Case 6 - Spatial Neglect

Question 1

Spatial Neglect Classic Definitions:

Answer 1

Heilman & Valenstein (1979): Inability to spontaneously report, respond, or orient towards events on the contralesional side of space with either limb or eye movements.
Mesulam (1985; 2000): Described as if that half of the world had abruptly ceased to exist in any meaningful form.

Question 2

Clinical Presentation:

Answer 2

Halligan & Robertson (1999): Reduced awareness of contralesional space, usually following stroke. In severe cases, it can extend to ipsilesional space.
Esposito et al. (2021): Incidence of neglect after stroke: 38% in RH damage, 18% in LH damage.

Question 3

Impact of Spatial Neglect:

Answer 3

Jehkonen et al. (2006); Hammerbeck et al. (2019): SN predicts poor functional recovery in RH stroke; longer hospital stays.
Chen et al. (2017): Significant pressure on caregivers of stroke survivors with spatial neglect.

Question 4

Symptoms and Clinical Value:

Answer 4

Rich et al. (in prep.): Terms used to describe spatial neglect include visuospatial neglect, unilateral (spatial) neglect, hemineglect, inattention, hemi-inattention.
Spaccavento et al. (2017): Spatial Reference Frames (SRFs): Personal, Peri-personal, Extra-personal.

Question 5

Clinical Value of SRFs:

Answer 5

Iosa et al. (2016); Moore et al. (2021): Different SRFs may have different associated outcomes and recovery processes.

Question 6

Spatial Neglect Subtypes:

Answer 6

Demeyere et al. (2019): Egocentric neglect (relative to bodily midline) vs. Allocentric neglect (relative to midline of objects).

Question 7

Spatial Neglect Modalities:

Answer 7

Rode et al. (2017): Different modalities include visual, auditory, motor, somatosensory, and representational neglect.

Question 8

Visual Neglect and Co-morbidities:

Answer 8

Schofield & Leff (2009): Differentiating neglect and hemianopia; both can coexist.

Question 9

Auditory Neglect:

Answer 9

Bellmann et al. (2001): Proposed subtypes based on lesion location (basal ganglia vs. frontotemporoparietal).

Question 10

Motor and Representational Neglect:

Answer 10

Guariglia et al. (2005): Motor neglect involves reduced/absent movement on one side; Representational neglect involves reduced awareness of one side of mental imagery.
Catherine Bergego Scale: Quantifies anosognosia, the inability to recognize spatial neglect.

Question 11

Causes of Spatial Neglect:

Answer 11

Li & Malhotra (2015); Karnath et al. (2001, 2004): Commonly caused by stroke in middle cerebral artery territory, often in right inferior parietal lobe/TPJ.

Question 12

Working Theories of Spatial Neglect:

Answer 12

Representational Approach
Directional Hypokinesia
Activating-Orientating Hypothesis
Attentional Approach

Question 13

Representational approach

Answer 13

Neglect is not a sensory disorder but a failure to exploit the left side of representational space.

Question 14

Directional hypokinesia

Answer 14

Unilateral lesion hypoarouses the hemisphere causing selective loss of orientating response in hemispace contralateral to the lesion.

Question 15

Activating-Orientating Hypothesis

Answer 15

Proposes that the allocation of attention is directed contralaterally to the activated hemisphere.

Question 16

Attentional approach

Answer 16

Changing location of attention involves disengagement, movement, and re-engagement at the new location.

Question 17

Neglect Characteristics:

Answer 17

Benefit from valid cues, but exhibit a higher cost when invalid cues are on the right, struggling to re-engage attention leftward. Neglect is identified as a problem in reallocating attention once directed to the right.

Question 18

Cognitive Assessments:

Answer 18

Measure neglect-influenced cognitive abilities (attention, spatial navigation, language) using batteries (e.g., BIT, OCS) or standalone tests (e.g., cancellation, bisection, drawing).

Question 19

Behavioural Inattention Test (BIT):

Answer 19

BIT-B: Behavioral, ADLs.
BIT-C: Conventional, cognitive subtests.
Subtests include star cancellation, line crossing, letter cancellation, line bisection, figure copying, and more.

Question 20

Functional Assessments:

Answer 20

Observe daily activities impacted by neglect (e.g., meal preparation, grooming) using structured (CBS/KF-NAP, DENA) or unstructured methods.

Question 21

Catherine Bergego Scale (CBS) and KF-NAP:

Answer 21

Clinician-rated and patient-rated scale for ADLs, also indicating anosognosia.

Question 22

Checketts et al. (2020) Study:

Answer 22

Surveyed stroke clinicians, revealing a translational gap between research and clinical practice.

Question 23

Importance of Treating Neglect:

Answer 23

Neglect predicts poor functional recovery; longer hospital stays; caregivers’ significant pressure.

Question 24

Top-Down Approaches:

Answer 24

Focus on hierarchical cognitive network organization, teaching compensatory strategies, and cognitive control by the patient.
Visual Scanning Training: Trains systematic searching towards the neglected side, but effectiveness limited to trained tasks.
Sustained Attention Training (SAT): Trains sustained attention to facilitate spatial awareness, with modest improvements reported.
Other Top-Down Approaches: Tonic and phasic alertness training (TAPAT), practicing scanning/searching, and saccadic or eye movement training.

Question 25

Bottom-Up Approaches:

Answer 25

Focus on afferent pathways to stimulate defective processes not under conscious control.
Caloric Vestibular Stimulation: Short-term effects, not well-established, uncomfortable side effects.
Prism Adaptation Training (PAT): Alters visual perception and recalibrates attention, showing promising results in improving neglect.

Question 26

Other Bottom-Up Approaches:

Answer 26

Limb activation training, neck vibration, trunk rotation, haptic feedback, and non-specific interventions like noninvasive brain stimulation, occupational therapy, and pharmacological treatments.