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|Classification and external resources|
Hemispatial neglect is most frequently associated with a lesion of the right parietal lobe (in yellow, at top)
|Classification and external resources|
Hemispatial neglect is most frequently associated with a lesion of the right parietal lobe (in yellow, at top)
Hemispatial neglect, also called hemiagnosia, hemineglect, unilateral neglect, spatial neglect, contralateral neglect, unilateral visual inattention, hemi-inattention, neglect syndrome or contralateral hemispatialagnosia is a neuropsychological condition in which, after damage to one hemisphere of the brain is sustained, a deficit in attention to and awareness of one side of space is observed. It is defined by the inability of a person to process and perceive stimuli on one side of the body or environment that is not due to a lack of sensation. Hemispatial neglect is very commonly contralateral to the damaged hemisphere, but instances of ipsilesional neglect (on the same side as the lesion) have been reported.
Hemispatial neglect results most commonly from brain injury to the right cerebral hemisphere, causing visual neglect of the left-hand side of space. Right-sided spatial neglect is rare because there is redundant processing of the right space by both the left and right cerebral hemispheres, whereas in most left-dominant brains the left space is only processed by the right cerebral hemisphere. Although most strikingly affecting visual perception ('visual neglect'), neglect in other forms of perception can also be found, either alone, or in combination with visual neglect.
For example, a stroke affecting the right parietal lobe of the brain can lead to neglect for the left side of the visual field, causing a patient with neglect to behave as if the left side of sensory space is nonexistent (although they can still turn left). In an extreme case, a patient with neglect might fail to eat the food on the left half of their plate, even though they complain of being hungry. If someone with neglect is asked to draw a clock, their drawing might show only numbers 12 to 6, or all 12 numbers on one half of the clock face, the other side being distorted or left blank. Neglect patients may also ignore the contralesional side of their body, shaving or adding make-up only to the non-neglected side. These patients may frequently collide with objects or structures such as door frames on the side being neglected.
Neglect may also present as a delusional form, where the patient denies ownership of a limb or an entire side of the body. Since this delusion often occurs alone without the accompaniment of other delusions, it is often labeled as a monothematic delusion.
Neglect not only affects present sensation but memory and recall perception as well. A patient suffering from neglect may also, when asked to recall a memory of a certain object and then draw said object, again, only draw half of the object. It is unclear, however, if this is due to a perceptive deficit of the memory (having lost pieces of spatial information of the memory) or whether the information within the memory is whole and intact, but simply being ignored, the same way portions of a physical object in the patient's presence would be ignored.
Brain areas in the parietal and frontal lobes are associated with the deployment of attention (internally, or through eye movements, head turns or limb reaches) into contralateral space. Neglect is most closely related to damage to the temporo-parietal junction and posterior parietal cortex. The lack of attention to the left side of space can manifest in the visual, auditory, proprioceptive, and olfactory domains. Although hemispatial neglect often manifests as a sensory deficit (and is frequently co-morbid with sensory deficit), it is essentially a failure to pay sufficient attention to sensory input. This is particularly evident in a related, but separate, condition known as extinction. A patient with extinction following right-hemisphere damage will successfully report the presence of an object in left space when it is the only object present. However, if the same object is presented simultaneously with an object in right space, the patient will only report the object on the right.
Although hemispatial neglect has been identified following left hemisphere damage (resulting in the neglect of the right side of space), it is most common after damage to the right hemisphere. This disparity is thought to reflect the fact that the right hemisphere of the brain is specialized for spatial perception and memory, whereas the left hemisphere is specialized for language - there is redundant processing of the right visual fields by both hemispheres. Hence the right hemisphere is able to compensate for the loss of left hemisphere function, but not vice versa. Neglect is not to be confused with hemianopsia. Hemianopsia arises from damage to the primary visual pathways cutting off the input to the cerebral hemispheres from the retinas. Neglect is damage to the processing areas. The cerebral hemispheres receive the input, but there is an error in the processing that is not well understood.
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Unilateral neglect is a heterogeneous syndrome with several subtypes, and it’s possible that many distinct disorders have been inaccurately lumped together under a single label. There is growing consensus that no single mechanism accounts for the full range of demonstrated symptoms. And it appears that impairments of several different mechanisms converge to result in neglect—each of which could exist singly without causing it. The complexity of attention alone—just one of several mechanisms that may interact—has generated multiple competing hypothetical explanations of neglect. So it’s not surprising that it’s proven difficult to assign particular presentations of neglect to specific neuroanatomical loci. But despite such limitations, we may loosely describe unilateral neglect with four overlapping variables: type, range, axis, and orientation
Types of hemispatial neglect are broadly divided into disorders of input and disorders of output. The neglect of input, or “inattention,” includes ignoring contralesional sights, sounds, smells, or tactile stimuli. Surprisingly, this inattention can even apply to imagined stimuli. In what’s termed “representational neglect,” patients may ignore the left side of memories, dreams, and hallucinations.
Output neglect includes motor and pre-motor deficits. A patient with motor neglect does not use a contralesional limb despite the neuromuscular ability to do so. One with pre-motor neglect, or directional hypokinesia, can move unaffected limbs ably in ipsilateral space, but has difficulty directing them into contralesional space. Thus a patient with pre-motor neglect may struggle with grasping an object on the left side even when using the unaffected right arm.
Hemispatial neglect can have a wide range in terms of what the patient neglects. The first range of neglect, commonly referred to as “egocentric” neglect, is found in patients who neglect their own body or personal space. These patients tend to neglect the opposite side of their lesion, based on the midline of the body, head, or retina. For example, in a gap detection test, subjects with egocentric hemi spatial neglect on the right side often make errors on the far right of the page, as they are neglecting the space in their right visual field.
The next range of neglect is “allocentric” neglect, where individuals neglect either their peri-personal or extrapersonal space. Peri-personal space refers to the space within the patient’s normal reach, whereas extrapersonal space refers to the objects/environment beyond body’s current contact or reaching ability. Patients with allocentric neglect tend to neglect the contralesional side of individual items, regardless of where they appear with respect to the viewer. For example, In the same gap detection test as mentioned above, subjects with allocentric hemi spatial neglect on the right side will make errors on all areas of the page, specifically neglecting the right side of each individual item.
This differentiation is significant because the majority of assessment measures test only for neglect within the reaching, or peri-personal, range. But a patient who passes a standard paper-and-pencil test of neglect may nonetheless ignore a left arm or not notice distant objects on the left side of the room.
In cases of somatoparaphrenia, which may be caused by personal neglect, patients deny ownership of contralesional limbs. Sacks (1985) described a patient who fell out of bed after pushing out what he perceived to be the severed leg of a cadaver that the staff had hidden under his blanket. Patients may say things like, “I don’t know whose hand that is, but they’d better get my ring off!” or, “This is a fake arm someone put on me. I sent my daughter to find my real one.”
Most tests for neglect look for rightward or leftward errors. But patients may also neglect stimuli on one side of a horizontal or radial axis. For example, when asked to circle all the stars on a printed page, they may locate targets on both the left and right sides of the page while ignoring those across the top or bottom.
In a recent study, researchers asked patients with left neglect to project their midline with a neon bulb and found that they tended to point it straight ahead but position it rightward of their true midline. This shift may account for the success of therapeutic prism glasses, which shift left visual space toward the right. By shifting visual input, they seem to correct the mind's sense of midline. The result is not only the amelioration of visual neglect, but also of tactile, motor, and even representational neglect.
An important question in studies of neglect has been: "left of what?" The answer has proven complex. It turns out that subjects may neglect objects to the left of their own midline (egocentric neglect) or may instead see all the objects in a room but neglect the left half of each individual object (allocentric neglect).
These two broad categories may be further subdivided. Patients with egocentric neglect may ignore the stimuli leftward of their trunks, their heads, or their retinae. Those with allocentric neglect may neglect the true left of a presented object or, amazingly, may first correct in their mind’s eye a slanted or inverted object and then neglect the side then interpreted as being on the left. So, for example, if patients are presented with an upside-down photograph of a face, they may mentally flip the object right side up and then neglect the left side of the adjusted image. This also occurs with slanted or mirror-image presentations. A patient looking at a mirror image of a map of the World may neglect to see the Western Hemisphere despite their inverted placement onto the right side of the map.
Though frequently underappreciated, unilateral neglect can have dramatic consequences. It has more negative effect on functional ability, as measured by the Barthel ADL index, than age, sex, power, side of stroke, balance, proprioception, cognition, or premorbid ADL status. Its presence within the first 10 days of a stroke is a stronger predictor of poor functional recovery after one year than several other variables, including hemiparesis, hemianopsia, age, visual memory, verbal memory, or visuoconstructional ability. Neglect is likely among the reasons that patients with right hemisphere damage are twice as likely to fall as those with left brain damage. Patients with neglect rehabilitate longer and make less daily progress than other patients with similar functional status. And patients with neglect are less likely to live independently than even patients who have both severe aphasia and right hemiparesis.
Treatment consists of finding ways to bring the patient's attention toward the left, usually done incrementally, by going just a few degrees past midline, and progressing from there. Rehabilitation of neglect is often carried out by Neuropsychologists, Occupational Therapist, Speech-Language Pathologists, Physical Therapists, Optometrists and Orthoptists
Forms of treatment that have been tested with variable reports of success include prismatic adaptation, where a prism lens is worn to pull the vision of the patient towards the left, constrained movement therapy where the "good" limb is constrained in a sling to encourage use of the contralesional limb. Eye-patching has similarly been used, placing a patch over the "good" eye. Pharmaceutical treatments have mostly focused on dopaminergic therapies such as bromocriptine, levodopa, and amphetamines, though these tests have had mixed results, helping in some cases and accentuating hemispatial neglect in others. Caloric Vestibular Stimulation (CVS) has been shown to bring about a brief remission in some cases. however this technique has been known to elicit unpleasant side-effects such as nystagmus, vertigo and vomiting. A study done by Schindler and colleagues examined the use of neck muscle vibration on the contralesional posterior neck muscles to induce diversion of gaze from the subjective straight ahead. Subjects received 15 consecutive treatment sessions and were evaluated on different aspects of the neglect disorder including perception of midline, and scanning deficits. The study found that there is evidence that neck muscle stimulation may work, especially if combined with visual scanning techniques. The improvement was evident 2 months after the completion of treatment.
Other areas of emerging treatment options include the use of prisms, visual scanning training, mental imagery training, video feedback training, trunk rotation, Galvanic Vestibular Stimulation (GVS), Transcranial Magnetic Stimulation (TMS) and Transcranial direct-current stimulation (tDCS). Of these emerging treatment options, the most studied intervention is prism adaptation and there is evidence of relatively long-term functional gains from comparatively short-term usage. However, all of these treatment interventions (particularly the stimulation techniques) are relatively new and randomised, controlled trial evidence is still limited. Further research is mandatory in this field of research in order to provide more support in evidence-based practice.
In a review article by Pierce & Buxbaum (2002), they concluded that the evidence for Hemispheric Activation Approaches, which focuses on moving the limb on the side of the neglect, has conflicting evidence in the literature. The authors note that a possible limitation in this approach is the requirement for the patients to actively move the neglected limb, which may not be possible for many patients. Constraint-Induced Therapy (CIT), appears to be an effective, long-term treatment for improving neglect in various studies. However, the use of CIT is limited to patients who have active control of wrist and hand extension. Prism Glasses, Hemispatial Glasses, and Eye-Patching have all appear to be effective in improving performance on neglect tests. Caloric Stimulation treatment appears to be effective in improving neglect; however, the effects are generally short-term. The review also suggests that Optokinetic Stimulation is effective in improving position sense, motor skills, body orientation, and perceptual neglect on a short-term basis. As with Caloric Stimulation treatment, long-term studies will be necessary to show its effectiveness. A few Trunk Rotation Therapy studies suggest its effectiveness in improving performance on neglect tests as well as the Functional Independence Measure (FIM). Some less studied treatment possibilities include treatments that target Dorsal Stream of visual processing, Mental Imagery Training, and Neck Vibration Therapy. Trunk rotation therapies aimed at improving postural disorders and balance deficits in patients with unilateral neglect, have demonstrated optimistic results in regaining voluntary trunk control when using specific postural rehabilitative devices. One such device is the Bon Saint Côme apparatus, which uses spatial exploratory tasks in combination with auditory and visual feedback mechanisms to develop trunk control. The Bon Saint Côme device has been shown to be effective with hemiplegic subjects due to the combination of trunk stability exercises, along with the cognitive requirements needed to perform the postural tasks.