An Unusual Case of Posttraumatic Visual Agnosia Posing Challenges to Rehabilitation.

ABSTRACT: Acquired focal visuoperceptual deficits are rarely reported, and rehabilitation strategies are not well established. This is a report on visuoperceptual deficit after traumatic brain injury that initially went unnoticed. Missing visual agnosia is not unusual especially when perceptual deficits present with visual field defects, impaired insight, and inattention. This case is made more interesting because of the rarity of visual agnosia with predominant ventral pathway involvement, affecting object and face recognition. This report provides a brief discussion on visual agnosia spectrum deficits and rehabilitation measures.

[Constraint-induced movement therapy in the rehabilitation of hemineglect after a stroke]. / Terapia del movimiento inducido por restricción en la rehabilitación de la heminegligencia después de un ictus.

INTRODUCTION: Hemineglect produces a lower capacity for recovery after the stroke and so far there are no rehabilitation techniques that have proven to be effective at functional level. AIMS: The main objective of this work was to assess whether the modified constraint-induced movement therapy (mCIMT)for hemineglect produces greater benefits than conventional therapy on functional hemineglect. Secondary objectives were to assess whether mCIMT produces greater benefits on upper and lower limb function as well as on the degree of autonomy and disability of patients with in relation to conventional therapy. PATIENTS AND METHODS: We have recruited 30 patients with ischemic stroke and diagnosis of hemineglect randomly assigned to mCIMT group (n = 15) or conventional therapy group (n = 15). We used the Catherine Bergego Scale (CBS) for assessment hemineglect; Fugl-Meyer tests for the motor function of lower and upper limb, and Barthel index and modified Rankin scale for the rest of objectives. RESULTS: We have found significant differences in favour of mCIMT group in the CBS after treatment and three months later once finished. We have not found differences between groups for the rest of variables. CONCLUSIONS: mCIMT could be a more effective therapy than conventional therapy to improve the symptoms of hemineglect in the acute stroke. However, it may be clinically more recommended in patients with a certain motor function after stroke.

TITLE: Terapia del movimiento inducido por restricción en la rehabilitación de la heminegligencia después de un ictus.Introducción. La heminegligencia produce una menor capacidad de recuperación después del ictus y hasta el momento no existen técnicas de rehabilitación que hayan demostrado ser funcionalmente efectivas. Objetivos. El objetivo principal de este trabajo fue valorar si la terapia de movimiento inducido por restricción modificada (TMIRm) para la heminegligencia produce mayores beneficios que la terapia convencional sobre la heminegligencia funcional. Los objetivos secundarios fueron evaluar si la TMIRm produce mayores beneficios en la función del miembro superior y del miembro inferior, así como sobre el grado de autonomía y discapacidad de los pacientes con respecto a la terapia convencional. Pacientes y métodos. Se seleccionó a 30 pacientes con ictus isquémico y diagnóstico de heminegligencia, que fueron asignados aleatoriamente al grupo de TMIRm (n = 15) o al grupo de terapia convencional (n = 15). Se empleó la Catherine Bergego Scale (CBS) para la valoración de la heminegligencia; las pruebas Fugl-Meyer para la función motora del miembro inferior y del miembro superior, y el índice de Barthel y la escala de Rankin modificada para el resto de los objetivos. Resultados. Se hallaron diferencias significativas en favor del grupo de TMIRm para la CBS en la valoración después del tratamiento y a los tres meses de finalizado. No se encontraron diferencias entre grupos para el resto de las variables. Conclusiones. La TMIRm podría ser una terapia más efectiva que la convencional para mejorar la sintomatología de la heminegligencia en la fase aguda del ictus. Sin embargo, podría ser clínicamente más recomendable en pacientes con una determinada función motora después del ictus.

A combined therapy for limb apraxia and related anosognosia.

Left hemisphere stroke frequently leads to limb apraxia, a disorder that has been reported to impact independence in daily life and rehabilitation success. Nonetheless, there is a shortcoming in research and availability of applicable trainings. Further, to date, anosognosia for limb apraxia has largely been neglected. Therefore, we developed a Naturalistic Action Therapy that trains object selection and application with an errorless learning approach and which includes supported self-evaluation. The current study presents the results of two stroke patients participating in the training. The procedure entailed two baseline and one post-training sessions including standardized limb apraxia and anosognosia assessments as well as 18 naturalistic action tasks. The training consisted of 15 sessions during which 4-6 of the 18 naturalistic action tasks (e.g., pour water into a glass, make a phone call) were trained. Both patients showed improvement in trained and untrained tasks as well as in standardized apraxia and anosognosia assessments. Training effects appeared strongest for the trained items. The procedure is documented in detail and easy to administer and thus may have the potential to be applied by relatives. The results of this pilot-study are promising and suggest that the approach is suitable for further evaluation.

Recovery from tactile agnosia: a single case study.

In a patient suffering from tactile agnosia a comparison was made (using the ABABAB paradigm) between three blocks of neuropsychological rehabilitation sessions involving off-line anodal transcranial direct current stimulation (anodal-tDCS) and three blocks of rehabilitation sessions without tDCS. During the blocks with anodal-tDCS, the stimulation was administered in counterbalanced order to two sites: i) the perilesional parietal area (specific stimulation) and ii) an occipital area far from the lesion (nonspecific stimulation).Rehabilitation associated with anodal-tDCS (in particular in the perilesional areas) is more efficacious than without stimulation.

Computer-Based Cognitive Rehabilitation in Patients with Visuospatial Neglect or Homonymous Hemianopia after Stroke.

OBJECTIVES: The purpose of this pilot study was to investigate the feasibility and effects of computer-based cognitive rehabilitation (CBCR) in patients with symptoms of visuospatial neglect or homonymous hemianopia in the subacute phase following stroke. METHOD: A randomized, controlled, unblinded cross-over design was completed with early versus late CBCR including 7 patients in the early intervention group (EI) and 7 patients in the late intervention group (LI). EI received CBCR training immediately after inclusion (m = 19 days after stroke onset) for 3 weeks and LI waited for 3 weeks after inclusion before receiving CBCR training for 3 weeks (m = 44 days after stroke onset). RESULTS: CBCR improved visuospatial symptoms after stroke significantly when administered early in the subacute phase after stroke. The same significant effect was not found when CBCR was administered later in the rehabilitation. The difference in the development of the EI and LI groups during the first 3 weeks was not significant, which could be due to a lack of statistical power. CBCR did not impact mental well-being negatively in any of the groups. In the LI group, the anticipation of CBCR seemed to have a positive impact of mental well-being. CONCLUSION: CBCR is feasible and has a positive effect on symptoms in patients with visuospatial symptoms in the subacute phase after stroke. The study was small and confirmation in larger samples with blinded outcome assessors is needed.

Rehabilitación de la anosognosia en pacientes con heminegligencia visuoespacial / Rehabilitation of anosognosia in patients with unilateral visuospatial neglect

Introducción. Habitualmente, el paciente con heminegligencia visuoespacial secundaria a un ictus no es consciente de que su percepción y exploración del espacio contralesional son defectuosas. Este fenómeno clínico, conocido como anosognosia, condiciona directamente el proceso rehabilitador y amplía sensiblemente su duración, al tiempo que dificulta la adhesión del paciente a dicho proceso. Objetivo. Valorar la eficacia de un programa de rehabilitación específico para el tratamiento de la anosognosia en pacientes que presentan heminegligencia visuoespacial. Pacientes y métodos. Se distribuyó a 12 pacientes con ictus hemisférico derecho en dos grupos. El grupo experimental recibió 15 sesiones de tratamiento cognitivo informatizado junto con 15 sesiones de rehabilitación específicas para la anosognosia. El grupo control realizó 15 sesiones de tratamiento cognitivo informatizado. A todos ellos se les administró, antes y después del tratamiento, una batería de test para evaluar la atención visuoespacial. El nivel de funcionalidad se valoró mediante la Catherine Bergego Scale. Resultados. Tras la intervención, el grupo control mostró diferencias psicométricas estadísticamente significativas. No sucedió lo mismo con el grupo experimental. No se obtuvieron diferencias en las comparaciones intergrupales pre y postratamiento, ni en las medidas psicométricas ni en la escala funcional. Conclusiones. Es necesario seguir realizando investigaciones que nos ayuden a mejorar el tratamiento de la anosognosia en pacientes que presentan heminegligencia visuoespacial. Se plantean algunas recomendaciones metodológicas surgidas de las limitaciones identificadas en el presente estudio

Introduction. Patients with unilateral visuospatial neglect secondary to a stroke are usually unaware of the fact that their perception and exploration of contralesional space are deficient. This clinical phenomenon, know as anosognosia, directly conditions the rehabilitation process and prolongs its duration to a significant extent, while also making it more difficult for the patient to adhere to it. Aim. To assess the efficacy of a specific rehabilitation programme for the treatment of anosognosia in patients presenting with unilateral visuospatial neglect. Patients and methods. Twelve patients with a stroke in the right hemisphere were divided into two groups. The experimental group received 15 sessions of computerised cognitive therapy along with 15 sessions of specific rehabilitation for anosognosia. The control group underwent 15 sessions of computerised cognitive treatment. All of them were administered, before and after treatment, a battery of tests to evaluate visuospatial attention. The level of functionality was evaluated by means of the Catherine Bergego Scale. Results. After the intervention, the control group showed statistically significant psychometric differences. The same did not occur with the experimental group. No differences were obtained in the pre- and post-treatment intergroup comparisons, or in the psychometric measures or on the functional scale. Conclusions. Further research is needed to help us improve the treatment of anosognosia in patients with unilateral visuospatial neglect. Some methodological recommendations emerge from the limitations identified in this study

Effects of a robot intervention on visuospatial hemineglect in postacute stroke patients: a randomized controlled trial.

OBJECTIVE: To evaluate the effects of an intervention using the robot device PARO on visuospatial hemineglect and activities of daily living, and its acceptance during stroke rehabilitation. PARO is an interactive robotic toy with the appearance of a baby seal, which can move, produce sounds, and react to speech and touch. DESIGN: A randomized controlled trial. SETTING: Hospital for neurorehabilitation. SUBJECTS: Patients above 60 years old who have suffered their first stroke within the previous three months with left hemineglect (n = 39). INTERVENTIONS: The PARO group (n = 21) was exposed to PARO over a period of two weeks, three times per week. The participants of the control group (n = 18) were read to aloud. OUTCOME MEASURE: Visuospatial hemineglect was measured by a cancellation test and a Line Bisection Test, and independence in the activities of daily living was assessed by Scores of Independence Index for Neurological and Geriatric Rehabilitation (SINGER) test. The acceptance of PARO was also evaluated. Data were collected blinded at three times: baseline (T0), after two weeks of interventions (T1), and after additional two weeks as follow-up (T2). RESULTS: Improvement of hemineglect at T1 and T2 was significantly higher in the PARO group (T1: mean (SD) = 6.23 (3.81); T2: mean (SD) = 7.85 (3.68)) compared to the control group (T1: mean (SD) = 2.66 (4.19); T2: mean (SD) = 3.33 (4.16)) (T1: P < 0.05; T2: P < 0.05). CONCLUSION: The study showed that the use of the PARO is well accepted and can help to improve neglect symptoms in patients with subacute stroke.

The Effect of Continuous Theta-Burst Transcranial Magnetic Stimulation Combined with Prism Adaptation on the Neglect Recovery in Stroke Patients.

OBJECTIVES: This study was designed to investigate the effect of prism adaptation (PA) combined with continuous theta-burst transcranial magnetic stimulation (cTBS) on the neglect recovery of stroke patients with unilateral neglect. METHODS: A total of 14 stroke patients with unilateral neglect were randomly assigned to 2 groups including an intervention group undergone PA combined with cTBS over the left intact parietal cortex and a control group. PA combined with sham cTBS was perfomed for 2 weeks in 10 daily sessions. Before and after the intervention, patients were evaluated for visuospatial neglect measured using the Star Cancellation Test (SCT), Line Bisection Task (LBT), Figure Copying Test, and Clock Drawing Task. Neurological function was evaluated using the Modified Rankin Scale (MRS). RESULTS: Both groups (PA alone and PA+ cTBS) showed improvement in their neglected symptoms (measured by SCT, LBT, Figure Copying Test, and Clock Drawing Task), and in their disability in the neurological function (measured by MRS) (P< .05). CONCLUSIONS: The results of the present study showed that, transcranial magnetic stimulation did not increase the effect of PA on neglect symptoms in stroke patients.

[Rehabilitation of anosognosia in patients with unilateral visuospatial neglect]. / Rehabilitacion de la anosognosia en pacientes con heminegligencia visuoespacial.

INTRODUCTION: Patients with unilateral visuospatial neglect secondary to a stroke are usually unaware of the fact that their perception and exploration of contralesional space are deficient. This clinical phenomenon, know as anosognosia, directly conditions the rehabilitation process and prolongs its duration to a significant extent, while also making it more difficult for the patient to adhere to it. AIM: To assess the efficacy of a specific rehabilitation programme for the treatment of anosognosia in patients presenting with unilateral visuospatial neglect. PATIENTS AND METHODS: Twelve patients with a stroke in the right hemisphere were divided into two groups. The experimental group received 15 sessions of computerised cognitive therapy along with 15 sessions of specific rehabilitation for anosognosia. The control group underwent 15 sessions of computerised cognitive treatment. All of them were administered, before and after treatment, a battery of tests to evaluate visuospatial attention. The level of functionality was evaluated by means of the Catherine Bergego Scale. RESULTS: After the intervention, the control group showed statistically significant psychometric differences. The same did not occur with the experimental group. No differences were obtained in the pre- and post-treatment intergroup comparisons, or in the psychometric measures or on the functional scale. CONCLUSIONS: Further research is needed to help us improve the treatment of anosognosia in patients with unilateral visuospatial neglect. Some methodological recommendations emerge from the limitations identified in this study.

TITLE: Rehabilitacion de la anosognosia en pacientes con heminegligencia visuoespacial.Introduccion. Habitualmente, el paciente con heminegligencia visuoespacial secundaria a un ictus no es consciente de que su percepcion y exploracion del espacio contralesional son defectuosas. Este fenomeno clinico, conocido como anosognosia, condiciona directamente el proceso rehabilitador y amplia sensiblemente su duracion, al tiempo que dificulta la adhesion del paciente a dicho proceso. Objetivo. Valorar la eficacia de un programa de rehabilitacion especifico para el tratamiento de la anosognosia en pacientes que presentan heminegligencia visuoespacial. Pacientes y metodos. Se distribuyo a 12 pacientes con ictus hemisferico derecho en dos grupos. El grupo experimental recibio 15 sesiones de tratamiento cognitivo informatizado junto con 15 sesiones de rehabilitacion especificas para la anosognosia. El grupo control realizo 15 sesiones de tratamiento cognitivo informatizado. A todos ellos se les administro, antes y despues del tratamiento, una bateria de test para evaluar la atencion visuoespacial. El nivel de funcionalidad se valoro mediante la Catherine Bergego Scale. Resultados. Tras la intervencion, el grupo control mostro diferencias psicometricas estadisticamente significativas. No sucedio lo mismo con el grupo experimental. No se obtuvieron diferencias en las comparaciones intergrupales pre y postratamiento, ni en las medidas psicometricas ni en la escala funcional. Conclusiones. Es necesario seguir realizando investigaciones que nos ayuden a mejorar el tratamiento de la anosognosia en pacientes que presentan heminegligencia visuoespacial. Se plantean algunas recomendaciones metodologicas surgidas de las limitaciones identificadas en el presente estudio.

The neuropsychological rehabilitation of visual agnosia and Balint's syndrome.

Visual agnosia and Balint's syndrome are complex neurological disorders of the higher visual system that can have a remarkable impact on individuals' lives. Rehabilitation of these individuals is important to enable participation in everyday activities despite the impairment. However, the literature about the rehabilitation of these disorders is virtually silent. Therefore, the aim of this systematic review is to give an overview of available literature describing treatment approaches and their effectiveness with regard to these disorders. The search engines Psychinfo, Amed, and Medline were used, resulting in 22 articles meeting the criteria for inclusion. Only articles describing acquired disorders were considered. These articles revealed that there is some information available on the major subtypes of visual agnosia as well as on Balint's syndrome which practising clinicians can consult for guidance. With regard to the type of rehabilitation, compensatory strategies have proven to be beneficial in most of the cases. Restorative training on the other hand has produced mixed results. Concluding, although still scarce, a scientific foundation about the rehabilitation of visual agnosia and Balint's syndrome is evolving. The available approaches give valuable information that can be built upon in the future.

Auditory agnosia caused by bilateral putamen haemorrhage.

A 55-year-old right-handed man with a history of hypertension suddenly fell and developed right hemiparesis. Neurological examination revealed that he was alert, but did not appropriately respond to verbal questions and commands. Detailed examination revealed that he could correctly respond to written commands. His speech was almost fluent, showing no paraphasia and normal articulation. His written sentences were legible. Pure tone audiometry showed that his auditory acuity was relatively preserved. His brainstem auditory evoked potential components from I to V were recorded bilaterally with normal latency. Cerebral CT demonstrated fresh bleeding in the left putamen and an old haemorrhage on the opposite side. He was treated by antihypertensive therapy and rehabilitation. Although there remained mild sensory deficit on his right extremities and he felt a slight noise during conversation, he had little difficulty with verbal communication when he was transferred to another hospital on day 38.

Auditory agnosia associated with bilateral putaminal hemorrhage: A case report of clinical course of recovery.

A 45-year-old right-handed man with a past history (10 years) of putaminal hemorrage presented with auditory agnosia associated with left putaminal hemorrhage. It was suspected that the auditory agnosia was due to bilateral damage in the acoustic radiations. Generalized auditory agnosia, verbal and non-verbal (music and environmental), was diagnosed by neuropsychological examinations. It improved 4 months after the onset. However, the clinical assessment of attention remained poor. The cognition for speech sounds improved slowly, but once it started to improve, the progress of improvement was rapid. Subsequently, the cognition for music sounds also improved, while the recovery of the cognition for environmental sounds remained delayed. There was a dissociation in recovery between these cognitions. He was able to return to work a year after the onset. We also reviewed the literature for cases with auditory agnosia and discuss their course of recovery in this report.

A Framework for Ethical Decision Making in the Rehabilitation of Patients with Anosognosia.

Currently, the number of patients diagnosed with impaired self-awareness of their own deficits after brain injury-anosognosia-is increasing. One reason is a growing understanding of this multifaceted phenomenon. Another is the development and accessibility of alternative measurements that allow more detailed diagnoses. Anosognosia can adversely affect successful rehabilitation, as often patients lack confidence in the need for treatment. Planning such treatment can become a complex process full of ethical dilemmas. To date, there is no systematic way to deal with different aspects of anosognosia rehabilitation planning. This is the first article to present a framework for ethical decision making in establishing rehabilitation plans that are focused on increasing patients' self-awareness of their own deficits after brain injury. It concentrates especially on addressing the ethical dilemmas that may arise, and describes stepwise procedures that can be applied to distinct theoretical approaches, as well as diagnostic and rehabilitation methods. To show the flexibility of the use of this framework, alternative approaches are discussed.

Treatment response profiles: An extension of the double dissociation concept in neuropsychological research.

The presence of double dissociations in patients with neurological damage has long been used as evidence that the dissociated functions cannot be explained in terms of a common system or module. Shallice (1988) has suggested that a second procedure, the double critical variable method, can provide evidence for a similar conclusion. In this paper we examine the situation where double dissocations are not naturally present, suggesting that the two phenomena are merely aspects of the same underlying condition. We propose that the logic of the double critical variable method can be applied in this situation, whenever responses to treatment vary in a particular manner across syndromes and patients. This logic was previously used by Beschin, Cocchini, Allen, and Della Sala (2012) to show a dissociation between anosognosia and neglect in stroke patients; we suggest that it might have a more general application. As an aid in understanding the concept we also introduce the performance/performance curve; this builds on the existing idea of performance/resource curves to draw a single graph from two such curves, whose points may be derived from direct observation. It enables the empirical testing of hypotheses about the functional form of unobservable performance/resource relationships, and may be of use beyond the existing application to treatment response profiles.

Agnosias visuales / Visual agnosia

Las agnosias visuales se definen como una alteración en la capacidad de reconocer objetos con la vista, en ausencia de pérdida de agudeza visual o disfunción cognitiva que explique esta alteración. Están producidas por lesiones de la corteza visual asociativa, respetando la corteza visual primaria. Existen 2 vías principales de procesamiento de la información visual: la vía ventral, encargada del reconocimiento de objetos, y la vía dorsal, encargada de su localización en el espacio. Las agnosias visuales pueden, por tanto, dividirse en 2 grandes grupos dependiendo de cuál de las 2 vías esté lesionada. El objetivo de este artículo es realizar una revisión narrativa sobre los diferentes síndromes agnósicos visuales, incluyendo los últimos avances realizados en algunos de ellos (AU)

Visual agnosia is defined as an impairment of object recognition, in the absence of visual acuity or cognitive dysfunction that would explain this impairment. This condition is caused by lesions in the visual association cortex, sparing primary visual cortex. There are 2 main pathways that process visual information: the ventral stream, tasked with object recognition, and the dorsal stream, in charge of locating objects in space. Visual agnosia can therefore be divided into 2 major groups depending on which of the two streams is damaged. The aim of this article is to conduct a narrative review of the various visual agnosia syndromes, including recent developments in a number of these syndromes (AU)

Functional cerebral space theory: Towards an integration of theory and mechanisms of left hemineglect, anosognosia, and anosodiaphoria.

BACKGROUND: The current case study presents a 43 year old African American woman admitted to a Tertiary Care Rehabilitation unit at a major medical center for concerns over left-sided anesthesia and weakness. Head scans indicate a right middle cerebral arterial distribution infarct altering blood flow in temporal, parietal, and occipital regions in the right cerebral hemisphere. OBJECTIVE: Physician and therapist reports (i.e., speech and occupational therapists) referred the patient for a neuropsychological evaluation for concerns over the patient's capacity to recognize the severity of her deficits and self-care, with potential rule-outs indicated by the extant literature on right CVA for anosognosia, anosodiaphoria, and left hemibody/hemispace neglect. METHODS: The current case integrates interdisciplinary physician notation, magnetic resonance imaging and magnetic resonance angiogram, observations and reports from speech and occupational therapy, and neuropsychological assessment via standardized tests and neurobehavioral syndrome analysis. RESULTS: Evidence was found for co-occurring syndromes of moderate anosognosia, anosodiaphoria, and left hemibody/hemispatial neglect derived from shared functional cerebral space with overlapping temporal, parietal, and occipital damage. CONCLUSIONS: Clinical implications are discussed, including recommendations for therapy approaches based on functional cerebral space theory that may indicate the use of known techniques (e.g., for left hemibody neglect) that may also have therapeutic implications for treating other, more mercurial co-occurring syndromes of anosognosia and anosodiaphoria.

[Recognition and rehabilitation of impaired awareness of illness, i.e. anosognosia in a patient with cerebrovascular disease]. / Aivoverenkiertohäiriöpotilaan oiretiedostuksen puutteellisuuden eli anosognosian tunnistaminen ja kuntoutus.

The prevalence of anosognosia after stroke is approximately 30%. Anosognosia refers to the lack of awareness of illness or specific symptom of illness in patients with neurological diseases. Because stroke patients with anosognosia are not properly comprehending the nature of their medical situation, they may not seek treatment in time, which weakens patients' commitment to treatment and rehabilitation. Anosognosia also exposes patients to dangerous situations in daily life. Anosognosia is associated with poor functional outcome after stroke, which makes the early neuropsychological identification and treatment of anosognosia important.

Use of prism adaptation in children with unilateral brain lesion: Is it feasible?

INTRODUCTION: Unilateral visuospatial deficits have been observed in children with brain damage. While the effectiveness of prism adaptation for treating unilateral neglect in adult stroke patients has been demonstrated previously, the usefulness of prism adaptation in a pediatric population is still unknown. The present study aims at evaluating the feasibility of prism adaptation in children with unilateral brain lesion and comparing the validity of a game procedure designed for child-friendly paediatric intervention, with the ecological task used for prism adaptation in adult patients. METHODS: Twenty-one children with unilateral brain lesion randomly were assigned to a prism group wearing prismatic glasses, or a control group wearing neutral glasses during a bimanual task intervention. All children performed two different bimanual tasks on randomly assigned consecutive days: ecological tasks or game tasks. The efficacy of prism adaptation was measured by assessing its after-effects with visual open loop pointing (visuoproprioceptive test) and subjective straight-ahead pointing (proprioceptive test). RESULTS: Game tasks and ecological tasks produced similar after-effects. Prismatic glasses elicited a significant shift of visuospatial coordinates which was not observed in the control group. CONCLUSION: Prism adaptation performed with game tasks seems an effective procedure to obtain after-effects in children with unilateral brain lesion. The usefulness of repetitive prism adaptation sessions as a therapeutic intervention in children with visuospatial deficits and/or neglect, should be investigated in future studies.