Unilateral Spatial Neglect

Laurie Swan
PHYS THER. 2001; 81:1572-1580.

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Update

Unilateral Spatial Neglect

eglect has been defined as the failure to report, respond, or orient

to novel or meaningful stimuli presented to the side opposite a
brain lesion, when this failure cannot be attributed to either
sensory or motor defects.1(p279) The purpose of this update is to
provide a focused review of unilateral spatial neglect (USN). This update will
describe the 3 major categories of USN, identify USN as an attentional deficit
by describing a model for directed attention, and discuss the incidence and
treatment of USN. An understanding of the different types of neglect and the
emerging treatment ideas is important for physical therapists to provide
optimal care for individuals with USN. This update will not address homonymous hemianopsia, hemihypesthesia, or hemiparesis that may occur after a
stroke. Although these impairments frequently occur with USN, they are
separate entities from USN.2

Categories of Neglect
Researchers have subdivided USN into 3 major categories of attentional
deficits: the memory and representational deficits, the action-intentional
disorders (motor neglect), and inattention (sensory neglect).1,3 Neglect of
representational space has been described by Bisiach and Luzzatti,4 who asked
2 patients with left unilateral neglect to describe, from memory, a square in
Milan that contained a cathedral, shops, and palaces. The patients were
oriented to their place in the square in relation to the cathedral. The patients
described the right side of the square accurately, but they omitted descriptions of the left side. When the patients were turned around in their
memory, they began to accurately describe what had previously been to their
left while omitting what had previously been to their right. This study

[Swan L. Unilateral spatial neglect. Phys Ther. 2001;81:15721580.]

Key Words: Attentional deficits, Brain function, Cognition, Sensorimotor integration.

1572

Laurie Swan

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Unilateral spatial
neglect is a
suggested that the memory of extrapersonal space is
stored with a body-centered coordinate system. For these
patients with right parietal lobe damage, the attentional
deficits in mental representations reflected this bodycentered frame of reference. More recently, Beschin
et al5 described a patient who had had a cerebrovascular
accident (CVA) of the right parietal lobe. This patient
had a pure representational neglect. The patient
showed no evidence of a visual perceptual neglect, but
had great difficulty describing details of imagined representations from his long-term memory. The studies of
representational space have demonstrated that neglect is
not limited to motor and sensory deficits and that
behavioral aspects of brain function can be involved.
Motor neglect is not a deficit of the motor pathway, but
rather a failure or decreased ability to move in the
contralesional space (space contralateral to the damaged hemisphere) despite being aware of a stimulus in
that space.1 Motor neglect can be seen in the eyes, head,
limbs, or trunk of the individual.1 The concept of
hemispace is crucial to understanding the research
studies that have examined action-intentional disorders.
Hemispace is a frame of reference for right and left that
is defined with respect to a specified person. The trunk
of the person is the reference point for defining hemispace, with the left side of the trunk in the left hemispace and the right side of the trunk in the right
hemispace. Because the eyes and head can rotate in
reference to the trunk, they may be shifted partially or
wholly into the right or left hemispace.3 When a person
is positioned with the trunk, head, and eyes facing
directly forward, his or her right hemispace is the field
that starts at the midline of the body and extends
laterally to the right.1 The left hemispace is the field that

begins at the midline

and extends laterally to
the left.1 If the person
attention that may
shifts his or her eyes to a
rightward gaze without
occur following
moving the head or
trunk, then the right
stroke.
and left visual fields are
now in the persons
right hemispace.1 As the person turns his or her head to
the right, the entire head enters the right hemispace.1

complex deficit in

Watson et al6 demonstrated support for neglect exhibiting the signs and symptoms of an action-intentional
disorder. These researchers trained 5 monkeys to open a
door to their right after left leg stimulation and to open a
door to their left after right leg stimulation. Unilateral
lesions were surgically completed in the frontal arcuate
gyrus or the intralaminar nucleus of the thalamus and
the mesencephalic reticular formation. The unilateral
lesions were placed in the right or left hemisphere of the
brain. Postsurgery, the monkeys demonstrated USN, as
seen by their orientation to right and left sides and by
their response to visual or light touch stimuli. None of the
monkeys displayed weakness of their limbs. When
retested on the door-opening task, the monkeys made
mistakes when the stimulus was applied to the ipsilesional limb (the limb ipsilateral to the damaged hemisphere) (the contralesional limb response was in error).
When the stimulus was applied to the contralesional
limb, the monkeys correctly performed the task with the
ipsilesional limb. Watson et al showed that motor
responses were being made following a sensory stimulus;
however, the contralesional limb motor responses were

L Swan, PT, MPT, NCS, is Assistant Professor, Program in Physical Therapy, Department of Health Promotion and Rehabilitation, Central
Michigan University, Pearce Hall 134, Mt Pleasant, MI 48859 (USA) (laurie.swan@cmich.edu).
Ms Swan provided concept/project design and writing. She acknowledges Shelby J Clayson, PT, MS, for her thoughtful review of the manuscript.
Peter Loubert, PT, PhD, and Cheryl Dusty-DeLauro provided assistance with the content and design of the figures.

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Figure 1.
Attentional differences in the hemispheres of the brain. In an individual
without pathology of the brain, the right hemisphere of the brain attends
to both hemispaces while the left hemisphere attends primarily to the
right hemispace (A). After a right hemisphere lesion, the left hemisphere
attends primarily to the right hemispace (B). After a left hemisphere
lesion, the right hemisphere attends to both hemispaces (C).

decreased, as shown by the number of incorrect

responses or by no response.
Inattention (sensory neglect) is a lack of awareness,
or decreased awareness, of sensory stimulation in the
contralesional hemispace.1 This decreased sensory
awareness occurs even though the sensory pathways and
the primary sensory cortical areas are intact.1 Clinical
observers have noted that, following a right hemisphere
stroke, patients often fail to attend to the left hemispace.
Over time, those observations have led to the development of the following theory: in an individual with no
known neurological pathology or impairments, the right
hemisphere of the brain attends to both the right and
left hemispaces while the left hemisphere attends primarily to the right hemispace2,7 (Fig. 1). Following a
right hemisphere lesion, attention is directed primarily
to the right hemispace, resulting in a neglect of the left
hemispace.2,7 A lesion of the left hemisphere does not
usually result in USN because the intact right hemisphere can direct attention to both hemispaces.2,7
Unilateral spatial neglect can occur as a result of lesions
at different anatomical sites and varies in its presentation.2 Researchers have proposed many different theories to explain neglect, yet there is no one theory that
fully accounts for the idiosyncratic presentations of
neglect. Marshall et al8 made the analogy between the
concepts of aphasia and neglect. Aphasia is a broad
term that refers to disorders of language, but any further
explanation requires one to make distinctions, for example, between Werniekes aphasia, Brocas aphasia, global
aphasia, and so on.8 Just as the term aphasia refers to
a broad category, so does the term neglect.8 A theory
may adequately explain the neglect caused by a lesion in
one anatomic area, but no one theory can account for
the numerous variations of behavior associated with
USN.8

1574 . Swan

Unilateral Spatial Neglect and a Model for

Directed Attention
Unilateral spatial neglect can occur with a lesion in any
of the following areas: posterior parietal cortex, frontal
lobe, cingulate gyrus, striatum, and thalamus.3 Although
these areas are located throughout the brain, they are all
important components in the process of attention. Some
experts have focused on the posterior parietal lobe as
the focal point of lesions that resulted in USN.3 More
recent research has shown that attention is mediated by
a network of many different anatomic areas working
together.3 Although there are extensive interconnections among the anatomic areas contributing to attention, only the major pathways will be discussed here.
The posterior parietal lobe is the site of converging
information from visual, auditory, somatosensory, and
vestibular unimodal areas.3 Mesulam3 has proposed that
the integration of the many sensory inputs leads to the
formation of a sensory representation of extrapersonal
events (events occurring in the hemispaces surrounding
the individual). The primary anatomical region for
attention in the parietal lobe is centered on the sulcus
separating the superior and inferior parietal lobes; however, adjacent parietal areas also are probably involved.3
The posterior parietal lobe has extensive interconnections with the premotor cortex, the frontal eye fields, the
superior colliculus, and the paralimbic areas.3 The cingulate gyrus is the strongest interconnection between
the posterior parietal lobe and the paralimbic areas.3
Mesulam3 postulated that the limbic systems role in
attention is organized into 2 components. The anterior
cingulate gyrus plays a role in the motivational relevance
of the many extrapersonal sensory inputs.3 The posterior
cingulate gyrus monitors post-saccadic shifts in the direction of overt visual attention.3
Input from the reticular activating system originates in
the raphe nuclei and nucleus locus coeruleus of the
brain stem, the nucleus basalis, the ventral tegmental
area, and the intralaminar thalamic nuclei.3 The
intralaminar thalamic nuclei determine the relevance of
stimuli and control transmission of information from the
thalamus to the cortex.3 The primary function of the
reticular pathway is to control the activation and level of
arousal of the attentional network.3
Mesulam3 speculated further that motor planning and
output are focused in the frontal eye fields and the
adjacent premotor areas. These regions are directly
involved in overt and covert shifts of directed attention.3
Researchers studying the neuroanatomy of monkeys
have found extensive interconnections between the
frontal eye fields and the posterior parietal cortex,
cingulate gyrus, thalamus, subthalamic nuclei, superior

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Figure 2.
A model for directed attention (after Mesulam3,9,10). The central component for attention is the posterior parietal cortex where integration of afferent
input from the sensory association areas, reticular formation and thalamus, and limbic system occurs. The primary output is to the motor planning
region of the frontal lobe.

colliculus, and other premotor and prefrontal areas.3

The cortical and subcortical input to the frontal eye
fields and adjacent motor regions directs the eyes, head,
and limbs to scan and explore the environment.3
Mesulam3,9,10 has developed a model of the neural
networks involved in the distribution of attention
(Fig. 2). The posterior parietal lobe, limbic system, and
frontal eye fields/adjacent premotor areas are selfcontained local networks, and each has a role to play in
attention.3,9,10 These local networks have extensive interconnections with each other and the reticular activating
system that form a larger neural network for attention.3,9,10 The task of the larger network is to form a
representation of the external environment, target specific stimuli, and then explore those stimuli through
visual scanning and motor acts.3,9,10 The posterior parietal lobe is primarily responsible for creating a sensory
representation of extrapersonal events, and for targeting
specific stimuli.3,9,10 The cingulate gyrus determines the
motivational relevance of the extrapersonal sensory

input.3,9,10 The frontal eye fields and adjacent premotor

areas regulate visual scanning, orient the head and eyes
to explore the environment, and initiate motor acts for
limb movement.3,9,10 Although it may be tempting to
associate deficits with a lesion in one area, Mesulam3
cautions us against this. Mesulam3,9,10 contends there are
no rigid boundaries of different types of USN because
the attentional network is tightly interwoven. A specific
behavior is not a product of one specific anatomic area,
but rather a result of the many connections that are
found within that area and with other more distant
regions.3,9,10
Incidence of Unilateral Spatial Neglect
The incidence of neglect is not clearly documented in
the literature. Stone et al12 reported that over 80% of
patients demonstrate a visual neglect following a right
CVA, whereas Denes et al13 reported a 17% rate of
occurrence of USN following a right CVA. Left neglect
after a right hemisphere stroke is most common,12,14,15
but right neglect after a left hemisphere stroke can

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occur.16 Right neglect after a right hemisphere stroke

has also been reported.17 The normal variations that
occur in the side of cerebral dominance18 may account
for the variations in the side of neglect and location of
the stroke. Left neglect is more severe, as measured in
neuropsychological testing, than right neglect,13,19 and
larger lesions increase the severity of neglect.20,21
Although neglect is most apparent in one hemispace,
test batteries have revealed that neglect occurs in both
hemispaces.22 The rate of recovery from neglect is
greatest in the first month poststroke,22 and recovery can
range from a persistent neglect to complete recovery.15
The presence of neglect has been associated with poor
outcome measures on functional activities following a
stroke.23,24 Patients with neglect have been found to have
longer lengths of stay in rehabilitation facilities and
lower scores on the Functional Independence Measure
(FIM),25 and thus require more assistance at discharge
than patients without neglect.13,26
Treatment
Treatment strategies for USN most often have been
focused on the training of attention in the left hemispace. Weinberg et al27 designed a treatment program to
train patients with right hemisphere lesions in scanning
to the left. An initial target that served as an anchoring
point was placed in the left hemispace of a reading task.
The density of the stimuli (size of print relative to lines
of print) and the pace of the patients visual tracking
pattern (slow versus fast) were manipulated by the
examiner. A battery of neuropsychological tests were
completed prior to and on completion of the treatment
program. The experimental group showed improvement
over the control group after 20 hours of intervention,
and the effects of treatment were still present after 1
year. In a follow-up study, Weinberg et al28 expanded
their program to include training of sensory awareness
and spatial organization. Patients with right hemisphere
lesions were given 20 hours of training in sensory
awareness (identifying the location of a light touch
stimulus applied to the posterior trunk) and spatial
organization (estimating the sizes of plexiglass rods of
differing lengths). The experimental group again
showed improvement on numerous neuropsychological
tests over the control group, and Weinberg et al concluded that the combination of visual scanning, sensory
awareness, and spatial organization training is an effective treatment strategy for patients with right hemisphere lesions.
Robertson et al29 designed a strategy to decrease USN by
facilitating activation of the sustained attention system.
This strategy is based on the premise that sustained
attention is a system that engages attention in preparation for response in the absence of external stimuli.
Patients with right hemisphere lesions completed sort-

1576 . Swan

ing tasks while a trainer provided an auditory reminder

to attend to the task. The auditory reminder consisted of
unpredictable loud knocking on the desk and a loud
verbal command to Attend! The patients gradually
took over the responsibility of performing the auditory
command. The auditory reminders were then phased
into internal mental reminders, and the patients were
encouraged to apply this strategy to their daily tasks. The
patients were assessed before and after treatment using 2
measures of sustained attention, 2 measures of neglect,
and 2 measures of a control task in which the patients
performance was not expected to change as a result of
the treatment. Robertson et al found changes in 2 of the
4 outcome measures, and no effect in 2 of the outcome
measures. The 2 control measures showed no effect.
Robertson et al concluded that their treatment program
improved the patients ability to sustain attention.
More recently, Smania et al30 used visual and movement
imagery exercises to target the representational deficits
seen in patients with USN. Two patients with USN
following stroke were examined in this case study. The
patients were more than 6 months post-onset of their
stroke, and neuropsychological tests indicated that their
level of USN had been stable for 45 days. Thus, the
patients in this study were beyond the normal time frame
for complete recovery.22 Visual imagery exercises
included tasks such as describing the position of objects
in a room of their home and visualizing a word and then
spelling it backwards. During movement imagery exercises, the examiner began in one posture and then
moved to another posture. The patients were required to
watch the examiner and verbally describe the changes in
postures. The patients also learned a specific sequence
of movements while in sitting. They were taught to
visualize moving through the sequence and to verbalize
their visual representations. Smania et al conducted
extensive neuropsychological tests before beginning the
visual and movement imagery exercises, at the end of the
treatment program (40 sessions), and 6 months after
completion of the treatment program. They found
improvements in performance at the end of the treatment program. These improvements were sustained at
the 6-month follow-up evaluation.
Several researchers3135 have shown a reduction in USN
following manipulation of sensory input that conveys
perception of the head in space. A temporary remission
of USN has been noted in several studies following
vestibular stimulation through caloric irrigation.3133
The neural pathways responsible for this remission are
unknown.32,33 Unilateral spatial neglect has also been
reduced temporarily through galvanic stimulation of the
vestibular nerves.34 Rorsman et al34 found that galvanic
stimulation applied during visuomotor tasks decreased
the severity of neglect. The galvanic stimulation was

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removed on completion of the visuomotor tasks, and by

the next day, the patients prior level of neglect had
returned. Karnath et al35 found that lengthening of the
left posterior neck muscles by trunk rotation induced a
transient remission of left USN, presumably due to the
sensory input that this supplied to the central nervous
system. This effect was seen during lengthening of the
muscles accomplished by rotating the trunk 15 degrees
to the left while the head remained stationary and
during vibration of the left posterior neck muscles.

follows the stronger pathway to the right superior colliculus, which generates leftward saccades.39 This eye
patch is theorized to affect perception and attention by
facilitating the direction of attention.39 When the right
hemifields of both eyes are covered with patches in an
individual with left USN (Fig. 4), visual input is thought
to follow the remaining pathways and converge primarily
on the right superior colliculus, generating leftward
saccades.39 This method is thought to control the intention and direction of gaze.39

Modifications of the visual input to patients with USN

have shown some success as a treatment intervention.
Rossi et al36 used prisms that were attached bilaterally to
the left half of eyeglasses of patients with left-sided USN.
The prisms shifted peripheral images to a more central
position on the retina. The patients with USN showed
improvement on visual perception tests after 4 weeks of
wearing the prisms when compared with patients in the
control group. However, there was no difference
between the experimental group and the control group
on improvement in function as measured by the Barthel
Index.36,37 Rossetti et al38 investigated the use of widefield prismatic lenses with patients with USN. The widefield prismatic lenses were fitted to goggles and created
an optical shift of the visual field 10 degrees to the right.
Twelve patients with USN were randomly assigned to the
prism group or a control group. The patients underwent
neuropsychological assessments for USN. Immediately
after testing, the patients donned their goggles and
performed a series of 50 pointing responses to visual
targets appearing 10 degrees to the left or right of their
body midline. This task took 2 to 5 minutes. Immediately
afterward, the neuropsychological assessments were
again administered to the patients, followed by a third
assessment 2 hours later. The patients wearing the prism
lenses demonstrated improvement during the 2 posttests, whereas the patients wearing goggles without
prisms showed no difference. Rossetti et al concluded
that the adaptation to the prisms affects spatial representation in the brain.

Butter and Kirsch40 examined patients with a right CVA

and left USN and found that placing a patch over the
right eye improved performance on a standard test
battery for neglect. The patients wore the eye patch only
during the administration of the test battery, and the
beneficial effect was limited to the time in which the
patients wore the eye patch.40 Walker et al41 examined 9
patients with a right CVA and left USN. The patients
performance on standard tests for neglect were evaluated during normal viewing conditions, while they wore
a right monocular eye patch, and while they wore a left
monocular eye patch. Walker et al had theorized that the
patients performance would improve when the right eye
patch was worn and would diminish when the left eye
patch was worn. Walker et al found no differences
between the normal viewing condition and when the
right or left eye was covered with a patch. Beis et al39
studied the effects of eye patches of various types on
right eye movements measured by photo-oculography, a
letter cancellation test, and the overall score on the
FIM.25 Patients with right CVA and left USN were
assigned to a control group, a group with a monocular
patch covering the right eye, or a group with a binocular
patch covering the right hemifield. The patches were
attached to the patients glasses and were worn approximately 12 hours per day for 3 months. The patients with
the right hemifield covered with a patch showed
improvements in FIM scores and right eye movement in
the left field when compared with the control group and
group with the monocular patch covering the right eye.

Several researchers39 41 have examined the effects of

using an eye patch on USN. Their studies were based on
a combination of neuroanatomical, neurophysiological,
and psychophysiological models. Research has demonstrated that, in an individual with an intact nervous
system, retinal input from the eye is strongest to the
contralateral superior colliculus42 (Fig. 3). Visual stimuli
to the right superior colliculus generates leftward saccades (quick, involuntary movements of the eyes as they
change from one point of gaze to another), whereas
visual stimuli to the left superior colliculus generates
rightward saccades.43 When the entire right eye of an
individual with left USN is covered with a patch, the
remaining visual stimuli to the left eye presumably

Mirrors also have been used as therapeutic devices to

facilitate attention to the neglected side.44,45 Ramachandran and colleagues44,45 placed a mirror in the right
parasagittal plane of patients with left USN so that the
left hemispace was visible to the patient. When the
patients were asked to reach for an object in the left
hemispace that was visible in the mirror on the right,
some patients were able to locate the object in the left
hemispace. Other patients attempted to reach for the
mirror image of the object, and Ramachandran and
colleagues named this behavior mirror agnosia. Ramachandran et al45 presented 3 possible interpretations
for mirror agnosia: (1) the patient may be projecting the
mirror image to the neglected side, thus ignoring the

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Figure 3.
Effects of using an eye patch on unilateral spatial neglect (USN). In an individual without brain injury, retinal input is strongest to the contralateral
superior colliculus (A). The right superior colliculus generates leftward saccades while the left superior colliculus generates rightward saccades. An
individual with a right cerebrovascular accident and left USN whose right eye is covered with a patch should generate leftward saccades (B), as
should the same individual with the right hemifield covered by a patch (C).

Figure 4.
Illustration of eyeglasses used for eye patching of bilateral right hemifields.

image along with everything else in the left hemispace,

(2) parietal lobe lesions may impair spatial representations, or (3) the patient may have difficulty with use of
metaphorical language, resulting in reaching directly
toward the mirror image.
1578 . Swan

Summary
Unilateral spatial neglect is a complex, but fascinating,
deficit in attention that may occur following stroke. The
phrase unilateral spatial neglect belies the complex
mixture of disorders in representational memory, hypokinesia in the opposite hemispace, and inattention to
sensory stimuli in the opposite hemispace.3 Unilateral
spatial neglect occurs as a result of damage to the
posterior parietal cortex, frontal lobe, cingulate gyrus,
striatum, thalamus, or specific brain-stem nuclei.3 This
neural network for attention is an excellent example of
how different anatomic areas work together to produce
a specific behavior. Traditional treatment strategies for
USN have focused on training attention in the left
hemispace using a variety of techniques, including sensory awareness, visual scanning, and spatial organization.2729 Recently, additional treatment strategies have
emerged that focus on representational aspects of brain
functioning. These strategies have included visual and
movement imagery,30 manipulation of sensory input that
conveys perception of the head in space,3135 and manip-

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ulation of visual input using prisms and eye patches.36,38 41 The complex nature of USN provides numerous directions for future research. Continued research
will play a pivotal role in devising effective treatment
strategies for patients with USN.

19 Albert ML. A simple test of visual neglect. Neurology. 1973;23:

658 664.

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