Visuospatial memory in apraxia: Exploring quantitative drawing metrics to assess the representation of local and global information.

Neuropsychological evidence suggests that visuospatial memory is subserved by two separable processing systems, with dorsal underpinnings for global form and ventral underpinnings for the integration of part elements. Previous drawing studies have explored the effects of Gestalt organisation upon memory for hierarchical stimuli, and we here present an exploratory study of an apraxic dorsal stream patient's (MH) performance. We presented MH with a stimulus set (previously reported by Riddoch et al., Cognitive Neuropsychology, 20(7), 641-671, 2003) and devised a novel quantitative scoring system to obtain a finer grain of insight into performance. Stimuli possessed either good or poor Gestalt qualities and were reproduced in a copy condition and two visual memory conditions (with unlimited viewing before the model was removed, or with 3 s viewing). MH's copying performance was impaired in comparison to younger adult and age-matched older adult controls, with a variety of errors at the local level but relatively few at the global level. However, his performance in the visual memory conditions revealed impairments at the global level. For all participants, drawing errors were modulated by the Gestalt qualities of the stimuli, with accuracy at the global and local levels being lesser for poor global stimuli in all conditions. These data extend previous observations of this patient, and support theories that posit interaction between dorsal and ventral streams in the representation of hierarchical stimuli. We discuss the implications of these findings for our understanding of visuospatial memory in neurological patients, and also evaluate the application of quantitative metrics to the interpretation of drawings.

Unconscious Familiarity-based Color-Form Binding: Evidence from Visual Extinction.

There is good evidence that early visual processing involves the coding of different features in independent brain regions. A major question, then, is how we see the world in an integrated manner, in which the different features are "bound" together. A standard account of this has been that feature binding depends on attention to the stimulus, which enables only the relevant features to be linked together [Treisman, A., & Gelade, G. A feature-integration theory of attention. Cognitive Psychology, 12, 97-136, 1980]. Here we test this influential idea by examining whether, in patients showing visual extinction, the processing of otherwise unconscious (extinguished) stimuli is modulated by presenting objects in their correct (familiar) color. Correctly colored objects showed reduced extinction when they had a learned color, and this color matched across the ipsi- and contralesional items (red strawberry + red tomato). In contrast, there was no reduction in extinction under the same conditions when the stimuli were colored incorrectly (blue strawberry + blue tomato; Experiment 1). The result was not due to the speeded identification of a correctly colored ipsilesional item, as there was no benefit from having correctly colored objects in different colors (red strawberry + yellow lemon; Experiment 2). There was also no benefit to extinction from presenting the correct colors in the background of each item (Experiment 3). The data suggest that learned color-form binding can reduce extinction even when color is irrelevant for the task. The result is consistent with preattentive binding of color and shape for familiar stimuli.

Systematic assessment of apraxia and functional predictions from the Birmingham Cognitive Screen.

OBJECTIVE: The validity and functional predictive values of the apraxia tests in the Birmingham Cognitive Screen (BCoS) were evaluated. BCoS was developed to identify patients with different forms of praxic deficit using procedures designed to be inclusive for patients with aphasia and/or spatial neglect. METHOD: Observational studies were conducted from a university neuropsychological assessment centre and from acute and rehabilitation stroke care hospitals throughout an English region. Volunteers from referred patients with chronic acquired brain injuries, a consecutive hospital sample of patients within 3 months of stroke (n=635) and a population based healthy control sample (n=100) were recruited. The main outcome measures used were the Barthel Index, the Nottingham Extended Activities of Daily Living Scale as well as recovery from apraxia. RESULTS: There were high inter-rater reliabilities and correlations between the BCoS apraxia tasks and counterpart tests from the literature. The vast majority (88.3%) of the stroke survivors were able to complete the screen. Pantomime and gesture recognition tasks were more sensitive in differentiating between individuals with left hemisphere damage and right hemisphere damage whereas the Multistep Object Use test and the imitation task had higher functional correlates over and above effects of hemiplegia. Together, the initial scores of the four tasks enabled predictions with 75% accuracy, the recovery of apraxia and independence level at 9 months. CONCLUSIONS: As a model based assessment, BCoS offers a quick and valid way to detect apraxia and predict functional recovery. It enables early and informative assessment of most stroke patients for rehabilitation planning.

Functional relations trump implied motion in recovery from extinction: evidence from the effects of animacy on extinction.

Patients with extinction show a characteristic impairment in the identification of objects when two items are presented simultaneously, typically reporting the ipsilesional item only. The effect is thought to be due to a spatial bias advantaging the ipsilesional item under conditions of competing concurrent stimulation. Action relations between objects can result in recovery from extinction as the object pair may be perceived as a single group rather than competing perceptual units. However, objects interacting together can also have implied motion. Here we test whether implied motion is necessary to generate recovery from extinction. We varied orthogonally whether animate and inanimate objects were paired together in positions related or unrelated to action. Implied motion was greater when an animate object was present than when both stimuli were inanimate. Despite this, recovery from extinction was greater when actions were shown between inanimate objects. We suggest that actions between inanimate objects are perceived more easily due to the surfaces of these stimuli being designed for functional goals (e.g., the flat surface of a hammer head is designed to hit the flattened head of a nail). Attention is sensitive to the fit between potential action and the functional properties of objects, and not just to implied motion between stimuli.

Modulating wheelchair navigation in patients with spatial neglect.

Patients who have had a stroke resulting in the deficit of visuo-spatial neglect are normally not provided with a powered wheelchair, as they are either considered or found to be unsafe navigating about their environment. As these patients are relatively unlikely to regain functional mobility by walking, the denial of alternative forms of mobility is of particular concern. Modest progress has been made over the past two decades with regards to the rehabilitation of neglect but there have been calls for further research which addresses "real world" measures of independence such as wheelchair navigation. In this study, we investigated the ability of patients with neglect to improve their performance when navigating a powered wheelchair by using theoretically-driven strategies that have shown promise in previous studies (spatial cueing and limb activation). Strategies were applied and tested in the most realistic and practical manner for each individual, based on their abilities and concurrent deficits. Performance was improved by the experimental strategies. The data suggest it is possible to apply theoretically-driven strategies to improve wheelchair navigation in patients with neglect and are supportive of further studies that could lead to improved access to powered mobility by this population in the future.

Handgrip Based Action Information Modulates Attentional Selection: An ERP Study.

Prior work shows that the possibility of action to an object (visual affordance) facilitates attentional deployment. We sought to investigate the neural mechanisms underlying this modulation of attention by examining ERPs to target objects that were either congruently or incongruently gripped for their use in the presence of a congruently or incongruently gripped distractor. Participants responded to the presence or absence of a target object matching a preceding action word with a distractor object presented in the opposite location. Participants were faster in responding to congruently gripped targets compared to incongruently gripped targets. There was a reduced N2pc potential when the target was congruently gripped, and the distractor was incongruently gripped compared to the conditions where targets were incongruently gripped or when the distractor, as well as target, was congruently gripped. The N2pc results indicate that target selection is easier when action information is congruent with an object's use.

Recovery of Visuospatial Neglect Subtypes and Relationship to Functional Outcome Six Months After Stroke.

Background/Objective. This study aims to investigate how complex visuospatial neglect behavioural phenotypes predict long-term outcomes, both in terms of neglect recovery and broader functional outcomes after 6 months post-stroke. Methods. This study presents a secondary cohort study of acute and 6-month follow-up data from 400 stroke survivors who completed the Oxford Cognitive Screen's Cancellation Task. At follow-up, patients also completed the Stroke Impact Scale questionnaire. These data were analysed to identify whether any specific combination of neglect symptoms is more likely to result in long-lasting neglect or higher levels of functional impairment, therefore warranting more targeted rehabilitation. Results. Overall, 98/142 (69%) neglect cases recovered by follow-up, and there was no significant difference in the persistence of egocentric/allocentric (X2 [1] = .66 and P = .418) or left/right neglect (X2 [2] = .781 and P = .677). Egocentric neglect was found to follow a proportional recovery pattern with all patients demonstrating a similar level of improvement over time. Conversely, allocentric neglect followed a non-proportional recovery pattern with chronic neglect patients exhibiting a slower rate of improvement than those who recovered. A multiple regression analysis revealed that the initial severity of acute allocentric, but not egocentric, neglect impairment acted as a significant predictor of poor long-term functional outcomes (F [9,300] = 4.742, P < .001 and adjusted R2 = .098). Conclusions. Our findings call for systematic neuropsychological assessment of both egocentric and allocentric neglect following stroke, as the occurrence and severity of these conditions may help predict recovery outcomes over and above stroke severity alone.

Fractionating the binding process: neuropsychological evidence from reversed search efficiencies.

The authors present neuropsychological evidence distinguishing binding between form, color, and size (cross-domain binding) and binding between form elements. They contrasted conjunctive search with difficult feature search using control participants and patients with unilateral parietal or fronto/temporal lesions. To rule out effects of task difficulty or loss of top-down guidance of search, the authors made conjunction search easier than feature search. Despite this, parietal patients were selectively impaired at detecting conjunction targets in their contralateral field. In contrast, the parietal patients performed like the other participants with form conjunctions, with form conjunctions being easier to detect than difficult feature targets. These data indicate a qualitative difference between binding in the form domain and binding across form, color, and size, consistent with theories that propose distinct binding processes in vision.

Are faces special? A case of pure prosopagnosia.

The ability to recognize individual faces is of crucial social importance for humans and evolutionarily necessary for survival. Consequently, faces may be "special" stimuli, for which we have developed unique modular perceptual and recognition processes. Some of the strongest evidence for face processing being modular comes from cases of prosopagnosia, where patients are unable to recognize faces whilst retaining the ability to recognize other objects. Here we present the case of an acquired prosopagnosic whose poor recognition was linked to a perceptual impairment in face processing. Despite this, she had intact object recognition, even at a subordinate level. She also showed a normal ability to learn and to generalize learning of nonfacial exemplars differing in the nature and arrangement of their parts, along with impaired learning and generalization of facial exemplars. The case provides evidence for modular perceptual processes for faces.

A tale of two agnosias: distinctions between form and integrative agnosia.

The performance of two patients with visual agnosia was compared across a number of tests examining visual processing. The patients were distinguished by having dorsal and medial ventral extrastriate lesions. While inanimate objects were disadvantaged for the patient with a dorsal extrastriate lesion, animate items are disadvantaged for the patient with the medial ventral extrastriate lesion. The patients also showed contrasting patterns of performance on the Navon Test: The patient with a dorsal extrastriate lesion demonstrated a local bias while the patient with a medial ventral extrastriate lesion had a global bias. We propose that the dorsal and medial ventral visual pathways may be characterized at an extrastriate level by differences in local relative to more global visual processing and that this can link to visually based category-specific deficits in processing.

Seeing the action: neuropsychological evidence for action-based effects on object selection.

Previous studies have shown that selection for perceptual report is often limited to one object at a time, with elements being selected together if they belong to part of the same perceptual group. Here we used the neuropsychological phenomenon of extinction in human patients with parietal lesions to show that selection is influenced also by action relations between objects. Performance was better for objects that were positioned spatially so that they could be used together, relative to objects that were positioned inappropriately for their combined use. The action relation was critical, as performance for pictures did not improve if the items were only verbally associated. We found the opposite result with words. Effects of action relations emerged even on trials where only one object could be reported, showing implicit coding of 'action' units for selection. The effects of verbal associations may instead reflect priming between lexical entries.

Motor neglect: implications for movement and rehabilitation following stroke.

PURPOSE: The syndrome of unilateral neglect following stroke is associated with poor outcome and presents significant challenges to those providing therapy for affected individuals. In contrast to a number of reviews which have recently appeared in therapy and rehabilitation journals relating to sensory aspects of neglect, this review focuses on 'motor neglect'. SEARCH STRATEGY: We searched the clinical and scientific literature for papers concerning motor neglect. The search included the databases Web of Science, Pubmed and Cinahl, primarily using the term 'motor neglect'. There was also a large degree of secondary searching involved. DISCUSSION: Motor neglect refers to the under-utilization of a limb opposite a brain lesion that cannot be fully explained by primary sensory and motor deficits. The paper discusses classical descriptions of motor neglect and highlights the difficulties in disentangling motor neglect from hemiparesis. The related problem of motor extinction is introduced as a useful clinical measure of neglect-related movement difficulties and a significant clinical problem in its own right. CONCLUSION: Motor neglect is a relatively under-recognized deficit which may have a significant impact on patient performance and recovery following stroke. We conclude with a discussion of the implications of motor neglect for rehabilitation, including the relative contributions that may be made by Constraint-induced movement therapy and Bilateral movement therapy in managing patients with neglect-related movement problems.

On the importance of cognitive profiling: A graphical modelling analysis of domain-specific and domain-general deficits after stroke.

Cognitive problems following stroke are typically analysed using either short but relatively uninformative general tests or through detailed but time consuming tests of domain specific deficits (e.g., in language, memory, praxis). Here we present an analysis of neuropsychological deficits detected using a screen designed to fall between other screens by being 'broad' (testing multiple cognitive abilities) but 'shallow' (sampling the abilities briefly, to be time efficient) - the BCoS. Assessment using the Birmingham Cognitive Screen (BCoS) enables the relations between 'domain specific' and 'domain general' cognitive deficits to be evaluated as the test generates an overall cognitive profile for individual patients. We analysed data from 287 patients tested at a sub-acute stage of stroke (<3 months). Graphical modelling techniques were used to investigate the associative structure and conditional independence between deficits within and across the domains sampled by BCoS (attention and executive functions, language, memory, praxis and number processing). The patterns of deficit within each domain conformed to existing cognitive models. However, these within-domain patterns underwent substantial change when the whole dataset was modelled, indicating that domain-specific deficits can only be understood in relation to linked changes in domain-general processes. The data point to the importance of using over-arching cognitive screens, measuring domain-general as well as domain-specific processes, in order to account for neuropsychological deficits after stroke. The paper also highlights the utility of using graphical modelling to understand the relations between cognitive components in complex datasets.

The Oxford Cognitive Screen (OCS): validation of a stroke-specific short cognitive screening tool.

There is currently no existing freely available short screen for cognitive problems that targets stroke survivors specifically. We have developed a short cognitive screen, the Oxford Cognitive Screen (OCS), to be completed in 15-20 min, designed for use with stroke patients. To maximize inclusion, the test is aphasia- and neglect friendly and covers domains of cognition where deficits frequently occur after stroke, including apraxia and unilateral neglect as well as memory, language, executive function, and number abilities. Domain-specific scores are returned to help direct rehabilitation. This article presents the normative data in a large sample of 140 neurologically healthy participants, a report on incidences of impairments in a sample of 208 acute stroke patients (within 3 weeks of stroke onset), measures of test-retest reliability on an alternate form and convergent and divergent validity. In addition, the full test materials are made freely available for clinical use.

The BCoS cognitive profile screen: Utility and predictive value for stroke.

OBJECTIVE: We examined the utility of the Birmingham Cognitive Screen (BCoS) in discriminating cognitive profiles and recovery of function across stroke survivors. BCoS was designed for stroke-specific problems across 5 cognitive domains: (a) controlled and spatial attention, (b) language, (c) memory, (d) number processing, and (e) praxis. METHOD: On the basis of specific inclusion criteria, this cross-section observational study analyzed cognitive profiles of 657 subacute stroke patients, 331 of them reassessed at 9 months. Impairments on 32 measures were evaluated by comparison with 100 matched healthy controls. Measures of affect, apathy, and activities of daily living were also taken. Between-subjects group comparisons of mean performance scores and impairment rates and within-subject examination of impairment rates over time were conducted. Logistic regressions and general linear modeling were used for multivariate analysis of domain-level effects on outcomes. RESULTS: Individuals with repeated stroke experienced significantly less cognitive recovery at 9 months than those with a first stroke despite similar initial level of cognitive performance. Individuals with left hemisphere lesions performed more poorly than those with right hemisphere lesions, but both groups showed similar extent of recovery at 9 months. BCoS also revealed lesion-side-specific deficits and common areas of persistent problems. Functional outcome at 9 months correlated with domain-level deficits in controlled attention, spatial attention, and praxis over and above initial dependency and concurrent levels of affect and apathy. CONCLUSION: The study demonstrates how BCoS can identify differential cognitive profiles across patient groups. This can potentially help predict outcomes and inform rehabilitation.

Visual agnosia.

As was originally proposed by Lissauer, visual recognition may break down either at an apperceptive or at an associative level. At an apperceptive level, finer grain distinctions may be made; the authors distinguished here between disorders of shape recognition and perceptual integration. It is not the case, however, that all patients with visual recognition deficits have impaired perception: poor recognition and naming may also result from damage to stored perceptual knowledge (e.g., structural descriptions), from problems in accessing semantic knowledge, from perceptual knowledge, or from impairments to semantic knowledge itself. These represent different types of associative deficit. In some cases, mild damage to stored perceptual knowledge also generates problems that are more severe on naming than on recognition and more severe for some categories of objects than others.

Treatment of visual neglect in elderly patients with stroke: a single-subject series using either a scanning and cueing strategy or a left-limb activation strategy.

BACKGROUND AND PURPOSE: The presence of unilateral visual neglect (UVN) may adversely affect functional recovery, and rehabilitation strategies that are practical for use in clinical settings are needed. The purpose of this study was to evaluate the use of 2 approaches to reduce UVN in people who have had strokes. SUBJECTS: Seven elderly patients with stroke and severe left UVN, aged 60 to 85 years, were recruited from a stroke rehabilitation unit. METHODS: A nonconcurrent, multiple-baselines-across-subjects approach, with an A-B-A treatment-withdrawal single-subject experimental design, was used. Five subjects received a scanning and cueing approach, and 2 subjects received a contralesional limb activation approach, for 10 one-hour sessions. In the former approach, active scanning to the left was encouraged by the therapist, using visual and verbal cues and a mental imagery technique, during reading and copying tasks and simple board games. In the latter approach, functional and goal-oriented left upper-limb activities in neglected hemispace were encouraged. Unilateral visual neglect was examined by a masked (blinded) examiner throughout all phases using the Star Cancellation Test, the Line Bisection Test, and the Baking Tray Task. Data were analyzed using visual and inferential statistical techniques. RESULTS: Both subjects who received limb activation and 3 of the 5 subjects who received scanning and cueing showed a reduction in UVN in one or more tests. This improvement was maintained during the withdrawal phase. DISCUSSION AND CONCLUSION: Both approaches had a positive effect of reducing aspects of UVN in some subjects relative to no-treatment baselines. However, causality cannot be assured in the absence of controls. The approaches are practical for use in rehabilitation settings. These procedures warrant further replication across subjects, settings, and therapists.

Hierarchical processing in Balint's syndrome: a failure of flexible top-down attention.

Patients with Balint' s syndrome are typically impaired at perceiving multiple objects simultaneously, and at evaluating the relationship between multiple objects in a scene (simultanagnosia). These deficits may not only be observed in complex scenes, but also when local elements of individual objects must be integrated into a perceptual global whole. Thus, unlike normal observers, patients with simultanagnosia typically show a bias towards the local forms, even to the extent that they cannot identify the global stimuli. However, we have previously shown that global processing is still attainable in Balint patients in certain scenarios (e.g., when local elements are unfamiliar). This suggests that in addition to a possible perceptual deficit that favors the local elements in these patients, impaired attentional control may be at the core of their unique performance. To test this hypothesis we manipulated the perceptual saliency of the local and global elements in a compound letter task so that it included global-more-salient or local-more-salient displays. We show that a Balint patient was able to accurately identify both global and local targets as long as they were the salient aspect of the compound letter. However, substantial impairment was evident when either the global or local elements were the less salient aspect of the compound letter. We conclude that in Balint' s syndrome there is a failure of flexible top-down attention both in biasing attention away from salient irrelevant aspects of the display (salience-based-selection) and in impaired disengagement from irrelevant but salient items once they have been selected.

The attraction of yellow corn: reduced attentional constraints on coding learned conjunctive relations.

Physiological evidence indicates that different visual features are computed quasi-independently. The subsequent step of binding features, to generate coherent perception, is typically considered a major rate-limiting process, confined to one location at a time and taking 25 ms per item or longer (A. Treisman & S. Gormican, 1988, Feature analysis in early vision: Evidence from search asymmetries, Psychological Review, Vol. 95, pp. 15-48). We examined whether these processing limitations remain once bindings are learned for familiar objects. Participants searched for objects that could appear either in familiar or unfamiliar colors. Objects in familiar colors were detected efficiently at rates consistent with simultaneous binding across multiple stimuli. Processing limitations were evident for objects in unfamiliar colors. The advantage for the learned color for known targets was eliminated when participants searched for geometric shapes carrying the object colors and when the colors fell in local background areas around the shapes. The effect occurred irrespective of whether the nontargets had familiar colors, but was largest when nontargets had incorrect colors. The efficient search for targets in familiar colors held, even when the search was biased to favor objects in unfamiliar colors. The data indicate that learned bindings can be computed with minimal attentional limitations, consistent with the direct activation of learned conjunctive representations in vision.

Motor extinction: a deficit of attention or intention?

Motor extinction refers to a deficit of motor production on the side opposite a brain lesion that either only becomes apparent or disproportionately worsens during bilateral motor activity. It may arise due either to a contralesional deficit in setting the motor activation level (an intentional deficit) or a deficit in contralesional awareness of the sensory consequences of movement (an attentional deficit). In this study, we investigate the nature of motor extinction in a patient (LR) with a right fronto-temporal lesion through the kinematic analysis of unimanual and bimanual circle-drawing movements. While the ipsi- and contralesional limbs performed comparably for unimanual movements, the contralesional limb demonstrated marked bradykinesia and hypometria during bimanual movements. Furthermore, these deficits were not overcome when visual feedback of the contralesional limb was provided (Experiment 1). However, when performing bimanual movements in the presence of a visual template (Experiment 2), LR was able to overcome the contralesional hypometria but not the bradykinesia which proved intractable across both experiments. Both the bradykinesia and hypometria could result from an intentional deficit of motor production. However, in Experiment 2, LR also demonstrated an abnormal level of positional drift in the contralesional limb for bimanual movements indicative of an additional attentional deficit. We conclude that LR's presentation of motor extinction is the result of a primary intentional deficit and a secondary attentional deficit.