Does repetitive transcranial magnetic stimulation have a beneficial effect on improving unilateral spatial neglect caused by stroke? A meta-analysis.

This review aimed to assess the effect of repetitive transcranial magnetic stimulation (rTMS) in improving post-stroke unilateral spatial neglect (USN) using a meta-analysis. Further, we aimed to identify any association between rTMS parameters, patient demographics, and treatment effect sizes using subgroup analyses and meta-regression. A literature search was conducted through four databases from inception to March 6, 2024, to retrieve all relevant controlled trials investigating the effects of rTMS on symptoms of USN in post-stroke patients. Overall, rTMS significantly improved post-stroke USN, as measured by the line bisection test (Hedges' g = - 1.301, p < 0.0001), the cancelation test (Hedge's g = - 1.512, p < 0.0001), and the Catherine Bergego Scale (Hedges'g = - 0.770, p < 0.0001), compared to sham stimulation. Subgroup analysis found that generally larger effect sizes following excitatory rTMS across several outcome measures, indicating that excitatory rTMS on the ipsilesional hemisphere may be more effective than inhibitory rTMS on the contralesional hemisphere in ameliorating neglect symptoms. Meta-regression analysis of the line bisection test showed a significant difference in the chronicity of stroke patients, suggesting that rTMS may be more effective for USN in patients at the acute stage (within 3 months since stroke) than in those at the post-acute stage (p = 0.035). In conclusion, rTMS appears to be effective in promoting recovery from post-stroke USN. Excitatory protocols and early intervention may enhance recovery outcomes for neglect behaviors in post-stroke survivors.

Advancements in brain-computer interfaces for the rehabilitation of unilateral spatial neglect: a concise review.

This short review examines recent advancements in neurotechnologies within the context of managing unilateral spatial neglect (USN), a common condition following stroke. Despite the success of brain-computer interfaces (BCIs) in restoring motor function, there is a notable absence of effective BCI devices for treating cerebral visual impairments, a prevalent consequence of brain lesions that significantly hinders rehabilitation. This review analyzes current non-invasive BCIs and technological solutions dedicated to cognitive rehabilitation, with a focus on visuo-attentional disorders. We emphasize the need for further research into the use of BCIs for managing cognitive impairments and propose a new potential solution for USN rehabilitation, by combining the clinical subtleties of this syndrome with the technological advancements made in the field of neurotechnologies.

Study of the Possibility of Using Virtual Reality Application in Rehabilitation among Elderly Post-Stroke Patients.

Thanks to medical advances, life expectancy is increasing. With it comes an increased incidence of diseases, of which age is a risk factor. Stroke is among these diseases, and is one of the causes of long-term disability. The opportunity to treat these patients is via rehabilitation. A promising new technology that can enhance rehabilitation is virtual reality (VR). However, this technology is not widely used by elderly patients, and, moreover, the elderly often do not use modern technology at all. It therefore becomes a legitimate question whether elderly people will be able to use virtual reality in rehabilitation. This article presents a rehabilitation application dedicated to patients with upper limb paresis and unilateral spatial neglect (USN). The application was tested on a group of 60 individuals including 30 post-stroke patients with an average age of 72.83 years. The results of the conducted study include a self-assessment by the patients, the physiotherapist's evaluation, as well as the patients' performance of the exercise in VR. The study showed that elderly post-stroke patients are able to use virtual reality applications, but the ability to correctly and fully perform an exercise in VR depends on several factors. One of them is the ability to make logical contact (p = 0.0001 < 0.05). However, the study presented here shows that the ability to use VR applications does not depend on age but on mental and physical condition, which gives hope that virtual reality applications can be used in post-stroke rehabilitation among patients of all ages.

Computer-Assisted Rehabilitation Shows Greater Efficacy Than Traditional in Visuospatial Skills and Cognition in Neglect Patients.

This study is crucial for improving unilateral spatial neglect (USN) treatments, focusing on comparing the effectiveness of computer-assisted cognitive rehabilitation (CACR) against conventional rehabilitation (CR) methods. It aimed to address a significant research gap and improve patient outcomes by evaluating the impact of CACR versus CR on visuospatial perception, visual field and attention, and visual memory in patients with USN. This study was a randomized controlled trial. Forty-five consecutive patients with USN from a university rehabilitation center were divided into two groups: 22 patients received CACR with Rehacom software, focusing on saccadic eye movement, visual field, and visual-motor coordination, while 23 underwent CR that combined hemispheric activation approach, mental imagery training, and vibration therapy. Assessments included the Motor-Free Visual Perception Test (MVPT), Line Bisection Test (LBT), Visual Span Test (VST), and Visual Recognition Test (VRT). The study employed ANCOVA and effect size calculations to evaluate the effectiveness of CACR compared to CR in treating patients with USN. Results indicated that CACR significantly outperformed CR in improving visuospatial perception, visual field, attention, and memory, showcasing its effectiveness in treating USN. These findings demonstrate the superiority of CACR over CR, particularly in enhancing visual memory and attention, as evidenced by the large effect size in VRT and moderate effects in LBT and VST. This suggests CACR's potential as a more effective approach for rehabilitation in patients with USN due to brain injuries.

A systematic review of vestibular stimulation in post-stroke visual neglect.

Unilateral visual neglect is a condition that negatively impacts the lives of many stroke survivors. Studies have investigated different forms of vestibular stimulation as a potential therapy, but evidence is yet to be systematically reviewed. We therefore reviewed the effects of vestibular stimulation on outcomes of neglect and activities of daily living (ADL) for people with visual neglect. We searched relevant databases up until September 2022. Eligible articles included any form of vestibular stimulation, study design, or control condition. Included participants were 18 years or older, presenting with neglect following a haemorrhagic or ischaemic stroke. Relevant outcomes were clinically validated measures of neglect and ADL. Cochrane risk of bias tools were used to assess study quality. Meta-analyses and narrative methods were used to synthesize the data. Our search returned 17 relevant studies comprising 180 participants. Meta-analyses showed no difference between galvanic vestibular stimulation and sham conditions on outcomes, whereas caloric vestibular stimulation led to improvement compared to pre-stimulation scores. Narrative syntheses showed mixed results. Clinical and methodological heterogeneity was found both within and between studies. Overall, results were inconsistent regarding the effects of vestibular stimulation as a treatment for neglect. Further trials are warranted but require more careful methodological planning.

An immersive virtual reality tool for assessing left and right unilateral spatial neglect.

The reported rate of the occurrence of unilateral spatial neglect (USN) is highly variable likely due to the lack of validity and low sensitivity of classical tools used to assess it. Virtual reality (VR) assessments try to overcome these limitations by proposing immersive and complex environments. Nevertheless, existing VR-based tasks are mostly focused only on near space and lack analysis of psychometric properties and/or clinical validation. The present study evaluates the clinical validity and sensitivity of a new immersive VR-based task to assess USN in the extra-personal space and examines the neuronal correlates of deficits of far space exploration. The task was administrated to two groups of patients with right (N = 28) or left (N = 11) hemispheric brain lesions, also undergoing classical paper-and-pencil assessment, as well as a group of healthy participants. Our VR-based task detected 44% of neglect cases compared to 31% by paper-and-pencil tests in the total sample. Importantly, 30% of the patients (with right or left brain lesions) with no clear sign of USN on the paper-and-pencil tests performed outside the normal range in the VR-based task. Voxel lesion-symptom mapping revealed that deficits detected in VR were associated with lesions in insular and temporal cortex, part of the neural network involved in spatial processing. These results show that our immersive VR-based task is efficient and sensitive in detecting mild to strong manifestations of USN affecting the extra-personal space, which may be undetected using standard tools.

Evaluation of driving fitness using driving simulators in patients with right-hemisphere damage: an unmatched case-control study.

BACKGROUND: Patients with right hemisphere damage (RHD) may exhibit mild unilateral spatial neglect (USN), which is difficult to detect in general assessments performed during driving rehabilitation. OBJECTIVES: We compared driving simulator performance, practical driving performance, and neuropsychological test results between patients with RHD who were able and unable to return to driving to predict driving fitness based on driving simulator performance. METHODS: This unmatched case-control study included 29 patients with RHD who were able (return-to-driving group, n = 16) and unable (non-return-to-driving group, n = 13) to return to driving. Patient demographics, motor function, attention, driving simulator performance (participants' reaction time and rate to green lamps appearing in any of the three displays and average lane position), and practical driving performance were compared between the groups. Receiver operating characteristic (ROC) analysis was performed to examine the predictive performance of driving fitness in reaction rate and paper-and-pencil tests. RESULTS: The non-return-to-driving group had a significantly lower reaction rate than the return-to-driving group (p = 0.027; 95% confidence interval [CI], 0-7; r = 0.407). No significant difference in reaction time or lane position in either the left or right lane during driving simulation was observed. ROC analysis of the reaction rate in the driving simulator task showed sensitivity of 0.692, specificity of 0.812, and area under the curve of 0.738 [95% CI, 0.541-0.935]. CONCLUSIONS: Decreases in reaction rates during simulated driving assessments are associated with an inability to resume driving in patients with RHD. Such assessments may aid in predicting fitness for driving in these patients.

Spontaneous unilateral spatial neglect recovery after brain tumour resection: A multimodal diffusion and rs-fMRI case report.

Patients with unilateral spatial neglect (USN) are unable to explore or to report stimuli presented in the left personal and extra-personal space. USN is usually caused by lesion of the right parietal lobe: nowadays, it is also clear the key role of structural connections (the second and the third branch of the right Superior Longitudinal Fasciculus, respectively, SLF II and III) and functional networks (Dorsal and Ventral Attention Network, respectively, DAN and VAN) in USN. In this multimodal case report, we have merged those structural and functional information derived from a patient with a right parietal lobe tumour and USN before surgery. Functional, structural and neuropsychological data were also collected 6 months after surgery, when the USN was spontaneously recovered. Diffusion metrics and Functional Connectivity (FC) of the right SLF and DAN, before and after surgery, were compared with the same data of a patient with a tumour in a similar location, but without USN, and with a control sample. Results indicate an impairment in the right SLF III and a reduction of FC of the right DAN in patients with USN before surgery compared to controls; after surgery, when USN was recovered, patient's diffusion metrics and FC showed no differences compared to the controls. This single case and its multimodal approach reinforce the crucial role of the right SLF III and DAN in the development and recovery of egocentric and allocentric extra-personal USN, highlighting the need to preserve these structural and functional areas during brain surgery.

Clinical application of repetitive transcranial magnetic stimulation in improving functional impairments post-stroke: review of the current evidence and potential challenges.

In recent years, the stroke incidence has been increasing year by year, and the related sequelae after stroke, such as cognitive impairment, motor dysfunction, and post-stroke depression, seriously affect the patient's rehabilitation and daily activities. Repetitive transcranial magnetic stimulation (rTMS), as a safe, non-invasive, and effective new rehabilitation method, has been widely recognized in clinical practice. This article reviews the application and research progress of rTMS in treating different functional impairments (cognitive impairment, motor dysfunction, unilateral spatial neglect, depression) after stroke in recent years, and preliminary summarized the possible mechanisms. It has been found that the key parameters that determine the effectiveness of rTMS in improving post-stroke functional impairments include pulse number, stimulated brain areas, stimulation intensity and frequency, as well as duration. Generally, high-frequency stimulation is used to excite the ipsilateral cerebral cortex, while low-frequency stimulation is used to inhibit the contralateral cerebral cortex, thus achieving a balance of excitability between the two hemispheres. However, the specific mechanisms and the optimal stimulation mode for different functional impairments have not yet reached a consistent conclusion, and more research is needed to explore and clarify the best way to use rTMS. Furthermore, we will identify the issues and challenges in the current research, explore possible mechanisms to deepen understanding of rTMS, propose future research directions, and offer insightful insights for better clinical applications.

Recombination of the right cerebral cortex in patients with left side USN after stroke: fNIRS evidence from resting state.

Objective: Unilateral spatial neglect (USN) is an impaired contralesional stimulus detection, response, or action, causing functional disability. After a stroke, the right hemisphere experiences USN more noticeably, severely, and persistently than the left. However, few studies using fNIRS have been reported in cases of USN. This study aimed to confirm weaker RSFC in USN and investigate the potential inherent features in hemodynamic fluctuations that may be associated with USN. Furthermore, these features were combined into a mathematical model for more accurate classification. Methods: A total of 33 stroke patients with right-sided brain damage were chosen, of whom 12 had non-USN after stroke, and 21 had USN after stroke (the USN group). Graph theory was used to evaluate the hemodynamic signals of the brain's right cerebral cortex during rest. Furthermore, a support vector machine model was built to categorize the subjects into two groups based on the chosen network properties. Results: First, mean functional connectivity was lower in the USN group (0.745 ± 0.239) than in the non-USN group (0.843 ± 0.254) (t = -4.300, p < 0.001). Second, compared with the non-USN group, USN patients had a larger clustering coefficient (C) (t = 3.145, p < 0.001), local efficiency (LE) (t = 3.189, p < 0.001), and smaller global efficiency (GE) (t = 3.047, p < 0.001). Notably, there were differences in characteristic path length (L) and small worldness (σ) values between the two groups at certain thresholds, mainly as higher L (t = 3.074, p < 0.001) and lower small worldness (σ) values (t = 2.998, p < 0.001) in USN patients compared with non-USN patients. Finally, the classification accuracy of the SVM model based on AUC aC (t = -2.259, p = 0.031) and AUC aLE (t = -2.063, p = 0.048) was 85%, the sensitivity was 75%, and the specificity was 89%. Conclusion: The functional network architecture of the right cerebral cortex exhibits significant topological alterations in individuals with USN following stroke, and the sensitivity index based on the small-world property AUC may be utilized to identify these patients accurately.

The Neurophysiological Features Associated with Unilateral Spatial Neglect Recovery: A Scoping Review.

The purpose of this scoping review is to provide updated information on the neural basis and neurophysiological features associated with unilateral spatial neglect (USN) recovery. We applied the Preferred Reporting Systems for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) framework and identified 16 relevant papers from the databases. Critical appraisal was performed by two independent reviewers using a standardized appraisal instrument developed by the PRISMA-ScR. We identified and categorized investigation methods for the neural basis and neurophysiological features of USN recovery after stroke using magnetic resonance imaging (MRI), functional MRI, and electroencephalography (EEG). This review found two brain-level mechanisms underlying USN recovery at the behavioral level. These include the absence of stroke-related damage to the right ventral attention network during the acute phase and compensatory recruitment of analogous areas of the undamaged opposite hemisphere and prefrontal cortex during visual search tasks in the subacute or later phases. However, the relationship between the neural and neurophysiological findings and improvements in USN-related activities of daily living remains unknown. This review adds to the growing body of evidence regarding the neural mechanisms underlying USN recovery.

Effect of stimulation-driven attention in virtual reality balloon search training of patients with left unilateral spatial neglect after stroke: A randomized crossover study.

Patients with unilateral spatial neglect (USN) commonly experiences stimulus-driven attention deficit characterized by unexpected stimuli detection. We investigated whether virtual reality (VR) balloon search training with the screen background shifted to left space could improve stimulus-driven attention in patients with USN. The participants were divided into two groups: immediate VR group (n = 14) and delayed VR group (n = 14). The immediate VR group first received VR balloon search training, followed by control training, for two weeks each. Delayed VR group received the same training in reverse order. Outcomes were changes in scores on Catherine Bergego Scale (CBS) and reaction time on the modified Posner task (MPT). There was significant improvement in CBS score change after VR balloon retrieval training (all F > 2.71; P < 0.002). In the invalid condition of MPT, significant improvements were shown after VR balloon search training in left-sided reaction time (improvement of stimulation-driven attention). This study shows that VR balloon search training can improve neglect symptoms by using an intensive intervention lasting 2 weeks.

Sensitivity and Specificity of the Brentano Illusion Test in the Detection of Visual Hemi-Field Deficits in Patients with Unilateral Spatial Neglect.

Stroke survivors with right-brain damage (RBD) often present with attentional deficits such as left unilateral spatial neglect. Some patients also present with contralesional visual hemi-field deficits. A late detection of visual hemi-field deficits (VHFD) contributes to hampering neurorehabilitation and functional outcome of patients with neglect. The Brentano Illusion Test (BRIT) may be used for an early detection of VHFD during the neuropsychological assessment. In the present study, we determined the sensitivity and specificity of the BRIT for screening VHFD in patients with neglect. Sixty-four consecutive RBD patients were examined. Forty-five presented with neglect. Of these, 23 presented with VHFD (hemianopia or quadrantanopia) as detected by the Humphrey automated static visual field testing (reference standard). Consecutive patients also included 19 participants without neglect, who did not have any VHFD. The sensitivity and specificity of the BRIT for neglect patients were 78.3% (95% CI: 61.4-95.1) and 90.9 (95% CI: 78.9-100.0), respectively. Positive predictive value (PPV) was 89.6% (95% CI: 76.4-100.0); negative predictive value (NPV) 80.7% (95% CI: 65.2-96.2). No false positives in the group without neglect were identified. We conclude that the BRIT is an effective tool for clinical neuropsychologists to screen for possible VHFD in neglect patients during the neuropsychological assessment, allowing the refinement of the clinical picture in the neuropsychological report. An early detection of VHFD also allows referring the patient to standard diagnostics for a formal visual field examination, right from the first neuropsychological assessment.

Virtual reality rehabilitation for unilateral spatial neglect: A systematic review of immersive, semi-immersive and non-immersive techniques.

INTRODUCTION: In recent decades, new virtual reality (VR)-based protocols have been proposed for the rehabilitation of Unilateral Spatial Neglect (USN), a debilitating disorder of spatial awareness. However, it remains unclear which type of VR protocol and level of VR immersion can maximize the clinical benefits. To answer these questions, we conducted a systematic review of the use of VR for the rehabilitation of USN. METHOD: Studies between 2000 and 2022 that met the inclusion criteria were classified according to their research design and degree of immersion (non-immersive, NIVR; semi-immersive, SIVR; immersive, IVR). RESULTS: A total of 375 studies were identified, of which 26 met the inclusion criteria. Improvements were found in 84.6% of the reviewed studies: 85.7% used NIVR, 100% used SIVR and 55.6% used IVR. However, only 42.3% of them included a control group and only 19.2% were randomized control trials (RCT). CONCLUSION: VR protocols may offer new opportunities for USN rehabilitation, although further RCTs are needed to validate their clinical efficacy.

Validation of "Neurit.Space": Three Digital Tests for the Neuropsychological Evaluation of Unilateral Spatial Neglect.

Patients suffering from Unilateral Spatial Neglect (USN) fail to pay attention to, respond to, and report sensory events occurring in the contralesional side of space. The traditional neuropsychological assessment of USN is based on paper-and-pencil tests, whose data recording and scoring may be subjected to human error. The utilization of technological devices can be expected to improve the assessment of USN. Therefore, we built Neurit.Space, a modified digital version of three paper-and-pencil tests, widely used to detect signs of USN, namely: Bells Cancellation, Line Bisection and Five Elements Drawing Test. Administration and data processing is fully automatic. Twelve right brain-damaged patients (six with and six without USN) and 12 age- and education-balanced healthy participants were enrolled in the study. All participants were administered both the computerized and the paper-and-pencil versions of the tests. The results of this preliminary study showed good sensitivity, specificity, and usability of Neurit.Space, suggesting that these digital tests are a promising tool for the evaluation of USN, both in clinical and in research settings.

Full-field input generated from right visual field information for healthy participants reproduces performance simulating left unilateral spatial neglect in line bisection.

Patients with left unilateral spatial neglect (USN) typically place the subjective midpoint to the right of the objective centre when bisecting a horizontal line. This pathological phenomenon may be explained as a result of greater dependence on the right endpoint in the external reference frame (Koyama et al., Brain Cogn, 35, 1997, 271; McIntosh et al., Cogn Brain Res, 25, 2005, 833). Ishiai et al. (Brain, 112, 1989, 1485) reported that once patients with USN fixated on a certain point on the right part of the presented line, they persisted with this point and marked the subjective midpoint there without leftward searches. Ishiai et al.'s interpretation was that the patients saw a totalised line representation that extended equidistantly to the right and left sides, based on the information of the attended rightward extent from the subjective midpoint. Accordingly, we used virtual reality goggles (VRG) and devised a mirror-image viewing (MV) condition that showed a full-field view based on the right visual field information to test whether healthy participants would thereby show neglect-like bisection performance. The participants were 30 healthy adults (22-37 years old; 15 women and 15 men). In this condition, 96.7% (29/30) of participants were judged to exhibit USN-like performance of line bisection, indicating the effectiveness of MV condition to simulate USN. The novelty of the present study lies in the use of a task-specific intervention of neglect-like visuospatial processing during line bisection without attempting to modify the direction of spatial attention. This approach may contribute to the understanding of the pathological visuospatial processing of USN.

Quantification and Rehabilitation of Unilateral Spatial Neglect in Immersive Virtual Reality: A Validation Study in Healthy Subjects.

Unilateral spatial neglect is a common sensorimotor disorder following the occurrence of a stroke, for which prismatic adaptation is a promising rehabilitation method. However, the use of prisms for rehabilitation often requires the use of specific equipment that may not be available in clinics. To address this limitation, we developed a new software package that allows for the quantification and rehabilitation of unilateral spatial neglect using immersive virtual reality. In this study, we compared the effects of virtual and real prisms in healthy subjects and evaluated the performance of our virtual reality tool (HTC Vive) against a validated motion capture tool. Ten healthy subjects were randomly exposed to virtual and real prisms, and measurements were taken before and after exposure. Our findings indicate that virtual prisms are at least as effective as real prisms in inducing aftereffects (4.39° ± 2.91° with the virtual prisms compared to 4.30° ± 3.49° with the real prisms), but that these effects were not sustained beyond 2 h regardless of exposure modality. The virtual measurements obtained with our software showed excellent metrological qualities (ICC = 0.95, error = 0.52° ± 1.18°), demonstrating its validity and reliability for quantifying deviation during pointing movements. Overall, our results suggest that our virtual reality software (Virtualis, Montpellier, France) could provide an easy and reliable means of quantifying and rehabilitating spatial neglect. Further validation of these results is required in individuals with unilateral spatial neglect.

An immersive virtual reality system for ecological assessment of peripersonal and extrapersonal unilateral spatial neglect.

BACKGROUND: Unilateral spatial neglect (USN) is a debilitating neuropsychological syndrome that often follows brain injury, in particular a stroke affecting the right hemisphere. In current clinical practice, the assessment of neglect is based on old-fashioned paper-and-pencil and behavioral tasks, and sometimes relies on the examiner's subjective judgment. Therefore, there is a need for more exhaustive, objective and ecological assessments of USN. METHODS: In this paper, we present two tasks in immersive virtual reality to assess peripersonal and extrapersonal USN. The tasks are designed with several levels of difficulty to increase sensitivity of the assessment. We then validate the feasibility of both assessments in a group of healthy adult participants. RESULTS: We report data from a study with a group of neurologically unimpaired participants (N = 39). The results yield positive feedback on comfort, usability and design of the tasks. We propose new objective scores based on participant's performance captured by head gaze and hand position information, including, for instance, time of exploration, moving time towards left/right and time-to-reach, which could be used for the evaluation of the attentional spatial bias with neurological patients. Together with the number of omissions, the new proposed parameters can result in lateralized index ratios as a measure of asymmetry in space exploration. CONCLUSIONS: We presented two innovative assessments for USN based on immersive virtual reality, evaluating the far and the near space, using ecological tasks in multimodal, realistic environments. The proposed protocols and objective scores can help distinguish neurological patients with and without USN.

The Neuropsychological Assessment of Unilateral Spatial Neglect Through Computerized and Virtual Reality Tools: A Scoping Review.

Unilateral Spatial Neglect is a disabling neuropsychological deficit. Patients with spatial neglect fail to detect and report events, and to perform actions in the side of space contralateral to a hemispheric cerebral lesion. Neglect is assessed by evaluating the patients' abilities in daily life activities and by psychometric tests. Computer-based, portable and Virtual Reality technologies may provide more and precise data, and be more sensitive and informative, compared to current paper-and-pencil procedures. Studies since 2010, in which such technologies have been used, are reviewed. Forty-two articles meeting inclusion criteria are categorized according to their technological approaches (computer-, graphics tablet or tablet-, virtual reality-based assessment, and other). The results are promising. However, a definite golden standard, technologically based procedure cannot be still established. Developing technologically based tests is a laborious process, which requires technical and user experience improvements as well as normative data, to increase the evidence of efficacy for clinical evaluation of at least some of the tests considered in this review.

Virtual Reality-Assisted Awake Craniotomy: A Retrospective Study.

BACKGROUND: Awake craniotomy (AC) with brain mapping for language and motor functions is often performed for tumors within or adjacent to eloquent brain regions. However, other important functions, such as vision and visuospatial and social cognition, are less frequently mapped, at least partly due to the difficulty of defining tasks suitable for the constrained AC environment. OBJECTIVE: The aim of this retrospective study was to demonstrate, through illustrative cases, how a virtual reality headset (VRH) equipped with eye tracking can open up new possibilities for the mapping of language, the visual field and complex cognitive functions in the operating room. METHODS: Virtual reality (VR) tasks performed during 69 ACs were evaluated retrospectively. Three types of VR tasks were used: VR-DO80 for language evaluation, VR-Esterman for visual field assessment and VR-TANGO for the evaluation of visuospatial and social functions. RESULTS: Surgery was performed on the right hemisphere for 29 of the 69 ACs performed (42.0%). One AC (1.5%) was performed with all three VR tasks, 14 ACs (20.3%) were performed with two VR tasks and 54 ACs (78.3%) were performed with one VR task. The median duration of VRH use per patient was 15.5 min. None of the patients had "VR sickness". Only transitory focal seizures of no consequence and unrelated to VRH use were observed during AC. Patients were able to perform all VR tasks. Eye tracking was functional, enabling the medical team to analyze the patients' attention and exploration of the visual field of the VRH directly. CONCLUSIONS: This preliminary experiment shows that VR approaches can provide neurosurgeons with a way of investigating various functions, including social cognition during AC. Given the rapid advances in VR technology and the unbelievable sense of immersion provided by the most recent devices, there is a need for ongoing reflection and discussions of the ethical and methodological considerations associated with the use of these advanced technologies in AC and brain mapping procedures.