Split-brain syndrome after subarachnoid haemorrhage.

We present the case of a patient with extensive ischaemia of the corpus callosum (CC) including all its anatomical subdivisions, caused by a ruptured aneurysm of the anterior cerebral artery (ACA). This resulted in subarachnoid haemorrhage (SAH) and subsequently in cerebral vasospasm. The aneurysm was coiled, the vasospasm treated with repetitive intra-arterial spasmolysis and the patient then received intensive neurorehabilitative care. The case is an example of ischaemic infarction, which happens rarely in the CC after SAH, and even more rarely affects the CC along its entire length. The case is further remarkable for the resulting nearly complete and isolated split-brain syndrome: CC disconnection syndromes are only exceptionally seen after vascular callosal damage because they are most often overshadowed by symptoms resulting from coaffected adjacent brain areas.

Production of co-speech gestures in the right hemisphere: Evidence from individuals with complete or anterior callosotomy.

INTRODUCTION: A right-hand preference for co-speech gestures in right-handed neurotypical individuals as well as the co-occurrence of speech and gesture has induced neuropsychological research to primarily target the left hemisphere when investigating co-speech gesture production. However, the substantial number of spontaneous left-hand gestures in right-handed individuals has, thus far, been unexplained. Recent studies in individuals with complete callosotomy and exclusive left hemisphere speech production show a reliable left-hand preference for co-speech gestures, indicating a right hemispheric generation. However, the findings raise the issue if the separate right hemisphere is able to also generate representational gestures. The present study challenges the proposition of a specific right hemispheric contribution to gesture production by differentiating gesture types including representational ones in individuals with complete callosotomy and by including individuals with anterior callosotomy in whom neural reorganization is less extensive. METHODS: Three right-handed individuals with complete commissurotomy (A.A., N.G., G.C.) and three right-handed individuals with anterior callosotomy (C.E., S.R., L. D), all with left hemisphere language dominance, and a matched right-handed neurotypical control group (n = 10) were examined in an experimental setting, including re-narration of a nonverbal animated cartoon and responding to intelligence questions. The participants' video-taped hand movement behavior was analyzed by two independent certified raters with the NEUROGES-ELAN system for nonverbal behavior and gesture. Unimanual right-hand and left-hand gestures were classified into eight gesture types. RESULTS: The individuals with complete and anterior callosotomy performed unimanual co-speech gestures with the left as well as the right hand, with no significant preference of one hand for gestures overall. Concerning the specific gesture types, the group with complete callosotomy showed a significant right-hand preference for pantomime gestures, which also applied to the callosotomy total group. The group with anterior callosotomy displayed a significant left-hand preference for form presentation gestures. As a trend, the callosotomy total group differed from the neurotypical group as they performed more left-hand egocentric deictic and left-hand form presentation gestures. DISCUSSION: The present study replicates the finding of a substantial left-hand use for unimanual co-speech gestures in individuals with complete callosotomy. The proposition of a right hemispheric contribution to gesture production independent from left hemispheric language production is corroborated by the finding that individuals with anterior callosotomy show a similar pattern of hand use for gestures. Representational gestures were displayed with either hand, suggesting that in particular right hemispheric spatial cognition can be directly expressed in gesture. The significant right-hand preference for pantomime gesture was outstanding and compatible with the established left hemispheric specialization for tool use praxis. The findings shed a new light on the left-hand gestures in neurotypical individuals, suggesting that these can be generated in the right hemisphere.

Revisiting the attentional bias in the split brain.

Previous research has revealed a strong right bias in allocation of attention in split brain subjects, suggesting that a pathological attention bias occurs not only after unilateral (usually right-hemispheric) damage but also after functional disconnection of intact right-hemispheric areas involved in allocation of attention from those in the left hemisphere. Here, we investigated the laterality bias in spatial attention, as measured with the greyscales task, in two split-brain subjects (D.D.C. and D.D.V.) who had undergone complete callosotomy. The greyscales task requires participants to judge the darker (or brighter) of two left-right mirror-reversed luminance gradients under conditions of free viewing, and offers an efficient means of quantifying pathological attentional biases in patients with unilateral lesions. As predicted, the results of the two split-brain subjects revealed a pathological rightward bias in allocation of attention, suggesting strong dependence on a single hemisphere (the left) in spatial attention, which is opposite to what one expects from people with intact commissures, and is remarkable in that it occurs in free viewing. In that sense both split-brain patients are behaving as though the brain is indeed split, especially in D.D.C. who had undergone partial resection of the anterior commissure in addition to complete callosotomy, whereas the anterior commissure is still intact in D.D.V. The findings support the view that the commissural pathways play a significant role in integration of attentional processes across cerebral hemispheres.

Can the mind be split? A historical introduction.

The idea that the mind might be composed of distinct conscious entities goes back at least to the mid-19th century, and was at first based on the bilateral symmetry of the brain, with each side seemingly a mirror-image replica of the other. This led to early speculation as to whether section of the forebrain commissures might lead to separate, independent consciousnesses. This was not put to the test until the 1960s, first in commissurotomized cats and monkeys, and then in humans who had undergone commissurotomy for the relief of intractable epilepsy. Initial results did indeed suggest independent consciousness in each separated hemisphere, but later findings have also revealed a degree of mental unity, especially in some perceptual functions and in motor control. Some of these findings might be interpreted in terms of subcortical connections or external cross-cuing, and also address questions about the nature of consciousness in a more concrete way.

Independent and unified consciousness co-existence in commissurotomy cases.

Independent hemispheric consciousness was observed following complete commissurotomy under controlled laboratory conditions that restricted stimulus input and response output to a single hemisphere. Hemispheric specialization was investigated in this way. Consciousness of the self was tested directly as well and found to be represented in each of the hemispheres. Unified consciousness was evidenced in unaltered personality, character, humor, and past knowledge (autobiographical and knowledge of the world). Intact cortico-subcortical projections to intact subcortical regions are offered as explanation for why both unified and independent are possible in the same brain.

Consciousness after split-brain surgery: The recent challenge to the classical picture.

In a recent series of experiments, Pinto and colleagues found that the split-brain patient D.D.C. was able to respond accurately to stimuli in either visual field, whether using his right hand, his left hand, or verbally. Pinto and colleagues argue that this demonstrates that a split-brain patient remains a unitary agent and thus continues to possess a unified consciousness. This paper provides a critical evaluation of that claim. First, we argue that two conceptions of the unity of consciousness need to be distinguished: an agency-based conception and an experience-based conception. Second, we argue that it is an open question whether the data presented by Pinto and colleagues is best understood in terms of the unity of agency. Whether that interpretation is correct depends not only on the mechanisms that produce split-brain behaviour, but also on what is involved in being a single agent. Third, we argue that even if the behavioral data indicated that D.D.C has a unified consciousness in the agency-based sense of the term, it is difficult to reconcile them with the claim that his consciousness is fully unified in the experience-based sense.

Comorbid seizure reduction after pallidothalamic tractotomy for movement disorders: Revival of Jinnai's Forel-H-tomy.

Forel-H-tomy for intractable epilepsy was introduced by Dennosuke Jinnai in the 1960s. Recently, Forel-H-tomy was renamed to "pallidothalamic tractotomy" and revived for the treatment of Parkinson's disease and dystonia. Two of our patients with movement disorders and comorbid epilepsy experienced significant seizure reduction after pallidothalamic tractotomy, demonstrating the efficacy of this method. The first was a 29-year-old woman who had temporal lobe epilepsy with focal impaired awareness seizure once every three months and an aura 10-20 times daily, even with four antiseizure medicines. For the treatment of hand dyskinesia, she underwent left pallidothalamic tractotomy and her right-hand dyskinesia significantly improved. Fourteen months later, she had experienced no focal impaired awareness seizure and the aura decreased to one to three times per month. The second case was that of a 15-year-old boy diagnosed with progressive myoclonic epilepsy, who developed generalized tonic-clonic seizure, which manifested once every month, despite treatment with five antiseizure medicines. After surgery, myoclonic movements in his right hand slightly improved. A one-year follow-up revealed that he had not experienced a generalized tonic-clonic seizure. The lesion locations in the two cases were close to the vicinity of Jinnai's Forel-H-tomy. Forel's field H deserves reconsideration as a treatment target for intractable epilepsy.

Singularity and consciousness: A neuropsychological contribution.

In common sense experience based on introspection, consciousness is singular. There is only one 'me' and that is the one that is conscious. This means that 'singularity' is a defining aspect of 'consciousness'. However, the three main theories of consciousness, Integrated Information, Global Workspace and Recurrent Processing theory, are generally not very clear on this issue. These theories have traditionally relied heavily on neuropsychological observations and have interpreted various disorders, such as anosognosia, neglect and split-brain as impairments in conscious awareness without any reference to 'the singularity'. In this review, we will re-examine the theoretical implications of these impairments in conscious awareness and propose a new way how to conceptualize consciousness of singularity. We will argue that the subjective feeling of singularity can coexist with several disunified conscious experiences. Singularity awareness may only come into existence due to environmental response constraints. That is, perceptual, language, memory, attentional and motor processes may largely proceed unintegrated in parallel, whereas a sense of unity only arises when organisms need to respond coherently constrained by the affordances of the environment. Next, we examine from this perspective psychiatric disorders and psycho-active drugs. Finally, we present a first attempt to test this hypothesis with a resting state imaging experiment in a split-brain patient. The results suggest that there is substantial coherence of activation across the two hemispheres. These data show that a complete lesioning of the corpus callosum does not, in general, alter the resting state networks of the brain. Thus, we propose that we have separate systems in the brain that generate distributed conscious. The sense of singularity, the experience of a 'Me-ness', emerges in the interaction between the world and response-planning systems, and this leads to coherent activation in the different functional networks across the cortex.

Foundations of the Diagnosis and Surgical Treatment of Epilepsy.

The diagnostic and surgical management of epilepsy has made enormous strides over the past 3 decades, concomitant with advances in technology and electrophysiologic understanding of neuronal connectivity. Distinct zones have been identified within this network that each communicate and play a role in the genesis of seizures. Invasive and noninvasive modalities for defining the epileptogenic lesion or region have been able to more accurately determine which patients are optimal candidates for treatment when their seizures are refractory to conventional conservative management. Ablative, palliative, and disconnecting procedures have been developed as alternatives for traditional open resection techniques, and in recent studies, they have shown excellent seizure control and mitigation of complications. In this review, we discuss the evolution of these advancements in the management of epilepsy and provide an overview of current and future neurosurgical therapeutic modalities.

Integrity of Corpus Callosum Is Essential for theCross-Hemispheric Propagation of Sleep Slow Waves:A High-Density EEG Study in Split-Brain Patients.

The slow waves of non-rapid eye movement (NREM) sleep reflect experience-dependent plasticity and play a direct role in the restorative functions of sleep. Importantly, slow waves behave as traveling waves, and their propagation is assumed to occur through cortico-cortical white matter connections. In this light, the corpus callosum (CC) may represent the main responsible for cross-hemispheric slow-wave propagation. To verify this hypothesis, we performed overnight high-density (hd)-EEG recordings in five patients who underwent total callosotomy due to drug-resistant epilepsy (CPs; two females), in three noncallosotomized neurologic patients (NPs; two females), and in a sample of 24 healthy adult subjects (HSs; 13 females). In all CPs slow waves displayed a significantly reduced probability of cross-hemispheric propagation and a stronger inter-hemispheric asymmetry. In both CPs and HSs, the incidence of large slow waves within individual NREM epochs tended to differ across hemispheres, with a relative overall predominance of the right over the left hemisphere. The absolute magnitude of this asymmetry was greater in CPs relative to HSs. However, the CC resection had no significant effects on the distribution of slow-wave origin probability across hemispheres. The present results indicate that CC integrity is essential for the cross-hemispheric traveling of slow waves in human sleep, which is in line with the assumption of a direct relationship between white matter integrity and slow-wave propagation. Our findings also revealed a residual cross-hemispheric slow-wave propagation that may rely on alternative pathways, including cortico-subcortico-cortical loops. Finally, these data indicate that the lack of the CC does not lead to differences in slow-wave generation across brain hemispheres.SIGNIFICANCE STATEMENT The slow waves of NREM sleep behave as traveling waves, and their propagation has been suggested to reflect the integrity of white matter cortico-cortical connections. To directly assess this hypothesis, here we investigated the role of the corpus callosum in the cortical spreading of NREM slow waves through the study of a rare population of totally callosotomized patients. Our results demonstrate a causal role of the corpus callosum in the cross-hemispheric traveling of sleep slow waves. Additionally, we found that callosotomy does not affect the relative tendency of each hemisphere at generating slow waves. Incidentally, we also found that slow waves tend to originate more often in the right than in the left hemisphere in both callosotomized and healthy adult individuals.

Split-Brain: What We Know Now and Why This is Important for Understanding Consciousness.

Recently, the discussion regarding the consequences of cutting the corpus callosum ("split-brain") has regained momentum (Corballis, Corballis, Berlucchi, & Marzi, Brain, 141(6), e46, 2018; Pinto et al., Brain, 140(5), 1231-1237, 2017a; Pinto, Lamme, & de Haan, Brain, 140(11), e68, 2017; Volz & Gazzaniga, Brain, 140(7), 2051-2060, 2017; Volz, Hillyard, Miller, & Gazzaniga, Brain, 141(3), e15, 2018). This collective review paper aims to summarize the empirical common ground, to delineate the different interpretations, and to identify the remaining questions. In short, callosotomy leads to a broad breakdown of functional integration ranging from perception to attention. However, the breakdown is not absolute as several processes, such as action control, seem to remain unified. Disagreement exists about the responsible mechanisms for this remaining unity. The main issue concerns the first-person perspective of a split-brain patient. Does a split-brain harbor a split consciousness or is consciousness unified? The current consensus is that the body of evidence is insufficient to answer this question, and different suggestions are made with respect to how future studies might address this paucity. In addition, it is suggested that the answers might not be a simple yes or no but that intermediate conceptualizations need to be considered.

Unified tactile detection and localisation in split-brain patients.

In 'split-brain' patients, the corpus callosum has been surgically severed to alleviate medically intractable, severe epilepsy. The classic claim is that after removal of the corpus callosum an object presented in the right visual field will be identified correctly verbally and with the right hand but not with the left hand. When the object is presented in the left visual field the patient verbally states that he saw nothing but nevertheless identifies it accurately with the left hand. This interaction suggests that perception, recognition and responding are separated in the two isolated hemispheres. However, there is now accumulating evidence that this interaction is not absolute. Recently, we (Pinto et al., 2017) showed that accurate detection and location of stimuli anywhere in the visual field could be performed with both hands. In this study, we explored detection and localisation of tactile stimulation on the body. In line with our previous results, we observed that split-brain patients can signal detection and localisation with either hand anywhere on the body (be it the arm or the leg) but they remain unable to match positions touched on both arms or legs simultaneously. These results add to the evidence suggesting that the effects of removal of the corpus callosum may be less severe than sometimes claimed.

Attention and awareness: Representation of visuomotor space in split-brain patients.

Each cerebral hemisphere primarily controls and receives sensory input with regard to the contralateral hand. In the disconnected brain (split-brain), when the hands are uncrossed, direct visual access to each hand is available to the controlling (contralateral) hemisphere. However, when a hand crosses the midline, visual and tactile information regarding the hand are presented to different hemispheres. It is unknown how a contralateral hemisphere codes the position and orientation of a visually inaccessible hand in the disconnected brain. The present work addresses this issue. We ask how each hemisphere represents "its" hand across hand positions that span the midline in the absence of cortical input from the contralateral hemisphere. In other words, when a hand is placed across the midline and is visually inaccessible, is it represented by the controlling hemisphere: (1) in accordance with its new position with respect to the body (e.g., a left hand "becomes" a right effector when it crosses the midline), (2) with left/right position information unaltered (e.g., the left hand is represented as "left" regardless of its location), or (3) stripped of its location information altogether? The relationship between hand position and the spatial codes assigned to potential responses (an index of hand representation) was investigated in two split-brain patients using direct (Experiment 1) and orthogonal (Experiment 2) S-R compatibility paradigms. S-R compatibility effects in split-brain patients were consistent with those displayed by typical individuals. These findings suggest that position-based compatibility effects do not rely on cross-cortical connections. Rather, each hemisphere can accurately represent the full visuomotor space, a process that appears to be subserved by subcortical connections between the hemispheres.

What would a synthetic connectome look like?

A major challenge of contemporary neuroscience is to unravel the structure of the connectome, the ensemble of neural connections that link between different functional units of the brain, and to reveal how this structure relates to brain function. This thriving area of research largely follows the general tradition in biology of reverse-engineering, which consists of first observing and characterizing a biological system or process, and then deconstructing it into its fundamental building blocks in order to infer its modes of operation. However, a complementary form of biology has emerged, synthetic biology, which emphasizes construction-based forward-engineering. The synthetic biology approach comprises the assembly of new biological systems out of elementary biological parts. The rationale is that the act of building a system can be a powerful method for gaining deep understanding of how that system works. As the fields of connectomics and synthetic biology are independently growing, I propose to consider the benefits of combining the two, to create synthetic connectomics, a new form of neuroscience and a new form of synthetic biology. The goal of synthetic connectomics would be to artificially design and construct the connectomes of live behaving organisms. Synthetic connectomics could serve as a unifying platform for unraveling the complexities of brain operation and perhaps also for generating new forms of artificial life, and, in general, could provide a valuable opportunity for empirically exploring theoretical predictions about network function. What would a synthetic connectome look like? What purposes would it serve? How could it be constructed? This review delineates the novel notion of a synthetic connectome and aims to lay out the initial steps towards its implementation, contemplating its impact on science and society.

The "split brain" and Roger Wolcott Sperry (1913-1994).

The concepts of cerebral localization were established in the early 19th century. From these arose the idea that the dominant (usually left) hemisphere mainly subserved functions of cognition and language. The "relatively retarded right hemisphere" by contrast was mute, agraphic, apraxic, and lacking generally in higher cognitive function. This essay sketches the import of the work of Sperry and colleagues on patients subjected to callosal section eg., "split brain". They showed that the minor hemisphere possessed considerable capacity for cognitive understanding and language. His Nobel prize-winning "Split-Brain Experiments"confirmed the role of the corpus callosum in interhemispheric transfer of information.

[Time Perception in an Individual with Split Brain].

Time information is processed and perceived consciously and unconsciously in our daily life. Since time information is based on multiple inputs from multiple sensory modalities, its processing involves various brain regions. In this study, we investigated the role of the corpus callosum in time perception of task-relevant visual stimuli, with inhibition of the task-irrelevant stimuli, in an individual with agenesis of the corpus callosum.

[The Current Status of Corpus Callosotomy for Epilepsies].

Surgery is considered a therapeutic option for drug-resistant epilepsies. As a first step, the epileptic focus is carefully examined using extra- and intra-cranial EEG and various neurodiagnostic imaging techniques, such as magnetic resonance imaging, intra-ictal single photon emission computed tomography, magnetoencephalography, and functional near-infrared spectoroscopy. Only when the epileptogenic focus can not be identified, callosotomy is considered as a palliative surgical method. It is indicated especially in cases with drop attacks, which severely exacerbate the patient's quality of life. Almost complete drop attack remission can be expected after callosotomy. Each year, about 40 cases of callosotomy are registered in Japan. Postsurgical split-brain syndromes are observed for several months and gradually disappear, especially in young children.

Split-brain patients: Visual biases for faces.

Split-brain patients constitute a small subpopulation of epileptic patients who have received the surgical resection of the callosal fibers in an attempt to reduce the spread of epileptic foci between the cerebral hemispheres. The study of callosotomy patients allowed neuropsychologists to investigate the effects of the hemispheric disconnection, shedding more light on the perceptual and cognitive abilities of each hemisphere in isolation. This view that callosotomy completely isolates the hemispheres has now been revised, in favor of the idea of a dynamic functional reorganization of the two sides of the brain; however, the evidence collected from split-brain patients is still a milestone in the neurosciences. The right-hemispheric superiority found in the healthy population concerning face perception has been further supported with split-brains, and it has been shown that the right disconnected hemisphere appears superior to the left hemisphere in recognizing and processing faces with similar characteristics as the observers' (e.g., gender, identity, etc.). Even more controversial is the field of hemispheric asymmetries for processing facial emotion, some evidence suggesting a right-hemispheric superiority for all emotions, some others showing a complementary hemispheric asymmetry depending on the positive or negative emotional valence. Although the practice of callosotomy is mostly abandoned today in favor of pharmacological alternatives, further studies on the remaining split-brain patients could help advance our understanding of hemispheric specialization for social stimuli.

Preservation of electrophysiological functional connectivity after partial corpus callosotomy: case report.

Prior studies of functional connectivity following callosotomy have disagreed in the observed effects on interhemispheric functional connectivity. These connectivity studies, in multiple electrophysiological methods and functional MRI, have found conflicting reductions in connectivity or patterns resembling typical individuals. The authors examined a case of partial anterior corpus callosum connection, where pairs of bilateral electrocorticographic electrodes had been placed over homologous regions in the left and right hemispheres. They sorted electrode pairs by whether their direct corpus callosum connection had been disconnected or preserved using diffusion tensor imaging and native anatomical MRI, and they estimated functional connectivity between pairs of electrodes over homologous regions using phase-locking value. They found no significant differences in any frequency band between pairs of electrodes that had their corpus callosum connection disconnected and those that had an intact connection. The authors' results may imply that the corpus callosum is not an obligatory mediator of connectivity between homologous sites in opposite hemispheres. This interhemispheric synchronization may also be linked to disruption of seizure activity.