Neglect …

Victor W Mark MD

Neurobehavioral & Cognitive Disorders

Updated 12.11.2023
Released 11.15.1997
Expires For CME 12.11.2026

Neglect

Author: Victor W Mark MD

See Contributor Disclosures

Neglect

In This Article

Quick Link

Introduction

Overview

Unilateral spatial neglect, or “neglect” for short, commonly follows the acute onset of focal hemispheric brain disease but may also appear in progressive cerebral degeneration. It involves a directional bias of spatial attention or action (intention) that is usually toward the side of brain injury, thus, neglect for the opposite side of space, including that side of one’s body. This article indicates that neglect is distinct from other hemibody deficits of movement (hemiparesis) or perception (hemianopia, hemianesthesia) because the spatial deficit can be overcome by cuing or increasing motivation, such as through reward. Nonetheless, the disorder commonly signifies a profound impairment in recovery of self-care abilities. Efficacious treatment has not yet been developed.

Key points

	• Neglect is a common consequence of focal brain injury.
	• Neglect is easily assessed with bedside evaluations.
	• Neglect commonly predicts impaired recovery of self-care after brain injury, although it is not yet clear whether functional impairment is primarily from neglect itself or from other, concurrent cognitive deficits.
	• Neglect tends to improve in most persons following acute brain injury, but chronically can remain in a small proportion of patients.
	• No standard of rehabilitation care has thus far been developed for neglect.

Historical note and terminology

Neglect appears to have not received the same scrutiny in the 19th century as the aphasias, agnosias, and apraxias. Late 19th century experiments in laboratory mammals induced asymmetric behavior that could not be accounted for by hemiblindness or hemiparesis (15; 55; 142). In the 1880s, Loeb obtained asymmetric responses to bilateral simultaneous stimulation (extinction) in animals, which was quickly confirmed in humans by Oppenheim (Benton 1956). In 1865, Prevost reported that Vulpian had found contralesional conjugate eye deviation following brain injury in humans (67), which if not precisely neglect, is closely related. Jackson reported a British patient whose right hemisphere tumor was associated with a right-to-left reading approach to an eye chart, which the patient could not explain (91). In the early part of the 20th century, Zingerle described neglect as a disorder of spatial representations (231). Poppelreuter, and then Brain, emphasized the role of spatial attention in the underlying deficit in neglect (149; 25). In the 1950s, Denny-Brown introduced the notion of "amorphosynthesis," meaning that patients with neglect were unable to synthesize contralateral stimuli into coherent percepts (50). Systematic theoretical approaches to neglect emerged in the 1970s.

Clinical manifestations

Presentation and course

	• Unilateral spatial neglect, or simply neglect—the reduced awareness of space to one side or activity toward that spatial area—commonly follows acute unilateral brain injury.
	• Neglect applies to one’s own body, the spatial area within one’s arm reach, or areas beyond reach.
	• Neglect can occur in the three dimensions of space centered about the patient.
	• Patients often are unaware of their neglect, and even when they are aware, commonly lack the ability to overcome the deficit.

Although patients with acquired brain lesions may often be generally inattentive, the term “neglect” is used to describe inattention that is primarily in one spatial direction. In the most severe instances, patients with neglect act as though entire regions of space have vanished from existence. They do not orient toward, respond to, or act on meaningful stimuli in one direction, usually contralateral to the side of brain injury (83). These patients are often lethargic in the first few days after brain damage and lie in bed with their head and eyes deviated ipsilaterally (Vulpian sign) (141). They may eat food only on ipsilateral parts of their plate. Despite being able to hear sound emanating from contralateral space, they may search only ipsilaterally for its source.

Often unilateral neglect as much involves over-attention to ipsilateral space as under-attention to contralateral space. The removal of prominent objects from ipsilateral space (even when performed by the patient) results in improved exploration of contralateral space (122; 177). When navigating with a wheelchair, patients with unilateral neglect may pay extra attention to ipsilateral obstacles, such that when traversing narrow passageways, they may “cross over” their activities toward the neglected side, thus demonstrating a paradoxical relationship with their surroundings that is not found under other circumstances (153; 202).

In addition, unilateral neglect commonly occurs with nonlateralized inattention (nonspatial attention deficit). Such deficits include reduced alertness and difficulty with maintaining attention to a particular task (187). This was shown by the lag when reacting to the appearance of a central visible symbol on a computer screen, incorrectly counting the number of auditory tones. Such deficits can also occur in the absence of unilateral neglect, thus reflecting general effects of brain damage.

A frequent finding in neglect is the mislocalization of stimuli that are presented on the neglected side of space, but that are reported or demonstrated by the patient to be on the opposite side (127). This phenomenon is termed allochiria (Greek for “other hand”). Allochiria may be seen on copying tasks (75), as well as with unilateral tactile, auditory, or olfactory stimuli (12; 127; 203).

In the early stages, patients may also neglect parts of their own bodies (personal neglect) and deny ownership of their contralateral limbs (somatoparaphrenia). Patients may fail to groom the contralateral side of the body and not comb part of their scalp or shave part of the face. Asymmetries of stance and gait after stroke have been correlated with concurrent spatial neglect (64). Despite being functionally devastated, as well as frequently having accompanying motor and sensory deficits, these patients often appear unaware of or peculiarly unconcerned about their condition; the lack of awareness is called anosognosia, and a lack of concern is called anosodiaphoria. An easily demonstrated finding in acute severe neglect is “one-handed clapping,” which occurs when the hemiplegic neglect patient is asked to clap hands together, but only brings the less-affected hand toward the body’s midline repeatedly, thus showing both neglect for the opposite hemibody as well as anosognosia for hemiplegia (138). Many patients with anosognosia for hemiplegia also have personal neglect for the same side (46). Personal neglect and extrapersonal neglect are not strictly associated with each other (19). Generally, personal neglect appears concurrently with severe extrapersonal neglect, although it is not unusual for extrapersonal neglect to occur without personal neglect (110).

It is surprising that some patients can acknowledge their neglect, but they fail to improve on it (28; 86).

The laterality of neglected stimuli may depend on the kinds of stimuli that are presented. In one case study, a patient with an intracerebral hemorrhage neglected right-sided stimuli when he marked nonverbal designs but showed primarily left neglect when reading aloud single words (44). These findings suggest that the spatial attributes of visual stimuli may not be processed all in the same manner, at least in persons who have neglect. In the chronic stages, some patients with neglect may hyperorient toward contralateral space and, thus, actually manifest ipsilateral neglect (105; 01); however, this phenomenon is specific to line bisection. In a case of acute focal parenchymal hemorrhage, ipsilateral neglect was discovered at 2 weeks into the illness, as reflected by neglect of ipsilateral double simultaneous visual stimuli and a contralateral deviation of the gaze (220). Concurrent brain imaging did not identify a new lesion. Such a case suggests that the regulation of directional spatial attention may not exclusively involve contralateral direction of attention at the level of the cerebral hemisphere.

Even healthy persons may have significant, albeit small, directional biases during certain tests (93), a phenomenon called “pseudoneglect.” This does not appear to affect everyday activities. Of interest, the incidence of pseudoneglect in Italy as inferred from left-sided commencing of marking targets on a cancellation test was noted to increase during the 2021 COVID pandemic, which was correlated with perceived stress (185). In addition, persons with acute brain injury that results primarily in hemianopic visual field loss and minimal other disturbance tend to strongly err toward their hemianopic fields during line bisection tests (99). The error is unrelated to the extent of the visual field loss, thus, leaving unexplained its precise mechanism (178). The clinical use of the term “neglect,” however, is intended for the pathologic (ie, extreme) occurrence of directional spatial bias, usually when accompanied by several specific nonlateralized cognitive disturbances (eg, generalized inattention, poor initiation of activity, anosognosia, emotional flattening). Because patients with acute, nonprogressive cerebral disease often recover, it is not surprising that their neglect may reduce. Hence, the initially dramatic presentation of neglect often yields to an intermittent, milder disorder that, in some cases, may not be recognized except through specialized testing (76).

Although neglect is more commonly recognized along the horizontal (left-right) axis, it also occurs along the altitudinal (up-down) and radial (near-far) axes. Patients, often with bilateral lesions, may neglect either upper or lower space, as well as either near or far peripersonal space (155; 180; 129). Finally, neglect may appear in two dimensions simultaneously, resulting in a “diagonal” skewing of inattention, such as toward the near-left parts of space (120; 121).

Objects in space are anchored to different reference frames. These frames are generally divided by researchers into viewer-centered, object-centered, and environment-centered coordinate systems. Viewer-centered frames refer to the location of stimuli in relation to the viewer: left-right, near-far, or above-below. These coordinates change with movement of the viewer. Environment-centered reference frames refer to an object's relationship to the environment, structured by geographic and gravitational coordinates. Object-centered coordinates refer to an object's intrinsic spatial coordinates of an object. Object-centered reference frames remain stable irrespective of movements of the viewer or object. Neglect may occur in any of these reference frames (106; 30; 53; 33; 128; 52).

Prognosis and complications

Across as well as within patients, the severity of neglect and pattern of recovery can be highly variable (76). Clinically, neglect has been assessed primarily following stroke. Hier and colleagues found that after right hemisphere stroke, visual inattention and neglect recovered much more quickly (median 8 to 9 weeks) than hemianopia (median 32 weeks) or hemiparesis (median 64 weeks). More subtle symptoms associated with neglect, such as extinction (median 19 weeks) and motor impersistence (median 26 weeks), lasted longer (85). Recovery was related to size of lesion, and hemorrhagic strokes recovered more quickly than ischemic strokes. Neglect severity and its recovery are also adversely affected by premorbid cortical atrophy, suggesting that the integrity of undamaged structures plays a role in the recovery from neglect (109). Unfortunately, studies that have evaluated neglect and its recovery have not used consistent methods, subject recruitment, criteria for neglect, or intervals between stroke onset and assessment. Consequently, definitive conclusions concerning the frequency, severity, and recovery from neglect are not available (24). Some studies suggest that the prevalence of neglect following acute stroke markedly reduces to about one third of its incidence by the end of the first year (161; 136). At 7 years, the number declines to about 10%. It is interesting that the patients with chronic neglect at 7 years also had significantly slowed target marking on cancellation tests (described under Diagnostic workup section) in the acute phase (66). The individual’s recovery course from neglect, however, can be inconsistent, showing marked fluctuations over time (92). This suggests that measuring neglect may be influenced by complex factors that change over time.

A lawful relationship has been found for neglect; the severity of neglect at 6 months after stroke is proportional to the initial severity of neglect, based on the cancellation test (225). Generally, the sixth-month severity of neglect is 70% of the initial severity. This relationship, which was found in other post-stroke deficits as well, suggests a biological limit to recovery, at least following usual care. However, this rule does not pertain to the most severe presentations of neglect.

Despite substantial reduction in the prevalence of neglect during stroke recovery, acute neglect is associated with longer hospitalizations and poorer recovery to functional independence in chronic stroke patients (49; 103; 191; 94; 37; 140; 27; 65). Following stroke, patients with neglect are more likely to have spasticity of their paretic limbs than patients without neglect (222). Neglect patients are prone to accidents resulting from collisions on their neglected side (200; 154). Recovery of arm motor function appears to be significantly affected by neglect (104). Neglect severity predicts the extent to which chronic stroke patients are homebound (137). However, other authors suggest that anosognosia, rather than neglect per se, is more often associated with poor functional recovery (143). In addition, the functional correlates of generalized inattention, which commonly accompanies neglect, have been little investigated (168). In a study of high-functioning acute stroke patients, a continuous performance test of attention was about as likely as a cancellation test of neglect to predict disability; the nonspatial attentional deficit was more common than neglect (08). Another study, however, found only that the occurrence of neglected targets on the ipsilateral side on a challenging cancellation test predicted disability after acute stroke, unlike contralateral neglect; this suggested that a general degree of inattention rather than unilateral neglect per se was more associated with self-care ability (21). However, these findings were not supported in a later, larger study that used a simpler cancellation test (212). Hence, there is no consensus concerning the relative strength of unilateral neglect versus nonlateralized inattention with regard to functional recovery after stroke at this time.

In addition, the prevailing view that spatial neglect is a leading correlate of poor functional recovery may be an artifact of clinical investigation, due to the ease of assessing neglect compared to other cognitive disorders. Consequently, neglect assessment has been favored over all other cognitive assessments in functional outcomes research after stroke (119). It is also worth noting that chronic unilateral spatial neglect in elderly stroke patients has been associated with previous stroke and deficits in multiple cognitive domains (111). Thus, neglect may be a nonspecific marker for extensive cerebral injury, which may help to indicate its predictive value for impaired functional recovery. The common association between unilateral neglect and nonlateralized attentional disturbances supports this notion (131).

Primate studies implicate interhemispheric and intrahemispheric mechanisms in recovery. Monkeys with neglect from frontal ablations have more severe neglect if the corpus callosum is divided (45; 216), suggesting that compensatory mechanisms are mediated through the contralateral hemisphere. However, the rate of recovery after callosal division remains relatively unchanged, implicating intrahemispheric factors in recovery (216). Consistent with these findings, recovery of severe left-sided neglect in humans is associated with remission of metabolic abnormalities in the left and undamaged right hemisphere on PET studies (144).

Clinical vignette

A 65-year-old man with left-sided weakness was brought to the hospital by his family. For the first 2 days of his hospitalization, he was lethargic but arousable. He lay in bed at an angle, and his eyes and head deviated to the right. As his level of arousal improved, he only shaved on the right side of his face and combed his hair on the right. When approached and talked to from his left, he oriented to the right when replying. At meals, he sometimes neglected the left side of his food tray. Food often collected in the left side of his mouth. The patient seemed unaware of his deficits, but he also seemed unconcerned about being in the hospital. He admitted to being weak but denied any specific left-sided weakness. He omitted left-sided targets on cancellation tasks and neglected left-sided details in copying tasks and in spontaneous drawings, neuroimaging studies revealed a large stroke in the distribution of the right middle cerebral artery.

Neglect of left-sided targets on cancellation tasks

This drawing demonstrates neglect of left-sided targets on cancellation tasks. (Contributed by Dr. Anjan Chatterjee.)
Neglect of left-sided details in copying tasks

This drawing demonstrates neglect of left-sided details in copying tasks. (Contributed by Dr. Anjan Chatterjee.)
Neglect of left-sided details

This spontaneous drawing demonstrates neglect of left-sided details. (Contributed by Dr. Anjan Chatterjee.)

In the subsequent weeks, he verbally acknowledged his left-sided weakness but had limited insight into the practical limitations imposed by his deficits. Physical therapists observed that he fatigued easily and seemed unmotivated during therapy sessions.

Biological basis

Etiology and pathogenesis

Asymmetries in spatial bias are undoubtedly phylogenetically ancient, even without neurologic disease. Lungfish, a species transitional between fish and amphibians, shows a consistent turning to the left with simulated predator approach and rightward turning during foraging (112). Similarly, humans misplace line bisections to a small but significant degree to the left of center, which is called pseudoneglect and suggests primarily right hemisphere recruitment for such tasks (93). The consistency of misplacing action toward the left dissipates in later life (59). Focal brain disease can thus aggravate natural spatial biases to a point that they are disabling.

Neglect is most often caused by stroke, tumor, or trauma. The etiopathogenesis of neglect involves sensory attentional, premotor intentional, and representational mechanisms.

Sensory attentional theories. These theories try to explain why patients with neglect are selectively aware of rightward stimuli and why neglect is more common and severe after right than left brain damage. Kinsbourne postulated that each hemisphere generates a vector of spatial attention directed toward contralateral space, and this attentional vector is inhibited by the opposite hemisphere (101). Support for this interhemispheric balance hypothesis came from applying of transcranial magnetic stimulation to the posterior parietal cortex in healthy individuals (47). Unilateral stimulation abolished the detection of contralateral visual signals, regardless of which hemisphere was stimulated, whereas bilateral simultaneous transcranial magnetic stimulation to the parietal cortices did not lead to inattention to visual signals. Research on experimental neglect in cats suggests that the interhemispheric imbalance may be related to differential metabolic activity between the superior colliculi, which has been termed the Sprague effect (172). Additional support comes from fMRI examination in recovery from acute left neglect following right hemisphere lesion, which indicates relatively increased left hemisphere activity that gradually subsides as neglect improves (41). The left hemisphere's vector of spatial attention is powerfully directed, whereas the right hemisphere only produces a weak vector. As a consequence of this neural organization of spatially directed attention, after right brain damage, the left hemisphere's unfettered vector of attention is powerfully oriented to the right. Because the right hemisphere's intrinsic vector of attention is only weakly directed, after left brain damage, there is not a similar orientation bias to the left. Thus, right-sided neglect is less common and not as severe as left-sided neglect.

In contrast to Kinsbourne, Heilman and colleagues proposed that the right hemisphere is dominant for arousal and spatial attention (81). Patients with right brain damage have greater electroencephalographic slowing than those with left brain damage. They also demonstrated diminished galvanic skin responses, compared to normal control subjects or patients with left hemisphere damage (79). According to this model, the right hemisphere is capable of directing attention into both hemispaces, whereas the left hemisphere directs attention only into contralateral space. Thus, after right brain damage, the left hemisphere is ill-equipped to direct attention into left hemispace. The more severe the neglect after right hemisphere damage, the more slowed the responses are to visual stimuli, even on the right side of space (11). After left brain damage, however, the right is capable of directing attention into both hemispaces, and neglect does not occur with the same severity as after right brain damage.

Posner and colleagues proposed that spatially directed attention involves elementary operations, such as "engage," "disengage," and "shift" (150). They reported that patients with right parietal damage are selectively impaired at disengaging attention from right-sided stimuli to shift toward and engage left-sided stimuli (152); this may account for some symptoms in neglect. However, some research suggests that voluntary exploration to the left may be intact in left neglect patients, as long as they can attend to closely spaced visual stimuli (116). Instead, the impairment may result from overactive automatic engagement of right-sided stimuli.

Motor intentional theories. Watson and colleagues advanced the idea that neglect patients may have a motor intentional deficit, a disinclination to initiate movements or move toward or into contralateral hemispace (214). Similarly, Rizzolatti and colleagues emphasized that the facilitation of perception by attentional mechanisms is a consequence of activation of circuits responsible for motor preparation (162). In most situations, attention and intention are inextricably linked, because attention is usually directed to objects on which one acts. To dissect intentional from attentional factors, however, Coslett and colleagues had patients bisect lines in right and left hemispace (43). Visual feedback for the task was restricted to a video monitor placed in either right or left hemispace. Thus, by dissociating the locus of attention (location of the monitor) from the locus of intention (location of their movements), they demonstrated that some patients' errors were primarily influenced by the intentional, rather than attentional, demands of the task. Bisiach and colleagues used a set of pulleys to dissociate the direction wherein attention and intention were moved in a line bisection task, and also confirmed the intentional influences on the deficits in some patients (17). Intentional neglect tends to be associated with frontal lesions; however, Mattingley and colleagues reported that slowness in the initiation of leftward movements is associated with right posterior lesions, whereas slowness in the execution of leftward movements is associated with right anterior and subcortical lesions (126).

Representational theories. Representational theories propose that the inability to form adequate contralateral mental representations of space underlies the behavioral deficits in neglect (16). Bisiach and Luzzatti asked two patients to imagine the Piazza del Duomo in Milan, Italy, from two perspectives: looking into the square toward the cathedral and looking from the cathedral door into the square (18). The patients only reported structures to the right of their imaginal space, resulting (in both conditions) in the reporting of different structures. Rapid eye movements in sleeping neglect patients are also restricted ipsilaterally (51), raising the possibility that these patients' dreams are spatially restricted.

Cortical lesions. Neglect is more commonly associated with right than left hemisphere damage (60). The technique of lesion-symptom mapping in stroke patients has identified the following loci important to the manifestations of neglect: the inferior parietal lobule for perceptual aspects of neglect, the dorsolateral prefrontal cortex for the motor-exploratory aspects of neglect, and the deep temporal lobe for object-centered neglect (210). The cortical areas associated with neglect are supramodal or polymodal, areas into which unimodal association cortices project. This observation underscores the idea of neglect as a spatial disorder, not one of primary sensory processing (such as a visual field defect).

Subcortical lesions. Subcortical lesions in the thalamus, basal ganglia, and midbrain may also produce neglect. Neglect in humans is associated with decreased arousal (79). Interruptions of ascending monoaminergic or cholinergic projections may, in part, mediate this clinical observation. The thalamic extension of the reticular system (nucleus reticularis) is a thin shell of neurons encasing much of the thalamus. These neurons inhibit sensory thalamic relays to the cortex. Both ascending mesencephalic reticular systems and polymodal association cortices project to and inhibit the nucleus reticularis. Therefore, damage to these systems may result in a release of the inhibitory action of the nucleus reticularis on thalamic relay nuclei, with the resultant impairment of sensory processing (215). Damage to the pulvinar, having reciprocal connections with the posterior parietal lobule, may also produce neglect. Lesions of the basal ganglia, being tightly linked to prefrontal and cingulate cortices, may also produce neglect (84) and particularly are associated with a motor disturbance of neglect, directional hypokinesia (174).

Distributed neural networks. The clinical observations that lesions to disparate cortical and subcortical structures produce neglect led Heilman and colleagues to propose that an anatomically distributed network mediates spatially directed attention (80; 215; 82). The limbic connections to the anterior cingulate may provide an anatomic basis for the abnormal alerting (213) or poor motivation in neglect patients. Mesulam also proposed a similar model and suggested that different regions within a large-scale network implement different aspects of an individual's interaction with the spatial environment (132), thus, emphasizing the interconnectivity of the different brain regions associated with neglect. Support for this model was found by a tract-based spatial statistics imaging evaluation of patients with post-stroke neglect (115). In the subacute phase, neglect was associated primarily with reduced white matter integrity along the superior longitudinal fasciculus of the damaged hemisphere, which links intrahemispheric frontal and parietal cortical regions. In contrast, in the chronic phase, neglect was primarily associated with structural disruption of the posterior portion of the corpus callosum, which links interhemispheric posterior brain regions. Primate studies indicate that neurons within frontal and parietal cortices are selectively sensitive to stimuli encoded in distinct spatial reference frames (40).

Functional MRI has been used to evaluate the coherence of oxygen-dependent metabolic changes in disparate brain areas in response to particular attentional tasks. He and colleagues have postulated that neglect commonly results from disruption of two systems: a bihemispheric dorsal attentional network linking the dorsal parietal cortex with the ipsilateral frontal eye field, which is involved with allocating attention to contralateral visual targets; and a ventral attentional network that, in contrast, is in the right hemisphere and mediates attention to unexpected events from either side (78). This ventral system links the temporoparietal junction with ipsilateral ventral frontal cortex. Functional MRI research supports these metabolically linked systems. Neglect tends to result from lesions that overlap more the ventral than dorsal networks, even though functional connectivity within both systems may be acutely disrupted. However, He and colleagues found that in neglect patients the dorsal network tends to recover more than the ventral network. This account suggests why patients who have recovered from unilateral spatial neglect may nonetheless have impaired functional recovery long after stroke onset, owing perhaps to reduced recovery of the ventral attentional system (103).

Motor neglect. This term applies to the patient’s lack of initiating use of parts of the body contralateral to the brain lesion, specifically the limbs, unless cued to move (31). In contrast to the perceptual and intentional aspects of neglect, as of now no pathophysiological model for motor neglect has been developed (10).

Epidemiology

Spatial neglect may follow focal brain injury on either side, but it is more commonly recognized following right hemisphere injury (161). However, within the first week of stroke onset, neglect has been found to occur with nearly equal frequency following right versus left hemisphere injury (192). Another study using a different method of assessment found reduced neglect incidence following left hemispheric stroke in the first week of onset, but with about the same severity as following right hemispheric stroke (193). Spatial neglect is most commonly associated with acute stroke; as many as two thirds of acute right hemisphere stroke patients may show neglect (141). Neglect after stroke is more common with older age, cortical rather than subcortical lesions, and larger lesions (161; 68). Neglect may occur in as many as 30% to 40% of patients with traumatic brain injury who are admitted for acute neurologic rehabilitation and evaluated by occupational therapists on functional tasks (36). The disorder has also been identified in many persons with posterior cortical atrophy, an uncommon neurodegenerative disease of older age (04). Early in Parkinson disease, when motor symptoms are biased to one side, a modest amount of unilateral neglect has been found in patients with predominantly left motor deficits, unlike patients with right-sided motor deficits (211). Effects of such spatial bias on everyday activities in Parkinson disease have not so far been evaluated. Rare reports have also observed neglect in Alzheimer disease and Huntington disease, in association with asymmetric cerebral atrophy or metabolism (209; 87). Persons with cervical dystonia can show greater error when pointing to distant objects in their left hemispace compared to the right hemispace, regardless of the hand used (199). This phenomenon may not qualify as neglect, yet the lateralized imprecision in these patients suggests an asymmetric self-monitoring of performance.

Individuals of any age may be affected by neglect following focal brain injury. Although uncommon, neglect has been reported in children as young as age 7 months (107; 23).

Differential diagnosis

Confusing conditions

Neglect needs to be differentiated from lateralized sensory deficits such as hemianopic visual field defects, hemisensory loss, or unilateral hearing loss. Such deficits may coexist with neglect but are neither necessary nor sufficient to produce neglect. Patients with hemianopias and without neglect who are evaluated on other assessments can successfully explore contralateral portions of space (90). Patients with a “pure” hemianopia who lack other evidence of contralesional hemispatial neglect may significantly err when bisecting horizontal lines, but the errors tend to be negligible. The error on horizontal lines toward the side of hemianopia may represent a substantial behavioral compensation to adapt to the loss of vision to one side (188). Tactile neglect may be differentiated from somatosensory loss by the improvement of awareness of stimuli in the former condition by explicitly requiring the patient to focus attention on the deficient side of the body (146). Neglect is also distinguished from integrative visual disorders such as visual agnosias, in that in the former, processing of the same stimulus varies along a spatial axis. In agnosias, recognition is not affected by the spatial location of the stimuli.

Similarly, neglect must be differentiated from unilateral weakness. “Motor neglect” is recognized when patients are disinclined to move their contralateral limbs spontaneously but improve when prompted (31). Often, depending on the social environment and motivation, hemiparetic stroke patients vary in the extent of spontaneous use of the more affected limb (05). Evidence indirectly supports the existence in humans of conditioned inhibition of limb use on the hemiparetic side (“learned nonuse”), in contrast to an unlearned mechanism that can be ascribed to spatial neglect (197). A possibly valid distinction between motor neglect and learned nonuse is that only patients with the latter disorder will complain of motor failure (123). It has also been suggested that because motor neglect is one form of acute attentional disorder, it should, in most instances, gradually improve, whereas learned nonuse, which becomes conditioned by unsuccessful movement attempts, should not ordinarily improve without the intervention of a specific rehabilitation program (197).

Numerous studies have drawn attention to “neglect-like phenomena” that are associated with acutely acquired unilateral limb pain, most often following trauma to the limb. This distinct disorder, termed complex regional pain syndrome (CRPS), has been associated with reduced spontaneous movement of the limb and increased effort to move the limb, independent of the occurrence or severity of the pain itself (61; 62; 58). Further research has found that persons with CRPS involving one limb can demonstrate unilateral neglect specifically for one’s own body (and not always with respect to the painful limb), but not for other aspects of the environment (158). If a subcategory of unilateral neglect, termed somatospatial inattention, were confirmed in CRPS, this could represent a form of pathological unilateral bodily neglect that somehow results as a reaction to injury located outside of the brain.

Associated or underlying disorders

Disorders that commonly occur with unilateral neglect include hemiparesis (ie, deficit in voluntary limb movement unrelated to inattention) and hemianopia (lack of visual perception to one side that is not modified by attention). In addition, particularly in acute presentation, neglect often occurs with anosognosia for hemiparesis as well as the neglect itself, emotional aprosodia (diminished modulation of vocal tone in relation to emotion), and anosodiaphoria (diminished emotional reaction to one’s own impairment, while acknowledging it). In addition, patients with unilateral neglect generally also have nonspatial inattention (207). Among such deficits are reduced arousal and limited sustained attention, which can be assessed by the elevator tone counting task from the Test of Everyday Attention (167).

Diagnostic workup

Several bedside tasks are used by neuropsychologists or other clinicians to detect neglect and assess its severity. These are simple enough for any clinician to perform.

Line bisection. Patients are asked to place a mark at the midpoint of lines (which are usually horizontal). The task is generally administered without restricting head or eye movements, and without time limitations. Patients with left-sided neglect typically place their mark to the right of the true midposition (176).

Cancellation. In cancellation tasks, sheets with arrays of targets are placed before patients. Patients are asked to place a mark on, or "cancel," each of the targets. Similar to line bisection tasks, cancellation tasks are usually administered without restricting head or eye movements and without time limitations. Patients with left-sided neglect cancel targets on the right side of arrays and neglect targets on the left (02).

Neglect of left-sided targets on cancellation tasks

This drawing demonstrates neglect of left-sided targets on cancellation tasks. (Contributed by Dr. Anjan Chatterjee.)

Increasing the number of targets may uncover neglect not evident on arrays with fewer targets (35). Although there can be variation of neglect on repeated administration of a cancellation test, generally the test reliably discriminates between patients with mild and more severe neglect over repeated administrations (117).

The sensitivity of cancellation tasks may be increased by presenting arrays wherein targets are difficult to discriminate from distracter stimuli (156). In addition, requiring the patient to cognitively manipulate the stimuli can aggravate neglect, such as, for example, requiring cancellation only of multiples of a specific number (such as 5) in an array of diverse numerals (130). Thus, the most sensitive cancellation tasks would contain a large number of stimuli (greater than 50), with distracters that are difficult to discriminate embedded in the array, and require identifying targets based on mental manipulations. However, the clinician can provide a simple cancellation test by drawing a patternless array of 20 lines 2 cm long, oriented in different directions across a sheet of hospital chart paper. The omission of two or more lines to one side will identify neglect in the more severe instances.

Although unilateral spatial neglect on cancellation tests has usually been graded by the number of omissions remaining after the patient has signaled test completion, this method is insensitive to the extent to which the omissions were located to one side. As an alternative, some authors have recommended calculating (or allowing a computer to calculate) the “center of cancellation,” that is, the geographic center of all of the canceled targets in relation to the width of the display (170). This method, thus, directly indicates the severity of the lateral spatial bias on the test.

Drawing. When asked to copy stimulus arrays with multiple objects, or complex objects with multiple parts, patients may omit left-sided objects in the array or omit the left side of individual objects, regardless of where they appear in the array (125; 179). Occasionally, patients may draw left-sided features of target items with less detail or even on the right side of their drawings (75).

Neglect of left-sided details in copying tasks

This drawing demonstrates neglect of left-sided details in copying tasks. (Contributed by Dr. Anjan Chatterjee.)
Neglect of left-sided details

This spontaneous drawing demonstrates neglect of left-sided details. (Contributed by Dr. Anjan Chatterjee.)

Reading. Patients with left-sided neglect may have trouble bringing their gaze to the left margin of the page when reading text. As a consequence, they may read lines starting in the middle of the page, resulting in sequences of words or sentences that do not make sense. When reading single words, they may either omit left-sided letters or substitute them with confabulated letters (34). Thus, the word "walnut" might be read as either "nut" or "peanut." This reading disorder is called neglect dyslexia (102).

Orientation to one’s own body: tests of personal neglect. A couple of assessments for examining the patient’s self-awareness of the body’s spatial extent have been popular. The Zoccolotti and Judica scale involves grading the extent to which the limb crosses over to the neglected side during requested use of a comb, razor for men, and facial powder for women (232). The Fluff Test, in contrast, examines whether patients can find lint (or “fluff”) on the contralesional arm and leg, following applying cardboard circles with Velcro on them; patients are required to find the circles with eyes closed (39). Personal neglect recovers to a different extent than extrapersonal neglect, which suggests that these are different processes that are involved with neglect (89).

Orientation to the environment. The patient’s spatial navigation can be assessed by placing target squares on both sides of hallways, and then to have the patient to either walk or propel a wheelchair through the hallways, and then find the targets (135). Alternatively, course collisions can be measured (154; 202). Although these assessments can indicate spatial neglect during self-operated navigation in hallways, the generalization of these findings to other test sites has not been evaluated. Moreover, measuring neglect in hallways may be complicated by the occurrence of patients or staff in the hallway, or arranging the exclusion of such individuals during testing.

Spontaneous visual exploration of pictures presented to the front of patients can be measured with infrared eye tracking. An advantage of this approach is that it can be used for individuals with severe aphasia, who might not comprehend other forms of testing (97). Whether this approach excels over simple clinical evaluation of patients at the bedside by inspection needs to be determined.

Double simultaneous stimulation. Many patients with neglect also demonstrate extinction to double, bilateral simultaneous stimulation. Extinction refers to the unawareness of stimuli that can be perceived alone but are lost when competing stimuli are simultaneously presented to the side that commands greater attention (13). Extinction may occur in visual, auditory, or tactile modalities. At the bedside, extinction may be tested by asking patients to count fingers presented to one or both hemifields, snapping fingers at one and both ears, and touching one and both hands. When presented with stimuli on both sides, patients with neglect preferentially report the stimulus ipsilateral to the brain lesion. Extinction for contralateral stimuli cannot be tested in the presence of a primary contralateral sensory disorder such as a visual field defect, unilateral hearing loss, or lateralized somatosensory loss. However, extinction of stimuli may be observed with double strictly ipsilateral visual or tactile stimuli (157; 54).

Virtual reality assessment. This kind of assessment is an emerging technology to assess and treat spatial neglect (173). In its present experimental version, head-worn virtual reality displays can allow assessing radial (ie, near vs. far) spatial biases or neglect in stroke patients (73).

Neglect test batteries. The Behavioural Inattention Test is a standardized neuropsychological battery to assess neglect (223). This test incorporates many of the conventional bedside tests above and provides scores that can be used to monitor change, recovery, or response to treatment. The test also simulates several spatial daily living activities, such as clock reading or recognizing objects from a familiar indoor scene.

The Catherine Bergego Scale (CBS) was developed as a structured method for assessing neglect on activities of daily living (07). The test battery is reliable, valid, and sensitive to change during rehabilitation (06). Although the CBS has gained popularity for assessing neglect on functionally related activities under test conditions in the clinic, it has also been shown to predict the extent of home-bound behavior in chronic patients (137). However, whether neglect per se is primarily responsible for home confinement among patients is not yet clear. Academic occupational therapists have suggested that the CBS should be revised to accommodate more complex, instrumental activities to improve sensitivity to unilateral spatial neglect on real-world daily living activities (69).

Simulated driving. Generally, neglect is assessed with static stimuli, for example, the cancellation test, in which the stimuli are immobile. Double simultaneous stimulation presents stimuli that although they flicker, they are situated in a relatively restricted area of space and are simple. Although more elaborate presentation of dynamic stimuli can uncover neglect, the methods at present are not standard or readily affordable. Spreij and colleagues found that a subset of acute stroke patients could show unilateral neglect on a simulated road test when they had appeared to have recovered on static neglect tests (190). It is surprising that other patients in their study showed the opposite dissociation, in which they showed neglect on static tests but normal performance on the driving simulation. There is at present no model that can account for these dissociations, other than to conclude that neglect is not all the same from one person to the next. Such findings underline the importance of providing a variety of assessments of directed spatial attention that may indicate the vulnerability of patients toward dependency or injury in different real-world tasks and conditions.

Management

Neglect patients may be distinguished by highly variable performance toward contralateral space, rather than a fixed deficiency of contralateral exploration (03). Hence, there is hope for improving contralateral inattention. Numerous promising rehabilitation approaches have been evaluated to date; a comprehensive overview of these methods as well as their historical development is available (100). However, most of these studies have assessed laboratory-based measures of neglect rather than measures from actual daily living activities, thus, limiting the rehabilitation implications of the findings (160). Moreover, long-term follow-up in these studies is generally lacking, and small sample sizes have limited statistical power (229). Although many of the more encouraging forms of treatment are reviewed below, presently there is insufficient evidence of treatments for real-world functional activities (224), and therefore, there is no recommend routine use of these in clinical practice (183).

Scanning. Weinberg and Diller developed an extensive rehabilitation program wherein patients with neglect are trained to systematically scan and explore the left side of space (218). This program is labor intensive, requiring 20 to 35 hours of training. Patients with severe neglect are most likely to improve. Benefit beyond the specific tasks being trained seems limited (163). This technique has been modified to train trunk rotation toward the neglected side in patients who can stand without assistance (221). Smooth pursuit scanning training of moving stimuli on a computer screen has preliminarily been reported to show a benefit over more basic visual scanning training of stationary stimuli (98). A computer-assisted scanning training program can improve wheelchair maneuvering in patients with neglect (217). The benefit on home activities in these approaches has, thus far, not been evaluated.

In a novel variant of scanning training, patients with left neglect had to practice musical scales and familiar melodies in a largely right to left manner on a xylophone (22). Excursions toward the left were furthermore shaped by spacing apart the chime bars with practice. This approach shows improved neglect on standard tests and suggests a motivationally based enhancement of spatial training.

Sensory cueing. Butter and colleagues postulated that dynamic visual stimulation would activate collicular neurons and serve as an attentional cue prompting patients to orient to the left side. They created a line bisection task on a computer screen wherein small squares on the top and bottom of the left end of lines appeared to jump back and forth (26). Patients' performances improved when patients were required to point to the middle of line with the dynamic visual stimulation at the left. Following this lead, they placed light-emitting diodes on the left edge of patients' spectacles. Unfortunately, the improvements on task performance did not generalize to everyday activities. Findings suggest that improved neglect under these circumstances does not result from nonspecifically improved arousal (148).

Motor cueing. Patients perform better on line bisection tasks if they use their left hand (74). These improvements can be matched if the right hand is first brought to the left end of the line (motor cueing) before patients bisect the lines. Robertson and colleagues similarly showed that some patients with neglect improve after being trained to use their left hand by placing it at the left margin of the area wherein an activity is to take place. Further analysis suggests that it is the movement of the arm, or the motor activation, rather than perceptual anchoring of the limb, that contributes to the improvement. These improvements may generalize to activities of daily living (165), and they may be specific to neglect in peripersonal space (164). Passive movement to the left arm may also benefit neglect on standard neuropsychologic tests (57).

Mirror training. In a variant of motor cueing, Pandian and colleagues observed that left neglect patients who practiced flexion-extension movements of their left hands (which were paretic) while their view of their left hands was blocked by an upright mirror, which overlay the image of their right hands practicing the same maneuvers, experienced significant and prolonged improvement on spatial tests (139). Moreover, the patients who had undergone such training were significantly less likely to be dependent for basic activities of daily living at 6 months follow-up compared to patients who had not undergone such training. The basis for this benefit is unclear. Pandian and colleagues suggested that observing the illusion of paretic hand movement may have stimulated premotor neurons in the damaged hemisphere and, thus, in some manner secondarily improved mechanisms of contralateral spatial exploration (139). Replication will be required with tighter control over lesion location before this simple but encouraging intervention can be accepted as treatment for neglect.

Eye patching. Posner and Rafal suggested that patching the right eye in left-sided neglect would decrease left superior collicular activation and mitigate the leftward orientational bias by altering the balance of activation between the colliculi (151). Each colliculus receives input from the contralateral eye and also inhibits the contralateral colliculus. In animal models, neglect is reduced by damaging the ipsilesional superior colliculus or by transecting the intracollicular commissure (189). Despite some encouraging findings, research to date has not identified a consistent benefit from eye patching in neglect (184).

Prism adaptation. Investigations into the use of spatially distorting lenses that bring the field of view toward the right have shown improved spatial attention and gaze in patients with left neglect (182). The training involves pointing to targets across a table without viewing the arm while wearing the lenses. In a 2023 review of studies of this approach for unilateral neglect, there was no evidence of benefit on functional activities (195).

Optokinetic stimulation. Despite numerous efforts to introduce optokinetic stimulation toward treating neglect, which continue to the present, research has not yet established that this intervention has any benefit over other interventions for neglect (147).

Vestibular stimulation. Injecting cold water into the ear contralateral to the lesion stimulates the vestibular system and temporarily ameliorates neglect (171). Interestingly, hemiparesis in neglect patients may also temporarily improve with cold water irrigation, unlike hemiparetic patients without neglect (169). Side-effects of vestibular stimulation, such as nausea, are not reported in neglect patients. It is not clear if improvement from vestibular stimulation is mediated through modality-specific (vestibular) mechanisms, or through increases in general arousal. Simply shifting orientation by driving the eyes to the left cannot be the only factor. Reported transient resolution of somatosensory inattention and anosognosia (29; 20) are not easily explained by the shift in gaze.

Cutaneous electrical stimulation. Contralateral electric stimulation of the neck has been examined in neglect patients, with various levels of success. Conflicting results have been reported regarding the effect of transcutaneous electric nerve stimulation to the neck on standard paper-and-pen assessments of neglect (copying, cancellation) (95; 204). In contrast, transcutaneous electric nerve stimulation seems to benefit the spatial completion of object drawings from memory and spatial orientation in environments devoid of distinguishing features (72; 71). Furthermore, transcutaneous electric nerve stimulation has also benefited sitting posture control in patients with neglect (145). These findings suggest that transcutaneous electric nerve stimulation may serve as a “sensory prosthesis” to compensate for some of the functional impairments of neglect. However, as with vestibular stimulation, the improvement is transient. It is, therefore, not yet clear whether transcutaneous electric nerve stimulation may be chronically effective in ameliorating neglect.

In related research, one study found benefit of electrical stimulation to the contralateral arm in most patients with neglect who were studied, with measurable benefits as long as 6 months after treatment and with apparent carryover to real-world activities, as reflected by improvement on the Barthel Index (77). The investigators suggested that an improved weighting of proprioception in the contralateral arm may have fostered these improvements.

Virtual reality training. In a 2023 review of various virtual reality interventions for unilateral spatial neglect, 26 studies met inclusion for review (173). Although, in general, the studies benefited within-laboratory assessments, there was scant evidence for translating the treatment benefits to real-world activity apart from a few single-case studies. Considerable growth in this area is needed before deciding whether this approach can benefit patients with neglect after they conclude their training.

Noninvasive cerebral stimulation. Nearly a decade of research has consistently indicated that repetitive transcranial magnetic stimulation (rTMS) over the left scalp among persons with left neglect can ameliorate the disorder, most likely as a result of reducing the amount of interhemispheric inhibition from the left hemisphere upon the right by way of the corpus callosum (32). The extension of improvement on laboratory tests to the real world has not so far been evaluated. Because treatment effects have not so far been shown to extend beyond a few weeks, it is doubtful that rTMS will advance to becoming a standard treatment for neglect. Similarly, some benefits of transcranial direct current stimulation (tDCS) have been reported for neglect (194; 48), but thus far without indicating improvement for daily living activities. A trial that combined rTMS with sensory cuing (in this case, a buzzer episodically stimulating the left arm) benefited neglect on formal tests, and yet had no benefit on self-care skills (228).

Pharmacological treatment. Lesions to ascending dopaminergic pathways in rats produce behavioral abnormalities that resemble neglect. The dopaminergic agonist, apomorphine, ameliorates these deficits, and this improvement can be blocked by pretreatment with spiroperidol, a dopamine receptor blocking agents (42). These observations led to a small open trial of the dopamine agonist bromocriptine in two patients with neglect (56). Both patients' performances improved on neuropsychologic testing. One patient had noted improvement in her activities of daily living as reported by her husband. Bromocriptine may produce greater improvement than methylphenidate (88). Levodopa with carbidopa (like bromocriptine, a standard treatment for Parkinson disease) at a dose of 25 to 100 mg three times a day has been associated with improved neuropsychologic test performance and functional activities in stroke (134). However, a control group was not assessed and, therefore, it was not clear how much benefit the medication had over spontaneous recovery. In a related study, levodopa 100 mg every morning was associated with significantly improved neglect dyslexia, which persisted after discontinuation of the drug (175). Dopamine agonists may be more effective in treating perceptuomotor behaviors than strictly perceptual ones (63). Methylphenidate has been reported to improve line bisection error in children with attention deficit hyperactivity disorder (181). The reinstatement of recovered unilateral neglect by a gamma aminobutyric acid agonist (midazolam) suggests that GABA antagonists may benefit recovery from neglect (108). A preliminary study has associated the improvement of arousal and unilateral right neglect with modafinil (226). Similarly, a noradrenergic agonist that is generally used to treat hypertension, guanfacine, has been shown to improve spatial inattention after stroke on computerized cancellation assessment (118), but the benefit to daily living activities was not evaluated. A trial of transdermal nicotine in stroke benefited arousal but had only limited effect on neglect (114).

These reports of pharmacologic efficacy in neglect are single-case or small-case series. Side effects may ensue (63), and treatment may even exacerbate inattention or search inefficiency (70; 09). Although the value of pharmacologic treatment in the neglect syndrome deserves improved understanding, one must consider the potential for such treatment to interfere with neurologic rehabilitation (159).

Constraint-induced movement therapy (CI therapy). Constraint-induced movement therapy for chronic mild-moderate hemiparesis involves restricting use of the less-affected arm while promoting use and repetitive task practice with the more-affected arm. In one study of an infant with congenital hemiparesis and unilateral spatial neglect (23), 1 year of training (without actually restraining the less-affected arm) was associated with improvement in both impairments. In a study of three children, constraint-induced movement therapy was reported to have limited benefit for spatial neglect (38). Whether such extended training would be practical in most clinical settings remains unclear. However, one trial of 3 weeks of constraint-induced movement therapy for post-stroke adults observed a significant improvement on the Catherine Bergego Scale of neglect assessments of everyday activities (227). Another study observed neglect patients to benefit in their use of the more paretic arm after constraint-induced movement therapy, although without indicating whether real-world neglect tasks had themselves improved (219). Encouraging as these findings are, it is important to note that preliminary studies have found that cognitive impairment may limit the treatment gains from constraint-induced movement therapy for adults (205; 124), and so the generalizability of constraint-induced movement therapy for patients with spatial neglect at present is uncertain. On the other hand, it may be possible to adapt the constraint-induced movement therapy method to systematically improve unilateral inattention without motor training; an outline of such an approach has been published (196).

Improving motivation. Providing a pleasant setting or rewards for spatial task completion can benefit neglect. For example, paying a patient for each canceled stimulus can improve neglect during formal testing (133). Neglect during cancellation can also improve when music that is preferred by the patient is played (186) or when classical music is played (201). In a variant of this approach, the lateral source of the favorite music of neglect patients was gradually shifted toward the neglected side over 10 minutes (96). The benefits were shown on a cancellation test and self-selected visual exploration of pictures. However, such interventions have not been shown to carry over to real-world activities.

General attention training. Patients with unilateral neglect commonly have disturbances of general (ie, nondirectional) attention (131). Attempts to improve neglect through training alertness or general attention has had limited success thus far (166; 198; 208).

Outcomes

Numerous clinical trials for unilateral neglect have not been found to improve everyday activity for any personally relevant extended periods (113). For example, although a trial to improve general attention in neglect patients initially improved the Catherine Bergego test and the Barthel scale, the gains receded to baseline by 3 months (206). In a review of clinical trials of mirror therapy for unilateral neglect (230), one study in the Chinese literature reported improvements on the Barthel activities scale at 1 month follow-up but no further follow-up was reported.

In short, there is yet to be demonstrated a form of neglect therapy that can yield to sustained gains in functional improvement after discharge from the program.

Media

References

01: Adair JC, Chatterjee A, Schwartz RL, Heilman KM. Ipsilateral neglect: reversal of bias or exaggerated cross-over phenomenon. Cortex 1998;34:147-53. PMID 9534001
02: Albert ML. A simple test of visual neglect. Neurology 1973;23:658-64. PMID 4736313
03: Anderson B, Mennemeier M, Chatterjee A. Variability not ability: another basis for performance decrements in neglect. Neuropsychologia 2000;38:785-96. PMID 10689054
04: Andrade K, Samri D, Sarazin M, et al. Visual neglect in posterior cortical atrophy. BMC Neurol 2010;10;10:68. PMID 20698982
05: Andrews K, Stewart J. Stroke recovery: he can but does he. Rheumatol Rehabil 1979;18:43-8. PMID 424667
06: Azouvi P. The ecological assessment of unilateral neglect. Ann Phys Rehabil Med 2017;60:186-90. PMID 26830087
07: Azouvi P, Marchal F, Samuel C, et al. Functional consequences and awareness of unilateral neglect: study of an evaluation scale. Neuropsychol Rehabil 1996;6:133-50.
08: Barker-Collo S, Feigin VL, Lawes CM, Parag V, Senior H. Attention deficits after incident stroke in the acute period: frequency across types of attention and relationships to patient characteristics and functional outcomes. Top Stroke Rehabil 2010;17:463-76. PMID 21239370
09: Barrett AM, Crucian GP, Schwartz RL, Heilman KM. Adverse effect of dopamine agonist therapy in a patient with motor-intentional neglect. Arch Phys Med Rehabil 1999;80:600-3. PMID 10326927
10: Bartolomeo P. Visual and motor neglect: clinical and neurocognitive aspects [review]. Rev Neurol (Paris) 2021;177(6):619-26. PMID 33455830
11: Bartolomeo P, Chokron S. Left unilateral neglect or right hyperattention? Neurology 1999;53:2023-7. PMID 10599775
12: Bellas DN, Novelly RA, Eskenazi B, Wasserstein J. Unilateral displacement in the olfactory sense: a manifestation of the unilateral neglect syndrome. Cortex 1988;24:267-75. PMID 3416609
13: Bender MB, Furlow CT. Phenomenon of visual extinction and homonomous fields and psychological principles involved. Arch Neurol Psychiatry 1945;53:29-33.
14: Benton AL. Jaques Loeb and the method of double stimulation. J Hist Med Allied Sci 1956;11:47-53. (Reprinted in Costa L, Spreen O, editors. Studies in neuropsychology. Selected papers of Arthur Benton. New York: Oxford University Press, 1985:103-8.)
15: Bianchi L. The functions of the frontal lobes. Brain 1895;18:497-522.
16: Bisiach E. Mental representation in unilateral neglect and related disorders: the twentieth Bartlett Memorial lecture. Q J Exp Psychol 1993;46A:435-61. PMID 8378550
17: Bisiach E, Geminiani G, Berti A, Rusconi ML. Perceptual and premotor factors of unilateral neglect. Neurology 1990;40:1278-81. PMID 2381538
18: Bisiach E, Luzzatti C. Unilateral neglect of representational space. Cortex 1978;14:129-33. PMID 16295118
19: Bisiach E, Perani D, Vallar G, Berti A. Unilateral neglect: personal and extra-personal. Neuropsychologia 1986;24:759-67. PMID 3100983
20: Bisiach E, Rusconi M, Vallar G. Remission of somatoparaphrenic delusion through vestibular stimulation. Neuropsychologia 1991;29:1029-31. PMID 1762671
21: Blanc-Garin J. Patterns of recovery from hemiplegia following stroke. Neuropsychol Rehabil 1994;4:359-85.
22: Bodak R, Malhotra P, Bernardi NF, Cocchini G, Stewart L. Reducing chronic visuo-spatial neglect following right hemisphere stroke through instrument playing. Front Hum Neurosci 2014;8:413. PMID 24966827
23: Bollea L, Rosa GD, Gisondi A, et al. Recovery from hemiparesis and unilateral spatial neglect after neonatal stroke. Case report and rehabilitation of an infant. Brain Inj 2007;21:81-91. PMID 17364523
24: Bowen A, McKenna K, Tallis RC. Reasons for variability in the reported rate of occurrence of unilateral spatial neglect after stroke. Stroke 1999;30:1196-202. PMID 10356099
25: Brain WR. Visual disorientation with special reference to lesions of the right hemisphere. Brain 1941;64:224-72.
26: Butter CM, Kirsch NL, Reeves G. The effect of dynamic stimuli on unilateral spatial neglect following right hemisphere lesions. Rest Neurol Neurosci 1990;2:39-46. PMID 21551871
27: Buxbaum LJ, Ferraro MK, Veramonti T, et al. Hemispatial neglect: Subtypes, neuroanatomy, and disability. Neurology 2004;62:749-56. PMID 15007125
28: Cantagallo A, Della Sala S. Preserved insight in an artist with extrapersonal spatial neglect. Cortex 1998;34:163-89. PMID 9606584
29: Cappa S, Sterzi R, Guiseppe V, Bisiach E. Remission of hemineglect and anosognosia during vestibular stimulation. Neuropsychologia 1987;25:775-82. PMID 3501552
30: Caramazza A, Hillis AE. Levels of representation, coordinate frames, and unilateral neglect. Cogn Neuropsychol 1990;7:391-445.
31: Castaigne P, Laplane D, Degos JD. Three cases of motor-disorder due to retro-rolandic lesions [Article in French]. Rev Neurol (Paris) 1970;122(4):233-42. PMID 5472040
32: Cazzoli D, Müri RM, Hess CW, Nyffeler T. Treatment of hemispatial neglect by means of rTMS—a review. Restor Neurol Neurosci 2010;28:499-510. PMID 20714074
33: Chatterjee A. Picturing unilateral spatial neglect: viewer versus object centered reference frames. J Neurol Neurosurg Psychiatry 1994;57:1236-40. PMID 7931386
34: Chatterjee A. Cross over, completion and confabulation in unilateral spatial neglect. Brain 1995;118:455-65. PMID 7735886
35: Chatterjee A, Mennemeier M, Heilman KM. A stimulus-response relationship in unilateral neglect: the power function. Neuropsychologia 1992;30:1101-8. PMID 1484604
36: Chen P, Hreha K. Spatial neglect not only occurs after stroke but also after traumatic brain injury. Ann Phys Rehabil Med 2023;66:101778. PMID 37890428
37: Cherney LR, Halper AS, Kwasnica CM, Harvey RL, Zhang M. Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect. Arch Phys Med Rehabil 2001;82:322-8. PMID 11245753
38: Chevignard M, Azzi V, Abada G, et al. Intérêt de la thérapie par contrainte induite chez l’enfant hémiplégique après lésion cérébrale acquise. [Article in French] Ann Readapt Med Phys 2008;51:238-47. PMID 18395284
39: Cocchini G, Beschin N, Jehkonen M. The Fluff Test: a simple task to assess body representation neglect. Neuropsychol Rehabil 2001;11:17-31.
40: Colby CL. Action-oriented spatial reference frames in cortex. Neuron 1998;20:15-24. PMID 9459438
41: Corbetta M, Kincade MJ, Lewis C, Snyder AZ, Sapir A. Neural basis and recovery of spatial attention deficits in spatial neglect. Nat Neurosci 2005;8:1603-10. PMID 16234807
42: Corwin JV, Kanter S, Watson RT, Heilman KM, Valenstein E, Hashimoto A. Apomorphine has a therapeutic effect on neglect produced by unilateral dorsomedial prefrontal cortex lesions in rats. Exp Neurol 1986;36:683-98. PMID 3780914
43: Coslett HB, Bowers D, Fitzpatrick E, Haws B, Heilman KM. Directional hypokinesia and hemispatial inattention in neglect. Brain 1990;113:475-86. PMID 2328414
44: Costello ADL, Warrington EK. The dissociation of visuospatial neglect and neglect dyslexia. J Neurol Neurosurg Psychiatry 1987;50:1110-6. PMID 3668560
45: Crowne DP, Yeo CH, Russell IS. The effects of unilateral frontal eye field lesions in the monkey: visual-motor guidance and avoidance behavior. Behav Brain Res 1981;2:165-85. PMID 7248056
46: Cutting J. Study of anosognosia. J Neurol Neurosurg Psychiatry 1978;41:548-55. PMID 671066
47: Dambeck N, Sparing R, Meister IG, et al. Interhemispheric imbalance during visuospatial attention investigated by unilateral and bilateral TMS over human parietal cortices. Brain Res 2006;1072:194-9. PMID 16426588
48: da Silva TR, de Carvalho Nunes HR, Martins LG, et al. Brain stimulation can reduce unilateral spatial neglect after stroke: ELETRON trial. Ann Neurol 2022;92:400-10. PMID 35688801
49: Denes G, Semenza C, Stoppa E, Lis A. Unilateral spatial neglect and recovery from hemiplegia. Brain 1982;105:543-52. PMID 7104665
50: Denny-Brown D, Banker BQ. Amorphosynthesis from left parietal lesions. Arch Neurol Psychiatry 1954;71:302-13.
51: Doricchi F, Guariglia C, Paolucci S, Pizzamiglio L. Disturbance of the rapid eye movements (REM) of REM sleep in patients with unilateral attentional neglect: clue for the understanding of the functional meaning of REMs. Electroencephalogr Clin Neurophysiol 1993;87:105-16. PMID 7691538
52: Driver J. Object segmentation and visual neglect. Behav Brain Res 1995;71:135-46. PMID 8747181
53: Farah MJ, Brun JL, Wong AB, Wallace MA, Carpenter PA. Frames of reference for allocating attention to space: evidence from the neglect syndrome. Neuropsychologia 1990;28:335-47. PMID 2342640
54: Feinberg T, Haber L, Stacy C. Ipsilateral extinction in the hemineglect syndrome. Arch Neurol 1990;47:802-4. PMID 2357162
55: Fishman RS. Ferrier's mistake revisited, or when it comes to the brain, nothing is simple. Arch Neurol 1995;52:725-30. PMID 7619030
56: Fleet WS, Valenstein E, Watson RT, Heilman KM. Dopamine agonist therapy for neglect in humans. Neurology 1987;37:1765-70. PMID 3670614
57: Frassinetti F, Rossi M, Ladavas E. Passive limb movements improve visual neglect. Neuropsychologia 2001;39:725-33. PMID 11311302
58: Frettlöh J, Hüppe M, Maier C. Severity and specificity of neglect-like symptoms in patients with complex regional pain syndrome (CRPS) compared to chronic limb pain of other origins. Pain 2006;124:184-9. PMID 16730904
59: Friedrich TE, Hunter PV, Elias LJ. The trajectory of pseudoneglect in adults: a systematic review. Neuropsychol Rev 2018;28:436-52. PMID 30460436
60: Gainotti G, Messerli P, Tissot R. Qualitative analysis of unilateral and spatial neglect in relation to laterality of cerebral lesions. J Neurol Neurosurg Psychiatry 1972;35:545-50. PMID 5049813
61: Galer BS, Butler S, Jensen MP. Case reports and hypothesis: a neglect-like syndrome may be responsible for the motor disturbance in reflex sympathetic dystrophy (Complex Regional Pain Syndrome-1). J Pain Symptom Manage 1995;10:385-91. PMID 7673771
62: Galer BS, Jensen M. Neglect-like symptoms in complex regional pain syndrome: results of a self-administered survey. J Pain Symptom Manage 1999;18:213-7. PMID 10517043
63: Geminiani G, Bottini G, Sterzi R. Dopaminergic stimulation in unilateral neglect. J Neurol Neurosurg Psychiatry 1998;65:344-7. PMID 9728946
64: Genthon N, Rougier P, Gissot AS, Froger J, Pélissier J, Pérennou D. Contribution of each lower limb to upright standing in stroke patients. Stroke 2008;39:1793-9. PMID 18369174
65: Gerafi J, Samuelsson H, Viken JI, et al. Neglect and aphasia in the acute phase as predictors of functional outcome seven years after ischemic stroke. Eur J Neurol 2017;24:1407-15. PMID 28803458
66: Gerafi J, Samuelsson H, Viken JI, Jern C, Blomstrand C, Jood K. The presence and prediction of lateralized inattention 7 years post-stroke. Acta Neurol Scand 2020;141:423-30. PMID 31930478
67: Goodwin JA, Kansu T. Vulpian’s sign: conjugate eye deviation in acute cerebral hemispheric lesions. Neurology 1986;36:711-2. PMID 3517695
68: Gottesman RF, Kleinman JT, Davis C, et al. Unilateral neglect is more severe and common in older patients with right hemispheric stroke. Neurology 2008;71:1439-44. PMID 18955687
69: Grattan ES, Lang CE, Birkenmeier R, et al. Examining the feasibility, tolerability, and preliminary efficacy of repetitive task-specific practice for people with unilateral spatial neglect. Am J Occup Ther 2016;70:7004290020p1-8. PMID 27294994
70: Grujic Z, Mapstone M, Gitelman DR, et al. Dopamine agonists reorient visual exploration away from the neglected hemispace. Neurology 1998;51:1395-8. PMID 9818867
71: Guariglia C, Coriale G, Cosentino T, Pizzamiglio L. TENS modulates spatial reorientation in neglect patients. Cogn Neurosci 2000;11:1945-8. PMID 10884048
72: Guariglia C, Lippolis G, Pizzamiglio L. Somatosensory stimulation improves imagery disorders in neglect. Cortex 1998;34:233-41. PMID 9606588
73: Guilbert A, Bara TG, Bouchara T, Gaffard M, Bourlon C. Feasibility and relevance of an immersive virtual reality cancellation task assessing far space in unilateral spatial neglect. J Neuropsychol 2023. [Epub ahead of print]
74: Halligan PW, Marshall JC. Figural modulation of visuo-spatial neglect: a case study. Neuropsychologia 1991;29:165-76 PMID 1944865
75: Halligan PW, Marshall JC, Wade DT. Left on the right: allochiria in a case of left visuo-spatial neglect. J Neurol Neurosurg Psychiatry 1992;55:717-9. PMID 1527545
76: Hamilton RH, Coslett HB, Buxbaum LJ, Whyte J, Ferraro MK. Inconsistency of performance on neglect subtype tests following acute right hemisphere stroke. J Int Neuropsychol Soc 2008;14:23-32. PMID 18078528
77: Harding P, Riddoch MJ. Functional Electrical Stimulation (FES) of the upper limb alleviates unilateral neglect: a case series analysis. Neuropsychol Rehabil 2009;19:14-63. PMID 18609022
78: He BJ, Snyder AZ, Vincent JL, Epstein A, Shulman GL, Corbetta M. Breakdown of functional connectivity in frontoparietal networks underlies behavioral deficits in spatial neglect. Neuron 2007;53:905-18. PMID 17359924
79: Heilman KM, Schwartz HD, Watson RT. Hypoarousal in patients with the neglect syndrome and emotional indifference. Neurology 1978;28:229-32. PMID 564476
80: Heilman KM, Valenstein E. Frontal lobe neglect in man. Neurology 1972;22:660-4. PMID 4673341
81: Heilman KM, Van Den Abell T. Right hemisphere dominance for attention: the mechanisms underlying hemispheric asymmetries of inattention (neglect). Neurology 1980;30:327-30. PMID 7189037
82: Heilman KM, Watson RT, Valenstein E. Localization of lesions in neglect and related disorders. In: Kertesz A, editor. Localization and neuroimaging neuropsychology. New York: Academic Press, 1994:495-524.
83: Heilman KM, Watson RT, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E, editors. Clinical neuropsychology. 4th ed. New York: Oxford University Press, 2003:296-346.
84: Hier DB, Davis KR, Richardson EP, Mohr JP. Hypertensive putaminal hemorrhage. Ann Neurol 1977;1:152-9. PMID 889299
85: Hier DB, Mondlock J, Caplan LR. Recovery of behavioral abnormalities after right hemisphere stroke. Neurology 1983;33:345-50. PMID 6681880
86: Hjaltason H, Tegnér R, Tham K, Levander M, Ericson K. Sustained attention and awareness of disability in chronic neglect. Neuropsychologia 1996;34:1229-33. PMID 8951834
87: Ho AK, Manly T, Nestor PJ, et al. A case of unilateral neglect in Huntington's disease. Neurocase 2003;9:261-73. PMID 12925932
88: Hurford P, Stringer AY, Jan B. Neuropharmacologic treatment of hemineglect: a case report comparing bromocriptine and methylphenidate. Arch Phys Med Rehabil 1998;79:346-9. PMID 9523791
89: Iosa M, Guariglia C, Matano A, Paolucci S, Pizzamiglio G. Recovery of personal neglect. Eur J Phys Rehabil Med 2016;52:791-8. PMID 26616358
90: Ishiai S, Furukawa T, Tsukagoshi H. Visuospatial processes of line bisection and the mechanism underlying unilateral spatial neglect. Brain 1989;112:1485-502. PMID 2597992
91: Jackson JH. Case of large cerebral tumour without optic neuritis and with left hemiplegia and imperception. Roy Lond Ophthalm Hosp Rep 1876;8:434-44.
92: Jehkonen M, Laihosalo M, Koivisto AM, Dastidar P, Ahonen JP. Fluctuation in spontaneous recovery of left visual neglect: a 1-year follow-up. Eur Neurol 2007;58: 210-4. PMID 17823534
93: Jewell G, McCourt ME. Pseudoneglect: a review and meta-analysis of performance factors in line bisection tasks. Neuropsychologia 2000;38:93-110. PMID 10617294
94: Kalra L, Perez I, Gupta S, Wittink M. The influence of visual neglect on stroke rehabilitation. Stroke 1997;28:1386-91. PMID 9227688
95: Karnath HO. Transcutaneous electrical stimulation and vibration of neck muscles in neglect. Exp Brain Res 1995;105:321-4. PMID 7498386
96: Kaufmann BC, Cazzoli D, Bartolomeo P, et al. Auditory spatial cueing reduces neglect after right-hemispheric stroke: a proof of concept study. Cortex 2022;148:152-16. PMID 35176552
97: Kaufmann BC, Cazzoli D, Koenig-Bruhin M, Muri RM, Nef T, Nyffeler T. Video-oculography during free visual exploration to detect right spatial neglect in left-hemispheric stroke patients with aphasia: a feasibility study. Front Neurosci 2021;15:640049. PMID 33854413
98: Kerkhoff G, Reinhart S, Ziegler W, Artinger F, Marquardt C, Keller I. Smooth pursuit eye movement training promotes recovery from auditory and visual neglect a randomized controlled study. Neurorehabil Neural Repair 2013;27:789-98. PMID 23797459
99: Kerkhoff G, Schenk T. Line bisection in homonymous visual field defects—recent findings and future directions. Cortex 2011;47:53-8. PMID 20678761
100: Kerkhoff G, Schenk T. Rehabilitation of neglect: an update. Neuropsychologia 2012;50:1072-9. PMID 22306520
101: Kinsbourne M. Mechanisms of unilateral neglect. In: Jeannerod M, editor. Neurophysiological and neuropsychological aspects of spatial neglect. New York: North Holland, 1987:69-86.
102: Kinsbourne M, Warrington EK. Variety of reading disability associated with right hemisphere lesions. J Neurol Neurosurg Psychiatry 1962;25:339-44. PMID 14032919
103: Kinsella G, Ford B. Hemi-inattention and the recovery patterns of stroke patients. Int Rehabil Med 1985;7:102-6. PMID 4066172
104: Kwakkel G, Kollen B. Predicting improvement in the upper paretic limb after stroke: a longitudinal prospective study. Restor Neurol Neurosci 2007;25:453-60. PMID 18334763
105: Kwon SE, Heilman KM. Ipsilateral neglect in a patient following a unilateral frontal lesion. Neurology 1991;41:2001-4. PMID 1745365
106: Làdavas E. Is the hemispatial damage produced by right parietal lobe damage associated with retinal or gravitational coordinates. Brain 1987;110:167-80. PMID 3801848
107: Laurent-Vannier A, Pradat-Diehl P, Chevignard M, Abada G, De Agostini M. Spatial and motor neglect in children. Neurology 2003;60:202-7. PMID 12552031
108: Lazar RS, Fitzsimmons BF, Marshall RS, et al. Reemergence of stroke deficits with midazolam challenge. Stroke 2002;33:283-5. PMID 11779924
109: Levine DN, Warach JD, Benowitz L, Calvanio R. Left spatial neglect: effects of lesion size and premorbid brain atrophy on severity and recovery following right cerebral infarction. Neurology 1986;36:362-6. PMID 3951703
110: Lindell AB, Jalas JM, Tenovuo O, Brunila T, Voeten MJM, Hämäläinen H. Clinical assessment of hemispatial neglect: evaluation of different measures and dimensions. Clin Neuropsychol 2007;21:479-97. PMID 17455032
111: Linden T, Samuelsson H, Skoog I, Blomstrand C. Visual neglect and cognitive impairment in elderly patients late after stroke. Acta Neurol Scand 2005;111:163-8. PMID 15691284
112: Lippolis G, Joss JMP, Rogers LJ. Australian lungfish (Neoceratodus forsteri): a missing link in the evolution of complementary side biases for predator avoidance and prey capture. Brain Behav Evol 2009;73:295-303. PMID 19641309
113: Longley V, Hazelton C, Heal C, et al. Non-pharmacological interventions for spatial neglect or inattention following stroke and other non-progressive brain injury [review]. Cochrane Database Syst Rev 2021;7:CD003586. PMID 34196963
114: Lucas N, Saj A, Schwartz S, et al. Effects of pro-cholinergic treatment in patients suffering from spatial neglect. Front Hum Neurosci 2013;7:574. PMID 24062674
115: Lunven M, Thiebaut de Schotten M, Bourton C, et al. White matter lesional predictors of chronic visual neglect: a longitudinal study. Brain 2015;138:746-60. PMID 25609686
116: Luo CR, Anderson JM, Caramazza A. Impaired stimulus-driven orienting of attention and preserved goal-directed orienting of attention in unilateral visual neglect. Am J Psychol 1998;111:487-507. PMID 9845948
117: Machner B, Mah YH, Gorgoraptis N, Husain M. How reliable is repeated testing for hemispatial neglect? Implications for clinical follow-up and treatment trials. J Neurol Neurosurg Psychiatry 2012;83:1032-4. PMID 22923514
118: Malhotra PA, Parton AD, Greenwood R, Husain M. Noradrenergic modulation of space exploration in visual neglect. Ann Neurol 2006;59:186-90. PMID 16261567
119: Mark VW. Acute versus chronic functional aspects of unilateral spatial neglect. Front Biosci 2003;8:e172-89. PMID 12456357
120: Mark VW, Heilman KM. Diagonal neglect on cancellation. Neuropsychologia 1997;35:1425-36. PMID 9352520
121: Mark VW, Heilman KM. Diagonal spatial neglect. J Neurol Neurosurg Psychiatry 1998;65:348-52. PMID 9728947
122: Mark VW, Kooistra CA, Heilman KM. Hemispatial neglect affected by non-neglected stimuli. Neurology 1988;38:1207-11. PMID 3399068
123: Mark VW, Taub E. Constraint-induced movement therapy for chronic stroke hemiparesis and other disabilities. Restor Neurol Neurosci 2004;22:317-36. PMID 15502259
124: Mark VW, Woods AJ, Mennemeier M, Abbas S, Taub E. Cognitive assessment for CI therapy in the outpatient clinic. NeuroRehabilitation 2006;21:139-46. PMID 16917160
125: Marshall JC, Halligan PW. Visuo-spatial neglect: a new copying test to assess perceptual parsing. J Neurol 1993;240:37-40. PMID 8423461
126: Mattingley JB, Bradshaw JL, Phillips JG. Impairments of movement initiation and execution in unilateral neglect. Brain 1992;115:1849-74. PMID 1486464
127: Meador KJ, Allen ME, Adams RJ, Loring DW. Allochiria vs allesthesia. Is there a misperception. Arch Neurol 1991;48:546-9. PMID 2021370
128: Mennemeier M, Chatterjee A, Heilman KM. A comparison of the influences of body and environment centered references on neglect. Brain 1994;117:1013-21. PMID 7953585
129: Mennemeier M, Wertman E, Heilman KM. Neglect of near peripersonal space: evidence for multidirectional attentional systems in humans. Brain 1992;115:37-50. PMID 1559162
130: Mennemeier MS, Morris M, Heilman KM. Just thinking about targets can aggravate neglect on cancellation tests. Neurocase 2004;10:29-38. PMID 15849157
131: Merzenich M, Van Vleet TM, Nahum M. Brain plasticity-based therapeutics. Front Hum Neurosci 2014;8:385. PMID 25018719
132: Mesulam MM. A cortical network for directed attention and unilateral neglect. Ann Neurol 1981;10:309-25. PMID 7032417
133: Mesulam MM. Attention, confusional states, and neglect. In: Mesulam MM (editor). Principles of Behavioral Neurology. Philadelphia: F.A. Davis, 1985:125-68.
134: Mukand JA, Guilmette TJ, Allen DG, et al. Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series. Arch Phys Med Rehabil 2001;82:1279-82. PMID 11552204
135: Nelemans KN, Nijboer TCW, Ten Brink AF, Knowledge Neglect Study Group. The mobility assessment course: a ready-to-use dynamic measure of visuospatial neglect. J Neuropsychol 2022;16:498-517. PMID 35445544
136: Nys GM, van Zandvoort MJ, de Kort PL, et al. The prognostic value of domain-specific cognitive abilities in acute first-ever stroke. Neurology 2005;64:821-7. PMID 15753416
137: Oh-Park M, Hung C, Chen P, Barrett AM. Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility after stroke. PM R 2014;6:716-22. PMID 24412266
138: Ostrow LW, Llinás RH. Eastchester clapping sign: a novel test of parietal neglect. Ann Neurol 2009;66:114-7. PMID 19670437
139: Pandian JD, Arora R, Kaur P, Sharma D, Vishwambaran DK, Arima H. Mirror therapy in unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology 2014;83:1012-7. PMID 25107877
140: Paolucci S, Antonucci G, Grasso MG, Pizzamiglio L. The role of unilateral spatial neglect in rehabilitation of right brain- damaged ischemic stroke patients: A matched comparison. Arch Phys Med Rehabil 2001;82:743-9. PMID 11387577
141: Parton A, Malhotra P, Husain M. Hemispatial neglect. J Neurol Neurosurg Psychiatry 2004;75:13-21. PMID 14707298
142: Pearce JM. Samuel Jones Gee (1839-1911) and stereotypic movements caused by apomorphia. J Neurol Neurosurg Psychiatry 1995;59:279. PMID 7673956
143: Pedersen PM, Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Hemineglect in acute stroke- incidence and prognostic implications. Am J Phys Med Rehabil 1997;76:122-7. PMID 9129518
144: Perani D, Vallar G, Paulesi E, Alberoni M, Fazio F. Left and right hemisphere contributions to recovery from neglect after right hemisphere damage: an [18F]FDG PET study of 2 cases. Neuropsychologia 1993;40:1278-81. PMID 8455781
145: Perennou DA, Leblond C, Amblard B, Micallef JP, Herisson C, Pelissier JY. Transcutaneous electric nerve stimulation reduces neglect-related postural instability after stroke. Arch Phys Med Rehabil 2001;82:440-8. PMID 11295002
146: Pitteri M, Venneri A, Meneghello F, Priftis K. How to differentiate hemianesthesia from left tactile neglect: a preliminary case report. Behav Neurol 2013;26:151-5. PMID 22713380
147: Pizzamiglio L, Fasotti L, Jehkonen M, et al. The use of optokinetic stimulation in rehabilitation of the hemineglect disorder. Cortex 2004;40:441-50. PMID 15259325
148: Plummer P, Dunai J, Morris ME. Understanding the effects of moving visual stimuli on unilateral neglect following stroke. Brain Cogn 2006;60:156-65. PMID 16466838
149: Poppelreuter W. Die Psychischen Schadigungen durch Kopfschluss im Krieg 1914-1916: die Stotungen der Niederen und Hoheren Schleistungen durch Verletzungen des Okzipitalhirns. Leipzig: Voss, 1917.
150: Posner MI, Dehaene S. Attentional networks. Trends Neurosci 1994;17:75-9. PMID 7512772
151: Posner MI, Rafal RD. Cognitive theories of attention and the rehabilitation of attentional deficits. In: Meier MJ, Benton A, Diller L, editors. Neuropsychological rehabilitation. New York: Guilford, 1987:182-201.
152: Posner MI, Walker J, Friedrich F, Rafal R. Effects of parietal injury on covert orienting of attention. J Neurosci 1984;4:1863-74. PMID 6737043
153: Punt TD, Kitadono K, Hulleman J, Humphreys GW, Riddoch MJ. From both sides now: crossover effects influence navigation in patients with unilateral neglect. J Neurol Neurosurg Psychiatry 2008;79:464-6. PMID 18032453
154: Qiang W, Sonoda S, Suzuki M, Okamoto S, Saitoh E. Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke. Am J Phys Med Rehabil 2005;84:161-6. PMID 15725789
155: Rapcsak SZ, Fleet WS, Verfaellie M, Heilman KM. Altitudinal neglect. Neurology 1988;38:277-81. PMID 3340293
156: Rapcsak SZ, Verfaellie M, Fleet W, Heilman K. Selective attention in hemispatial neglect. Arch Neurol 1989;46:172-8. PMID 2916956
157: Rapcsak SZ, Watson RT, Heilman KM. Hemispace-visual field interactions in visual extinction. J Neurol Neurosurg Psychiatry 1987;50:1117-24. PMID 3668561
158: Reid E, Wallwork SB, Harvie D, et al. A new kind of spatial inattention associated with chronic limb pain? Ann Neurol 2016;79:701-4. PMID 26878698
159: Riestra AR, Barrett AM. Rehabilitation of spatial neglect. Handb Clin Neurol 2013;110:347-55. PMID 23312654
160: Riggs RV, Andrews K, Roberts P, Gilewski M. Visual deficit interventions in adult stroke and brain injury: a systematic review. Am J Phys Med Rehabil 2007;86:853-60. PMID 17885320
161: Ringman JM, Saver JL, Wollson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of unilateral neglect in an acute stroke cohort. Neurology 2004;63:468-74. PMID 15304577
162: Rizzolatti G, Berti A. Neural mechanisms of spatial neglect. In: Robertson IH, Marshall JC, editors. Unilateral neglect: clinical and experimental studies. Hillsdale: Lawrence Erlbaum Associates, 1993:87-105.
163: Robertson IH, Halligan PW, Marshall JC. Prospects for the rehabilitation of unilateral neglect. In: Robertson IH, Marshall JC, editors. Unilateral neglect: clinical and experimental studies. Hillsdale: Lawrence Earlbaum, 1993:279-92.
164: Robertson IH, Hogg K, McMillan TM. Rehabilitation of unilateral neglect: improving function by contralesional limb activation. Neuropsychological Rehabil 1998;8:19-29.
165: Robertson IH, North N, Geggie C. Spatiomotor cueing in unilateral left neglect: three case studies in its therapeutic effects. J Neurol Neurosurg Psychiatry 1992;55:799-805. PMID 1402971
166: Robertson IH, Tegnér R, Tham K, Lo A, Nimmo-Smith I. Sustained attention training for unilateral neglect: theoretical and rehabilitation implications. J Clin Exp Neuropsychol 1995;17:416-30. PMID 7650103
167: Robertson IH, Ward T, Ridgeway V, Nimmo-Smith I. Test of everyday attention. London: Harcourt Assessment, 1994.
168: Robertson IH, Ward T, Ridgeway V, Nimmo-Smith I. The structure of normal human attention: the test of everyday attention. J Int Neuropsychol Soc 1996;2:525-34. PMID 9375156
169: Rode G, Perenin MT, Honore J, Boisson D. Improvement of the motor deficit of neglect patients through vestibular stimulation: evidence for a motor neglect component. Cortex 1998;34:253-61. PMID 9606590
170: Rorden C, Karnath HO. A simple measure of neglect severity. Neuropsychologia 2010;48:2758-63. PMID 20433859
171: Rubens A. Caloric stimulation and unilateral neglect. Neurology 1985;35:1019-24. PMID 4010940
172: Rushmore RJ, Valero-Cabre A, Lomber SG, Hilgetag CC, Payne BR. Functional circuitry underlying visual neglect. Brain 2006;129:1803-21. PMID 16731540
173: Salatino A, Zavattaro C, Gammeri R, et al. Virtual reality rehabilitation for unilateral spatial neglect: a systematic review of immersive, semi-immersive and non-immersive techniques. Neurosci Biobehav Rev 2023;152:105248. PMID 37247829
174: Sapir A, Kaplan JB, He BJ, Corbetta M. Anatomical correlates of directional hypokinesia in patients with hemispatial neglect. J Neurosci 2007;27:4045-51. PMID 17428982
175: Scheidtmann K. Advances in adjuvant pharmacotherapy for motor rehabilitation: effects of levodopa. Restor Neurol Neurosci 2004;22:393-8. PMID 15502279
176: Schenkenberg T, Bradford DC, Ajax ET. Line bisection and unilateral visual neglect in patients with neurologic impairment. Neurology 1980;30:509-17. PMID 7189256
177: Schnider A, Durbec VB, Ptak R. Absence of visual feedback abolishes expression of hemispatial neglect in self-guided spatial completion. J Neurol Neurosurg Psychiatry 2011;82:1279-82. PMID 21746740
178: Schuett S, Dauner R, Zihl J. Line bisection in unilateral homonymous visual field defects. Cortex 2011;47:47-52. PMID 20172510
179: Seki K, Ishiai S. Diverse patterns of performance in copying and severity of unilateral spatial neglect. J Neurol 1996;243:1-8. PMID 8869379
180: Shelton PA, Bowers D, Heilman KM. Peripersonal and vertical neglect. Brain 1990;113:191-205. PMID 2302532
181: Sheppard DM, Bradshaw JL, Mattingley JB, Lee P. Effects of stimulant medication on the lateralisation of line bisection judgments of children with attention deficit hyperactivity disorder. J Neurol Neurosurg Psychiatry 1999;66:57-63. PMID 9886453
182: Shiraishi H, Yamakawa Y, Itou A, Muraki T, Asada T. Long-term effects of prism adaptation on chronic neglect after stroke. NeuroRehabilitation 2008;23:137-51. PMID 18525135
183: Singh-Curry V, Husain M. Rehabilitation in practice: hemispatial neglect: approaches to rehabilitation. Clin Rehabil 2010;24:675-84. PMID 20702515
184: Smania N, Fonte C, Picelli A, Gandolfi M, Varalta V. Effect of eye patching in rehabilitation of hemispatial neglect. Front Hum Neurosci 2013;7:527. PMID 24032011
185: Somma F, Bartolomeo P, Vallone F, et al. Further to the left: stress-induced increase of spatial pseudoneglect during the COVID-19 lockdown. Front Psychol 2021;12:573846. PMID 33746815
186: Soto D, Funes MJ, Guzmán-García A, Warbrick T, Rotshtein P, Humphreys GW. Pleasant music overcomes the loss of awareness in patients with visual neglect. Proc Natl Acad Sci U S A 2009;106:6011-6. PMID 19307566
187: Spaccavento S, Marinelli CV, Nardulli R, et al. Attention deficits in stroke patients: the role of lesion characteristics, time from stroke, and concomitant neuropsychological deficits. Behav Neurol 2019;2019:7835710. PMID 31263512
188: Sperber C, Karnath HO. Diagnostic validity of line bisection in the acute phase of stroke. Neuropsychologia 2016;82:200-4. PMID 26808420
189: Sprague J. Interaction of cortex and superior colliculus in visually guided behavior. Science 1966;153:1544-7. PMID 5917786
190: Spreij LA, Ten Brink AF, Visser-Meily JMA, Nijboer TCW. Simulated driving: the added value of dynamic testing in the assessment of visuo-spatial neglect after stroke. J Neuropsychol 2020;14:28-45. PMID 30325578
191: Stone SP, Patel P, Greenwood RJ. Selection of acute stroke patients for treatment of visual neglect. J Neurol Neurosurg Psychiatry 1993;56:463-6. PMID 8505635
192: Stone SP, Wilson B, Wroot A, et al. The assessment of visuo-spatial neglect after acute stroke. J Neurol Neurosurg Psychiatry 1991;54:345-50. PMID 2056321
193: Suchan J, Rorden C, Karnath HO. Neglect severity after left and right brain damage. Neuropsychologia 2012;50:1136-41. PMID 22230231
194: Sunwoo H, Kim YH, Chang WH, Noh S, Kim EJ, Ko MH. Effects of dual transcranial direct current stimulation on post-stroke unilateral visuospatial neglect. Neurosci Lett 2013;554:94-8. PMID 24021804
195: Szekely O, Ten Brink AF, Mitchell AG, Bultitude JH, McIntosh RD. No short-term treatment effect of prism adaptation for spatial neglect: an inclusive meta-analysis [review]. Neuropsychologia 2023;189:108566. PMID 37149126
196: Taub E, Mark VW, Uswatte G. Implications of CI therapy for visual deficit training. Front Integr Neurosci 2014;8:78. PMID 25346665
197: Taub E, Uswatte G, Mark VW, Morris DM. The learned nonuse phenomenon: implications for rehabilitation. Eura Medicophys 2006;42:241-56. PMID 17039223
198: Thimm M, Fink GR, Küst J, Karbe H, Sturm W. Impact of alertness training on spatial neglect: a behavioural and fMRI study. Neuropsychologia 2006;44:1230-46. PMID 16280140
199: Tramonti Fantozzi MP, Benedetti R, Crecchi A, et al. Pointing in cervical dystonia patients. Front Syst Neurosci 2023;17:1306387. PMID 38090048
200: Tromp E, Dinkla A, Mulder T. Walking through doorways: an analysis of navigation skills in patients with neglect. Neuropsychol Rehabil 1995;5:319-31.
201: Tsai PL, Chen MC, Huang YT, Lin KC, Chen KL, Hsu YW. Listening to classical music ameliorates unilateral neglect after stroke. Am J Occup Ther 2013;67:328-35. PMID 23597691
202: Turton AJ, Dewar SJ, Lievesley A, O'Leary K, Gabb J, Gilchrist ID. Walking and wheelchair navigation in patients with left visual neglect. Neuropsychol Rehabil 2009;19:274-90. PMID 18609014
203: Vallar G, Guariglia C, Nico D, Bisiach E. Spatial hemineglect in back space. Brain 1995a;118:467-72. PMID 7735887
204: Vallar G, Rusconi ML, Barozzi S, et al. Improvement of left visuo-spatial hemineglect by left-sided transcutaneous electrical stimulation. Neuropsychologia 1995b;33:73-82. PMID 7731542
205: van der Lee JH, Wagenaar RC, Lankhorst GJ, Vogelaar TW, Devillé WL, Bouter LM. Forced use of the upper extremity in chronic stroke patients. Results from a single-blind randomized clinical trial. Stroke 1999;30:2369-75. PMID 10548673
206: Van Vleet T, Bonato P, Fabara E, et al. Alertness training improves spatial bias and functional ability in spatial neglect. Ann Neurol 2020;88:747-58. PMID 32740976
207: Van Vleet TM, DeGutis JM. The nonspatial side of spatial neglect and related approaches to treatment. Prog Brain Res 2013a;207:327-49. PMID 24309261
208: Van Vleet TM, DeGutis J. Cross-training in hemispatial neglect: auditory sustained attention training ameliorates visual attention deficits. Cortex 2013b;49:679-90. PMID 22578712
209: Venneri A, Pentore R, Cotticelli B, Della Sala S. Unilateral spatial neglect in the late stage of Alzheimer's disease. Cortex 1998;34:743-52. PMID 9872376
210: Verdon V, Schwartz S, Lovblad KO, Hauert CA, Vuilleumier P. Neuroanatomy of hemispatial neglect and its functional components: a study using voxel-based lesion-symptom mapping. Brain 2010;133:880-94. PMID 20028714
211: Verreyt N, Nys GMS, Santens P, Vingerhoets G. Cognitive differences between patients with left-sided and right-sided Parkinson's disease. A review. Neuropsychol Rev 2011;21:405-24. PMID 21956794
212: Viken JI, Samuelsson H, Jern C, Jood K, Blomstrand C. The prediction of functional dependency by lateralized and non-lateralized neglect in a large prospective stroke sample. Eur J Neurol 2012;19:128-34. PMID 21631651
213: Watson RT, Heilman KM, Cauthen JC, King FA. Neglect after cingulectomy. Neurology 1973;23:1003-7. PMID 4199186
214: Watson RT, Valenstein E, Heilman KM. Nonsensory neglect. Ann Neurol 1978;3:505-8. PMID 98100
215: Watson RT, Valenstein E, Heilman KM. Thalamic neglect. Arch Neurol 1981;38:501-6. PMID 7247787
216: Watson RT, Valenstein E, Heilman KM. The effect of corpus callosum section on unilateral neglect in monkeys. Neurology 1984;34:812-5. PMID 6539447
217: Webster JS, McFarland PT, Rapport LJ, Morrill B, Roades LA, Abadee PS. Computer-assisted training for improving wheelchair mobility in unilateral neglect patients. Arch Phys Med Rehabil 2001;82:769-75. PMID 11387581
218: Weinberg M, Diller L, Goedon W, et al. Training sensory awareness and spatial organization in people with right brain damage. Arch Phys Med Rehabil 1979;60:491-6. PMID 508074
219: Welfringer A, Schmidt-Viereck R, Brandt T. Constraint-induced movement therapy (CIMT) in patients showing chronic neglect symptoms–a randomized controlled study [abstract]. J Int Neuropsychol Soc 2013;19:34.
220: Weppner J, Meriggi J, Franzese K. Case report: fluctuating mental status and new paradoxical left hemispatial neglect during inpatient rehabilitation for left temporo-occipital intracerebral hemorrhage with intraventricular hemorrhage. Am J Phys Med Rehabil 2020;99:562-5. PMID 31464754
221: Wiart L, Bon Saint Come A, Debelleix X, Petit H, Joseph PA, Mazaux JM. Unilateral neglect syndrome rehabilitation by trunk rotation and scanning training. Arch Phys Med Rehabil 1997;78:424-9. PMID 9111464
222: Wilkinson D, Sakel M, Camp SJ, Hammond L. Patients with hemispatial neglect are more prone to limb spasticity, but this does not prolong their hospital stay. Arch Phys Med Rehabil 2012;93:1191-5. PMID 22483722
223: Wilson B, Cockburn J, Halligan PW. Behavioral inattention test. Titchfield: Thames Valley Test Co., 1987.
224: Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guide for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016;47:e98-169. PMID 27145936
225: Winters C, van Wegen EEH, Daffertshofer A, Kwakkel G. Generalizability of the maximum proportional recovery rule to visuospatial neglect early poststroke. Neurorehabil Neural Repair 2017;31:334-42. PMID 27913798
226: Woods AJ, Garcia-Rill E, Meythaler J, Mark VW, Jewell GR, Mennemeier M. Altered magnitude estimation in neglect following left-hemisphere damage improves with pharmacologic treatment for arousal. J Int Neuropsychol Soc 2004;10:91-2.
227: Wu CY, Wang TN, Chen YT, et al. Effects of constraint-induced therapy combined with eye patching on functional outcomes and movement kinematics in poststroke neglect. Am J Occup Ther 2013;67:236-45. PMID 23433279
228: Yang NY, Fong KN, Li-Tsang CW, Zhou D. Effects of repetitive transcranial magnetic stimulation combined with sensory cueing on unilateral neglect in subacute patients with right hemispheric stroke: a randomized controlled study. Clin Rehabil 2017;31:1154-63. PMID 27920261
229: Yang NY, Zhou D, Chung RC, Li-Tsang CW, Fong KN. Rehabilitation interventions for unilateral neglect after stroke: a systematic review from 1997 through 2012. Front Hum Neurosci 2013;7:187. PMID 23675339
230: Zhang Y, Xing Y, Li C, et al. Mirror therapy for unilateral neglect after stroke: a systematic review. Eur J Neurol 2022;29:358-71. PMID 34558762
231: Zingerle H. Ueber stoerungen der warnemung des eigenen koerpers bei organischen gehirnerkrankungen. Monatsschr Psychiatrie Neurologie 1913;34:13-36.
232: Zoccolotti P, Judica A. Functional evaluation of hemineglect by means of semistructured scale: personal extrapersonal differentiation. Neuropsychol Rehabil 1991;1:33-44.

Patient Profile

Age range of presentation: 0 month to 65+ years
Sex preponderance: male=female
Heredity: none
Population groups selectively affected: none selectively affected
Occupation groups selectively affected: none selectively affected

This is an article preview.
Start a Free Account
to access the full version.

Nearly 3,000 illustrations, including video clips of neurologic disorders.
Every article is reviewed by our esteemed Editorial Board for accuracy and currency.
Full spectrum of neurology in 1,200 comprehensive articles.
Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink®, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660

Support: service@medlink.com

Editor: editor@medlink.com

ISSN: 2831-9125

Neglect

Associated Disorders

Allesthesia
Anosognosia for hemiplegia
Hypokinesia

Differential Diagnosis

lateralized sensory disorders
hemianopic visual field defects
hemisensory loss
unilateral hearing loss
hemianopias
- somatosensory loss
- integrative visual disorders
- visual agnosia
- unilateral weakness
- motor neglect
- learned nonuse
- “neglect-like phenomena”
- complex regional pain syndrome
- hemiparesis

Also Relevant

Acalculia
Alexia
Alien hand syndrome
Anterior cerebral artery stroke syndromes
Automatic-voluntary dissociation
- Basilar artery stroke
- Functional movement disorders
- Ischemic stroke
- Medical complications of stroke
- Mental status examination
- Stroke associated with atrial fibrillation
- Stroke in young adults
- Stroke syndromes and their anatomic localization

Clinical Categories

Neurobehavioral & Cognitive Disorders

Neglect …

Neglect

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Media

References

Contributors

Author

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview.
Start a Free Account
to access the full version.

Questions or Comment?

Also in This Category

Wilson disease

Anti-LGI1 encephalitis

Fatal familial insomnia

Hyperventilation syndrome

Apraxia

Neurologic disorders associated with behavioral symptoms

Cortical blindness

Leukodystrophies

Neglect

Introduction

Overview

Key points

Historical note and terminology

Clinical manifestations

Presentation and course

Prognosis and complications

Clinical vignette

Biological basis

Etiology and pathogenesis

Epidemiology

Prevention

Differential diagnosis

Confusing conditions

Associated or underlying disorders

Diagnostic workup

Management

Outcomes

Media

References

Contributors

Author

Former Authors

Patient Profile

ICD & OMIM codes

This is an article preview. Start a Free Account to access the full version.

Questions or Comment?

Also in This Category

Wilson disease

Anti-LGI1 encephalitis

Fatal familial insomnia

Hyperventilation syndrome

Apraxia

Neurologic disorders associated with behavioral symptoms

Cortical blindness

Leukodystrophies

This is an article preview.
Start a Free Account
to access the full version.