Deficits of contralesional awareness: a case study on what paper-and-pencil tests neglect.

OBJECTIVE Attentional orienting and awareness for contralesional hemispace were studied longitudinally in a woman (GB) who suffered a right hemispheric stroke without any motor impairment and who presented normal performance on standard paper-and-pencil tests for neglect but manifested difficulties in everyday life. We aimed to test whether computer-based, dual-task paradigms were sufficiently sensitive to detect the presence of subclinical neglect in GB. METHOD We assessed the spatial awareness of GB by means of cued-detection tasks, paper-and-pencil tests, attentionally demanding dual tasks, and in several ecological settings after her discharge from the hospital. A group of right brain-damaged patients and an age-matched healthy participant were also tested with the dual tasks. RESULTS Dramatic awareness deficits for the left contralesional hemispace emerged in GB only under dual-task conditions, both in computer-based and in ecological settings, as if her degree of contralesional space awareness impairment was closely dependent on the quantity of available attentional resources. Our dual-task paradigm was also effective in quantifying awareness improvements over time. The absence of motor impairments, uncommon for a postacute patient with severe albeit hidden neglect, allowed us to ascribe her everyday life impairments for contralesional hemispace to awareness deficits. The performance of the group of patients confirmed the detrimental effects of the dual tasks, whereas the performance of the healthy control we tested was not affected by dual-task manipulation. CONCLUSIONS Our results confirm the well-known lack of sensitivity of standard neuropsychological tests to detect subclinical forms of neglect, which, nonetheless, may result in negative consequences in everyday life. Computer-based, resource-demanding paradigms seem to be a promising solution to uncover subtle awareness deficits that can affect the everyday life of stroke patients.

[1]  P. Garthwaite,et al.  Investigation of the single case in neuropsychology: confidence limits on the abnormality of test scores and test score differences , 2002, Neuropsychologia.

[2]  R. Tallis,et al.  Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke. , 1999, Stroke.

[3]  Masud Husain,et al.  Attention modulates the visual field in healthy observers and parietal patients , 2004, Neuroreport.

[4]  L. Gauthier,et al.  The Bells Test: A quantitative and qualitative test for visual neglect. , 1989 .

[5]  Marcus J. Fuhrer,et al.  Rehabilitation outcomes : analysis and measurement , 1987 .

[6]  J Driver,et al.  Group study of an “undercover” test for visuospatial neglect: invisible cancellation can reveal more neglect than standard cancellation , 2004, Journal of Neurology, Neurosurgery & Psychiatry.

[7]  Hans-Otto Karnath,et al.  A simple measure of neglect severity , 2010, Neuropsychologia.

[8]  P. Azouvi,et al.  Functional consequences and awareness of unilateral neglect : study of an evaluation scale , 1996 .

[9]  Carlo Umiltà,et al.  A rehabilitation study of hemispatial neglect , 1994 .

[10]  R. Ptak,et al.  A non-spatial bias favouring fixated stimuli revealed in patients with spatial neglect. , 2007, Brain : a journal of neurology.

[11]  Marco Zorzi,et al.  Normal and Impaired Reflexive Orienting of Attention after Central Nonpredictive Cues , 2009, Journal of Cognitive Neuroscience.

[12]  S. Ferber,et al.  How to Assess Spatial Neglect - Line Bisection or Cancellation Tasks? , 2001, Journal of clinical and experimental neuropsychology.

[13]  Patrizia Bisiacchi,et al.  Esame Neuropsicologico Breve , 2003 .

[14]  D. Wade,et al.  Assessing motor impairment after stroke: a pilot reliability study. , 1990, Journal of neurology, neurosurgery, and psychiatry.

[15]  Marc Rousseaux,et al.  Ineffectiveness of prism adaptation on spatial neglect signs. , 2006, Stroke.

[16]  J. Bradshaw,et al.  Residual rightward attentional bias after apparent recovery from right hemisphere damage: implications for a multicomponent model of neglect. , 1994, Journal of neurology, neurosurgery, and psychiatry.

[17]  C Miniussi,et al.  What exactly is extinguished in unilateral visual extinction? Neurophysiological evidence , 2001, Neuropsychologia.

[18]  S. Cappa,et al.  The Mini-Mental State Examination in Alzheimer's Disease and Multi-Infarct Dementia , 1996, International Psychogeriatrics.

[19]  J. Driver,et al.  Task-related modulation of visual neglect in cancellation tasks , 2009, Neuropsychologia.

[20]  Ian H. Robertson,et al.  Cognitive Rehabilitation Interventions for Neglect and Related Disorders: Moving from Bench to Bedside in Stroke Patients , 2006, Journal of Cognitive Neuroscience.

[21]  E Làdavas,et al.  Selective spatial attention in patients with visual extinction. , 1990, Brain : a journal of neurology.

[22]  Hans-Otto Karnath,et al.  Deficits of attention in acute and recovered visual hemi-neglect , 1988, Neuropsychologia.

[23]  John Duncan,et al.  Modulation of spatial bias in the dual task paradigm: Evidence from patients with unilateral parietal lesions and controls , 2006, Neuropsychologia.

[24]  Chris Rorden,et al.  Non-spatially lateralized mechanisms in hemispatial neglect , 2003, Nature Reviews Neuroscience.

[25]  D. LaBerge,et al.  Reducing the effects of adjacent distractors by narrowing attention. , 1991, Journal of experimental psychology. Human perception and performance.

[26]  J. Driver,et al.  Perceptual awareness and its loss in unilateral neglect and extinction , 2001, Cognition.

[27]  J. Marshall,et al.  VISUOSPATIAL NEGLECT: UNDERLYING FACTORS AND TEST SENSITIVITY , 1989, The Lancet.

[28]  R. Frasca,et al.  Attentional load and visual neglect. , 1992, The International journal of neuroscience.

[29]  F. Meneghello,et al.  Long-lasting amelioration of visuospatial neglect by prism adaptation. , 2002, Brain : a journal of neurology.

[30]  F. J. Friedrich,et al.  Effects of parietal injury on covert orienting of attention , 1984, The Journal of neuroscience : the official journal of the Society for Neuroscience.

[31]  Nachum Soroker,et al.  Assessment of spatial attention after brain damage with a dynamic reaction time test , 2005, Journal of the International Neuropsychological Society.

[32]  A. Geurts,et al.  Visuospatial asymmetry and non-spatial attention in subacute stroke patients with and without neglect , 2010, Cortex.

[33]  Gianna Cocchini,et al.  The Fluff Test: A simple task to assess body representation neglect , 2001 .

[34]  Alan Kingstone,et al.  Involuntary but not voluntary orienting contributes to a disengage deficit in visual neglect , 2010, Cortex.

[35]  Mahoney Fi,et al.  FUNCTIONAL EVALUATION: THE BARTHEL INDEX. , 1965 .

[36]  R. Klein,et al.  A review of the evidence for a disengage deficit following parietal lobe damage , 2001, Neuroscience & Biobehavioral Reviews.

[37]  J Whyte,et al.  Hemispatial neglect , 2004, Neurology.

[38]  Marco Zorzi,et al.  Increased attentional demands impair contralesional space awareness following stroke , 2010, Neuropsychologia.

[39]  F. J. Friedrich,et al.  Spatial attention deficits in humans: a comparison of superior parietal and temporal-parietal junction lesions. , 1998, Neuropsychology.

[40]  Y. Rossetti,et al.  Left size distortion (hyperschematia) after right brain damage , 2006, Neurology.

[41]  P. Bartolomeo,et al.  Impaired orienting of attention in left unilateral neglect: a componential analysis. , 2007, Neuropsychology.

[42]  P. Nichelli,et al.  The Frontal Assessment Battery (FAB): normative values in an Italian population sample , 2005, Neurological Sciences.

[43]  J. Mattingley,et al.  Effects of prismatic adaptation on spatial gradients in unilateral neglect: A comparison of visual and auditory target detection with central attentional load , 2010, Neuropsychologia.

[44]  Patrik Vuilleumier,et al.  Abnormal Attentional Modulation of Retinotopic Cortex in Parietal Patients with Spatial Neglect , 2008, Current Biology.

[45]  A. Biancardi,et al.  Il Test delle Campanelle modificato: una proposta per lo studio dell’attenzione in età evolutiva , 1997 .

[46]  John C. Marshall,et al.  Left Visuo-Spatial Neglect: A Meaningless Entity? , 1992, Cortex.

[47]  Marco Zorzi,et al.  Modulation of hemispatial neglect by directional and numerical cues in the line bisection task , 2008, Neuropsychologia.

[48]  I Litvan,et al.  The FAB: A frontal assessment battery at bedside , 2000, Neurology.

[49]  J-M Beis,et al.  Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke , 2002, Journal of neurology, neurosurgery, and psychiatry.

[50]  Maurizio Corbetta,et al.  Is the posner reaction time test more accurate than clinical tests in detecting left neglect in acute and chronic stroke? , 2009, Archives of physical medicine and rehabilitation.

[51]  Lynn C. Robertson,et al.  Using Reaction Time to Assess Patients With Unilateral Neglect and Extinction , 2002, Journal of clinical and experimental neuropsychology.

[52]  B. Hamilton A uniform national data system for medical rehabilitation. , 1987 .

[53]  G. Vallar,et al.  Guida all'Esame Neuropsicologico , 1983 .

[54]  J. Mattingley,et al.  Phasic alerting of neglect patients overcomes their spatial deficit in visual awareness , 1998, Nature.

[55]  D. LaBerge,et al.  Theory of attentional operations in shape identification. , 1989 .

[56]  Ian H. Robertson,et al.  Improving the Clinical Diagnosis of Personal Neglect: A Reformulated Comb and Razor Test , 2000, Cortex.

[57]  P. Faglioni,et al.  Recognition of random shapes by patients with unilateral lesions as a function of complexity, association value and delay. , 1974, Cortex; a journal devoted to the study of the nervous system and behavior.

[58]  J. Driver,et al.  Looking at human eyes affects contralesional stimulus processing after right hemispheric stroke , 2007, Neurology.

[59]  H Samuelsson,et al.  Different criteria in the assessment of visuospatial neglect. , 1995, Journal of neurology, neurosurgery, and psychiatry.

[60]  P. Halligan,et al.  Measuring visual neglect in acute stroke and predicting its recovery: the visual neglect recovery index. , 1992, Journal of neurology, neurosurgery, and psychiatry.

[61]  C Hershler,et al.  Visual neglect and extinction: a new test. , 1988, Archives of physical medicine and rehabilitation.

[62]  Ian H. Robertson,et al.  Personal Versus Extrapersonal Neglect: A Group Study of their Dissociation Using a Reliable Clinical Test , 1997, Cortex.

[63]  M. Posner,et al.  Orienting of Attention* , 1980, The Quarterly journal of experimental psychology.