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lesson 18 Flashcards

1
Q

Unilateral neglect - synonyms

A

Unilateral neglect, unilateral spatial neglect, spatial heminegligence, hemi-inattention, disorder of spatial awareness

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2
Q

Unilateral neglect

A

describes a multicomponent syndrome characterized by a failure to explore, pay attention, respond or orient (perceptual) and perform actions (motor) to stimuli presented in a specific location (i.e., the contralesional hemifield)

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3
Q

unilateral neglect - failure cannot be attribute to

A

Failure cannot be attributed to either sensory or motor deficits

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4
Q

unilateral neglect - is a disorder of

A

It is a disorder of spatial attention (not sensation nor perception) and awareness of controlesional space –> patient is not able to orient the attention in the contralesional space

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5
Q

appearance of patient

A

He “looks at the lesion side’

Paitent tends to say they don’t “see” very well but vision is spared –> attention deficit

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6
Q

unilateral neglect - what kind of deficit

A

attention deficit

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7
Q

He “looks at the lesion side’

A

For example, when neglect follows a right hemispheric damage:

Head and eyes turn to the right

Trunk turned to the right

Most movements are planned towards the right hemifield

Patient tends to bump into objects placed on their left– tends to ignore (neglect) items placed on the left (the fork and meal)

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8
Q

unilateral neglect frequency with hemispheric damage

A

one of the pathologies most frequently detected after a brain damage in the right hemisphere (40 – 81%)

Sometimes present after left brain damage (20%) –> usually, less severe symptoms

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9
Q

unilateral neglect - sensory/syndrome

A

A mulicomponent syndrome and might be specific for snesory modality (visual, auditory, somatosensory)

Every patient with spatial hemineglect is unique –> different clinical manifestations between patients, leading to different complex patterns of symptoms

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10
Q

Some clinical manifestations of unilateral neglect:

A

Asymmetries in spatial exploration (spatial deficit)

Asymmetries in the orientation of attention (attentional deficit)

Anosognosia for hemispatial neglect (awareness deficit)

Hemianopsia

Hemiplegia/hemiparesis

Hemianesthesia

Extinction (visual, tactile, auditory)

Allochiria

Directional hypokinesia

Anisometry of space

Perseverations

Somatoparaphrenia

Anosognosia for the previous symptoms

Discrete deficits can be concomitant or dissociated

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11
Q

Unilateral spatial neglect can be differently described distinguishing

A

Type of neglect, coordinates, space, sensory modalities, abstractness

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12
Q

Type of neglect

A

perceptual vs. Pre-motor neglect, or attention vs. Motor neglect

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13
Q

Coordinates

A

retinocentric vs. Egocentric vs. Allocentric

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14
Q

Space

A

personal vs. Peripersonal vs. Extrapersonal neglect

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15
Q

Sensory modalities

A

visual vs. Somatosensory vs. Auditory vs. Tactile, … –> unimodal vs. Crossmodal

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16
Q

Abstractness

A

real vs. Presentative neglect

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17
Q

Why in the right hemisphere?

A

Usually associated with a damage in the right posterior parietal cortex

Various hypotheses try to explain why the left hemifield is usually ignored

The Hemispheric specialization of attention model and Interhemispheric rivalry model

The Antagonist attentional vectors model

Neglect as a deficit of attentional disengagement

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18
Q

The Hemispheric specialization of attention model and Interhemispheric rivalry model

A

Left hemisphere controls the right space

A lesion on the left does not create an impairment: loss of attentional control is compensated by the right hemisphere

Right hemisphere controls both the left and right space

But a lesion on the right hemisphere cannot be compensated

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19
Q

The Antagonist attentional vectors model - left hemisphere

A

Left hemisphere: controls attentional shifts (vector) toward the right space (and it is stronger) –> lesion on the left weakens the vector but the attentional control remains balanced and produces a less pronounced imbalance towards the right hemispace

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20
Q

The Antagonist attentional vectors model - right hemisphere

A

Right hemisphere: controls attentional shifts (vector) toward the left space (and it is weaker) –> lesion on the right hemisphere makes the right vector vanish and produce a more pronounced imbalance towards the right hemispace

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21
Q

Neglect as a deficit of attentional disengagement

A

When a stimulus ‘calls for’ attention, you focus on it

A healthy attentional behavior is composed by sequences of attention switching (disengagement or ‘dis-anchoring’ and re-engagement again)

A right-lateralized lesion leads to a deficit in disengagement from ipsilesional (right) stimuli –> difficulty in orienting the attention towards the contralesional space (left)

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22
Q

Egocentric (or centered on the subject)

A

dependent on the point of view of the observer

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23
Q

Personal space

A

the body

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24
Q

Peri-personal space

A

the close extra-personal space – reachable, where to act

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25
Q

Extra-personal space

A

the distant extra-personal space (navigation, locomotion)

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26
Q

Allocentric

A

(or object-centered, centered around the stimulus): independent of the visual hemifield

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27
Q

PERSONAL SPACE: Personal Neglect

A

Tendency to ignore the contralesional hemi-body

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28
Q

EXTRA-PERSONAL SPACE

A

Egocentric versus allocentric

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29
Q

Tendency to ignore the contralesional hemi-body

A

Patient does not consider half of their body (e.g. when shaving or putting on makeup)

Might be independent from perceptual neglect for the extra-personal space

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30
Q

Tendency to ignore the contralesional hemi-body - neural correlates

A

Due to a lesion in a specific sub-region of the right parietal: the right supramarginal gyrus and the white-matter medial to it

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31
Q

Neural bases of personal and extra personal neglect in humans

A

Best known aspect is the visual neglect for near extra/peri personal space but another component for personal space is more often associated with, then double-dissociated from, extra personal neglect specially in chronic patients

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32
Q

Awareness of extra personal space is based on

A

integrity of a circuit of right frontal (ventral premotor cortex and middle frontal gyrus) and superior temporal regions

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33
Q

Awareness of personal space is rooted in

A

right inferior parietal regions (supramarginal gyrus, post-central gyrus and the WM medial to them)

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34
Q

Disconnect between regions important for

A

coding proprioceptive and somatosensory inputs, and regions coding more abstract egocentric representations of the body in space

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35
Q

How to test personal neglect?

A

Ask patient to: put on glasses, comb hair, shave/put makeup on

Ask patient to collect some markers placed on several target-points on the body

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36
Q

Premotor/intentional neglect

A

Unilateral neglect affecting actions related to the contralesional part of the body – in absence of hemiplegia

e.g. patient does not use the left lower limb

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37
Q

Extra-Personal Space

A

Tendency to not perform movements in the contralesional hemifield

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38
Q

Looking at mirror

A

perception does not influence performance of movements on the left (still reduced)

Compared to perceptual neglect where perception does influence performance of movements

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39
Q

Looking at mirror – perception does not influence

A

performance of movements on the left (still reduced)

Compared to perceptual neglect where perception does influence performance of movements

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40
Q

Representational neglect

A

tendency to ignore the contralesional hemifield even in the ‘internally represented’ (mental) space –> inability to process the contralesional side of visual mental images

Patients fail in describing both already known images or in the recall of novel material on the neglected side

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41
Q

Neglect also manifests in REM sleep

A

specific eye movements were altered and characterized by asymmetry –> reduction in the frequency and quality of eye movements towards the controlesional space

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42
Q

Patients dream reports showed a

A

congruency between the directional asymmetry of eye movements during REM sleep and the visual events in the dream scene

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43
Q

Implicit processing of stimulus in the contralesional field can be

A

preserved – the neglected stimulus is processed up to the level of attribution of meaning

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44
Q

Phenomena Related to Unilateral Neglect

A

Distinct from unilateral neglect, but in comorbidity

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45
Q

Unilateral Neglect: Defective Manifestations

A

Anosognosia for unilateral neglect, Hemianopsia, Hemiplegia, Hemianesthesia, Extinction, Allochiria, Neglect dyslexia, Anisometry of space, Directional hypokinesia

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46
Q

Directional hypokinesia

A

reluctance to initiate or complete movements towards the contralesional space

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47
Q

Anosognosia for unilateral neglect

A

patients are typically unaware of their poor performance on the left hemispace

48
Q

Hemianopsia

A

half of the hemifield is blind

49
Q

Hemiplegia

A

half of the hemifield is paretic

50
Q

Hemianesthesia

A

loss of sensation affecting only one part of the body

51
Q

Extinction

A

failure to detect a contralesional target in the presence of a competing ipsilesional stimulus

52
Q

Allochiria

A

the contralesional stimulus is perceived, but localized in the ipsilateral portion of the egocentric space, in a symmetrical position

53
Q

Neglect dyslexia

A

omission, addition, and substitution errors when reading

54
Q

Anisometry of space

A

distortion of the horizontal dimension of space

55
Q

Directional hypokinesia

A

reluctance to initiate or complete movements towards the contralesional space

56
Q

Hemianopsia

A

visual field deficit is generally caused by damage to the optic pathways (chiasm, optic tract, optic radiation, primary visual areas

57
Q

unilateral neglect - compared to hemianopsia

A

lesion of higher order cortical areas –> event-related potentials (ERPs) present in the primary visual cortex, demonstrating that sensory processing is spared

58
Q

Double stimulus extinction

A

patient can perceive single stimuli, even when presented in the space contralateral to the lesion – BUT contralateral stimuli are omitted or poorly identified when the stimulation is bilateral and simultaneously

59
Q

double stimulus extinction - what functions

A

Can be present for both sensory and motor function

60
Q

can extinction and neglect occur together?

A

Extinction and neglect can occur together or independently

61
Q

Extinction can often represent

A

the only noticeable sequence in a patient with good remission of heminattentive symptoms

62
Q

Auditory extinction

A

dichotic listening task: scientific evidence showed cases of double stimulus extinction even in the olfactive and gustatory modalities

63
Q

double stimulus extinction can also occur in

A

crossmodal situations (e.g., visuo-tactile or auditory-tactile modalities –> proximity effect

64
Q

Neglect dyslexia

A

patients commit consistently lateralized letter omission, addition, and substitution errors when reading individual words

65
Q

In patients with left-sided neglect dyslexia

A

failure to identify the initial portion of a letter string (e.g. reading “lend” for “blend”

66
Q

Right-sided neglect dyslexia

A

failure to identify the final portion of the letter string (e.g. reading “all” for “allow”)

Different sub-types: retino-centric, stimulus-centered and word-centered

67
Q

Somatoparaphrenia

A

the patient does not recognize the limb as his own but attributes it the relative, the doctor or someone else

Faced with attempts to rationalize the experience by those around them, the patient often responds with a confabulatory attitude and justification of their delusional beliefs

68
Q

Most commonly, the term neglect is referred to a

A

spatial hemi-inattention deficit that is perceptual, egocentric and regarding the extra-personal space

69
Q

TAKE HOME MESSAGE

A

multimodal syndrome: every patient has their own pattern of symptoms

70
Q

neural correlates - unilateral neglect

A

premotor cortex, inferior parietal lobule, temporo-parietal junction

71
Q

More frequent and serious after lesions of

A

the hemisphere opposite to the one in which language is represented (right in right-handed people)

72
Q

Perceptual deficits: more related to

A

posterior parietal damage

73
Q

visuo-motor exploration deficit has been recorded in

A

frontal premotor regions

74
Q

motor deficits have a

A

frontal correlate

75
Q

Personal neglect: lesions of the

A

inferior parietal lobule, particularly the supramarginal gyrus (BA 40) near the temporo-parietal junction sand the white matter medial to it

76
Q

Peripersonal neglect

A

damage in the inferior parietal lobe, particularly angular gyrus (BA 39) and supramarginal gyrus (BA 40)

77
Q

other cases of peripersonal neglect

A

lesion affects inferior parietal lobe together with dorsolateral premotor cortex: BA 44, 6, 8

78
Q

Allocentric neglect

A

associated with superior temporal lesions (BA 22), more ventral than those associated with egocentric neglect (posterior parietal)

79
Q

egocentric neglect neural correlates

A

posterior parietal

80
Q

neural correlates unilateral neglect also involvement of

A

subcortical structures (thalamus and basal ganglia)

81
Q

Visual-motor tests

A

typically involve the visual modality (but not only) and imply a motor response (ipsilesional hand)

Barrage tests, line bisection, drawing on copy, writing, symbol cancellation, letter/line cancellation

82
Q

Perceptual tests

A

involve only the visual modality, do not require a motor response

Description of image, recognition of chimerical figures, reading words, non-wrods, sentences and texts

83
Q

Evaluation of personal neglect

A

Non-standardized clinical methods (qualitative judgement), standardized tests

84
Q

Evaluation of representational neglect

A

Drawing on verbal command or spontaneously, verbal description of mental images, locating cities/states on a map

85
Q

Test batteries

A

standardized and ecological tests

86
Q

Non-standardized clinical methods (qualitative judgment)

A

OBSERVATION of patient’s behavior in everyday life: personal hygiene (e.g., unshaven or badly shaved on left side), dressing, position of limbs in wheelchair

ASK patient to touch left hand with right hand

MOTOR NEGLECT: ask the patient to raise their left arm, to shake examiner’s hand with their left hand

87
Q

Standardized tests

A

patient must simulate ecological actions, as shaving with a manual razor (or applying make-up) and comb their hair for 30 min: the number of movements made to the right and to the left are counted)

Fluff test

88
Q

Fluff test

A

while blindfolded, the patient must look for and remove all stimuli previously positioned on body, delivering them one by one

89
Q

Drawing on verbal command or spontaneously

A

Left side of graphically represented or imagined object can be: completely emitted, poor in details grossly distorted, located on the right (allochiria)

90
Q

Test Batteries of Unilateral Neglect

A

Behavioral inattention test – BIT

91
Q

Behavioral inattention test – BIT

A

comprehensive battery that combines traditional test with tests that examine impairment in daily life –> evaluate the impact of hemi-attention on patients’ lives

conventional and behavioral test

92
Q

Conventional test

A

cancellation of lines/letter/starts, copy of figures and objects, bisecting lines and drawing

93
Q

Behavioral test

A

exploring photographs, making phone calls, reading a menu/article/time on a clock and then adjusting the clock hands, coping addresses and phrases, coin/card sorting, navigation on map

94
Q

treatment purposes

A

treatment of both sensory-motor and attentional deficits

Traditionally, treatment often also include adapting the environment, so stimuli are constantly presented on neglected side

95
Q

Rehabilitation Approaches and Techniques

A

Cognitive-behavioral tasks

Rehabilitation techniques on sensory stimulation

Eye patching

Motor tasks

Mental imagery training

96
Q

Cognitive-behavioral tasks

A

patient is trained to re-learn/re-activate or compensate the ability to carry out activities compromised by the brain lesion

scanning training, Awareness of the deficit through conflict or feedback training

97
Q

Scanning training

A

visual exploration training aimed to improved different types of eye movements (e.g., smooth pursuit and saccadic eye movements), compensating for a deficient automatic system through a voluntary spatial attention system

98
Q

what is necessary for scanning training

A

Patient must be aware of difficulties and be able to develop voluntary strategies

Prolonged and massive stimulation with continuously varied stimuli requiring more complex responses produced an increasingly automated scanning of space

99
Q

Awareness of the deficit through conflict or feedback training

A

can be achieved through verbal, video and visual feedback

Simply pointing out a patient’s neglect behavior (verbal feedback) or showing them a video of their performance can lead to an increase in self-awareness and a decrease in neglect symptoms

100
Q

Awareness of the deficit through conflict or feedback training example

A

Ex: search for 15 objects arranged in space –> the discrepancy between the number of objects found by patient and number of elements described by the therapist must lead the patient to look for missing elements in the neglected hemifield

101
Q

Rehabilitation techniques on sensory stimulation

A

Vestibular caloric stimulation, Visual-vestibular or optokinetic stimulation, Transcutaneous electrical nerve stimulation (TENS), Vibratory stimulation of cervical muscles

The previous techniques combined with visual scanning training leads to significant and lasting improvements on neglect symptoms

102
Q

Vestibular caloric stimulation

A

cold water in contralesional ear –> reduced deviation towards the left hemifield

Affects visuo-motor deficits, personal and extrapersonal neglect, representational neglect, anosognosia and somatoparaphrenia, but short effects

103
Q

Visual-vestibular or optokinetic stimulation

A

optokinetic stimulation uses movement on a large visual display to change the patient’s perception of where the body is in space –> patient will try to reorient themself

104
Q

Transcutaneous electrical nerve stimulation (TENS)

A

acts on sensory nerves on the neck to reduce postural instability of neglect

105
Q

Vibratory stimulation of cervical muscles

A

neck muscle vibration has a proprioceptive effect whereby it creates the illusion that these muscles are being lengthened (i.e., the neck is turning to the left)

106
Q

Eye patching

A

an eye patch over the patient’s ipsilesional eye to stimulate the orientation of the eyes to the contralateral side

Usually requires patient to wear glasses with opaque mask over right lens

107
Q

Motor tasks

A

Motor activation training

108
Q

Motor activation training

A

movements (active and passive) of one limb towards the contralesional hemispace improve visual attention and increase voluntary movements towards the left extrapersonal space

Ex: active movements of the non-plegic left limb or active movements of the right limb and simultaneous passive movements of the left

109
Q

Mental imagery training

A

visual and motor imagery exercises can be used in individuals with neglect to improve contralesional space exploration

Mirror therapy

110
Q

Mirror therapy

A

patient places both arms on a table with a mirror between limbs –> patient looks in mirror while moving both arms; the reflecting side of the mirror faces the non-affected arm

Through the eyes, the brain is “re-learning” to perform correct movements

111
Q

Rehabilitation Techniques – Prismatic Adaption

A

Lenses deviated to the right –> prisms determine the deviation of the gaze to the right –> perceptual motor pointing tasks –> after-effect on the left

Multiple sessions (>10) lead to longer-lasting benefits + generalization of the improvement

112
Q

Rehabilitation Techniques – rTMS

A

Interhemispheric rivalry model

113
Q

Interhemispheric rivalry model

A

right hemisphere regulates attention towards both hemifields, while the left hemisphere only regulates it towards the right hemifield

Right brain damage –> affected hemisphere becomes hypoactive, while intact hemisphere becomes hyperactive

Neglect symptomatology

114
Q

Neglect symptomatology

A

is caused by both hypoactivity and hyperactivity –> to restore inter-hemispheric balance: low-frequency rTMS over the left hyperactive hemisphere

Note: differences between studies in (a) intensity and number of pulses per session, (b) number of sessions, (c) stimulation site and (d) cointervention(s)

115
Q

Rehabilitation Techniques – tDCS

A

Same thing with interhemispheric rivalry model with right brain damage and neglect symptomatology

To restore inter-hemispheric balance

116
Q

To restore inter-hemispheric balance

A

excitatory tDCS protocol to increase the activity of the damaged hemisphere + inhibitory tDCS protocol to reduce the activity in the intact hemisphere

Note: differences between studies in (a) intensity and number of pulses per session, (b) number of sessions, (c) stimulation site and (d) cointervention(s)

117
Q

Virtual Reality Training

A

can be performed through the use of a variety of different programs

More effective than conventional treatment

neuropsych (25 decks)

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