Tohoku J. Exp. Med., 1990, 161, Suppl., Right Unilateral Left Brain-Damaged 131-138 Spatial Neglect of the Patients MASAAKINAGAFUCHI Division of Audiology and Speech Sciences, Faculty Education, Tohoku University, Sendai 980 NAGAFUCHI, Patients. spatial neglect suffering from consisted of a the deprivation the unilateral 1) it in in homonymous figure drawing, is suggested addition drawing It then he if clinicians on USN left ; left a left dial examine brain-damaged spatial to 2) right as neglect one a box, plate attention left of the right carefully the patients, neglect test battery 2) bisecting 5) copying and brain-damaged his cases.•\unilateral brain-damage of of hemiplegia, apt A into that, the unilateral patients hemiplegia. guessed be Brain-Damaged brain-damaged function, with Left Right was would compared aphasia putting that hemiplegia. that to blocks mental and left ; impaired prominent three and 1) the 131-138 hemianopsia 4) and of Suppl., on revealed right hand, so some praxis Neglect 161, investigated generally 3) Spatial 1990, hemianopsia left not function greater 3) homonymous However, was investigation and was Unilateral Med., right line, from toward Right Exp. visuo-constructive The resulted USN J. (USN) horizontal drawing. right M. Tohoku of ; visual patients unilateral sensory for a patient would be right side. with attracted hemispheric Right lesion. visuo-constructive right USN spatial appears agnosia hemisphere The syndrome of unilateral spatial neglect (USN) consists of a tendency to neglect one half of extrapersonal space in such tasks as drawing and reading which require a symmetrical exploration of space. Hecaen (1962) reported that in his series of 59 patients with USN only one case was suffering from a left hemispheric lesion, and emphasized the relationship between USN and lesions of the right hemisphere. Gainotti (1968) attempted to study USN by means of a battery of tests simple enough to be administered to all patients, including severe aphasics. His results showed that USN is not only significantly more frequent, but also definitely more severe in patients suffering from lesions of the right hemisphere. Costa et al. (1969) found that the incidence of USN is greater in patients with right hemispheric lesions, but that severity and patterns of deficit are alike in both right and left lesioned groups. According to Benson (1979), full anosognosia is considerably less common following left hemisphere than right hemisphere damage, possibly because the severely aphasic patient cannot readily express denial of bodily problems. Left USN is common for right brain-damaged patients, as many investigators have reported. However, there are some cases of left brain damage showing right 131 132 M. Nagafuchi USN. The purpose USN of the left cerebral of the brain present damage study and is aimed to discuss to show them three in relation cases with right to laterality of lesions. CASE REPORTS Cases were three left brain-damaged patients with right hemiplegia and right homonymous hemianopsia. All cases were examined with the visuo-constructive test. The test consisted of 5 parts ; 1) block and box test : putting blocks into a box, 2) bisecting a line : marking the middle of a horizontal line, 3) figure drawing, 4) drawing of a dial plate and 5) copying a drawing. Case 1. The patient was a 37 year-old male who suffered from left brain damage due to a head injury occurring two years ago (Fig. 1). He suffered from a mild amnesic aphasia, but he Fig. 1. Case 1 has the left head injury. Fig. 2. The patient drew a dial plate without a model using his left hand. Right Unilateral Spatial Neglect 133 could understand what to do at the test and to perform it with the left hand. Sometimes mirror writing appeared. Right homonymous hemianopsia revealed at the visual field test, but he had no trouble in daily life. On the visuo-constructive test, he did not show any abnormality at the block and box test, bisection of a line and figure drawing. However, he showed an interesting abnormality at the drawing of a dial plate. When he was asked to draw a dial plate without a model, he neglected the right side and there were some mirror writings, 6 and 9, and a miss-spelling of 4. After finishing the drawing, he was unaware of the right side neglect and mirror writing until the mistakes were pointed out (Fig. 2). Next, the examiner showed him the dial plate as a model and asked him to copy it. Then, he did not neglect the right side. But some mirror writing and miss-spelling still remained uncorrected (Fig. 3). Fig. 3. Fig. 4. The patient CT of case 2 showed copyed a low density the model area of a dial plate. in the left front-temporal region. 134 M. Nagafuchi His right USN appeared when he drew some pictures on command without a model. When a model was shown to him, he attended to the right side as well as the left side. At all events, his right USN was not consistent. Case 2. The patient was a 68 year-old male who suffered from a stroke occurring six months ago. CT showed a low density area in the anterior part of the left hemisphere. He suffered from motor aphasia, but his auditory comprehension was good (Fig. 4). In daily life, he used to neglect the right side often, especially during a meal. Left hand use was so clumsy that he was very slow in hand writing. The figure drawing (Fig. 5) took about 4 min and the copying (Fig. 6) took about 10 min. As to figure drawing, he neglected an eyebrow and an ear on the right side. It was an incomplete USN. On the contrary, a complete right USN was revealed on copying. He succeeded on the block and box test and in bisecting the line. He often tried to look at the right side during the test. When the test was simple, it was easy for him to check the right side. But at the complex test, he tended to neglect the right side. Fig. 5. The patient drew Fig. 6. The patient a face without copyed a model the model with using his left hand. his left hand. Right Unilateral Spatial Neglect 135 Case 3. The patient was a 61 year-old female. She had suffered from a stroke and mild dementia remained as sequela. CT showed a low density area in the left hemisphere (Fig. 7). She was in a state of mental deterioration one month after the stroke and the right USN was pronounced. But three months after the stroke, she began to attend to the right side. This patient was shown as a case of improvement in the right USN. As to bisection of a horizontal line, she put the bisection point at the extreme left-hand side of the line one month after the stroke. However, three months after the stroke, she put the mark further towards the right side (Fig. 8). Fig. 9 is her figure drawing. One month after the stroke, she could draw only some small circles in the left-hand side of the large circle. Three months after the stroke, she could draw a face symmetrically (Fig. 9). At first her right USN was pronounced, and then she consciously tried to attend to the right side. Six months after the stroke, her right USN had nearly disappeared. Fig. 7. CT of case 3 showed a low density area in the left putaminal Fig. 8. The patient put the mark as the middle of the line. stroke, (2) 3 months after stroke. region. (1) 1 month after 136 M. Nagafuchi Fig. 9. The patient drew a face using her left hand. DISCUSSION The data of spatial neglect similar disturbances less the severe. found clinical relationships, whereas the The manifestation apraxia has Table is the left the the latter tend of •gperceptive•h disability, conceived the that as of incidence the inablity coherent but they the in respect is greater of When are definitely of and to reproduce clear-cut left simplified brainspatial versions been regarded left-sided a •gmotor-executive•h USN unilateral right has whereas that damage. existence of an impairment reflecting incidence the give state brain disability show to constructive been stressed drawing chiefly to right patients, have former us of brain-damaged right-sided 1 shows agreed in investigators since allow characteristic between patients, model. literature a syndrome are differences damaged it is Many qualitative and neuropsychological (USN) of as a constructional disorder. the following side right of the brain brain damage damage (Table 1). Kinsbourne think in left hemisphere right words, and of Arena lesions differences of these phenomena communicate with cases. It minimizes the is damaged, left clinically hemisphere a pathologically activity most when Thus, right explained verbally in hemisphere damaged. with (1970) neglect is resultant hemispheric cerebrum.•h residual Gainotti the right and were found between (1978) left imbalance studied right more and frequent of the constructional cerebral and hemisphere. left This between imbalance it is the : •gPatients clinician. amplifies because induced the the follows imbalance observed lesions, and as brain-damaged the form usually activates left and with the right and substantive interaction taken apraxia patients the is between by concurrent resulting According the the from to with them the , respect no Right Unilateral TABLE 1. to incidence These and findings perceptual recent attitude about right their hemiplegics aphasics right the paper (1979) side, are if must aphasia. That examined they would have Battersby in all also As to the the attention the right side. case of patients from left a patient is Conclusively, three sensory deprivation left-hand paid to stimuli on the right, and as the dementia that the parietal other who do not have the left brain-damaged 1) mental factors of ; such as is no right somato-sensory only . If carefully, decreased sensory present USN was prominent study of , at USN. subcortical present investiga- the why the hemianopsia patients and by right he is right CT. hemiplegia apt right-hand , to neglect side in and right was derived from 2) unilateral dementia, or for or and of severe critical ascertained is a are hemianopsia neglect deficit from left-sided were or aphasia the In That deterioration suffer In lobe hemianopsia the stronger unilateral combination anterior, hand. of improved. homonymous left there right the lesions on side patients from frequently. right homonymous hand, her persons expected. stems reported less for function. stroke far usually such all left much patients patients USN but significant than mental right left if of 1979). a on cases following the the then such that right toward on function more (Benson write brain-damaged subcortical with USN following the anterior attracted On on of suffered cases and and to USN but percent , severe number or to reported, paresis, the draw in disease their deny to (1973) (1983), or ignore gradually of been three hemiplegia and Heilman the half to impaired Beauvois defect to has tion, milder and of over tends examine due abnormal patient suggested generally damage) an 81 clinicians (1956) brain However, attitude, a evidence had to visuo-constructive dementia became hemianopic lesions al. (right the Left USN some : •gIf attention right with from it climbs suspected.•h paresis is lesion. hemiplegia abnormal follows is left admit group of demonstrated right either an attention most with 1978). a tendency get found Lhermitte his side cases with to disabilities. disturbances hemispheric hold as is to et 3 suffered According in the patients but aphasic to is why had first, (Cutting close be they case paralysis there needed inattention input percent those visuo-perceptive visuo-constructive stroke 87 137 neglect and the of too spatial for of suggested if only, stimuli acute in patients Benson 100 over considered brain-damaged basis percent were were his of 24 toward the independently phenomena only Unilateral Neglect visuo-constructive that study anosognosic while of suggest disorder, One of severity Spatial hemianopsia the hemiplegia. right and 3) the right 138 M. Nagafuchi hemiplegia. References 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Arena, R. & Gainotti, G. 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