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Neurocase. Author manuscript; available in PMC 2019 July 23.
Published in final edited form as:
Neurocase. 2018 June ; 24(3): 151–155. doi:10.1080/13554794.2018.1495741.

Illustrating where spatial perception versus memory-based
representation: spatial neglect in a distinguished artist; a case
report
Kimberly Hrehaa,b, Amit Chaudharic, Yekyung Konga,c, Maduri Prathushad, and A.M.
Barretta,b,c

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aInpatient Rehabilitation Department, Kessler Institute for Rehabilitation, West Orange, NJ, USA;
bKessler Foundation, West Orange, NJ, USA;
cRutgers – New Jersey Medical School, Newark, NJ, USA;
dLake Erie College of Osteopathic Medicine, Erie, PA, USA

Abstract

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Spatial neglect is a disorder of attention, perception, and processing of stimuli in contralesional
space. The heterogeneous behaviors involve diverse neuroanatomical mechanisms. Anecdotal
evidence suggests that neural circuitry of active spatial perception may differ from that used to
encode spatial memory. These differences can escape detection by conventional assessments,
thereby leading to missed diagnoses. We present a case, in an artist who demonstrates selective
impairment in a contralesional space during active Where spatial perception. His performance is
better when asked to draw entirely from memory. This case highlights the variability in neglect,
importance for comprehensive testing, and encourages further investigation.

Keywords
Cerebrovascular accident; spatial neglect; artists; representational neglect

Introduction

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Approximately 798,000 people in the United States have a stroke each year (Mozaffarian et
al., 2015). Of these, 350,000 (30–70% of right-brain stroke survivors and 20% of left-brain
stroke survivors) present with a cognitive disorder, known as spatial neglect (Bowen &
Lincoln, 2007; Katz, Hartman-Maeir, Ring, & Soroker, 1999). Although the presentation of
spatial neglect differs widely, it is defined as the inability to attend to, perceive, process, or
act on stimuli in contralesional space, which results in functional disability, poorer
rehabilitation outcomes, and an overall longer recovery (Chen, Hreha, Kong, & Barrett,

Kimberly Hreha khreha318@gmail.com.
Disclosure statement
All authors have nothing to disclose, except, Dr. A.M. Barrett. The time she spent preparing this publication was partly supported by
the Kessler Foundation and by the National Institutes of Health/National Center for Rehabilitation Research (K24 HD062647, PI
Barrett).

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2015; Heilman, Valenstein, & Watson, 2000; Nijboer, van de Port, Schepers, Post, & VisserMeily, 2013).

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Historically, spatial neglect has been underdiagnosed, possibly because of its diverse
behavioral presentation (Bowen, McKenna, & Tallis, 1999). It was reported that using more
than one test may decrease the false negative rate and optimize delivery of care (Azouvi et
al., 2002; Azouvi, 2017). This may be because spatial neglect may present differently in
different individuals and conventional assessments may be limited to only certain areas of
spatial performance (Bartolomeo, 2007). For example, the Apples test is widely accepted to
assess for allocentric (object-centered) spatial bias (Ota, Fujii, Suzuki, Fukatsu, & Yamadori,
2001). There is an argument that the National Institutes of Health (NIH) Stroke Scale may
be sub-par when assessing for spatial bias (Hillis, Wityk, Barker, Ulatowski, & Jacobs,
2003). Additionally, our group and others have previously reported on assessments,
including the Behavioral Inattention Test (BIT), to be better in detecting Where (perceptualattentional) spatial bias, as opposed to Aiming (motor-intentional) spatial bias (Goedert et
al., 2012; Na et al., 1998).
Despite these repeated demonstrations, most clinicians only use quick assessments (e.g.,
clock drawing) for the detection of spatial neglect. Research studies have however included
detailed neuropsychologic assessments to identify neglect behaviors (Cicerone et al., 2000;
Paolucci, Bureca, Multari, Nocentini, & Matano, 2010). Additionally, even for those
diagnosed in the acute phase, different types of spatial bias may respond differently to
interventions (Goedert, Chen, Boston, Foundas, & Barrett, 2014). Overall, this work
emphasizes the need to accurately diagnose and classify patient’s symptoms prior to starting
therapeutic treatments.

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Specifically, it may be very important to distinguish between active Where spatial perception
and memory-based representation to better enhance rehabilitation outcomes (Coslett,
Bowers, Fitzpatrick, Haws, & Heilman, 1990). Where spatial perception is associated with
perceiving or attending to real-time stimuli and has previously been shown to mediate
directional action, response inhibition, persistence, and motor/personal self-regulation
(Coslett et al., 1990; Na et al., 1998). Bias in this network can be measured by tasks that
require cancellation or figure copying. In contrast, tasks that require drawing from memory
may better assess neural networks used for storage/recall of spatial information.

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One way to distinguish between these processes is to examine the presentation of spatial
neglect in artists (Cantagallo & Della Sala, 1998; Marsh & Philwin, 1987). Artists use
complex memory-based representational systems when they engage in the creation of a
masterpiece. For example, a German artist, Lovis Corinth, said: “true art means to use
unreality”; in essence: “true art” is that which is produced only from the artist’s memory
(Bazner & Hennerici, 2006). Since artists engage in this process frequently, mechanisms of
memory representation may be more resistant to hypoperfusion during stroke in these
individuals (Cantagallo & Della Sala, 1998; Marsh & Philwin, 1987). Here, we examine this
possibility and question its implications for the diagnosis.

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Case report
A.R. (not his real initials) is a 68-year-old, right-handed, Chinese-American male artist with
a history of hypertension. During his internationally renowned career, A.R. painted for local
venues, participated in gallery showings, achieved numerous awards of distinction, and
published two books containing his artwork. He continued to be an avid lover of painting
until the evening of 25 April 2012, when his wife found him with left-sided weakness, a
right gaze preference, and slurred speech. He was diagnosed with a large right middle
cerebral artery (MCA) stroke involving the frontal, parietal, and occipital lobes (Figure 1).
There was a small hemorrhagic conversion with cerebral edema and midline shift.

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At the acute hospital, he was given tissue plasminogen activator and also had a Mechanical
Embolus Removal in Cerebral Ischemia (MERCI) clot retrieval procedure in order to help
with MCA revascularization. His initial neuromuscular and skeletal physical examination
was significant for impaired left facial droop, right gaze preference, and left-sided weakness.
He was alert and oriented to person, place, and time. His medical doctor treated him with
heparin and aspirin as a preventative measure for recurrent stroke. A.R. was not diagnosed
with spatial neglect because of normal performance on clinical measures, such as the
Function Independence Measure score and the NIH Stroke Scale, and thus, no spatial
neglect therapies were recommended. However, in the clinical documentation notes there are
specific wordage that directly suggests that A.R. did in fact have some form of spatial
neglect. For example, his occupational therapist wrote that he had a gaze preference toward
the right side and required verbal cues to turn his head and move his body toward the left.
This presentation shows two very common neglect behaviors. Ipsilesional directed gaze,
meaning that the person is looking away from the direction of the neglected space (or toward
the lesion), can range in severity; however, it is frequently observed. This head deviation is
not because of a muscle imbalance or purposeful but rather due to an attention network
problem (Corbetta & Shulman, 2011; Mesulum, 1999). Additionally, the directed body
movements are usually difficult to conduct in the contralesional space (neglected or space
opposite to the stroke lesion) (Barrett & Muzaffar, 2014). He also demonstrated not eating
food on the left side of his plate, on multiple occasions and not being aware of this error.
Anosogonia is also a common problem associated with spatial neglect (Azouvi et al., 1996).
Assessment of spatial neglect

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Approximately 1-year post stroke, A.R. visited an outpatient occupational therapist, because
he was interested in starting preventative therapies. At this time he displayed occasional
asymmetric behavior when attending to or initiating movement toward leftward stimuli. The
therapist then tested A.R. for neglect-related functional disability using the Catherine
Bergego Scale via Kessler Foundation-Neglect Assessment Process (KF-NAPâ„¢) (Chen,
Hreha, Fortis, Goedert, & Barrett, 2012). A.R.’s performance was consistent with mild
neglect. Specifically, these were his results: “gaze orientation” a score of 1, “limb
awareness” a score of 2, “grooming” a score of 2, “navigation” a score of 0, “dressing” a
score of 0, “personal belongings” a score of 0, “auditory attention” a score of 0, and
“collisions” a score of 1. There were two items that were not able to be scored: “eating” and
“cleaning after meal”. This was because A.R. was medically unable to consume any food or

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drink through his mouth and required total parenteral nutrition. Thus in order to calculate the
final score, we took the total score (which was 6), divided it by the items scored (8 items),
and then multiplied that score (which was = 0.75) by 10. The final score is a 7.5 or mild
neglect. The final score calculation supports the integrity of the diagnosis because the items
are all one factor (Chen, Chen, Hreha, Goedert, & Barrett, 2015).

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After the KF-NAP assessment was positive for spatial neglect, A.R. was referred to our
stroke research team and underwent additional neglect screening with the (1) BIT and (2)
five-element drawing test (Gainotti, Messerli, & Tissot, 1972; Wilson, Cockburn, &
Halligan, 1987). He was also tested for visual extinction and hemianopia, both of which
were negative. We found that A.R. exhibited clear neglect symptoms on tasks that required
copying objects (actively based Where perceptual-attentional spatial bias), primarily the BIT
figure copying section and line bisection, in addition to the five-element drawing test (see
Figure 2). However, A.R. exhibited less asymmetries on tasks that required drawing from
memory (memory-based representational spatial bias), for example the BIT face and
butterfly drawing section (see Figure 3).

Discussion

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Our participant A.R. was initially not diagnosed with spatial neglect, possibly because of a
likely lack of comprehensive initial assessment at the acute hospital. Difficulty with
comprehensive testing may be due to short length of stays at acute care hospitals, lack of
routine clinical procedures, or because of time constraints that therapists can have. However,
after reviewing the hospital reports (including clinical notes), it seemed conclusive that A.R.
did have signs of a spatial neglect syndrome. One year later, when his spatial performance
was formally assessed in outpatient therapy, he did in fact have spatial neglect. It was mild
however affecting his functional performance. A.R was referred to therapy, not due to an
acute event but rather because his family wanted him to start therapy in order to prevent
functional decline and improve his overall quality of life. Thus, no new imaging exams were
taken at the 1-year post-stroke time point. Despite the lack of imaging comparing A.R’s
initial and 1-year visit, his behavioral performance 1 year later still leads us to hypothesize
that neural networks underlying spatial performance may be selectively active during certain
behaviors. For example, there were differences in performance when A.R. was engaged in
cancellation or figure-copying tasks (Where perception) versus drawing from memory
(memory representation).

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This case report, categorizing deficits of spatial neglect in an artist, emphasizes the need for
comprehensive neglect testing that can assess for a diverse array of these networks to reduce
missed diagnoses and treatment delays. And potentially, having clinical procedures for
assessment of neglect will reduce the large variability of prevalence (30–70%) for right
brained stroke patients who present with spatial neglect. Further, evaluating the predominant
type of network affected in an individual’s stroke may better target therapies and enhance
rehabilitation outcomes.
In a prominent previous publication, the researchers argued that artists, because of their
frequent training and repetition, may have highly developed neuroanatomical mechanisms

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for spatial perception and memory (Cantagallo et al., 1998). Our hypothesis is consistent
with this argument. However, the categories used for evaluation of their patient, the
internationally renowned Federico Fellini, were significantly different from the ones used
here. The first category, visuo-perception, consisted of tasks such as reading and line
bisection. The second category, visuo-motor, consisted of tasks such as cancellation, figure
copying, and drawing. The authors found Fellini demonstrated spatial impairment only on
visuo-motor tasks, and not those involving visuo-perception.

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We did not test visuo-perception using reading or line bisection. Instead, we hypothesized
that the tasks used in their visuo-motor category may be grouped into those requiring active
Where spatial perception and those requiring memory representation. According to
Cantagallo and DellaSala’s raw data reports, Fellini demonstrated selective impairment only
on cancellation and figure-copying tasks. His performance on the Rey’s figure memory tasks
was non-pathologic. In addition, the authors present many figures that the Fellini drew from
memory post-stroke. Though he did omit some particulars on the left side and tended to
draw on the right side of the page, Fellini’s spatial bias on these tasks was rather mild.
Our findings are in line with their results; our participant A. R. also demonstrated clear signs
of spatial neglect only on cancellation and figure copying, tasks that require more active
Where spatial perception. His performance on tasks requiring drawing from spatial
representation in memory was not pathological, even though there was some asymmetry.

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The results of these two case reports can be summated to show that artists provide a unique
opportunity to differentiate for spatial mechanisms. In general, these individuals, post right
hemispheric stroke, are better at drawing from memory than engaging in cancellation tasks.
One possible explanation for this may be that the repetitive and creative nature of an artist’s
profession causes enhanced neurogenesis and thus increased angiogenesis in various parts of
the cortex. Thus, the increased collateral vessels may make a patient more resilient to
hypoperfusion during stroke. There are currently promising studies that show enhanced
neurogenesis in mice that have been cognitively challenged, particularly seen in post-stroke
mice (Xiong, Mahmood, & Chopp, 2010). However, while this finding is strongly in support
of this hypothesis, future research using brain imaging is indicated to confirm this theory.

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Since clock drawing is the most common bedside test used by clinicians for the diagnosis of
spatial neglect, it is very likely that individuals with training in artistic ventures, like A.R.
and Fellini, may escape detection. This would lead to significant chronic impairments and
increased healthcare costs. Thus, it is vital to routinely assess for spatial neglect and use a
comprehensive battery to ensure detection of the complexity of the behaviors, even if the
person does not show observable signs of neglect. Clinicians have reported that time is
always a barrier. Thus, we recommend using a functional assessment like the KF-NAP (tests
for egocentric neglect) and also the five-element drawing test (tests for allocentric neglect)
could improve the detection rate and thus offering people more chances to have treatment
opportunities.

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Conclusion
Our facility is fortunate to be equipped with a dynamic stroke research center that
collaborates well with our hospital team, which led to the detection of Where perceptual
errors that A.R. made on neglect assessments. By sharing this case report, we emphasize the
need for comprehensive testing that is able to evaluate a range of spatial perceptual networks
in order to make the diagnosis of SN prompt and accurate. Specific assessments may prevent
missed diagnoses for individuals with artistic talent or any other individuals who may be
cognitively stimulated in these two pathways.

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Further research should not only improve diagnostic testing, but also investigate into
therapies that target-specific networks affected in individuals with right hemispheric stroke,
thereby enhancing rehabilitation in people with spatial neglect. Studying the trends of
recovery in these patients coupled with assessment of modern imaging techniques would
additionally contribute to our understanding of neuronal repair and the link between
neurogenesis and angiogenesis.

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Figure 1.

Magnetic Resonance Imaging of A.R.’s Stroke.

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Figure 2.

Drawings that required copying or actively-based Where perceptual-attentional spatial bias.

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Figure 3.

Drawings completed from memory.

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