5625Journal of Neurology, Neurosurgery, and Psychiatry 1992;55:562-565

Directional hypokinesia in spatial hemineglect: a
case study
G Bottini, R Sterzi, G Vallar

Abstract
A patient with an ischaemic lesion involving the right frontal lobe and basal ganglia
showed left spatial hemineglect in visuomotor exploratory tasks, requiring the use
of the right unaffected hand. Her performance was, however, entirely preserved, with no evidence of neglect, when
she was required to identify targets among
distractors in both the left and right halves
of space, and in the Wundt-Jastrow illusion test. The latter tasks do not require
any arm movement in extrapersonal
space. In this patient spatial hemineglect
may be explained in terms of defective
organisation of movements towards the
left half-space (directional hypokinesia).
The frontal lesion of the patient may be
the neural correlate of this selective disorder. This pattern of impairment may be
contrasted with the typical deficit found in
patients with right brain damage with
perceptual neglect. One case had a defective performance both in visuomotor and
in purely perceptual tasks.
Patients with spatial hemineglect typically fail
to explore the half-space contralateral to the

side of the cerebral lesion. This exploratory
deficit may be due to their inability to plan and
initiate movements towards the neglected halfspace, even when the unaffected ipsilateral
hand is used. This premotor deficit (directional
hypokinesia) may be distinguished from the
perceptual aspects of spatial hemineglect.1-3
We report a patient with right brain damage
with a frontal lesion, who showed a dissociation between hypokinetic and perceptual
aspects of spatial hemineglect. This pattern of
performance is contrasted with the behaviour
of a second patient with a temporo-parietal
lesion and a perceptual visuo-spatial neglect.
Divisione di
Neurologia, Ospedale
di Niguarda, Milan
G Bottini
R Sterzi
Istituto di Clinica

Neurologica,
UniversitA di Milano,
Milan, Italy
G Vallar
Correspondence to:

Dr Vailar, Istituto di Clinica
Neurologica, Universita di
Milano, Via F Sforza 35,
20122, Milan, Italy
Received 18 March 1991
and in revised form
12 September 1991.
Accepted 28 October 1991

Case Reports
Case 1

A 49 year old right handed housekeeper with
five years of schooling was admitted to hospital
for suspected pulmonary thromboembolism
and right inferior limb thrombophlebitis. She
had had no previous psychiatic or neurological
disease. On admission the patient was treated
with heparin, amoxicillin and ranitidine. Two
days later she suddenly developed a left hemiplegia. A few minutes after the onset of
symptoms the patient was alert and cooperative, with a steady rightward deviation of the

head and eyes. Neurological examination
revealed a left hypotonic hemiplegia with
enhanced left tendon reflexes and a left Babinski sign, and a severe left hypoaesthesia for
touch, pinprick and proprioceptive stimulations. On confrontation, the patient could
accurately detect single left- and right-sided
visual stimuli, but showed left extinction on
bilateral simultaneous stimulation. The patient
was aware of her motor deficits and did not
show personal neglect for her left limbs. Blood
pressure was 130/180 mm Hg, pulse 80/min,
and temperature 36°C. Respiration was regular
at a normal rate. Routine blood and urine
examination gave normal results. ECG, chest
x-ray and perfusion lung scan confirmed pulmonary embolism. A CT performed a week
after stroke onset, showed a right corticosubcortical hypodense area involving the dorso-lateral frontal regions and the basal ganglia,
and extending posteriorly into the anterior
parietal cortex. Two weeks later a second CT
revealed haemorrhagic infarction (fig 1).

Neuropsychological assessment
Baseline tests. The patient was examined two
weeks after the onset of stroke. She had a left
hemiplegia, hypoaesthesia and visual extinction, while she recovered from the left-sided
conjugate gaze paresis. The patient showed a
left visuo-spatial neglect in a number of
exploratory tasks, in which a sheet of paper was
located in front of her, with the centre of the
sheet on the midsagittal plane of her trunk. For
these tasks she received instructions to search
and cross out targets (interspersed among
distractors) located in the left and in the right
halves of a sheet using her right unaffected
hand. In the Bells Test4 the target stimuli were
35 black outlines of bells (17 left-sided, one
central, 17 right-sided). Each bell was 7 mm
high and 5 mm wide. The 280 distractors were
outlines of common objects (such as, a fish, a
house, a horse) comparable in size to the bells.
The targets and the distractors, printed on a
29 x 21 cm sheet, were distributed in seven
columns; each column included five targets
and 40 distractors. The patient crossed out
only one out of 17 left sided targets (bells),
while her performance was errorless in the
right half of the sheet (17 out of 17). In the
Letter Cancellation Task5 312 letters 4 mm
high (104 target letters "H" and 208 distractor
letters) were printed in six rows on a
41-4 x 29*5 cm sheet. The patient crossed out
only 35/104 "H" target letters. Her omissions
included all 51 left sided targets and 18 "H"
letters located in the left portion of the right

Directional hypokinesia in spatial hemineglect: a case study

563

Figure CT showing a
cortico-subcortical lesion of
the right pre-motor and
sensory-motor cortex, the
superior and middle parts
of the temporal lobe,
marginally involving the
posteror parietal regions.
The right periventricular
white matter, the lenticular
and the caudate nuclei, the
anterior limb of the
internal capsule and other
structures (external
capsule, claustrum, insula)
are also involved.

half of the sheet. During the execution of this
task we noted that she looked at the left half of
the sheet, saying that she saw a great deal of
'Hs" on the left and that she was well able to
identify them among other letters. The patient
was nevertheless unable to cross out such leftsided "Hs", or even to point to them with her
right hand. This clinical observation raised the
possibility that her left neglect was mainly due
to directional hypokinesia, and therefore confined to tasks requiring the motor exploration
by the unaffected arm of the half-space contralateral to the lesion.

from the target. As in the previous tasks she
used the right unaffected hand. In the Identification condition the patient's task was to say
whether or not the stimulus indicated by the
examiner was a "bell" or an "H". In both
conditions the examiner (GB) sat in front of
the patient. Before pointing to each stimulus,
the examiner verbally warned the patient,
without mentioning whether the indicated
stimulus would have been left or right sided. In
both conditions the centre of the sheet was
located on the midsagittal plane of the
patient's trunk. Two blocks of trials were given
for each condition, using an ABBA design. The
Crossing Out vs identification of left-sided stimuli crossing out condition was tested first. In the
Prompted by this clinical observation, we Bells Test each block comprised 40 stimuli (20
devised two conditions of the Bells Test4 and of left sided and 20 right sided, 20 bells and 20
the Letter Cancellation Test,5 to explore the different objects) in a random fixed order. In
role of directional hypokinesia in producing the Letter Cancellation Test, each block
left hemineglect in the patient. On the Bells included 104 stimuli (52 left sided and 52 right
Test4 sheet six bells were added, one stimulus sided, 52 "H" and 52 different letters) in a
in each column, with the exception of the random fixed order.
central one. This version of the task sheet
In the Identification condition the patient
therefore comprised 40 target bells, 20 right was fully accurate in discriminating target and
sided and 20 left sided. The sheet of the Letter non-target stimuli: even though she had
Cancellation Test was identical to the original received instructions to say whether each item
version.5 In the Crossing Out condition the pointed out by the examiner was or was not the
patient received instructions to cross out with a target, she also spontaneously named each
pencil the stimulus (a "bell" or an "H") stimulus, with complete accuracy. In the
indicated by the examiner using a pointer, Crossing Out condition the patient accurately
abstaining from crossing out stimuli different complied with the directions and never crossed

564

Bottini, Sterzi, Vallar

Table I Case 1. Number of left sided correct responses (percentages in brackets) in the
Identfication and Crossing Out conditions of the Bells and Letter Tests. The scores refer to
target ("Bells" and "Hs") stimuli
Condition

Identification

Crossing out

Block I

Block 2

Total

Block I

Block 2

Total

Bells

10/10

10/10

4/10

6/10

Letter

26/26

26/26

20/20
(100%)
52/52

22/26

18/26

10/20
(50%)
40/52

(100%)

(77%)

Illusion Test may therefore be taken as an
indication that perceptual neglect is present.
The patient was not expected to be defective in
this task, as the previous studies had shown
neglect only when the paradigm required the
motor exploration of the left extrapersonal
space, contralateral to the lesion. The patient
was instructed to say whether the upper or the
lower fan was longer. Forty stimuli (20 with a
right sided and 20 with a left sided illusory
effect) were given in a random fixed order. The

patient's performance was errorless, scoring 40
out non-target stimuli.

For. the right sided
stimuli her performance was errorless in both
conditions. Table

shows the patient's per-

formance for left sided targets: it is apparent
that she was selectively impaired in the Crossing Out condition as compared with the
Identification condition, both in the Bells Test
(x2 = 13-33, df = 1, p < 0 001) a"nd in the
Letter Cancellation Test (X2 = 13*57, df = 1,
p < 0'001). The dissociation between defective Crossing Out and preserved identification
was clearly illustrated by the patient's. behaviour when making a left sided omission error in
the. Crossing Out condition. She correctly
named the target but did not initiate any
movement or the motor action was terminated
shortly after the start, before crossing the
midline. This behaviour contrasts with her
errorless Crossing Out of right sided stimuli.
On specific questioning the patient denied any
abnormality in her performance. The patient's
impairment in the Crossing Out condition was
less severe than in the standard exploratory
tasks reported above. In the Crossing Out
condition she was, however, given a number of
cues (each stimulus was indicated by the
examiner after a verbal warning). These are
lacking in the standard versions of the tasks,4'5
in which patients are simply required to search
for targets among distractors, without any
further prompting.

Wundt-Jastrow Illusion Test
These findings suggest that the patient's spatial
hemineglect may be traced back to her inability
to initiate and execute movements towards the
left half-space. To gather additional evidence
corroborating this interpretation our patient
was given the Wundt-Jastrow Illusion Test
devised by Massironi et al6 to detect spatial
hemineglect. In this test each stimulus comprises two black fans, identical in area but
different in shape, whereby one appears longer
than the other, even though they are equal in
length. In the version by Massironi et al the
illusory effect is produced either by the left or
by the right extremities of the fans. Patients
with left spatial hemineglect make errors (that
is, they fail to show the normal illusory effect)
when the illusion arises in the left halves of the
fans, while their performance is normal (that
is, they show the illusory effect) when the
illusion is produced by the right halves of the
fans. The test requires only a perceptual
judgement upon the stimulus, without any
motor exploration of the extrapersonal space.
Defective performance in the Wundt-Jastrow

out of 40 correct answers,

illusory effect.

with a normal

CONTROL PATIENT

Case 2
Patients showing perceptual left neglect in the
Wundt-Jastrow IllusionTest are typically defective also in visuomotor tasks requiring the
exploration of the left half-space.6 7 This suggests that a defective perceptual representation
of the extrapersonal space contralateral to the
lesion may produce neglect with both verbal
and motor responses. Patients with perceptual
neglect may therefore show a comparable
impairment in the identification and Crossing
Out conditions of the present task. We assessed
this prediction in a patient with right brain
damage with a severe perceptual neglect, as
assessed by the Wundt-Jastrow Illusion Test.
An 80 year old right handed woman with five
years of schooling was admitted to hospital due
to sudden onset of left hemiparesis. She had
not had any previous psychiatric or neurological disease. She was alert and cooperative,
with a steady rightward deviation of head and
gaze. A neurological examination revealed a
left hemiparesis, more severe in the upper
limb, and a left Babinski sign. No somatosensory deficits for touch, pinprick and proprioceptive stimulations were found. On confrontation, a left homonymous hemianopia was
shown. The patient denied her motor and
visual field deficits. Blood pressure was 160/80
mm Hg, pulse 80/min, temperature 368'GC.
Routine blood and urine examination, chest
x ray and ECG were normal. CT performed
one week after the onset of the neurological
deficit showed a tumour which involved the
right subcortical temporo-parietal region,
compressed the right lateral ventricle and was
surrounded by oedema. Intravenous injection
of contrast medium produced a homogeneous
enhancement in the tumour mass.

Neuropsychological assessment
The patient was examined 10 days after the
onset of the neurological deficits. She had a left
hemiparesis and a left homonymous hemianopia, and had recovered from the left sided
conjugate gaze paresis. The patient showed a
severe perceptual neglect on the Wundt-

Jastrow Illusion Test. The patient gave only one
out of 20 correct answers when the illusion was
left sided. By contrast, her performance was
virtually errorless (19 out of 20 correct responses) when the illusion was right sided. In the
Bells Test4 she failed to cross out all 17 left
sided targets and 12 out of 17 right sided

565

Directional hypokinesia in spatial hemineglect: a case study
Table 2 Case 2-control patient. For conditions and scores see table 1.
Condition
Identzfication
Bells
Letter

Crossing out

Block 1

Block 2

Total

Block I

Block 2

5/10

5/10

10/20

6/10

5/10

16/26

17/26

(50%)

33/52
(63%)

15/26

16/26

Total
11/20

(55%)

31/52
(60%)

targets; these right sided omissions involved
the left part of the right half of the sheet. She
showed a similar pattern of impairment in the

Letter Cancellation Task,5 in which she failed
to cross out all 51 left sided letters and 32 out

of 53 right sided letters. The patient's performance in the Identification and Crossing Out
conditions of the Bells and Letter Tests is
shown in table 2. The patient's errors were
confined to the left half of the sheet; in the case
of right sided targets her performance was
entirely correct. Unlike case 1 she showed a
comparable impairment in the two conditions
of the task. As previously found in case 1, the
overall performance of our control patient was
better in the Identification and Crossing Out
conditions, compared with the standard versions of the tasks.4'

Discussion
Case 1 shows a dissociation in the manifestations of left visuospatial hemineglect. A
defective exploration of extrapersonal space is
present only when the task requires the execution of movements in the left half-space, by
making use of the right unaffected arm. The
patient is entirely unimpaired in visuospatial
tasks, such as the identification of targets and
the Wundt-Jastrow Illusion Test, which involve
only a perceptual analysis of the left half-space.
By contrast, the control patient, case 2, who
had a severe perceptual neglect, assessed by the
Wundt-Jastrow Illusion Test, has a defective
performance in all exploratory tasks, without
any dissociation between motor vs identification response modalities. In the present experimental paradigm, a disordered perceptual representation of the left extrapersonal space may
affect the programming of all types of responses to left sided targets, both when output is a
lateralised motor response, and when the
identification of the stimulus is required.
The selective impairment of case 1 in the
execution of arm movements towards the left
half-space can be explained in terms of neither
primary motor deficits nor motor neglect.8 She
used her right unaffected arm and her per-

formance was errorless when the target was
located in the rightthalf-space. The failure to
plan and initiate movements towards the halfspace contralateral to the lesion is a component
of spatial hemineglect.1-3 In most published
cases both perceptual and premotor deficits
contribute to producing spatial hemineglect,3
while in a few patients directional hypokinesia
has been shown to be the main factor.2 In case
1 the exploratory deficit can be entirely attributed to directional hypokinesia, as her performance towards the left half-space is entirely
preserved when arm movements are not
required. The selectivity of the patient's behavioural impairment has an anatomical counterpart. The CT showed a lesion involving the
right frontal lobe and basal ganglia, with
comparatively minor damage of the posterior
parietal regions. Conversely, the control
patient (case 2), who showed a perceptual
neglect with no differences related to output
modality, had a temporo-parietal lesion. Suggestions have been made,9 10 and some empirical evidence exists in humans,2 3 11 that directional hypokinesia may be produced by
anterior cortical and subcortical lesions, while
the perceptual aspects of neglect are more
frequently associated with posterior (parietal)
lesions. In the present case, the anterior
localisation of the ischaemic lesion assessed by
CT may account for the unusually clear-cut
dissociation between premotor and perceptual
aspects of neglect.
This study was supported in part by CNR and MPI grants to
GV

1 Watson RT, Miller BD, Heilman KM. Nonsensory neglect.
Ann Neurol 1978;3:505-8.
2 Coslett HB, Bowers D, Fitzpatrick E, Haws B, Heilman
KM. Directional hypokinesia and hemispatial inattention
in neglect. Brain 1990;113:475-86.
3 Bisiach E, Geminiani G, Berti A, Rusconi ML. Perceptual
and premotor factors of unilateral neglect. Neurology
1990;40: 1278-81.
4 Gauthier L, Dehaut F, Joanette Y The bells test: a
quantitative and qualitative test for visual neglect. Int
Clin Neuropsychol 1989;11:49-54.
5 Diller L,Weinberg J. Hemi-Inattention in rehabilitation. The
evolution of a rational remediation program. In: Weinstein
EA, Friedland RP, eds. Hemi-inattention and hemisphere
specialization. Advances in neurology, Vol 18. New York:
Raven Press, 1977:62-82.
6 Massironi M, Antonucci G, Pizzamiglio L, Vitale MV,
Zoccolotti P. The Wundt-Jastrow illusion in the study of
spatial hemi-inattention. Neuropsychologia 1988;26:
161-6.
7 Pizzamiglio L, Cappa S, Vallar G, Zoccolotti P, Bottini G,
Ciurli P, et al. Visual neglect for far and near extrapersonal
space in humans. Cortex 1989;25:471-7.
8 Critchley M. The parietal lobes. New York: Hafner Press,
1953.
9 Heilman KM, Watson RT, Valenstein E. Neglect and related
disorders. In: Heilman KM, Valenstein E, eds. Clinical
Neuropsychology, 2nd ed. Oxford: Oxford University
Press, 1985:243-93.
10 Mesulam M-M. A cortical network for directed attention
and unilateral neglect. Ann Neurol 1981;11:309-25.
11 Tegner R, Levander M. Through a looking glass. A new
technique to demonstrate directional hypokinesia in
unilateral neglect. Brain 1991 ;l 14:1943-5.