The neuroanatomy of visual extinction following right hemisphere brain damage: Insights from multivariate and Bayesian lesion analyses in acute stroke.

Multi-target attention, that is, the ability to attend and respond to multiple visual targets presented simultaneously on the horizontal meridian across both visual fields, is essential for everyday real-world behaviour. Given the close link between the neuropsychological deficit of extinction and attentional limits in healthy subjects, investigating the anatomy that underlies extinction is uniquely capable of providing important insights concerning the anatomy critical for normal multi-target attention. Previous studies into the brain areas critical for multi-target attention and its failure in extinction patients have, however, produced heterogeneous results. In the current study, we used multivariate and Bayesian lesion analysis approaches to investigate the anatomical substrate of visual extinction in a large sample of 108 acute right hemisphere stroke patients. The use of acute stroke patient data and multivariate/Bayesian lesion analysis approaches allowed us to address limitations associated with previous studies and so obtain a more complete picture of the functional network associated with visual extinction. Our results demonstrate that the right temporo-parietal junction (TPJ) is critically associated with visual extinction. The Bayesian lesion analysis additionally implicated the right intraparietal sulcus (IPS), in line with the results of studies in neurologically healthy participants that highlighted the IPS as the area critical for multi-target attention. Our findings resolve the seemingly conflicting previous findings, and emphasise the urgent need for further research to clarify the precise cognitive role of the right TPJ in multi-target attention and its failure in extinction patients.

[Clinical examination of spatial neglect and other disorders of spatial cognition]. / Klinische Untersuchung des unilateralen Neglects und weiterer Störungen der Raumkognition.

Neglect occurring after stroke, neoplasms or degenerative processes can lead to considerable disability in everyday life as can other disorders of spatial orientation. Therefore, a dedicated examination and early diagnostic classification are obligatory. Behavioral tests are helpful in this respect, enabling the clinician to obtain an initial overview of the existing deficits even at the patient's bedside. The clinical (bedside) examination of spatial neglect as well as the corresponding differential diagnostic procedure for the clarification of (possibly additionally or exclusively existing) hemianopia and extinction, as well as the examination of disorders of visuospatial perception, visuoconstructive disorders, topographic disorders, Bálint's syndrome, simultanagnosia, and optic ataxia are presented. The presentation is based on the newly revised (year 2023) guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) on this subject area.

Functional reorganization during the recovery of contralesional target selection deficits after prefrontal cortex lesions in macaque monkeys.

Visual extinction has been characterized by the failure to respond to a visual stimulus in the contralesional hemifield when presented simultaneously with an ipsilesional stimulus (Corbetta and Shulman, 2011). Unilateral damage to the macaque frontoparietal cortex commonly leads to deficits in contralesional target selection that resemble visual extinction. Recently, we showed that macaque monkeys with unilateral lesions in the caudal prefrontal cortex (PFC) exhibited contralesional target selection deficits that recovered over 2-4 months (Adam et al., 2019). Here, we investigated the longitudinal changes in functional connectivity (FC) of the frontoparietal network after a small or large right caudal PFC lesion in four macaque monkeys. We collected ultra-high field resting-state fMRI at 7-T before the lesion and at weeks 1-16 post-lesion and compared the functional data with behavioural performance on a free-choice saccade task. We found that the pattern of frontoparietal network FC changes depended on lesion size, such that the recovery of contralesional extinction was associated with an initial increase in network FC that returned to baseline in the two small lesion monkeys, whereas FC continued to increase throughout recovery in the two monkeys with a larger lesion. We also found that the FC between contralesional dorsolateral PFC and ipsilesional parietal cortex correlated with behavioural recovery and that the contralesional dorsolateral PFC showed increasing degree centrality with the frontoparietal network. These findings suggest that both the contralesional and ipsilesional hemispheres play an important role in the recovery of function. Importantly, optimal compensation after large PFC lesions may require greater recruitment of distant and intact areas of the frontoparietal network, whereas recovery from smaller lesions was supported by a normalization of the functional network.

Recovery of contralesional saccade choice and reaction time deficits after a unilateral endothelin-1-induced lesion in the macaque caudal prefrontal cortex.

The caudal primate prefrontal cortex (PFC) is involved in target selection and visually guided saccades through both covert attention and overt orienting eye movements. Unilateral damage to the caudal PFC often leads to decreased awareness of a contralesional target alone, referred to as "neglect," or when it is presented simultaneously with an ipsilesional target, referred to as "extinction." In the current study, we examined whether deficits in contralesional target selection were due to contralesional oculomotor deficits, such as slower reaction times. We experimentally induced a focal ischemic lesion in the right caudal PFC of 4 male macaque monkeys using the vasoconstrictor endothelin-1 and measured saccade choice and reaction times on double-stimulus free-choice tasks and single-stimulus trials before and after the lesion. We found that 1) endothelin-1-induced lesions in the caudal PFC produced contralesional target selection deficits that varied in severity and duration based on lesion volume and location; 2) contralesional neglect-like deficits were transient and recovered by week 4 postlesion; 3) contralesional extinction-like deficits were longer lasting and recovered by weeks 8-16 postlesion; 4) contralesional reaction time returned to baseline well before the contralesional choice deficit had recovered; and 5) neither the mean reaction times nor the reaction time distributions could account for the degree of contralesional extinction on the free-choice task throughout recovery. These findings demonstrate that the saccade choice bias observed after a right caudal PFC lesion is not exclusively due to contralesional motor deficits, but instead reflects a combination of impaired motor and attentional processing.NEW & NOTEWORTHY Unilateral damage to the caudal prefrontal cortex in macaque monkeys results in impaired contralesional target selection during the simultaneous presentation of an ipsilesional target. We show that the recovery of contralesional target selection cannot be explained by the recovery of prolonged contralesional saccadic reaction times alone. This indicates that an impairment in contralesional attentional processing contributes to the magnitude of the saccade choice bias in the weeks following a unilateral caudal prefrontal cortex lesion.

Rehabilitation of visuospatial neglect by prism adaptation: effects of a mild treatment regime. A randomised controlled trial.

Closely examining the effects, optimal regime and time window of prism adaptation (PA) promotes guidelines for effective rehabilitation practice. The effects of short-term repetitive PA on spatial neglect manifestations were evaluated in patients with heterogeneous post-stroke delays, using a digital Visuospatial Neglect Test Battery. Subsequently, potential differences in PA effects between acute, subacute or chronic neglect were explored. A multicentre randomised controlled trial was conducted in 43 right-hemisphere neglect patients. They were treated with a mild PA regime: seven sessions of experimental or placebo prism training over 7-12 days. The outcome measures were diverse neglect variables related to peripersonal navigation, visual extinction, visuospatial memory, bisection, cancellation, drawing and visual search. The treatment effects were assessed after a short and a long time interval. Two to 24 hours after PA, conventional effects were found for drawing and centred bisection, and novel effects for peripersonal visuospatial navigation, visual extinction, and non-motor memory (with caution). No effects were found for visual search times and cancellation. The assessments after three months were still indicative of PA benefits for navigational, drawing and memory functions. PA did not prove to be more effective in acute, subacute or chronic patients. The extension of effects is theoretically framed within the debate about the levels of cognitive processing that are impacted by PA. Clinical suggestions are formulated regarding PA implementation in neglect treatment.

A Predominantly Visual Subdivision of The Right Temporo-Parietal Junction (vTPJ).

A multiplicity of sensory and cognitive functions has been attributed to the large cortical region at the temporo-parietal junction (TPJ). Using functional MRI, we report that a small region lateralized within the right TPJ responds robustly to certain simple visual stimuli ("vTPJ"). The vTPJ was found in all right hemispheres (n = 7), posterior to the auditory cortex. To manipulate stimuli and attention, subjects were presented with a mixture of visual and auditory stimuli in a concurrent block design in 2 experiments: (1) A simple visual stimulus (a grating pattern modulating in mean luminance) elicited robust responses in the vTPJ, whether or not the subject attended to vision and(2) a drifting low-contrast dartboard pattern of constant mean luminance evoked robust responses in the vTPJ when it was task-relevant (visual task), and smaller responses when it was not (auditory task). The results suggest a focal, visually responsive region within the right TPJ that is powerfully driven by certain visual stimuli (luminance fluctuations), and that can be driven by other visual stimuli when the subject is attending. The precise localization of this visually responsive region is helpful in segmenting the TPJ and to better understand its role in visual awareness and related disorders such as extinction and neglect.

Visual field asymmetries in object individuation.

Repetition blindness (RB) is a failure to detect both instances of two identical stimuli presented in close temporal proximity. It is due to an inability to form separate episodic tokens for a repeated stimulus, resulting in a single conscious representation. In three experiments, participants identified two targets presented simultaneously in different spatial locations. These stimuli were either the same or different. In two experiments the targets occurred on either side of fixation, and in a third experiment both were in the same hemifield. In all experiments, RB was more pronounced for stimuli in the right hemifield. In addition, there was a left hemifield advantage for both repeated and non-repeated stimuli when the two stimuli occurred in opposite visual fields and, thus, were processed by different hemispheres. These findings suggest that the right hemisphere plays a dominant role in attentional selection and in creating conscious representations of visual events.

Spatial distribution of attention and inter-hemispheric competition.

Considerable evidence has demonstrated functional asymmetry in spatial attention between the left and right hemispheres. In the present study, we aimed to examine the theoretical models of spatial attention by considering distribution and inter-hemispheric competition in neurologically healthy participants. Participants searched for a green circle target among green diamond non-targets in the presence or absence of a red singleton. Assuming that the salient singleton would increase the activation of the corresponding hemisphere, we manipulated the sides of the singleton visual fields and target visual fields. When the salient singleton was presented to the right visual field, target detection was faster for left visual field targets than for right visual field targets. In contrast, when the salient singleton was presented to the left visual field, target detection time was equivalent for left and right visual field targets. These results suggest that when the perceptually salient singleton acts as an activator, distribution of attention differs depending on the activated hemisphere induced by inter-hemispheric competition. These findings are in line with Kinsbourne's opponent processor theory.

Peripheral and bimanual reaching in a stroke survivor with left visual neglect and extinction.

Whether attentional deficits are accompanied by visuomotor impairments following posterior parietal lesions has been debated for quite some time. This single-case study investigated reaching in a stroke survivor (E.B.) with left visual neglect and visual extinction following right temporo-parietal-frontal strokes. Unlike most neglect patients, E.B. did not present left hemiparesis, homonymous hemianopia nor show evidence of motor neglect or extinction allowing us to examine, for the first time, if lateralised attentional deficits co-occur with deficits in peripheral and bimanual reaching. First, we found a classic optic ataxia field effect: E.B.'s accuracy was impaired when reaching to peripheral targets in her neglected left visual field (regardless of the hand used). Second, we found a larger bimanual cost for movement time in E.B. than controls when both hands reached to incongruent locations. E.B.'s visuomotor profile is similar to the one of patients with optic ataxia showing that attentional deficits are accompanied by visuomotor deficits in the affected field.

Attention capture by salient object groupings in the neglected visual field.

The integration of fragmentary parts into coherent whole objects has been proposed either to rely on the availability of attentional resources or to arise automatically, that is, from preattentive processing (prior to the engagement of selective attention). In the present study, these two alternative accounts were tested in a group of neglect patients with right-hemisphere parietal brain damage and associated deficits of selective attention in the left (visual) hemispace. The reported experiment employed a search task that required detection of targets in the left and/or right hemifields, which were embedded in configurations that consisted of variants of Kanizsa figures. The results showed that a salient, grouped Kanizsa triangle presented within the unattended, left hemifield can substantially improve contralesional target detection, though the very same triangle configuration does not facilitate target detection in the impaired hemifield when presented together with an ipsilesional, but non-salient (i.e., structurally non-integrated, isolated) target. That is, attention is captured by the grouped object in the impaired hemispace only when it is not engaged in the processing of an (isolated) object in the attended hemispace. This demonstrates that both part-to-whole-object integration and search guidance by salient, integrated objects crucially require attentional resources.

Dissociation of visual extinction and neglect in the left hemisphere.

Visual neglect and extinction are two distinct visuospatial attention deficits that frequently occur after right hemisphere cerebral stroke. However, their different lesion profiles remain a matter of debate. In the left hemisphere, a domain-general dual-loop model with distinct computational abilities onto which several cognitive functions may project, has been proposed: a dorsal stream for sensori-motor mapping in time and space and a ventral stream for comprehension and representation of concepts. We wondered whether such a distinction may apply to visual extinction and neglect in left hemisphere lesions. Of 165 prospectively studied patients with acute left hemispheric ischemic stroke with a single lesion on MRI, 122 had no visuospatial attention deficit, 10 had extinction, 31 neglect and 2 had both, visual extinction and neglect. Voxel-based-lesion-symptom mapping (VLSM, FDR<.05) showed a clear anatomical dissociation. Extinction occurred after damage to the parietal cortex (anterior bank of the intraparietal sulcus, inferior parietal lobe, and supramarginal gyrus), while visual neglect occurred after damage mainly to the temporal lobe (superior and middle temporal lobe, anterior temporal pole), inferior ventral premotor cortex, frontal operculum, angular gyrus, and insula. Direct comparison of both conditions linked extinction to intraparietal sulcus and supramarginal gyrus (FDR<.05). Thus, in the left hemisphere extinction seems to be related to dorsal stream lesions, whereas neglect maps more on the ventral stream. These data cannot be generalized to the right hemisphere. However, a domain-general point-of-view may stimulate discussion on visuospatial attention processing also in the right hemisphere.

Extinction as a deficit of the decision-making circuitry in the posterior parietal cortex.

Extinction is a common neurologic deficit that often occurs as one of a constellation of symptoms seen with lesions of the posterior parietal cortex (PPC). Although extinction has typically been considered a deficit in the allocation of attention, new findings, particularly from nonhuman primate studies, point to one potential and important source of extinction as damage to decision-making circuits for actions within the PPC. This new understanding provides clues to potential therapies for extinction. Also the finding that the PPC is important for action decisions and action planning has led to new neuroprosthetic applications using PPC recordings as control signals to assist paralyzed patients.

Effects of broken affordance on visual extinction.

Previous studies have shown that visual extinction can be reduced if two objects are positioned to "afford" an action. Here we tested if this affordance effect was disrupted by "breaking" the affordance, i.e., if one of the objects actively used in the action had a broken handle. We assessed the effects of broken affordance on recovery from extinction in eight patients with right hemisphere lesions and left-sided extinction. Patients viewed object pairs that were or were not commonly used together and that were positioned for left- or right-hand actions. In the unrelated pair conditions, either two tools or two objects were presented. In line with previous research (e.g., Riddoch et al., 2006), extinction was reduced when action-related object pairs and when unrelated tool pairs were presented compared to unrelated object pairs. There was no significant difference in recovery rate between action-related (object-tool) and unrelated tool pairs. In addition, performance with action-related objects decreased when the tool appeared on the ipsilesional side compared to when it was on the contralesional side, but only when the tool handle was intact. There were minimal effects of breaking the handle of an object rather than a tool, and there was no effect of breaking the handle on either tools or objects on single item trials. The data suggest that breaking the handle of a tool lessens the degree to which it captures attention, with this attentional capture being strongest when the tool appears on the ipsilesional side. The capture of attention by the ipsilesional item then reduces the chance of detecting the contralesional stimulus. This attentional capture effect is mediated by the affordance to the intact tool.

Once you feel it, you see it: insula and sensory-motor contribution to visual awareness for fearful bodies in parietal neglect.

The interplay between the neural mechanisms of visual awareness and those involved in emotion processing and the mapping of related somatic changes remains unclear. To address this issue we studied one patient with visual extinction following right parietal damage, in a combined behavioral, psychophysiological and neuroimaging experiment. Patient M.P. was presented with neutral and fearful bodily expressions, either unilaterally in the left (LVF) or right visual field (RVF), or in both visual fields simultaneously. Fearful expressions presented in the left visual field simultaneously with neutral bodies in the RVF were detected more often than left-side neutral bodies. Signal detection analysis showed that the preferential access of fearful bodies to visual awareness is related to higher perceptual sensitivity for these stimuli during attentional competition. Pupil dilation, which indexes autonomic arousal, increased for fearful more than for neutral bodies. Moreover, dilation for extinguished fearful bodies was bigger than for consciously perceived fearful bodies. This decoupling between (increased) arousal and (lack of) conscious visual experience argues against a direct relationship between visual awareness of emotional signals and peripheral changes. Neuroimaging results showed that fearful bodies activated the left amygdala and extrastriate cortex when consciously perceived as well as when extinguished. Critically, however, conscious perception of fearful bodies was uniquely associated with activity in the anterior insula, somatosensory, motor and premotor cortex (PMC), and the cerebellum. This suggests that the integration between peripheral arousal and the moment-to-moment mapping at the central neural level of these bodily changes is critical for the conscious visual experience of emotional signals.

Testing the inter-hemispheric competition account of visual extinction with combined TMS/fMRI.

Theoretical models of visual neglect and extinction entail claims about the normal functioning of attention and parietal cortex in the healthy brain: (1) 'pseudoneglect', a commonly observed attentional bias towards left space, reflects the greater dominance of parietal cortex activity of the right versus left hemisphere; (2) the capacity to distribute attention bilaterally depends causally on the relative balance of parietal activity between the hemispheres; (3) disruption of the dominant right parietal cortex shifts this inter-hemispheric balance leftward, causing a rightward shift in attentional bias. We tested these claims using low-frequency offline transcranial magnetic stimulation (TMS) to transiently inhibit activity in the right angular gyrus/intra-parietal sulcus, followed by a visual detection task to assess changes in attentional bias, and functional magnetic resonance imaging (fMRI) to test for the predicted leftward shift in brain activity. The task required participants to covertly monitor both hemifields to detect and report the location of upcoming transient visual targets that appeared on the left, right or bilaterally. In the behavioural experiment, participants exhibited a leftward attentional bias ('pseudoneglect') at baseline, which was abolished by TMS. In the fMRI experiment, participants activated an expected network of visual, parietal and frontal cortex bilaterally during the period of covert bilateral attention. TMS shifted the relative hemispheric balance of parietal activity from right to left. The consistent direction of TMS-induced behavioural and functional change indicates a causal role for parietal inter-hemispheric balance in distributing visual attention across space.

Processing of bilateral versus unilateral conditions: evidence for the functional contribution of the ventral attention network.

Processing of multiple or bilateral conditions presented simultaneously in both hemifields reflects the natural mode of perception in our multi-target environment, but is not yet completely understood. While region-of-interest based studies in healthy subjects reported single cortical areas as the right inferior parietal lobe (IPL) or temporoparietal junction (TPJ) to process bilateral conditions, studies in extinction patients with reduced ability in this regard suggested the right superior temporal cortex to hold a key role. The present fMRI study on healthy subjects aimed at resolving these discrepancies by contrasting bilateral versus unilateral visual conditions in a paradigm similar to the bed-side test for patients with visual extinction on a whole brain level. Additionally, reduced attentional capacity in spatial processing was investigated in normal aging. Processing of bilateral conditions compared to unilateral ones showed to require stronger activation of not one single cortical region but the entire right-lateralized ventral attention network, bilateral parietal and visual association areas. These results might suggest a conceptual difference between unilateral and bilateral spatial processing with the latter depending on additional anatomical and functional brain resources. Reduced attentional capacity in elderly subjects was associated with compensatory recruitment of contralateral functional homologues [left IPL, TPJ, frontal eye field (FEF)]. These data reveal the functional anatomy of our ability to visually process and respond to the entity of the environment and improve our understanding of neglect and extinction. Moreover, the data demonstrate that a restriction of the attentional capacity is based on processing limitations in the network of high-level cortical areas and not due to restriction in the primary sensory ones.

The frequency and severity of extinction after stroke affecting different vascular territories.

We examined the frequency and severity of visual versus tactile extinction based on data from a large group of sub-acute patients (n=454) with strokes affecting different vascular territories. After right hemisphere damage visual and tactile extinction were equally common. However, after left hemisphere damage tactile extinction was more common than visual. The frequency of extinction was significantly higher in patients with right compared to left hemisphere damage in both visual and tactile modalities but this held only for strokes affecting the MCA and PCA territories and not for strokes affecting other vascular territories. Furthermore, the severity of extinction did not differ as a function of either the stimulus modality (visual versus tactile), the affected hemisphere (left versus right) or the stroke territory (MCA, PCA or other vascular territories). We conclude that the frequency but not severity of extinction in both modalities relates to the side of damage (i.e. left versus right hemisphere) and the vascular territories affected by the stroke, and that left hemisphere dominance for motor control may link to the greater incidence of tactile than visual extinction after left hemisphere stroke. We discuss the implications of our findings for understanding hemispheric lateralization within visuospatial attention networks.

The compensatory dynamic of inter-hemispheric interactions in visuospatial attention revealed using rTMS and fMRI.

A balance of mutual tonic inhibition between bi-hemispheric posterior parietal cortices is believed to play an important role in bilateral visual attention. However, experimental support for this notion has been mainly drawn from clinical models of unilateral damage. We have previously shown that low-frequency repetitive TMS (rTMS) over the intraparietal sulcus (IPS) generates a contralateral attentional deficit in bilateral visual tracking. Here, we used functional magnetic resonance imaging (fMRI) to study whether rTMS temporarily disrupts the inter-hemispheric balance between bilateral IPS in visual attention. Following application of 1 Hz rTMS over the left IPS, subjects performed a bilateral visual tracking task while their brain activity was recorded using fMRI. Behaviorally, tracking accuracy was reduced immediately following rTMS. Areas ventro-lateral to left IPS, including inferior parietal lobule (IPL), lateral IPS (LIPS), and middle occipital gyrus (MoG), showed decreased activity following rTMS, while dorsomedial areas, such as Superior Parietal Lobule (SPL), Superior occipital gyrus (SoG), and lingual gyrus, as well as middle temporal areas (MT+), showed higher activity. The brain activity of the homologues of these regions in the un-stimulated, right hemisphere was reversed. Interestingly, the evolution of network-wide activation related to attentional behavior following rTMS showed that activation of most occipital synergists adaptively compensated for contralateral and ipsilateral decrement after rTMS, while activation of parietal synergists, and SoG remained competing. This pattern of ipsilateral and contralateral activations empirically supports the hypothesized loss of inter-hemispheric balance that underlies clinical manifestation of visual attentional extinction.

Contralesional rTMS relieves visual extinction in chronic stroke.

Patients affected by right parietal lobe lesion can be severely impaired in sustained attention tasks, particularly in the left visual field. For example, patients with right parietal stroke are commonly limited in their ability to attentionally track multiple moving objects in their left visual field when competing stimuli are simultaneously presented in the right, ipsilesional visual field. This is a hallmark of visual extinction, a failure to respond to contralesional visual stimuli, when competing stimuli are presented in the good hemifield. It has been hypothesized that post-stroke hyperactivity of the undamaged left hemisphere leads to excessive cross-hemispheric inhibition of the damaged right hemisphere, thus exacerbating the attentional deficits. However, there has been no direct physiological demonstration of this hypothesis, as most of the studies are conducted using unilateral tasks, a condition not sufficient to drive inter-hemispheric competition. The inter-hemispheric inhibition hypothesis also raises the possibility that if hyperactivity of the healthy hemisphere were reduced, this could relieve inter-hemispheric inhibition, disinhibiting the damaged hemisphere and potentially restoring some function. To test this hypothesis, and to examine whether we could relieve deficits in sustained attention in right parietal patients, we used repetitive transcranial magnetic stimulation (rTMS) to reduce the activity of the left, healthy hemisphere. Six patients suffering from visual extinction underwent two counterbalanced sessions: low frequency rTMS over the left parietal lobe and sham control stimulation. The patients' performance in an attentional tracking task significantly improved in the contralesional visual field immediately after rTMS, but not after sham. Performance remained unaltered in the ipsilesional field. We hypothesize that rTMS temporarily releases the damaged right hemisphere from excessive cross-hemispheric inhibition by the hyperactive healthy hemisphere, leading to some cognitive recovery after cortical lesion.

Common and distinct neural mechanisms of visual and tactile extinction: A large scale VBM study in sub-acute stroke.

Extinction is diagnosed when patients respond to a single contralesional item but fail to detect this item when an ipsilesional item is present concurrently. Extinction has been studied mainly in the visual modality but it occurs also in other sensory modalities (touch, audition) and hence can be considered a multisensory phenomenon. The functional and neuroanatomical relations between extinction in different modalities are poorly understood. Here, we used voxel-based mophometry (VBM) to examine the neuronal substrates of visual versus tactile extinction in a large group of sub-acute patients (n = 454) with strokes affecting different vascular territories. We found that extinction deficits in tactile and visual modalities were significantly correlated (r = 0.341; p < 0.01). Several lesions within the right hemisphere were linked to extinction including the inferior parietal lobule, the superior parietal lobule, the middle frontal and occipital gyri, while lesions involving the superior temporal gyrus, inferior temporal gyrus and putamen were associated with tactile extinction. Damage within the middle temporal gyrus and superior temporal sulcus was linked to both deficits. We conclude that extinction in different modalities emerges after damage to both common (supra-modal) and distinct (modality specific) brain regions, and that contrasting sites emerge after damage to different vascular territories. We discuss the implications for understanding extinction as a multisensory disorder.