy participants (<30 year-old). This evidence indicates that the fission and fusion illusions are dissociable multisensory phenomena, altered differently by impairments of visual perception (i.e. VFD) and spatial attention (i.e. USN). The occipital cortex represents a key cortical site for binding auditory and visual stimuli in the SIFI, while damage to right-hemisphere areas mediating spatial attention and awareness does not prevent the integration of audio-visual inputs in the temporal domain.

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.

Arousal and attention re-orienting in autism spectrum disorders: evidence from auditory event-related potentials

The extended phenotype of autism spectrum disorders (ASD) includes a combination of arousal regulation problems, sensory modulation difficulties, and attention re-orienting deficit. A slow and inefficient re-orienting to stimuli that appear outside of the attended sensory stream is thought to be especially detrimental for social functioning. Event-related potentials (ERPs) and magnetic fields (ERFs) may help to reveal which processing stages underlying brain response to unattended but salient sensory event are affected in individuals with ASD. Previous research focusing on two sequential stages of the brain response-automatic detection of physical changes in auditory stream, indexed by mismatch negativity (MMN), and evaluation of stimulus novelty, indexed by P3a component,-found in individuals with ASD either increased, decreased, or normal processing of deviance and novelty. The review examines these apparently conflicting results, notes gaps in previous findings, and suggests a potentially unifying hypothesis relating the dampened responses to unattended sensory events to the deficit in rapid arousal process. Specifically, "sensory gating" studies focused on pre-attentive arousal consistently demonstrated that brain response to unattended and temporally novel sound in ASD is already affected at around 100 ms after stimulus onset. We hypothesize that abnormalities in nicotinic cholinergic arousal pathways, previously reported in individuals with ASD, may contribute to these ERP/ERF aberrations and result in attention re-orienting deficit. Such cholinergic dysfunction may be present in individuals with ASD early in life and can influence both sensory processing and attention re-orienting behavior. Identification of early neurophysiological biomarkers for cholinergic deficit would help to detect infants "at risk" who can potentially benefit from particular types of therapies or interventions.

Microstructural damage of the posterior corpus callosum contributes to the clinical severity of neglect

One theory to account for neglect symptoms in patients with right focal damage invokes a release of inhibition of the right parietal cortex over the left parieto-frontal circuits, by disconnection mechanism. This theory is supported by transcranial magnetic stimulation studies showing the existence of asymmetric inhibitory interactions between the left and right posterior parietal cortex, with a right hemispheric advantage. These inhibitory mechanisms are mediated by direct transcallosal projections located in the posterior portions of the corpus callosum. The current study, using diffusion imaging and tract-based spatial statistics (TBSS), aims at assessing, in a data-driven fashion, the contribution of structural disconnection between hemispheres in determining the presence and severity of neglect. Eleven patients with right acute stroke and 11 healthy matched controls underwent MRI at 3T, including diffusion imaging, and T1-weighted volumes. TBSS was modified to account for the presence of the lesion and used to assess the presence and extension of changes in diffusion indices of microscopic white matter integrity in the left hemisphere of patients compared to controls, and to investigate, by correlation analysis, whether this damage might account for the presence and severity of patients' neglect, as assessed by the Behavioural Inattention Test (BIT). None of the patients had any macroscopic abnormality in the left hemisphere; however, 3 cases were discarded due to image artefacts in the MRI data. Conversely, TBSS analysis revealed widespread changes in diffusion indices in most of their left hemisphere tracts, with a predominant involvement of the corpus callosum and its projections on the parietal white matter. A region of association between patients' scores at BIT and brain FA values was found in the posterior part of the corpus callosum. This study strongly supports the hypothesis of a major role of structural disconnection between the right and left parietal cortex in determining 'neglect'.