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Abstract: Acquired focal visuoperceptual deficits are rarely reported, and rehabilitation strategies are not well established. This is a report on visuoperceptual deficit after traumatic brain injury that initially went unnoticed. Missing visual agnosia is not unusual especially when perceptual deficits present with visual field defects, impaired insight, and inattention. This case is made more interesting because of the rarity of visual agnosia with predominant ventral pathway involvement, affecting object and face recognition. This report provides a brief discussion on visual agnosia spectrum deficits and rehabilitation measures., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

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

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

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

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

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

Objectives: This study was designed to investigate the effect of prism adaptation (PA) combined with continuous theta-burst transcranial magnetic stimulation (cTBS) on the neglect recovery of stroke patients with unilateral neglect., Methods: A total of 14 stroke patients with unilateral neglect were randomly assigned to 2 groups including an intervention group undergone PA combined with cTBS over the left intact parietal cortex and a control group. PA combined with sham cTBS was perfomed for 2 weeks in 10 daily sessions. Before and after the intervention, patients were evaluated for visuospatial neglect measured using the Star Cancellation Test (SCT), Line Bisection Task (LBT), Figure Copying Test, and Clock Drawing Task. Neurological function was evaluated using the Modified Rankin Scale (MRS)., Results: Both groups (PA alone and PA+ cTBS) showed improvement in their neglected symptoms (measured by SCT, LBT, Figure Copying Test, and Clock Drawing Task), and in their disability in the neurological function (measured by MRS) (P< .05)., Conclusions: The results of the present study showed that, transcranial magnetic stimulation did not increase the effect of PA on neglect symptoms in stroke patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The purpose of this pilot study was to investigate the feasibility and effects of computer-based cognitive rehabilitation (CBCR) in patients with symptoms of visuospatial neglect or homonymous hemianopia in the subacute phase following stroke., Method: A randomized, controlled, unblinded cross-over design was completed with early versus late CBCR including 7 patients in the early intervention group (EI) and 7 patients in the late intervention group (LI). EI received CBCR training immediately after inclusion (m = 19 days after stroke onset) for 3 weeks and LI waited for 3 weeks after inclusion before receiving CBCR training for 3 weeks (m = 44 days after stroke onset)., Results: CBCR improved visuospatial symptoms after stroke significantly when administered early in the subacute phase after stroke. The same significant effect was not found when CBCR was administered later in the rehabilitation. The difference in the development of the EI and LI groups during the first 3 weeks was not significant, which could be due to a lack of statistical power. CBCR did not impact mental well-being negatively in any of the groups. In the LI group, the anticipation of CBCR seemed to have a positive impact of mental well-being., Conclusion: CBCR is feasible and has a positive effect on symptoms in patients with visuospatial symptoms in the subacute phase after stroke. The study was small and confirmation in larger samples with blinded outcome assessors is needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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

A 55-year-old right-handed man with a history of hypertension suddenly fell and developed right hemiparesis. Neurological examination revealed that he was alert, but did not appropriately respond to verbal questions and commands. Detailed examination revealed that he could correctly respond to written commands. His speech was almost fluent, showing no paraphasia and normal articulation. His written sentences were legible. Pure tone audiometry showed that his auditory acuity was relatively preserved. His brainstem auditory evoked potential components from I to V were recorded bilaterally with normal latency. Cerebral CT demonstrated fresh bleeding in the left putamen and an old haemorrhage on the opposite side. He was treated by antihypertensive therapy and rehabilitation. Although there remained mild sensory deficit on his right extremities and he felt a slight noise during conversation, he had little difficulty with verbal communication when he was transferred to another hospital on day 38., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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

Currently, the number of patients diagnosed with impaired self-awareness of their own deficits after brain injury-anosognosia-is increasing. One reason is a growing understanding of this multifaceted phenomenon. Another is the development and accessibility of alternative measurements that allow more detailed diagnoses. Anosognosia can adversely affect successful rehabilitation, as often patients lack confidence in the need for treatment. Planning such treatment can become a complex process full of ethical dilemmas. To date, there is no systematic way to deal with different aspects of anosognosia rehabilitation planning. This is the first article to present a framework for ethical decision making in establishing rehabilitation plans that are focused on increasing patients' self-awareness of their own deficits after brain injury. It concentrates especially on addressing the ethical dilemmas that may arise, and describes stepwise procedures that can be applied to distinct theoretical approaches, as well as diagnostic and rehabilitation methods. To show the flexibility of the use of this framework, alternative approaches are discussed., (Copyright 2016 The Journal of Clinical Ethics. All rights reserved.)

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

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

Introduction: Unilateral visuospatial deficits have been observed in children with brain damage. While the effectiveness of prism adaptation for treating unilateral neglect in adult stroke patients has been demonstrated previously, the usefulness of prism adaptation in a pediatric population is still unknown. The present study aims at evaluating the feasibility of prism adaptation in children with unilateral brain lesion and comparing the validity of a game procedure designed for child-friendly paediatric intervention, with the ecological task used for prism adaptation in adult patients., Methods: Twenty-one children with unilateral brain lesion randomly were assigned to a prism group wearing prismatic glasses, or a control group wearing neutral glasses during a bimanual task intervention. All children performed two different bimanual tasks on randomly assigned consecutive days: ecological tasks or game tasks. The efficacy of prism adaptation was measured by assessing its after-effects with visual open loop pointing (visuoproprioceptive test) and subjective straight-ahead pointing (proprioceptive test)., Results: Game tasks and ecological tasks produced similar after-effects. Prismatic glasses elicited a significant shift of visuospatial coordinates which was not observed in the control group., Conclusion: Prism adaptation performed with game tasks seems an effective procedure to obtain after-effects in children with unilateral brain lesion. The usefulness of repetitive prism adaptation sessions as a therapeutic intervention in children with visuospatial deficits and/or neglect, should be investigated in future studies., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

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

Purpose: To compare three ways of assessing self-awareness in children with traumatic brain injury (TBI) and to propose a model of child anosognosia., Method: Five single cases of children with severe TBI, aged 8-14, undergoing metacognitive training. Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness (a questionnaire and illustrated stories where child characters have everyday problems related to their executive dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task difficulty)., Results: All three measures showed good feasibility. Analysis of awareness deficit scores indicated large variability (1-100%). Three children showed dissociated scores., Conclusions: Based on these results, we propose a model of child self-awareness and anosognosia and a framework for awareness assessment for rehabilitation purposes. The model emphasizes (1) the role of on-line error detection in the construction of autobiographical memories that allow a child to build a self-knowledge of his/her strengths and difficulties; (2) the multiple components of awareness that need to be assessed separately; (3) the implications for rehabilitation: errorless versus error-based learning, rehabilitation approaches based on metacognition, rationale for rehabilitation intervention based on child's age and impaired awareness component, ethical and developmental consideration of confrontational methods., Implications for Rehabilitation: Self-awareness has multiple components that need to be assessed separately, to better adapt cognitive rehabilitation. Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include on-line error detection, which can be massively impaired in children, especially those with impaired executive functions. On-line error detection is important to promote and error-based learning is useful to allow a child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe episodic memory problems. Metacognitive trainings may not be appropriate for younger children who have age appropriate developmentally immature self-awareness, nor for patients with brain injury if they suffer anosognosia because of their brain injury.

Long-term deprivation of normal visual inputs can cause perceptual impairments at various levels of visual function, from basic visual acuity deficits, through mid-level deficits such as contour integration and motion coherence, to high-level face and object agnosia. Yet it is unclear whether training during adulthood, at a post-developmental stage of the adult visual system, can overcome such developmental impairments. Here, we visually trained LG, a developmental object and face agnosic individual. Prior to training, at the age of 20, LG's basic and mid-level visual functions such as visual acuity, crowding effects, and contour integration were underdeveloped relative to normal adult vision, corresponding to or poorer than those of 5-6 year olds (Gilaie-Dotan, Perry, Bonneh, Malach & Bentin, 2009). Intensive visual training, based on lateral interactions, was applied for a period of 9 months. LG's directly trained but also untrained visual functions such as visual acuity, crowding, binocular stereopsis and also mid-level contour integration improved significantly and reached near-age-level performance, with long-term (over 4 years) persistence. Moreover, mid-level functions that were tested post-training were found to be normal in LG. Some possible subtle improvement was observed in LG's higher-order visual functions such as object recognition and part integration, while LG's face perception skills have not improved thus far. These results suggest that corrective training at a post-developmental stage, even in the adult visual system, can prove effective, and its enduring effects are the basis for a revival of a developmental cascade that can lead to reduced perceptual impairments., (© 2014 The Authors. Developmental Science Published by John Wiley & Sons Ltd.)

Residual forms of awareness have recently been demonstrated in subjects affected by anosognosia for hemiplegia, but their potential effects in recovery of awareness remain to date unexplored. Emergent awareness refers to a specific facet of motor unawareness in which anosognosic subjects recognise their motor deficits only when they have been requested to perform an action and they realise their errors. Four participants in the chronic phase after a stroke with anosognosia for hemiplegia were recruited. They took part in an "error-full" or "analysis of error-based" rehabilitative training programme. They were asked to attempt to execute specific actions, analyse their own strategies and errors and discuss the reasons for their failures. Pre- and post-training and follow-up assessments showed that motor unawareness improved in all four patients. These results indicate that unsuccessful action attempts with concomitant error analysis may facilitate the recovery of emergent awareness and, sometimes, of more general aspects of awareness.

Anosognosia for hemiplegia (AHP), or unawareness of motor deficits contralateral to a brain lesion, has lasting negative implications for the management and rehabilitation of patients. A recent, bedside psychophysical intervention, namely self-observation by video replay, lead to a lasting remission of severe AHP in an acute stroke patient (Fotopoulou, A., Rudd, A., Holmes, P., & Kopelman, M. (2009). Self-observation reinstates motor awareness in anosognosia for hemiplegia. Neuropsychologia, 47, 1256-1260). This procedure has been adjusted and applied here, as the basis of two intervention protocols administered independently to two patients with severe AHP. The first study used multiple, successive sessions of video-based self-observation in an acute patient, targeting first the awareness of upper limb and subsequently lower limb paralysis. The second study used a single session of video-based, self- and other-observation in a patient at the chronic stage following onset. Both protocols also involved elements of rapport building and emotional support. The results revealed that video-based self-observation had dramatic, immediate effects on awareness in both acute and chronic stages and it seemed to act as an initial trigger for eventual symptom remission. Nevertheless, these effects did not automatically generalise to all functional domains. This study provides provisional support that video-based self-observation may be included in wider rehabilitation programmes for the management and restoration of anosognosia.

Objective: To assess whether, following a right-hemisphere stroke, the combined administration of computer-based cognitive rehabilitation and right hemifield eye-patching in patients with visuo-spatial neglect is more effective than computer-based cognitive rehabilitation alone., Methods: Twelve patients were randomized into two treatment groups: a single treatment group (n = 7) and a combination treatment group (n = 5). In both cases, the treatment consisted of a mean number of 15 sessions, each lasting 1 hour. Visuo-spatial neglect was assessed using a specific exploration protocol (Bell Cancellation Test, Figure Copying of Odgen, Line Bisection, Baking Tray Task and Reading Task). The functional effects of the treatment were assessed using the Catherine Bergego Scale., Results: Significant between-group differences were observed when comparing the pre- and post-treatment scores for the Reading Task. No differences were observed in either group in the Catherine Bergego Scale administered at baseline and at the final intervention., Conclusion: The results obtained do not allow one to conclude that the combination treatment with cognitive rehabilitation and right hemifield eye-patching is more effective than cognitive rehabilitation alone. Although partial improvement in the performance of neuropsychological tests was observed, this improvement is not present at functional level.

Objective: To evaluate the effects of individual or group mirror therapy on sensorimotor function, activities of daily living, quality of life and visuospatial neglect in patients with a severe arm paresis after stroke., Design: Randomized controlled trial., Setting: Inpatient rehabilitation centre., Subject: Sixty patients with a severe paresis of the arm within three months after stroke., Interventions: Three groups: (1) individual mirror therapy, (2) group mirror therapy and (3) control intervention with restricted view on the affected arm., Main Measures: Motor function on impairment (Fugl-Meyer Test) and activity level (Action Research Arm Test), independence in activities of daily living (Barthel Index), quality of life (Stroke Impact Scale) and visuospatial neglect (Star Cancellation Test)., Results: After five weeks, no significant group differences for motor function were found (P > 0.05). Pre-post differences for the Action Research Arm Test and Fugl-Meyer Test: individual mirror therapy: 3.4 (7.1) and 3.2 (3.8), group mirror therapy: 1.1 (3.1) and 5.1 (10.0) and control therapy: 2.8 (6.7) and 5.2 (8.7). However, a significant effect on visuospatial neglect for patients in the individual mirror therapy compared to control group could be shown (P < 0.01). Furthermore, it was possible to integrate a mirror therapy group intervention for severely affected patients after stroke., Conclusion: This study showed no effect on sensorimotor function of the arm, activities of daily living and quality of life of mirror therapy compared to a control intervention after stroke. However, a positive effect on visuospatial neglect was indicated.

Background: Video-games are becoming a common tool to guide patients through rehabilitation because of their power of motivating and engaging their users. Video-games may also be integrated into an infrastructure that allows patients, discharged from the hospital, to continue intensive rehabilitation at home under remote monitoring by the hospital itself, as suggested by the recently funded Rewire project., Objective: Goal of this work is to describe a novel low cost platform, based on video-games, targeted to neglect rehabilitation., Methods: The patient is guided to explore his neglected hemispace by a set of specifically designed games that ask him to reach targets, with an increasing level of difficulties. Visual and auditory cues helped the patient in the task and are progressively removed. A controlled randomization of scenarios, targets and distractors, a balanced reward system and music played in the background, all contribute to make rehabilitation more attractive, thus enabling intensive prolonged treatment., Results: Results from our first patient, who underwent rehabilitation for half an hour, for five days a week for one month, showed on one side a very positive attitude of the patient towards the platform for the whole period, on the other side a significant improvement was obtained. Importantly, this amelioration was confirmed at a follow up evaluation five months after the last rehabilitation session and generalized to everyday life activities., Conclusions: Such a system could well be integrated into a home based rehabilitation system.

Neglect and related phenomena, as anosognosia for hemiplegia and somatoparaphrenia, are often associated to right-hemisphere lesions. These deficits can be alleviated by caloric vestibular stimulation, but little is known about the efficacy of this physiological intervention on neglect following left-hemisphere lesions. Here we report the case of an ambidextrous left brain-damaged patient with severe right personal and extrapersonal neglect, anosognosia for right hemiplegia and somatoparaphrenia. These symptoms co-occurred with more typical manifestations of left-brain damage, such as aphasia and apraxia. Neurological examination revealed right hemiplegia, hemianesthesia and hemianopia. Visuo-spatial tests for personal and extrapersonal neglect, as well as an anosognosia questionnaire, were submitted before and after caloric vestibular stimulation. Results showed a dramatic improvement of anosognosia for hemiplegia and neglect; no change was observed for the remaining deficits. The results confirm the notion of the selectivity of vestibular stimulation for neglect and related disorders and extend this notion by showing that similar effects can be obtained after lesion of the left hemisphere, suggesting that similar mechanisms are responsible for left- and right-sided neglect. Such a peculiar association of language and visuo-spatial disorders jointly present after a left-sided lesion opens the question of the link between handedness and lateralization of cognitive functions.

We report the first case, to our knowledge, of successful return to work of a patient with alexia without agraphia. This case is also interesting as it is the first report of which we are aware of anosognosia for alexia without agraphia: the patient confabulated when asked to read English text, but immediately stated that he could not read Chinese text because he did not know that language. The selective nature of this confabulation would not be inconsistent with anosognosia being one of the brain's responses to absence of afferent information.

Unawareness of the diseases or its consequences can be a protective mechanism against a traumatic event. However, it can also result in dangerous behaviors and hamper the care management. Still not well understood, unawareness is a very complex and multidimensional construct involving neurological, neuropsychological, psychopathological and psychosocial dimensions. Sometimes considered to be a categorical phenomenon, unawareness is actually partial and dimensional. Nevertheless, no or only weak correlation are found between the results of various methods used to its assessment. We propose that the usual opposition between neurological (anosognosia) and psychopathological (denial) conceptions should be replaced by an integrative approach of the various dimensions involved in unawareness to allow a better adaptation of the care management.

This article reviews the history of sign language (SL) and the rationale for its use in children with profound auditory agnosia due to Landau-Kleffner syndrome (LKS), illustrated by studies of children and adults followed for many years and rare cases from the literature. The reasons that SL was successful and brought some children out of isolation while it could not be implemented in others are discussed. The nowadays earlier recognition and treatment of LKS and better awareness of the crucial need to maintain communication have certainly improved the outcome of affected children. Alternatives to oral language, even for less severe cases, are increasingly accepted. SL can be learned at different ages with a clear benefit, but the ambivalence of the patients and their families with the world and culture of the deaf may sometimes explain its refusal or limited acceptance. There are no data to support the fear that SL learning may delay or prevent oral language recovery in children with LKS. On the contrary, SL may even facilitate this recovery by stimulating functionally connected core language networks and by helping speech therapy and auditory training.

The number of older Americans afflicted by Alzheimer disease and related dementias will triple to 13 million persons by 2050, thus greatly increasing healthcare needs. An approach to this emerging crisis is the development and deployment of intelligent assistive technologies that compensate for the specific physical and cognitive deficits of older adults with dementia, and thereby also reduce caregiver burden. The authors conducted an extensive search of the computer science, engineering, and medical databases to review intelligent cognitive devices, physiologic and environmental sensors, and advanced integrated sensor networks that may find future applications in dementia care. Review of the extant literature reveals an overwhelming focus on the physical disability of younger persons with typically nonprogressive anoxic and traumatic brain injuries, with few clinical studies specifically involving persons with dementia. A discussion of the specific capabilities, strengths, and limitations of each technology is followed by an overview of research methodological challenges that must be addressed to achieve measurable progress to meet the healthcare needs of an aging America.

Background: Anosognosia in stroke patients showed a relevant detrimental effect on the rehabilitation course and patients' quality of life, especially in those with brain injury. Although a number of reliable scales for the assessment of anosognosia in stroke and traumatic brain injury have been developed, at present no single measure fully explores the multifaceted nature of the phenomenon., Method: A PubMed search with appropriate terms was carried out in order to critically review the issue., Results: The main dimensions to consider in the investigation of anosognosia in brain-injured patients are (a) awareness of deficit and related functional implications, (b) modality specificity, (c) causal attribution, (d) expectations of recovery, (e) implicit knowledge and (f) differential diagnosis with psychological denial. Time elapsed from stroke, aetiology, laterality, aphasia and clinical complications may influence all these characteristics and must be taken into consideration. Finally, an adequate association of the anosognosia evaluation with other neuropsychological and behavioural aspects is relevant for a modern holistic approach to the patient., Conclusions: This review is meant to stimulate the development of a new comprehensive assessment procedure for anosognosia in brain injury and particularly in stroke, in order to catch the multidimensionality of the phenomenon and to shape rehabilitation programmes suitable to the specific clinical features of every single patient.

Purpose of Review: The traditional focus of neurorehabilitaion has been on the patients' attention on their deficit, such that they should become aware of their problems and gain intentional control of compensatory strategies (descending approach). We review prism adaptation as one of the approaches that emphasize ascending rather than descending strategies to the rehabilitation of visuo-spatial disorders. The clinical outcome of prism adaptation highlights the need for a theoretical reconsideration of some previous stances to neurological rehabilitation., Recent Findings: Recent years have given rise to a growing body of experimental studies showing that the descending strategy is not always optimal, especially when higher-level cognition is affected by the patients' condition. Ascending approaches have, for example, used visuo-manual adaptation for the rehabilitation of visuo-spatial deficits. A simple task of pointing to visual targets while wearing prismatic goggles can produce remarkable improvements of various aspects of unilateral neglect., Summary: The neural mechanisms underpinning visuo-manual plasticity can be viewed as a powerful rehabilitation tool that produces straightforward effects not only on visual and motor parameters, but on visuo-spatial, attentional and higher cognitive neurological functions. The use of prism adaptation therapy in neglect and other visuo-spatial disorders has just started to reveal its potential, both at a practical and theoretical level.

It is now well established that the visual brain is divided into two visual streams, the ventral and the dorsal stream. Milner and Goodale have suggested that the ventral stream is dedicated for processing vision for perception and the dorsal stream vision for action [A.D. Milner & M.A. Goodale (1995) The Visual Brain in Action, Oxford University Press, Oxford]. However, it is possible that ongoing processes in the visuomotor stream will nevertheless have an effect on perceptual processes. This possibility was examined in the present study. We have examined the visual form-discrimination performance of the form-agnosic patient D.F. with and without a concurrent visuomotor task, and found that her performance was significantly improved in the former condition. This suggests that the visuomotor behaviour provides cues that enhance her ability to recognize the form of the target object. In control experiments we have ruled out proprioceptive and efferent cues, and therefore propose that D.F. can, to a significant degree, access the object's visuomotor representation in the dorsal stream. Moreover, we show that the grasping-induced perceptual improvement disappears if the target objects only differ with respect to their shape but not their width. This suggests that shape information per se is not used for this grasping task.

Agnosia, the impairment in object and face recognition despite intact vision and intelligence, is one of the most intriguing and debilitating neuropsychological deficits. The goal of this study was to determine whether S.M., an individual with longstanding visual agnosia and concomitant prosopagnosia, can be retrained to perform visual object recognition and, if so, what neural substrates mediate this reacquisition. Additionally, of interest is the extent to which training on one type of visual stimulus generalizes to other visual stimuli, as this informs our understanding of the organization of ventral visual cortex. Greebles were chosen as the stimuli for retraining given that, in neurologically normal individuals, these stimuli can engage the fusiform face area. Posttraining, S.M. showed significant improvement in recognizing Greebles, although he did not attain normal levels of performance. He was also able to recognize untrained Greebles and showed improvement in recognizing common objects. Surprisingly, his performance on face recognition, albeit poor initially, was even more impaired following training. A comparison of pre- and postintervention functional neuroimaging data mirrored the behavioral findings: Face-selective voxels in the fusiform gyrus prior to training were no longer so and were, in fact, more Greeble-selective. The findings indicate potential for experience-dependent dynamic reorganization in agnosia with the possibility that residual neural tissue, with limited capacity, will compete for representations.

Agnosia is a neurological recognition deficit that affects a single modality. Visual agnosias include pure object agnosia, prosopagnosia, akinetopsia, and pure alexia. Auditory agnosias include pure word deafness, phonagnosia, and pure sound agnosia. New neuroimaging tools have permitted scientists to better understand the loci of lesions that cause various agnosias and from that knowledge to develop theories about the processing networks that contribute to perception and recognition in each modality. These research data, in turn, inform the rehabilitation process. By utilizing current knowledge about neuroprocessing networks, clinical professionals can differentially diagnose agnosias from aphasia and other cognitive deficits. Practical approaches to treatment of agnosia will follow once the diagnosis is established.

Purpose: To show the recovery process for different forms of unilateral neglect (UN)--including personal neglect and neglect of far space--in relationship to impairment, disability, cognition and mood., Method: Patients were tested at 2-4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale., Results: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke., Conclusions: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.

A 10-year-old male was referred with difficulties at school. He had particular difficulty with reading long words, following the sequence of text down a page, writing words in the correct order, writing words in line, and copying from the blackboard. He had a history of infective endocarditis complicated by intracerebral haemorrhage at the age of three years. Detailed history taking revealed symptoms typical of 'dorsal stream' pathology, namely a deficit of 'vision for action'. This included a spatial disorder of attention (simultanagnosia), defective hand and foot movements under visual control (optic ataxia), and acquired oculomotor apraxia which are consistent with Balint's syndrome. Strategies were suggested for coping with the symptoms and one year later a distinct improvement in adapting to the disability was found.

The aim of the study was to investigate whether low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere can ameliorate visuospatial neglect. We treated three right brain damaged patients with left neglect. 900 pulses (1 Hz frequency) were given over left posterior parietal cortex every other day for 2 weeks. Patients performed a computerized task requiring length judgement of prebisected lines, tachistoscopically presented for 150 ms. With respect to rTMS the task was given 15 days before, at the beginning, at the end and 15 days after. At these times patients performed also line bisection and clock drawing tasks. rTMS induced a significant improvement of visuo-spatial performance that remained quite unchanged 15 days after. Patients performance at Time 3 and 4 improved also as concerns line bisection and clock drawing tasks., (Copyright 2002 Elsevier Science Ireland Ltd.)

It has been shown that unilateral left neglect can be significantly improved for a short time after a short period of adaptation to a prismatic shift of the visual field to the right. In neuropsychological studies, however, there is no evidence demonstrating long-lasting effects following treatment by prism adaptation (PA). The first aim of the present study was to find out whether the short-term amelioration found after prismatic adaptation could be converted into long-term therapeutic improvement. Secondly, we investigated whether the improvement of neglect in standard tests could be generalized to ecological visuospatial tests. Thirdly, the effects of prism adaptation on different spatial domains (far, near and personal space) were evaluated. Fourthly, the influence of PA on high-order visuospatial functions, such as spatial representation, and on a low-order factor, i.e. sensory--motor bias, was investigated. Finally, we investigated the possible correlation between neglect amelioration, the adaptation effect and the visuomotor after-effect, as assessed by a pointing task during and after PA. Seven patients with right hemisphere lesion and left visuospatial neglect were treated with prismatic lenses in twice-daily sessions over a period of 2 weeks. In each training session, patients were required to perform a pointing task wearing base-left wedge prisms inducing a shift of the visual field to the right by 10. The presence of visual neglect and the duration of the amelioration achieved were assessed before the treatment and 2 days, 1 week and 5 weeks after treatment by using a standardized battery that included a series of behavioural and ecological visuospatial tests. Six control, untreated patients, matched to the experimental group for gravity and duration of illness, were submitted to the same tests at the same intervals as the experimental patients. The results showed an improvement in the experimental patients' performance after PA, which was maintained during the 5-week period after treatment. The amelioration of neglect was found in standard as well as in behavioural tests and in all spatial domains. In contrast, control patients did not show any improvement in neglect. The amelioration of neglect occurred only in patients who showed the adaptation effect and the after-effect in the pointing task. Neglect amelioration did not occur in one patient who did not show the adaptation effect and had an unstable after-effect. In conclusion, these findings show that prism adaptation is a productive way of achieving long-lasting improvements in neglect treatment.

Objectives: The aim of this study was to explore predictive factors of the length of hospital stay at the acute stage of right hemisphere stroke. Special attention was paid to the possible role of anosognosia for hemiparesis and anosognosia for neglect in this prediction., Patients and Methods: A consecutive series of 57 patients having their first right hemisphere stroke were examined at the acute phase. Forty-nine patients were included in this study and followed-up for 12 months. The examinations were conducted within 2 weeks of onset. The outcome variable was the time (days) from stroke to discharge to home. The predictors were age, gender, size of infarct, neglect, hemiparesis, verbal memory, unawareness of illness, anosognosia for neglect, anosognosia for hemiparesis and presence of a relative at home., Results: Hemiparesis and unawareness of illness lengthened the duration of the hospital stay, the presence of a relative reduced it. Neglect was the best single predictor of poor outcome, but it had no additional value in the combination of the three predictors above. Neither anosognosia for hemiparesis nor anosognosia for neglect were important predictors., Conclusion: Hemiparesis, unawareness of illness and presence of a relative at home were the best predictors of the time from right hemisphere stroke to discharge to home.

Objective: Patients with right hemisphere syndrome may be labeled as "gauche" by the rehabilitation staff. This term corresponds to a variety of oddities in behavior or discourse. The aim of this study is to understand the coherence of these oddities with the classical elements of right hemisphere syndrome., Material: In this article, we present a detailed study of the discourse and the relation with others of a patient with severe left hemineglect, who was followed up for twelve months and did not exhibited any significant change in his symptomatology., Methods: This study relies on the data from neuropsychological examination, on notes written after rehabilitation session by the therapists and on data from weekly non-directive interviews., Results: This follow-up revealed disturbances of time sense, reduplication for places, misidentification of therapists, pseudo hallucinations, and showed that the transferential relation was "floating". The non-directive interviews permitted the patient to express his own interpretation of his troubles. He described them in terms of gaps in his body "carapace" and disorganization of the oral drive., Conclusion: We propose to consider the symptomatology of this patient in relation with the subjective effects of the breaking up of his body image and the concomitant intrusion of the oral object (in the psychoanalytic sense of this term) in his psychic reality.

Objective: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke., Design: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up., Setting: Urban, acute inpatient rehabilitation facility., Patients: Fifty-two consecutive admissions of adult right-handed patients with a single, right hemispheric stroke, confirmed by computed tomography scan., Main Outcome Measures: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale(R)., Results: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing., Conclusions: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors.

Objective: The purpose of this study was to investigate anosognosia for hemiplegia (AHP) in the rehabilitation phase after onset of stroke., Methods: Forty-six hemiplegic stroke patients, 29 with right hemisphere damage (RHD) and 17 with left hemisphere damage (LHD) were evaluated approximately 1 month after onset of stroke. Anosognosia was evaluated with an implicit measure designed to assess anosognosic behaviors (choosing between unimanual and bimanual tasks), in addition to a traditional explicit verbal measure., Results: AHP was found in 28% of the RHD and 24% of the LHD group. The majority of patients with AHP in the RHD group had large lesions involving the frontal, parietal, or temporal lobes and had coexisting sensory deficits and unilateral spatial neglect, whereas the LHD patients with AHP had predominantly small subcortical lesions and no sensory or attentional deficits. The functional outcomes of AHP patients in both hemisphere groups revealed their inability to retain safety measures at discharge from rehabilitation (p < 0.036) and their need for assistance in basic and instrumental activities of daily living at follow-up., Conclusions: AHP presents a significant risk for negative functional outcome in stroke rehabilitation. The underlying mechanisms of AHP may be different for left and right hemisphere patients, therefore requiring different intervention approaches.

Although special education under its diverse forms is consensually recognized as the privileged area of pervasive developmental delay, there is little studies on re-education intervention for autistic persons of normal intelligence. This article presents a psychoeducative intervention with a three year old autistic boy in a pedopsychiatric day care centre. The interest of this observation is double. On the one hand, this child, aside from autism, is carrier of an exceptional ailment: visual agnosia. On the other hand, his "restrictive autistic interest", namely perceptive attraction and his questioning of a particular class of objects or a particular parameter of these objects were used as lever to bring him to improve his capacities of communication and social interactions.

Balint's syndrome is characterized by faulty visual scanning, dysmetria secondary to a visual perceptual deficit, and an inability to recognize more than one object at a time. We report three cases of Balint's syndrome and the individualized rehabilitation they received. One patient developed symptoms of Balint's syndrome caused by bilateral occipitoparietal infarcts. In the two other cases the symptoms arose secondary to posterior cortical atrophy, a slowly progressive dementia with alexia and agraphia. All three patients initially responded to a multicontext treatment approach with intensive verbal cueing and organizational strategies with subsequent improvement in visual recognition, reaching and scanning. Continued deterioration from posterior cortical atrophy or a second infarction resulted in worsening dementia in two patients. Cognitive remediation was required as visual perceptual rehabilitation became ineffective. Clinicians should be familiar with Balint's syndrome and its various aetiologies. Lack of awareness of this syndrome may lead to a misdiagnosis and resulting inappropriate or inadequate treatment.

The indications for a specific rehabilitation training programme for elderly stroke patients are discussed. Special symptomatology, such as hemi-anesthesia as a result of a damaged perceptual process, apraxia including apraxia of dressing, communication disorders and affective disorders are presented. The measures to be taken for effective rehabilitation in hospital, in an institution for the elderly or in the home care situation are indicated. In addition, the physician has to have marked ability for empathic comportment.

The incapacity to focus attention in the direction contralateral to cerebral lesion (hemi-inattention) significantly affects the patient's day-to-day behaviour. Recent studies have demonstrated that although spontaneous recovery may occur during the weeks immediately after ictus, a significant number of patients continue to suffer from this disorder in a chronic manner. The paper describes a rehabilitation programme which has proved to be selectively effective in reducing hemi-inattention in the majority of patients persistently affected by the disorder. The results indicate a) that improvements are not confined to laboratory situations but extend to the patient's day-to-day behaviour in general, and b) that they are still present at a follow-up carried out several months after the end of therapy. Given the dramatic impact of this disorder on adult social relations it is important that rehabilitation centres dedicate time to this particular aspect.

Visuoperceptual deficits are common sequelae of damage to either hemisphere of the brain, but are typically more pronounced following injuries involving the right cerebral hemisphere. Common visuoperceptual disorders include visual field cuts, hemi-inattention and hemi-spatial neglect, hemi-perceptual deficits, and gaze and visual pursuit disturbances. A number of behavioral interventions have been developed to teach patients to compensate for acquired visual deficits. Studies addressing assessment and treatment issues in this area are reviewed, and future directions for research are outlined.