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