6 Repatriation Kingston Wd K&C 17/04/12 for rehabilitation Femoral DVT 24/04/12EnoxaparinWarfarin commenced after 4/52Vasculitis and thrombophilia screen negativeHomonomous hemianopia and left neglect reported in notesCitalopram for post-stroke depressionTransferred to NeuroRehab 15/06/12Normal visual fields on formal testing
11 Behavioural Assessment of Neglect, Azouvi Forgets to groom or shave the left part of his/her face1Experiences difficulty in adjusting his/her left sleeve or slipper3Forgets to eat food on the left side of his/her plateForgets to clean the left side of his/her mouth after eatingExperiences difficulty in looking towards the leftForgets about a left part of his/her body (e.g. forgets to put his/her upper limb on the armrest or his/her foot on the wheelchair rest, or forgets to use his/her left arm when he/she needs to)Has difficulty in paying attention to noise ore people addressing him/her from the leftCollides with people or objects on the left side, such as doors or furniture (either while walking or driving a wheelchair)Experiences difficulty in finding his/her way towards the left when travelling in familiar places or in the rehabilitation unitn/aExperiences difficulty finding his/her personal belongings in the room or bathroom when they are on the left side218/30Key: 0 = no neglect; 1= mild neglect; 2 = moderate neglect; 3 = severe neglect
13 Extinction testing Computerised test Attention paid to centre of screenSeries of numbers displayed centrally* flash up in peripheries up to two quadrants 100msPt reports when * seen and whereErrors/omission notedAll omissions by PR on left when concurrent R stimulus
15 Search testing Alternative task Inverted T present in 50% Pt reports present or absentObserver records present on L, R or absent and calculates accuracy
16 GVS Trial PR given GVS by Dr. Wilkinson's team Baseline measures Aug 2012Repeat at 1/52 following sham GVS2 further assessments after 5/7 GVS and 2/52 after
17 Increasing evidence of GVS benefit in neglect E.g. Utz et al. Neuropsychologia Apr;49(5): :“In neglect patients [...] GVS significantlyreduced the rightward line bisection erroras compared to baseline (without GVS)and sham stimulation”
18 Unfortunately minimal benefit in PR's extinction No improvement on computerised stimulus testing with *Transient improvement in search task at end of GVSBack to pre-GVS baseline after 1/52No residual improvement in extinction when pt discharged to intermediate care Sept 2012
20 Neglect Graded defect Cf field loss (1° visual cortex) Gradually declining awareness or performance moving towards contralesional sideDepends on head and thorax positionCf field loss (1° visual cortex)Clear borders, dependent on retinal positionParietal spatial mappingBut loss of location in space causes loss of awareness of existence of itemsLoss of other modalities of sensory information does not cause neglectIs parietal function in attention to identify single next visual target?
21 Extinction No neglect when single stimulus offered Requires multiple stimuliIpsilesional stimulation results in neglect of contralesional sideRelative relation between stimuli, even if both contralesionalExtinction less pronounced for stimuli with parallel pathwaysContralesional faces – fusiform gyrusContralesional spiders – limbic / amydalaExtinction in healthy subjects
22 Extinction vs Neglect ?Spectrum ?Different anatomy Right inferior parietal lobe, affecting both dorsal and ventral visual processing pathways; implicated in both processesNo consensus in literature for anatomical explanation
23 Extinction vs Neglect Why make the diagnosis? Do we miss many? Poorer prognosis in stroke pts with neglectTailored MDT rehab improves outcome in some patients with neglectPotentially greater benefit with extinction therapyDo we miss many?up to 75% of pts with hemiparesis have neglect or extinctionExtinction can still have profound impactShoppingDrivingCrossing road
24 Kerkhoff et al. demonstrated a sustained improvement in tactile extinction in 2 patient with chronic deficits following GVSUnfortunately, we have not demonstrated the same improvement with visual extinction in PRCould there be a role of GVS in diagnosis of visual extinction?
25 Thanks to Dr David Wilkinson, Senior Lecturer in Psychology & Olga Zubko, Research Associate
26 ReferencesDriver J,Vuilleumier P. Perceptual awareness and its loss in unilateral neglect and extinction. Cognition. 2001; 79:Kerkhoffa G, Hildebrandtb H, Reinharta S, Kardinala M, Dimovaa V, Utz KS. A long-lasting improvement of tactile extinction after galvanic vestibular stimulation: Two Sham-stimulation controlled case studies. Neuropsychologia Jan; 49(2): 186–195Utz KS, Keller I, Kardinal M, Kerkhoff G. Galvanic vestibular stimulation reduces the pathological rightward line bisection error in neglect-a sham stimulation-controlled study. Neuropsychologia Apr; 49(5):Vossel S, Eschenbeck P, Weiss PH, Weidner R, Saliger J, Karbe H, Fink GR. Visual extinction in relation to visuospatial neglect after right- hemispheric stroke: quantitative assessment and statistical lesion- symptom mapping. J Neurol Neurosurg Psychiatry. 2011; 82:Wilkinson D, Zubko O, Degutis J, Milberg W, Potter J. Improvement of a figure copying deficit during subsensory galvanic vestibular stimulation. J Neuropsychol Mar; 4(1):
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