Beruflich Dokumente
Kultur Dokumente
MAJOR REVIEW
Victoria Infirmary, Glasgow, UK; 2Nursing, Midwifery, and Allied Health Professionals (NMAHP) Research Unit,
Glasgow Caledonian University, Glasgow, UK; 3Tennent Institute of Ophthalmology, Gartnavel General Hospital,
Glasgow, UK; 4Royal Hospital for Sick Children, Glasgow, UK; 5Department of Vision Sciences, Glasgow Caledonian
University, Glasgow, UK; 6Western General Hospital, Edinburgh, UK; 7Royal Perth Hospital, Western
Australia, Australia; and 8Princess Alexandra Eye Pavilion, Edinburgh, UK
Abstract. Visual neglect is a common, yet frequently overlooked, neurological disorder following
stroke characterized by a deficit in attention and appreciation of stimuli on the contralesional side of
the body. It has a profound functional impact on affected individuals. A assessment and management
of this condition are hindered, however, by the lack of professional awareness and clinical guidelines.
Recent evidence suggests that the underlying deficit in visual attention is due to a disrupted
internalized representation of the outer world rather than a disorder of sensory inputs. Dysfunction of
the cortical domains and white-matter tracts, as well as inter-hemispheric imbalance, have been
implicated in the various manifestations of visual neglect. Optimal diagnosis requires careful historytaking from the patient, family, and friends, in addition to clinical assessment with the line bisection
test, the star cancellation test, and the Catherine Bergego Scale. Early recognition and prompt
rehabilitation employing a multidisciplinary approach is desirable. Although no treatment has been
definitively shown to be of benefit, those with promise include prism adaptation, visual scanning
therapy, and virtual reality--based techniques. Further high quality research to seek optimum shortand long-term rehabilitative strategies for visual neglect is required. (Surv Ophthalmol 56:114--134,
2011. 2011 Elsevier Inc. All rights reserved.)
Key words. assessment dorsal stream neglect rehabilitation
stroke unilateral neglect ventral stream visual neglect
I. Introduction
spatial representation
115
II. Epidemiology
141
A US study
of 1,281 stroke patients reported
a prevalence rate of VN of 43% and 20% following
right and left hemispheric stroke, respectively. This
asymmetry in prevalence of VN is consistent with
other literature4,13,21 and probably occurs because
the right hemisphere tends to allocate attention to
both hemispaces, but the left hemisphere accords
attention more selectively to right hemispace.66,116
Also, VN patients with right hemispheric stroke
generally have a worse prognosis than those with left
hemispheric stroke.13,46,131
Despite the high prevalence rate, 61% of patients
with VN were overlooked during hospital admission
in the US,40 and only 13% of stroke patients were
assessed with standardized neglect assessments in
a Canadian study.114 This low detection rate could
be explained by insufficient awareness of this
condition or may reflect inherent difficulties in
diagnosing neglect in the presence of other more
acute and readily recognizable features of stroke like
dysphagia, dysphasia, hemianopia, or hemiplegia.
In the UK, the documented prevalence rates of
VN post-stroke vary between 8%164 and 82%162 as
a result of heterogeneous patient cohorts, inconsistent definition, non-standardized assessment
methods, and different timings of the assessment.
Increased age has also been shown to be
associated with a higher incidence and severity of
VN.57,141 This could be attributed to prior cerebral
atrophy or a physiologically dampened reaction
time in the elderly population during visual searching activities, especially when intensive visual attention is required.57,102 Other demographic factors
like sex111,141 and handedness141 have no significant
influence on the occurrence of VN.
sory, auditory, and visual or visuospatial in contralesional hemispace. Premotor neglect is described as
failure to orientate the limbs towards contralesional
hemispace despite awareness of the stimulus. VN
has been primarily considered part of the spectrum
of sensory neglect; recent studies, however, suggest
that the underlying deficit primarily is a disrupted
internal computation of the spatial representation
of the external world rather than a true sensory
deficit (see section V. Pathophysiology in this
review) This has important implications in formulating optimal assessment and rehabilitation
strategies.
B. SPATIAL REPRESENTATION
116
TING ET AL
TABLE 1
V. Pathophysiology
VN is a multifaceted disorder. The anatomical,
physiological, and conceptual models of cortical
visual processing have always been highly contentious scientific issues. As mentioned, VN can be
conceptually divided into several categories according to the modality (input/output), the spatial
representation, and the range of space. Although
various mechanisms and models have been proposed and examined, none has fully and successfully
captured the entire spectrum of this heterogeneous
disorder. We attempt a systematic overview of
pathophysiology and clinico-anatomical correlations
of VN from different perspectives.
A. PHYSIOLOGY OF VISUOSPATIAL PERCEPTION
117
118
TING ET AL
119
Presentation
Parietal neglect
Frontal neglect
Cingulate neglect
120
Recommendations concerning the specific assessment methods of VN remain limited. US39 and
UK77,154 guidelines consistently recommend that
visuo-perceptual function, including the potential
for VN, should be assessed in patients in stroke units
employing a multidisciplinary approach. MiniMental State Examination and Addenbrookes
Cognitive Examination (2005) are the two most
well-recognized general cognitive assessment batteries in current clinical practice in the UK.47,121 The
limitation of both tests is that VN is only assessed by
drawing and copying objects (Table 3).
No specific assessment tool is recommended in
the US. On the other hand, the UK guidelines77
recommend the use of Behavioral Inattention Test
whereas the Canadian27 guidelines recommend the
use of specific assessment tools for VN, comprising
the Comb and Razor Test, the Line Bisection Test
(LBT), and the Behavioral Inattention Test with the
alternatives of the Rivermead, Ontario Society of
Occupational Therapy Perceptual Evaluation and
the Motor Free Visual Perceptual Test.
B. HOW IS VISUAL NEGLECT ASSESSED?
TING ET AL
Brief Description/Rationale
Patient is asked to cross out the visual targets on a paper sheet
Looking for disproportionate omission of visual targets on one
side of hemispace
Line Bisection Required to estimate and bisect the middle of straight lines
Deviation towards the ipsilesional side suggests orientation bias
and, hence, potential visual neglect
Strength
Limitation
60
Refer to
Easy to administer
Good validity
Reasonable sensitivity115 (60%43 to 76.4%8)
Comparable reliability to cancellation test
May help distinguish between motor and sensory
neglect with modification of test
TABLE 3
Comb and
Razor test
Good supplementary test for behavioral inattention as Only assesses personal space
it assesses attention for personal space
May be confounded by other
stroke conditions (e.g.,
hemiparesis)
Behavioral
Inattention
test62
Consists of six pencil-and-paper tests and nine behavioral subtests Assesses functional performance
Provides quantitative and objective assessment
Good predictive measure of functional performance
in daily living62,115
Catherine
Bergego
Scale5
Clinical
observation
Continuous observation during the delivery of care, looking for Allows continuous assessment of VN, which might be Does not provide quantitative
and objective assessment
signs indicative of VN, for instance, eating food from one side
missed earlier on
of the plate, colliding repetitively with obstacles on the same Improves the detection and assessment of VN when Cannot differentiate between
motor neglect and VN
side
used as a supplementary method to clinical VN
Non-standardized
tests81,164
These investigations only evaluate attention for peripersonal space and cannot differentiate between input and output neglect.
This table is modified from Plummer et al.137
Oculography
Tests
Allows assessment in a simulated environment reVirtual reality Requires a set of hardware (i.e., head-mounted display), eye
lating to daily life
trackers, and head-position sensor
Creates a more interactive, versatile and safer
Enables the users to explore real-time virtual images while
relevant information including head motion, scanning pattern,
environment for assessment of VN
Presence of eye trackers aid the assessor to record
and spatial orientation are recorded and analyzed
patients visual search pattern and develop better
understanding of the nature of VN
30
Brief Description/Rationale
Table 3 (continued )
Strength
Limitation
122
TING ET AL
123
Fig. 1. Examples of patient with VN neglecting the stimuli on the left hemispace in: (A) a cancellation task; (B) a line
bisection task; and (C) a copying and drawing task. (Adapted from http://ahsmail.uwaterloo.ca/waktse/assessment.
html.)
124
TING ET AL
125
Visual neglect
Lack of attention to contralesional
hemispace, independent of the
direction of gaze
Usually unaware of own deficit
Usually within the territory of the
middle cerebral artery
May associate with other modalities
like auditory, tactile and motor
Frequently associated49
Commonly leave out the details on
the affected hemispace
More commonly affected
Ipsilesional deviation
Presence of cueing may ameliorate
neglect (usually transiently)
Difficulty in maintaining central
fixation
Near normal response to stimulation
on both sides but prolonged
latency may be demonstrated on
the affected side160
Homonymous Hemianopia
Loss of visual field of contralesional
hemispace, with respect to the
position of the head and eyes
Usually retains awareness to a
certain extent
Usually within the territory of the
posterior cerebral artery
Strictly confined to visual modality
Less commonly associated
Normal and symmetrical
Usually not affected
Usually contralesional deviation122
Presence of cueing does not
modulate the disorder
Good control of central fixation
Marked disparity between the
normal and affected hemifield90
3. Restitutive
This form of rehabilitation focuses on retraining
of the impaired function92 and the modulation of
the internalized perception of the outer world,
rather than altering the afferent inputs. This may be
achieved by increasing self-awareness with mental
imagery, transcranial magnetic stimulation, virtual
reality--based space remapping, and, potentially,
feedback training (Table 5).
C. CURRENT EVIDENCE ON THE EFFECTIVENESS
OF REHABILITATION
126
TING ET AL
TABLE 5
Summary of Underlying Rationale/Concepts for Various Types of Rehabilitation for Unilateral Neglect
Types
Compensation
Interventions
Visual scanning therapy
174,178
Optokinetic stimulation124
Limb activation143
Training with cueing174
Neck muscle vibration86,88,152
Trunk rotation44,88
Caloric stimulation147
Eye patches44,179
Fresnel prisms148
Sustained attention training144
Substitution
Prism adaptation3,118,146
Diminished background
pattern and foreground clutter35
Restitution
Pharmacological treatment107
Mental imagery158
VR space remapping1
Compensation and
Restitution
Feedback training159
r-TMS/direct
polarization99,128,129
Unknown
Music therapy53
Included Studies
3
Aims
31 studiesmixed trials of
different quality
Riggs 2007140
Geusgen 200750
Bowen 200720
12 studiesall RCTs
Lincoln 2006103
Arene 2007
Key Findings
Passive sensory stimulation only confers shortlived improvement
Prism adaptation demonstrated long term functional gain
Visual scanning therapy
has no significant impact
on overall function
Improvement was observed with hemifield eye
patching, prism adaptation, and visuomotor
feedback, mainly by
means of standardized
neglect test like line bisection tests and cancellation tests
Almost all confer positive
impact on daily tasks or
daily living but three of
seven were not statistically
tested
Only spatiomotor cueing83 confers statistically
significant improvement
on performance in
standardized neglect
assessment
None showed statistical
significance in functional
performance
Rehabilitation observed
slight immediate and
persisting improvement
on standardised neglect
test
Effect on functioning was
statistically insignificant,
for either immediate or
persisting effects
Limitation of Evidence
Some of the interventions
were not included
Majority of the included
studies are not of high
quality
TABLE 6
127
Reviews
Aims
Pizzamiglio
2006136
Jutai 200382
Investigate effectiveness of a
variety of interventions
relating to visual neglect
Key Findings
Improvement has been
observed following VST,
mental imagery and video
feedback training
TR and NMV is partially
effective when coupled
with visual scanning
therapy
Fresnel prism and passive
sensory stimulation do
not afford positive functional impact
VST serves as a useful
neglect rehabilitative
intervention
No beneficial effect
gained with additional
peripheral sensory
stimulation
There is strong evidence
that rehabilitation specifically targeting visual neglect and visual scanning
improves functional
performance
There is moderate evidence that Fresnel prisms
and hemifield patching
improve performance in
standardized neglect tests
There is limited evidence
in favor of TENS, limb
activation, dopamine agonist therapy, caloric
stimulation improving visual neglect
Limitation of Evidence
There is need for further
high quality evidence to
confirm the effect
Luaute 2006
Included Studies
106
128
Table 6 (continued )
CCT 5 controlled clinical trial; NMV 5 neck muscle vibration; RCT 5 randomized controlled trial; TR 5 trunk rotation; VST 5 visual scanning therapy; TENS 5
transcutaneous electrical nerve stimulation.
TING ET AL
129
number and duration of therapeutic sessions instituted, and the difference in outcome measures
applied. This study did not address the anatomical
regions involved in their neglect patients. This is
important because some studies have suggested that
any potential beneficial effects of prism adaptation
may be lesion site--specific.151,155
The effectiveness of rehabilitation based on
passive sensory stimulation, such as eye patches,
Fresnel prism, trunk rotation, neck muscle vibration, limb activation, vestibular stimulation, and
optokinetic stimulation, remain inconclusive or
unsatisfactory.3,106
Although it seems logical that longer-term benefits
may be achieved with restitutive rehabilitation, the
evidence is limited. Within the context of restitutive
rehabilitation, Luaute et al106 consider mental imagery
and feedback training, as Grade B interventions,135
largely because the evidence of benefit is only based on
a case study of two patients.158 The efficacy of
pharmacological treatment (dopamine and noradrenergic agonists), transcranial magnetic stimulation128 or direct current polarization,99 virtual
reality--based space remapping,1 and music therapy
must be deemed inconclusive.158 There are conflicting
results from single case reports of the use of dopamine
and norepinephrine agonists to improve general
attention.3,10,72 Virtual reality--based space remapping
has shown to be of potential value, but has been
restricted to patients who have normal inferior
parietal/superior temporal lobes.1
The systematic reviews of Bowen et al20 and
Lincoln et al103 have concluded that none of the
interventions lead to a positive impact on functional
performance. They excluded the majority of the
research trials because of unsatisfactory levels of
evidence, highlighting the pressing need for high
quality research.
D. SUMMARY AND RECOMMENDATION FOR
REHABILITATION OF VISUAL NEGLECT
IX. Conclusion
VN is a common, but frequently overlooked,
condition. Greater awareness and understanding of
this condition should improve the quality of life of
post-stroke patients. Detection is by combination of
pen-and-paper tests, behavioral assessment tools,
clinical observation and history taking and, potentially, virtual reality assessment. Although there is
lack of robust evidence of the efficacy of VN
rehabilitation, visual scanning therapy and prism
adaptation warrant consideration. There is a pressing need for well designed, high quality research,
particularly randomized controlled trials, to
demonstrate the clinical efficacy of current rehabilitation strategies. Increasingly sophisticated neuroimaging tools, including magnetic resonance
scanning coupled with detailed clinical observation
and neuro-ophthalmic examination, will improve
understanding of the nature of VN, enabling
a deeper appreciation of how an individual with
VN recognizes, organizes, and orients self in
relation to the external environment.
XI. Disclosure
The authors reported no proprietary or commercial interest in any product mentioned or concept
discussed in this article. Alex Pollock is employed by
the Nursing Midwifery and Allied Health Professionals (NMAHP) Research Unit, which is funded by
the Scottish Governments Chief Scientists Office.
VIII. Prognosis
A few studies have observed spontaneous recovery
in patients with mild to moderate visual neglect,
especially during the acute phase,41 and recovery
has been seen up to 90 days post-stroke.126
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134
TING ET AL
Outline
I. Introduction
II. Epidemiology
III. Varieties of neglect
A. Modality (input/output)
B. Spatial representation
C. Range of space
of vi-
1. Compensatory
2. Substitutive
3. Restitutive
visual
visual
VIII.
IX.
X.
XI.
Prognosis
Conclusion
Method of Literature Search
Disclosure