Hemispatial Neglect
Neurological syndrome occurring after brain injury
Inability to orient, respond to or detect stimuli
appearing on the side contralateral to a cerebral lesion
(Luukainen-Makkula 2009)
The deficit must not be attributable to primary
sensory deficits or motor disturbance
Hemispatial Neglect
The prognosis for recovery of independent function in
patients with persisting spatial neglect is worse than in
those with seemingly more disabling deficits (e.g.
hemiparesis)
Although patients may recover from spatial neglect,
they often remain severely disabled.
Linked to longer hospitalisation and worse rehab
outcomes
Incidence
Reported incidence of neglect in stroke patients has varied
from as low as 8% of patients to as high as 90%.
Luukainen-Makkula report 30% of all acute stroke patients
suffer from neglect, while 2% suffer chronically
More common in injuries affecting right cortical
hemisphere
Causes of spatial neglect include stroke, traumatic brain
injury, brain tumors, and aneurysm. Rarely,
neurodegenerative diseases can cause neglect symptoms
This disorder is under-recognized in clinical practices,
which may result from the failure to document its presence
(Chen et al 2013)
Mechanisms
Many different cognitive deficits have been identified
in patients with neglect.
Led to a range of hypotheses about the mechanisms
underlying the condition
Mechanisms attention
Perception Attention disordered awareness
(Heilman 2003)
Deficit in directing spatial attention, specifically
in disengaging attention from ipsilesional objects and
shifting it contralesionally towards the neglected side
of space
Cueing attention towards the neglected side of space
can help to reduce spatial biases
Mechanisms - Spatial working
memory
Imagery/representation unable to maintain an
internal map or spatial knowledge of the environment
Patients have difficulty in keeping track of spatial
locations across saccadic eye movements
Suggests limitations in visual short term memory
(Malholtra et al 2004)
Symptoms
Deficits in attention to the area within reaching space
(peripersonal neglect) and beyond (extrapersonal neglect)
Personal neglect- deficit in grooming or dressing the
contralesional side.
Anosognosia- unaware of the deficit that is present (Occurs
in 20-58% of patients)
Deficits in attending to or perceiving contralesional space.
Motor neglect fail to use contralesional limbs even if
there is little weakness
Neglect vs. hemianopia
Hemianopia primary sensory deficit visual field
loss, pt is aware of deficit will turn head to see
Patients with neglect are unaware of their deficit of
the missing information on one side. Vision is intact,
attention is disrupted.
Once their attention is drawn to the missing
information, they become aware of it.
Prognosis
Most patients with neglect show early recovery, particularly
within the first month, and marked improvement may be
seen within 3 months.
Patients with neglect need to be monitored because they
may be more prone to falls or left-sided wheelchair
collisions. Patients may require sitters, vest restraints, gait
belts, or other interventions to prevent falling out of bed,
for which they are at high risk.
Spatial neglect may greatly increase morbidity and the risk
of acute and chronic complications of stroke (eg, hip
fracture). It is associated with a longer acute hospital stay.
Neglect patients who were not detected clinically stayed in
rehab longer than those who were (Chen et al 2013)
Testing for neglect
Individuals usually do not report attention or
perceptual problems. Thus, the disorder is usually
detected via clinical observation and testing
Line Bisection test Mark the center of the line
Cancellation task cross out lines on a page
Copying
Catherine Bergego Scale
Rx
Prism Adaptation
Motor bias rehabilitation/Constraint-induced therapy
Visual Scanning
Cueing
Trunk rotation
Vibration of contralesional neck muscles
Bed Placement/ Room rearrangement
Caloric stimulation
Rx
Interventions which simply attempt to improve
exploration of contralesional space (e.g. directing
gaze) are effective in reducing neglect on those tasks,
but have little transfer to functional benefits in
everyday life
However when combined with vibration of
contralateral neck muscles, there is evidence for
significant improvement in functional outcome
measures at 2 months follow up (Schindler et al., 2002)
Prism Adaptation
Prism adaptation causes an optical deviation of the visual field
to the Right, so objects appear farther to the subjects right than
is actually the case.
After repeated exposure, it forces patients to correct their reach
trajectory to accurately grasp objects, thus overriding the visual
impairment. (A recalibration of visuomotor hand-eye
coordination.)
Significant improvements in neglect tests, but not functional
performance.
Some have reported improvements in representational neglect,
haptic neglect, neglect dyslexia, postural imbalance in
hemiparesis
Mcintosh et al reported benefits for chronic neglect patients
Contralesional Limb Activation
Active and passive movement to reduce visual and
behavioural neglect
Passive movement was also induced by functional
electrical stimulation
Experimental groups appeared to have statistically
significant improvements on BIT, CBS and FIM
measures during rehabilitation, however had rather
large standard deviations
Constraint-Induced Therapy
Based on principle of learned non-use - Causes reduced
neural representation of that limb, diminishing their
potential to return to function
Mechanically forces patient to use their affected limb
van de Lee et al. (1999) compared CIT against
traditional therapy
66 Stroke patients 7 with neglect
Showed significant improvements vs normal rehab
But no proper neglect measures used!
Requires active + functional wrist and hand movement
Conclusion
There have been numerous studies on various treatments
for neglect that have shown statistically significant
improvements both immediately and in the long-term.
Daily life functions are often performed under more
challenging conditions than is the case for formal
neuropsychological testing/treatment environments
According to Cochrane review by Bowen and Lincoln
(2007) it is difficult to correlate an improvement in
standardised neglect tests, as they say little about the
persons ability to function in complex everyday activities
that are relevant to their life
More research is required on the various techniques and
the long-term effects
References
Luukkainen-Markkula, I.M. Tarkka, K. Pitkanen, J. Sivenius, and H. Hamalainen. Rehabilitation of
hemispatial neglect: A randomized study using either arm activation or visual scanning training.
Restorative Neurology and Neuroscience. (2009); 27: 665-674.
Schindler I, Kerkhoff G, Karnath HO, Keller I, Goldenberg G. Neck muscle vibration induces lasting
recovery in spatial neglect. J Neurol Neurosurg Psychiatry 2002;73(4):412-9.
Nicole Y. H. Yang, Dong Zhou, Raymond C. K. Chung, Cecilia W. P. Li-Tsang, and Kenneth N. K.
Fong. Rehabilitation interventions for Unilateral Negelct after stroke: A systematic review from 1997
through 2012. Frontiers in Human Neuroscience. (2013); 7: 187.
van de Lee, J., Wagenaar, R., Lankhorst, G., Vogelaar, T., Deville, W., Bouter, L. Forced Use of the
Upper Extremity in Chronic Stoke Patients. Stroke. (1999); 30: 2369-2375.
Bowen, A. & Lincoln, N. Cognitive Rehabilitation for Spatial Neglect Following Stroke. Cochrane
Database of Systematic Reviews. (2007); 2.
Heilman KM, Watson RW, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E,
eds. Clinical neuropsychology. 4th ed. New York, NY: 2003:296-346.
Ringman JM, Saver JL, Woolson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of
unilateral neglect in an acute stroke cohort. Neurology. Aug 10 2004;63(3):468-74.
Malhotra, P., Jager, H.R., Parton, A., Greenwood, R., Playford, E.D., Brown, M., Driver, J., and Husain, M. (2005). Spatial
working memory capacity in unilateral neglect. Brain 128, 424-435.
Chen, P., Pasquale, G.F. & Barret, A.M. Evidence of under-documentation of spatial neglect after stroke. Disabil
Rehabil. 2013 Jun;35(12):1033-8
