ORIGINAL ARTICLE

Copyright © 2014 the Canadian Journal of neurologiCal SCienCeS inC.

A Chinese Patient with Pusher Syndrome
and Unilateral Spatial Neglect Syndrome
Xiao-Wei Chen, Cheng-He Lin, Hua Zheng, Zhen-Lan Li

ABSTRACT: Objective: to observe clinical manifestations, behavioral characteristics, and effects of
rehabilitation on a patient with pusher syndrome and unilateral spatial neglect caused by right thalamic
hemorrhage. Methods: assessment of pusher syndrome was made by the Scale for Contraversive
pushing (SCp), and unilateral spatial neglect syndrome was diagnosed using line cancellation, letter and
star cancellation, line bisection tests and copy and continuation of graphic sequence test. behavioral
therapy, occupational therapy, reading training and traditional Chinese medicine methods were adopted
for treatment of pusher syndrome and unilateral spatial neglect. Results: the patient showed typical
pusher syndrome and unilateral spatial neglect symptoms. the pusher syndrome and unilateral spatial
neglect symptoms were significantly improved following rehabilitation treatments. Conclusions: pusher
syndrome and unilateral spatial neglect syndrome occurred simultaneously after right thalamic
hemorrhage. early rehabilitation therapy can reduce the symptoms of pusher syndrome and unilateral
spatial neglect syndrome and improve motor function.
RÉSUMÉ: Un patient chinois atteint du syndrome du Pusher et du syndrome de négligence spatiale
unilatérale. Objectif : le but de l’étude était d’observer les manifestations cliniques, les caractéristiques de
comportement et les résultats de la réadaptation chez un patient atteint du syndrome de pusher et du syndrome de
négligence spatiale unilatérale suite à une hémorragie thalamique droite. Méthode : l’évaluation du syndrome de
pusher a été effectuée au moyen du Scale for Contraversive pushing (SCp) et le syndrome de négligence spatiale
unilatérale a été diagnostiqué au moyen des tests de bisection de ligne, de barrage de lettres et d’étoiles et de
dysgraphie spatiale. le patient a été traité par thérapie comportementale, ergothérapie, entrainement à la lecture et
par des méthodes de médecine chinoise traditionnelle pour son syndrome de pusher et son syndrome de négligence
spatiale unilatérale. Résultats : le patient présentait un syndrome de pusher et des symptômes de négligence spatiale
unilatérale typiques. le syndrome de pusher et les symptômes de négligence spatiale unilatérale se sont améliorés
significativement suite à la réadaptation. Conclusions : le syndrome de pusher et le syndrome de négligence spatiale
unilatérale sont survenus simultanément après une hémorragie thalamique droite. la réadaptation précoce peut
diminuer les symptômes du syndrome de pusher et du syndrome de négligence spatiale unilatérale et améliorer la
motricité.

Can J neurol Sci. 2014; 41: 493-497

pusher syndrome is a clinical disorder characterized by a
particular behavioral pattern in stroke patients with hemiplegia.
generally, hemiplegia patients incline their body to the healthy
side in order to keep balance, while patients with the pusher
syndrome always actively push away from the non-hemiparetic
side and resist passive correction to the midline of the body.1
there are also patients who tilt their body backwards and resist
passive correction forwards,2 leading to impaired balance that
can affect the ability to walk. unilateral spatial neglect refers to
patients with brain injury who are unable to realize things in
contralateral space, which significantly affects the recovery of
motor function and quality of life. this condition also impairs
processing of visual cues, the patient disregarding the side of
space contralateral space to the lesion. however, it is unclear
whether the mechanism of this disability is primarily due to
sensory, motor or emotional impairment.3 pusher syndrome or

from the rehabilitation Medical Center, the first hospital of Jilin university,
Changchun, p. r. China.
reCeived deCeMber 5, 2013. final reviSionS SubMitted february 25, 2014.
Correspondence to: Zhen-lan li, rehabilitation Medical Center, the first hospital of
Jilin university, Changchun, 130021, p.r. China. email: lizhenlan1306040@163.com,
zhenlanli66@163.com.

the Canadian Journal of neurologiCal SCienCeS

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neglect has been reported widely. however, cases with patients
presenting with both pusher syndrome or neglect syndrome were
seldom reported. in this case report, we observed a patient with
both pusher syndrome and unilateral spatial neglect caused by
right thalamic hemorrhage, which provides a clinical basis for
the pathogenesis of simultaneous concurrence of pusher
syndrome and unilateral spatial neglect.

the Canadian Journal of neurologiCal SCienCeS

METHODS
Patient

li, a 55-year old, right-handed illiterate female was admitted
to the department of rehabilitation on february 20, 2012 due to
disability of the left limb. physical examination showed the
following: blood pressure was 140/90mmhg, normal cognition,
normal speech without facial apraxia and limb apraxia, but with
shallow left nasolabial, lolling middle, upward mobility of the
left eye. normal vision and hearing were assessed by coarse
measurement, without hemianopia. left hemiplegia was
observed. the left reflex-quads were normal, the left ankle jerk
was increased, and ankle clonus was classified as level 1 (3
second clonus). there was little spasticity in the lower limb. the
sensory modalities of proprioception, vibration, and light touch
were normal. a decreased response to pain stimulation was
detected. Mini mental status examination (MMSe) score was 22
points. according to the brunnstrom classification,4 the left
upper limb-hand-lower limb was Ⅲ-Ⅳ-iii degree. fugl-Meyer
scores5 were 170 points. the total movement score in this patient
was 64 points (the upper limb was 38 points, the lower limb was
26 points). the total balance score was 5 points, the total sensory
score was 15 points, the total range of motion score was 43
points, and the total pain score was 43 points (full fugl-Meyer
scores: 100 points for movement, 66 points for the upper limb,
34 points for the lower limb; 14 points for balance; 24 points for
sensory intact; 44 points for range of motion; 44 points for pain).
the barthel index for measurement of performance in
activities of daily living was 40 points (full score is 100 points).
a computer tomography (Ct) scan revealed high density flakes
in the right side of the thalamus, at a maximum level of 3.2 x 2.4
cm. bilateral ventricular enlargement was observed.
enlargement of the left ventricle was more evident than that of
the right ventricle. Similar high density was observed in the third
and fourth ventricule (figure 1). no obvious shift was seen in
midline structures. Clinical diagnosis of the right side of the
thalamus hemorrhage suggested an intra-ventricular hemorrhage.
one month after the initial examination, when the patient

came to the department for rehabilitation therapy, she tilted to
the affected side whenever in sitting or standing position, and
only ate food on the right of a plate when dining. We evaluated
her based on assessment standards of pusher syndrome and
unilateral spatial neglect, and diagnosis of the pusher syndrome
and unilateral spatial neglect were made after the assessment. a
one-month rehabilitation treatment was initiated, and we found
that motor function in this patient was markedly improved. the
patient was able to walk independently under supervision.
during the patient’s return visit on May 25, 2012, although she
could walk independently, fine motor function of her left hand
was comprised such that she could not button her own shirt. We
concluded that pusher syndrome had completely disappeared,
and that unilateral spatial neglect syndrome was significantly
improved. according to the brunnstrom classification, the left
upper limb-hand-lower limb was v-v-vi grade. fugl-Meyer
scores were 215 points: the total movement score was 94 points
(the score in the upper limb was 62 points, the score in the lower
limb was 32 points), the total balance score was 11 points, the
total sensory score was 24 points, the total range of motion score
was 43 points, the total pain score was 43 points. the barthel
index was 100 points. ethic approval of this study was provided
by the Clinical research ethics Committee in our hospital.
Evaluation Methods

Evaluations of Pusher syndrome6,7

Scale for Contraversive pushing (SCp) was applied for
evaluation of the pusher syndrome. the scale contains three
parts: (a): degree of symmetry of posture: 1, severe to suffering
from side to side tilt and fall; 0.75, severe to suffering from side
tilt, no fall; 0.25, mild to suffering from side tilt, no fall; 0, the
body is erect, without inclination; (b): the presence of abduction
or extension of the uninvolved extremities to increase the area of
contact with the supporting surface: 1, when the rest is; 0.5, only
the change in posture; 0 points, without stretching; (C): the
degree of resistance to passive postural correction: 1, a
resistance; 0, without resistance. each part is classified 0-1 point,

Figure 1: A respresentative CT scan image: A high density area was seen on the right side of the thalamus,
at the maximum level of 3.2 x 2.4cm, CT value 67HU. Bilateral ventricular enlargement was visible, more
evident at the left side. Similar high density was observed in the fourth and third ventricles.

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le Journal Canadien deS SCienCeS neurologiqueS

tested in both sitting and standing positions, the highest score is
6 points. if each result was ≥ 1 point (total scores ≥ 3 points),
pusher syndrome was diagnosed.
Unilateral spatial neglect assessments

Several tests were selected from a series of behavioral neglect
tests (behavioral inattention test, bit)8:
(a) line cancellation test: the patient was given a piece of
paper with 40 lines, each line was 25 mm long (18 in the left
space, 18 in the right space, 4 in the middle). the paper was
placed just in front of the patient. the patient was asked to cross
all lines on the paper using a pen. numbers that were crossed in
each space were recorded.
(b) letter cancellation test: the patient was given a piece of
paper with letters which were arranged in five rows, 34 letters in
each row, the letters e and r were placed across the whole page
(20 in the left space: 10 letters for e and 10 letters for r in the
left space; 20 in the right space: 10 letters for e and 10 letters for
r in the right space), the patient was asked to find all e and r on
the paper, and the number of e or r that were found in each
space were recorded.
(C) Star cancellation test: the patient was given a piece of
paper with big stars, letters and words which were arranged
randomly, along with 56 small stars diffused on the paper (27 in
the left space, 27 in the right space, 2 in the middle). the patient
was asked to cross all the small stars on the paper, and the
number of e or r that were crossed in each space were recorded.
(d) line bisection test: the patient was given a piece of paper
with three parallel, horizontal lines, each line of which was 2.04
cm long, the patient was asked to mark the midpoint of each line.
the length was measured from a point marked to the actual
midpoint.
(e) Copy and continuation of graphic sequence test: the
patient was asked to copy two symmetric graphics, the shape of
the copied graphics was observed.
Treatments

this patient underwent one course of rehabilitation treatment
which lasted for 30 days.
Treatments for Pusher syndrome

Correction of the patient’s abnormal posture was made by
visual feedback technology, including restoration of head
movement, maintaining full range of motion of the neck, guiding
active movement of the head and keeping the head in the normal
position. training of shifting center of gravity was performed,
including transferring weight to the non-paralyzed side in sitting
and standing positions, transitting to maintain the center of
gravity in the neutral position gradually, recovery of midline
standing, improving the muscle strength of the paralyzed lower
limb, practicing correct standing posture, and walking was
performed under supervision. a mirror was used during training
to remind the patient to correct their posture. training was
performed 40 minutes per day, five days a week, three weeks in
total. Walk training was performed by the lower limb robot for
20 minutes daily.

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Treatment for unilateral spatial neglect
Nursing

Stimulation of neglected side was performed by allowing the
patient to lie in right lateral supine position. family members or
medical staff stood on the neglected side of the patient when they
communicated with the patient. the patient was encouraged to
complete activities of daily living using the affected side as
much as possible.
Occupational therapy

attention to the neglected side was accomplished by marking
the edge of the neglected side with a bright color when
completing visual scanning training to increase sensory
stimulation of the neglected side. the patient received training
such as verbal, visual, tapping therapy, and electric stimulation
of sensory input. this task training focused on crossing the
midline from the healthy side to the ignored side for 40 minutes
daily.
Reading training

anchoring technology9 provides a visual cue to the neglected
side, which helped the patient find a starting point of reading.
however, as the patient improved, the visual cue was reduced.
training lasted for 20 minutes daily.
Acupuncture therapy

fu et al10 have shown that scalp acupuncture has a curative
effect for some cerebral diseases. the effects were especially
noticable in improving the motor function and mobility of
patients with unilateral spatial neglect by promoting cerebral
collateral circulation, and improving neural function defects
induced by cerebral ischemia and hypoxia . in this case, several
acupuncture points were chosen, including baihui, yintang,
fengchi, Jianyu, quchi, Waiguan, hegu, yanglingquan,
taichong, Zulinqi. acupuncture was performed for 15 minutes
daily by an acupuncturist at the department of rehabilitation,
the first hospital of Jilin university.
RESULTS

Evaluation results of Pusher syndrome prior to treatments

prior to treatment, we observed that the head of the patient
shifted to the right side when sitting, and the trunk leaned to the
left. She returned to her original (incorrect) position after she
was corrected to the neutral position.
Spatial neglect was observed on the left side, as exemplified
by the finding that when family members or a therapist talked on
her left side, she had no response.
When transferred from bed to chair, the patient could not
stretch her right leg, which was often accompanied by tilting of
her body backwards. the patient also could not stand upright
because of obvious leaning towards the left. the total SCp was
5 points (a, 1 point; b, 2 points; C, 2 points).

Evaluation results of unilateral spatial neglect prior to
treatment

the results of line cancellation test showed that 10 out of 18
lines were crossed in the left space (10/18), 4 out of 4 lines in the
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middle were crossed (4/4), 18 out of 18 lines in the right space
were crossed (18/18), these results indicated that spatial neglect
occurred on the left side.
the results of the letter cancellation test revealed that the
number of letter e in the left space was 8/10 (10 means 10 letters
for e on the left space, and 8 means 8 of the 10 letters were
deleted), and the number of letter e in the right space was 9/10.
the number of letter r in the left space was 6/10, and the number
of letter r in the right space was 9/10.
When the patient performed the star cancellation test, the
number of stars she crossed in the left space was 19 out of 27,
the crossed number in the middle was 2 out of 2, and the crossed
number in the right space was 26 out of 27.
after the patient marked the midpoint of three lines, the
results of the line bisection test revealed that r (r means the
distance between the midpoint which the patient marked and the
real midpoint) of three lines were -0.2 cm, 0.1 cm, and 3 cm. as
shown in figure 2, the patient had difficulty in copying standard
graphics provided.
Evaluation results of Pusher syndrome after treatments

after treatment, we found that the patient had no obvious
shift in supine position, sitting and standing. the visual feedback
in the left space improved, and she had normal response when
family members or therapists talked to her on the left side.
Moreover, she had no difficultly in transferring from sitting to
standing, and she could steadily stand upright. her SCp after
treatment was 1 point (a, 0 point; b, 0 point; C, 1 point: had little
resistance to passive postural correction in standing position).
Curative effect of rehabilitation therapy after treatment

after one month of rehabilitation, patient mobility markedly
increased without a noticable incline in any positions. upon
discharge, she could walk independently under supervision.
three months later, fine motor function of her left hand
improved, pusher syndrome had been completely corrected, and
unilateral spatial neglect significantly improved.

DISCUSSION

pusher syndrome is a disorder which manifests as severe
postural control impairment after stroke. the incidence of pusher
syndrome is 23% in Chinese patients with cerebrovascular
disease,11 other statistical data is 5%-63% in patients from other
countries.6 the difference in statistical data may be associated
with different diagnostic criteria and selected populations.12
although many pusher syndrome studies have been published
in recent years, morbidity in hospitalized patient and prognosis
of comprehensive rehabilitation treatment is seldom studied.
pusher syndrome presents after stroke and, in many cases, can be
corrected within six months; however, the phenotype is
occasionally persistent.13 it is thought that the prevalence of
pusher syndrome in right cerebral hemisphere-damaged patients
is higher than in left cerebral hemisphere-damaged patients.14
another study showed that pusher syndrome is related to
impairment of sensory pathways results from damage of the
posterior limb of the internal capsule; however, this cause has
not yet been confirmed.6 Santos-pontelli et al15 used neuroimaging scans to locate lesions in the anterior and posterior crus
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Figure 2: First row: A star cancellation test; Second row: A line
bisection test; Third row: A graphics copy test. Left column: standard
test; Right column: the patient cannot appropriately copy the images on
the left or with structure errors.

of the internal capsule, thalamus, frontal, temporal and parietal
lobes, insula and hemispheric lesions in patients with pusher
syndrome. in addition, damage in cortical and subcortical
regions, such as the insular cortex and posterior central gyrus,
have also been suggested to cause pusher syndrome.16 using
functional Mri, ticini et al13 confirmed that hypoperfusion of
the inferior frontal gyrus, middle temporal gyrus and inferior
parietal lobe affected postural control. these researchers suggest
that hypoperfusion may be causal in pusher syndrome.13
Moreover, baier et al found when the right hemisphere was
impaired, the insula, superior temporal gyrus and posterior tectal
zones had been identified to be associated with pusher
syndrome. When the left hemisphere is injured, the insular front,
top cover area and projection fibers to the lateral thalamus inner
portion of the sac were believed to be associated with pusher
syndrome. these brain areas are associated with postural
control, or related to processing of vestibular information.17
Currently, the pathogenesis of pusher syndrome is still
unclear. patients with pusher syndrome need much longer time
to recover motor function, compared to patients without pusher
syndrome.18 therefore, earlier diagnosis and treatment of pusher
syndrome can effectively facilitate the recovery of mobility and
shorten hospitalization time.19 Studies have reported that visual
feedback training, which corrects subjective vertical sense

le Journal Canadien deS SCienCeS neurologiqueS

through visual input, is beneficial to control symptoms of pusher
syndrome.20,21
it has been shown that gait training assisted by lower limb
robotics increases proprioceptive input of body upright position,
and improves pusher symptoms through the improvement of
postural control.22 Stimulation of the vestibular sensory input
channel by direct electrical stimulation of the vestibular system
improves subjective vertical sense, thereby it controls the
patient’s body inclining it to the normal position.23 Krewer et al
found that effect of lower limb robotic assisted ambulation
training is more remarkable than visual feedback training in
randomized double-blind trials, and that direct electrical
stimulation of the vestibular system has no significant effect.12
the current research uses visual feedback training and gait
training to correct pusher symptoms at an early phase of pusher
syndrome. this approach has been demonstrated to promote the
patient’s independent walking ability and shorten the time of
hospitalization.
patients (56.3%) with pusher syndrome have unilateral spatial
neglect, while the remaining patients without pusher syndrome
were presented with agnosia, apraxia and other neurocognitive
dysfunctions, suggesting that pusher syndrome and unilateral
spatial neglect may be two separate syndromes, and only appear
to have casual correlation with each other.10 davies et al has
reported that pusher syndrome caused by left hemisphere
damage had no association with unilateral spatial neglect.1 in
contrast, Karnath asserts that patients with pusher syndrome are
often associated with unilateral spatial neglect when there are
lesions in the right thalamus, pusher syndrome is accompanied
with aphasia if lesions are on the left side.24 in the patients with
right hemisphere injury, unilateral spatial neglect and pusher
syndrome are highly correlated. however, there is no evidence to
support the hypothesis that pusher syndrome is caused by
unilateral spatial neglect, because there are still 20% of patients
with pusher syndrome who have no unilateral spatial neglect
when the right hemisphere is damaged.
We present the first report of a patient with right thalamic
hemorrhage presenting with both pusher syndrome and unilateral
spatial neglect. We think that early rehabilitation treatment can
have a significant beneficial effect on disease progression that
shortens the time of hospitalization. this case provides clinical
evidence for further study into the pathogenesis and therapy of
pusher syndrome with unilateral spatial neglect.
a limitation of this study is the inadequate number of
patients, which limits the ability of this study to explain the
correlations between the lesion site and pusher syndrome with
unilateral spatial neglect. further collection of additional cases
and appropriate study design are necessary to explore the
pathogenesis.
ACKNOWLEDGEMENT

the authors thank Medjaden bioscience limited for assisting
in the preparation of this manuscript.
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