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Improvement of Mental Imagery After Prism Exposure in Neglect: a Case Study

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Improvement of Mental Imagery After Prism Exposure in Neglect: a Case Study 251 Improvement of mental imagery after prism exposure in neglect: a case study a,b, a,b a Gilles Rode ∗, Yves Rossetti , Ling Li and Neglect of imagined space may also be temporarily Dominique Boissona,b reduced by vestibular stimulation. This improvement aService de ReÂeducation Neurologique, Hopitalà may concern imagery-description of familiar squares Henry Gabrielle, Hospices Civils de Lyon and [6] or geographical maps [10]. In these experiments, Universite Claude Bernard, Lyon, France the improvement was exhibited as an increased number bInstitut National de la Sante Et de la Recherche of items recalled on the previously neglected side with Medicale, Unite 534: Espace et Action, 16 avenue little or no change on the ipsilesional side. This means Lepine, Case 13, 69676 Bron, France that the vestibular stimulation does not act through a non-speci®c mechanism such as an increase in gen- eral arousal, neither can it result from a mechanism Previous work has shown that various symptoms of unilateral ne- glect, including the pathological shift of the subjective midline to the of global activation of the right hemisphere with a right, may be improved by a short adaptation period to a prismatic decreasing imbalance between the two hemispheres. shift of the visual ®eld to the right. We report here the improvement Vestibular stimulation in neglect patients may thus of imagined neglect after prism exposure in a patient with a left uni- act speci®cally on integrative mechanisms involved in lateral neglect. Despite a strong neglect observed for mental images as well as for conventional tests, the mental evocation of left-sided the elaboration of the mental representation of space information from an internal image of the map of France map was [10, 11]. fully recovered following prism adaptation to the right. This im- Guariglia et al. [7] have shown that somatosensory provement could not be explained by the alteration of visuomotor responses induced by the prism adaptation. Prism adaptation may stimulation may also improve imagined neglect. In- therefore act not only on sensory-motor levels but also on a higher deed the effects of transcutaneous electrical neural cognitive level of mental space representation and/or exploration. stimulation on the left side of the neck induced an im- provement of performance on the left side in mental Keywords: Unilateral neglect, mental representation, prism adaptation, cognitive neuropsychology representation of objects as well as the free drawing of objects, shape comparison and imagery-description of familiar squares. These results thus suggested that 1. Introduction vestibular or somatosensory stimulation may in¯uence the central mechanisms of multimodal integration in- Following right hemisphere damage, patients may volved in object as well as in space representation. show unilateral neglect ± a neurological de®cit of per- Recently, using a short adaptation period to a pris- ception, attention, representation, and/or performing matic shift of the visual ®eld to the right, Rossetti actions within their left-sided space [8]. Most man- et al. [12] reported an improvement of various symp- ifestations of this syndrome may be temporarily re- toms of hemispatial neglect in a group of right brain duced by vestibular, proprioceptive or tanscutaneous damaged neglect patients. A reduction of the subjec- stimulations. Improvement not only concerns extrap- tive body midline shift toward the ipsilesional side, ersonal and personal neglect, but also anosognosia, shown by these patients, was also noted following somatoparaphrenic delusions and the somatosensory the prism adaptation. These ®ndings suggested that, and motor de®cits often seen in association with the unlike the previous sensory stimulations, the effect syndrome (see review in [15]). of prism adaptation may be conceived as stimulating active processes involved in brain plasticity related to multisensory integration and space representation. ∗Corresponding author: Gilles Rode, Service de ReÂeducation However the tasks used in this experiment involved Neurologique, Hopitalà Henry Gabrielle, Hospices Civils de Lyon, a visuo-manual response (e.g., line cancelling, draw- Route de Vourles, BP 57, F-69565 Saint-Genis Laval, France. Tel.: +33 04 78 86 50 24; Fax: +33 04 78 86 50 30; E-mail: ing). Therefore one may ask whether the effect of [email protected]. visuo-motor adaptation could be explained by a di- Behavioural Neurology 11 (1998/1999) 251±258 ISSN 0953-4180 / $8.00 1998/1999, IOS Press. All rights reserved 252 G. Rode et al. / Improvement of mental imagery after prism exposure in neglect: a case study rect alteration of the manual output inherent to the J.C.G. showed a ¯orid left visuo-spatial neglect. For tasks previously explored. An interesting question is example, the patient omitted most of the left side when whether the improvement observed after prism adap- asked to draw a daisy or to copy a bicycle or a house tation would also affect aspects of neglect, which are (Fig. 1). He failed to complete the clock-face on the free from manual responses. We report the improve- same occasion. On a line-cancellation test (1), the ment of mental imagery after a prism exposure in a patient omitted to cross the left and middle section of neglect patient. the test sheet (28/40). Requested to bisect horizon- tal lines, he placed his transections signi®cantly to the right of the centre (13). J.C.G. also showed a personal 2. Methods neglect, assessed by clinical examination. A left ne- glect of imagined space was also noted, when asked 2.1. Subjects the patient to evoke mentally a street or a place of his town. The patient was quite alert, well oriented in Three subjects participated in this study. One patient time and co-operative. At the time of examination, one with a left hemispatial neglect and two right-handed month post-onset, the patient was not anosognosic for control-subjects (2 males respectively 56 and 67 years the motor de®cit and the visual de®cit had disappeared. old). Neuropsychological examination also revealed a con- The patient, J.C.G., was a 46 year-old, right-handed structive apraxia dominant for 3D-objects. A CT scan man with 14 years of schooling and a long history performed 2 months after the stroke revealed a large of hypertension and diabetes. J.C.G. was admitted to area of hypodensity in the right hemisphere (Fig. 2). hospital on 6 June, 1996 after the sudden onset of a left Bilateral carotid and vertebral angiography showed a hemiparesis, with a left homonymous hemianopia and complete thrombosis of the right internal carotid artery. loss of somesthetic sensation on the left side. Head and gaze were deviated to the right, but the patient could 2.2. Procedure move his eyes towards the left both on verbal command and visual pursuit. Speech was mildly dysarthric and Three tasks were used to test the effectiveness of there was a right central facial paresis. prism adaptation in J.C.G. For the control-subjects, only the mental imagery task was performed before and after adaptation. 2.3. Pointing to straight-ahead Subjective body-midline was evaluated by a simple manual pointing task. The patient was seated blind- folded in front of a horizontal box that permitted mea- surement of the ®nger movement endpoints with an accuracy of 1 deg. He was required to point straight- ahead while his head was kept aligned with the body's sagittal axis. Ten pointing trials were performed in the pre-test (without goggles) and in the post-test (imme- diately upon the prism removal), in order to check that prism adaptation had been ef®cient. The cover of the experimental box allowed the patient to perform free pointing movements either without vision of the arm, or with a partial sight of the arm trajectory (exposure condition). 2.4. Free drawing of object The patient was asked to draw a daisy from memory; The drawing was repeated in three sessions: prior to Fig. 1. Examples of drawings performed by J.C.G. in copying: a prism exposure (Pre-test), on prism removal (Post-test) cube, a house and a bicycle. and 24 hours later (Late-test). G. Rode et al. / Improvement of mental imagery after prism exposure in neglect: a case study 253 Fig. 2. Extent of the right-hemisphere lesion plotted on axial templates obtained from a CT-scan performed 1 month after onset. Section shows a large lesion in the right hemisphere, centred around the temporo-parieto-occipital carrefour, respecting the thalamic region and encroaching upon the external capsule and the putamen. 2.5. Mental imagery task could see the target, the second half of their pointing trajectory and their terminal error. Their head was kept Subjects were asked to mentally evoke the map of aligned with the body's sagittal axis by a chin-rest and France and to name as many towns as possible on the controlled by an investigator. The total duration of this map that they could `see' within 2 minutes (see details exposure was about 3 minutes. in [8]). The patient was tested before adaptation (Pre This experimental procedure was applied one month test), immediately after (Post test) and 24 hours after post-onset. (Late test) prism exposition. Performance was rated by a global score corre- sponding to the total number of towns named within 3. Results 2 minutes (total score). In addition, 2 scores were computed according to the geographical position of 3.1. Pointing to straight-ahead each named town, either on the right of the map cen- tral axis (Perpignan-Lille)(right score), or on the left In the Pre-test, the patient's straight-ahead was ini- of this axis (left score). Four sub-scores relation to tially shifted to the left (mean: 5◦; Standard Error − the geographical position of named towns on each lat- of the Mean (SEM): 1.26).
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