A study of right unilateral spatial neglect in

left hemispheric lesions: the difference

between right-handed and non-right-handed
-

post-stroke patients
Maeshima S, Shigeno K, Dohi N, Kajiwara T, Komai N. A study of right S.Maeshima ’, K. Shigeno’, N. Dohi ’,
unilateral spatial neglect in left hemispheric lesions: the difference T. Kajiwara’, N. Komai3
between right-handed and non-right-handed post-stroke patients. ’
Departments of Rehabilitation Medicine, Fujita
Acta Neurol Scand 1992: 85: 418-424. Health University, Hisai, Neurology, lzu
Nirayama Rehabilitation Hospital, Shizuoka,
Neurological Surgery, Wakayama
We report 20 cases of right unilateral spatial neglect caused by lesions in Medical College, Japan
the left cerebral hemisphere. Differences in neuropsychological symptoms and
lesion sites are discussed in connection with handedness. Of the
right-handed patients, 6 had severe aphasia, 4 had Gerstmann’s syndrome,
and 1 had pure agraphia, but unilateral spatial neglect in these cases Key words: unilateral spatial neglect:
disappeared after a number of months. Six of the non-right-handed patients cerebrovascular disorders; agnosia;
had moderate-to-severe aphasia, while the other 3 cases had no aphasia left-hemisphere: cerebral dominance.
at all. Eight of the 9 cases in this group continued to have right unilateral S. Maeshima, Department of Rehabilitation
spatial neglect for more than 6 months. Lesion site as determined by CT Medicine, Nanakuri-Sanatorium, Fujita Health
differed as to hemisphere, but all fell into the common area previously University, 424-1, Oodori-cho. Hisai, 514-12
mentioned in connection with such disorders: i.e.. the temporal, parietal Mie, Japan.
and occipital lobes. Accepted for publication November 14, 1991

Unilateral spatial neglect refers to a condition in
which the patient disregards objects located in one
side of the patient’s field of perception (1-3). Brain
(1) first reported on three cases of left unilateral
spatial neglect and suggested that the condition was
related to lesions in the right hemisphere. Since then,
similar impairments in visual disorientation and
hemi-inattention have been considered as symptoms
of lesions in the non-dominant hemisphere. Left uni-
lateral spatial neglect has also been noted in cases
of crossed aphasia in the dextral where it is consid-
ered that lateralization of higher cortical function is
incomplete (4). Such observations have led us to
believe that strong laterality exists for the right hemi-
sphere. Right unilateral spatial neglect is seen to
appear occasionally in cases of left hemispheric le-
sions (5). There has also been extensive discussion
of the qualitative differences between the two states.
Zarit & Kahn (6) took note of the fact that many
such lesions in the left hemisphere are accompanied
by aphasia and dementia, making it impossible to
conduct thorough testing. They also postulate that
right hemispheric lesions occur far more frequently
than indicated by the literature. Albert (7) also main-
tains that there is no difference in the frequency with
which lesions occur in the right or left hemispheres,
but that the more serious cases are generally found
in the right hemisphere. Meanwhile, Gainotti et al.
(8) studied cases of lesions in the right hemisphere,
pointing out that there is no appreciable difference
between the hemisphere when it comes to omissions
of portions of the figure at limited areas around the
peripheries; however, in right hemispheric lesions
there is a temporary tendency to leave figures in-
complete. Caltagirone et al. (9) and Ogura et al. (10)
studied patients with lesions of both the right and left
hemispheres. By comparing drawings, they found
that neither side is omitted in cases of right unilat-
eral spatial neglect caused by left hemispheric le-
sions. There is, instead, distortion of the figure over-
all. However their study dealt mainly with right-
handed cases. To date there are still few reports
concerning patients who are left-handed or at least
not fully right-handed. Kawahara et al. (11) com-
pleted a study of 100 cases of cerebral hemorrhage
and stated that left-handedness was thought to be a
factor in all five cases of right unilateral spatial ne-
glect caused by left hemispheric lesions. Masure et al.
(12) described that the hemispheric cerebral organi-
zation with respect to the mediation of visuospatial
performance does not differ between right-handers
and left-handers.
Thus, many points remain to be clarified regard-
ing the relation among handedness, hemispheric

418

dominance, lesion site and accompanying neuropsy-
chological symptoms. Therefore, we investigated the
correlation with handedness in 20 cases of right uni-
lateral spatial neglect caused by lesions in the left
hemisphere.
Subjects and methods
Subjects included 20 CVA patients (14 of cerebral
hemorrhage and 6 of thrombosis) who, upon admis-
sion to this facility, showed signs of right unilateral
spatial neglect in standard neuropsychologcal tests
(details to follow). Lesions located in the left hemi-
sphere in all cases were later confirmed with CT.
There were 13 men and 7 women ranging in age from
31 to 77 years (mean: 60.8 years). The time from
onset of the condition to admission varied from 2
weeks to 6 months (mean: 7.31 weeks). Handedness
was determined using the Kertesz & Sheppard test
(13). Nine of the 20 subjects were left-handed from
birth. Eight had a family member who was left-
handed. Eight of these nine were ambidextrous, hav-
ing been trained in childhood to perform certain
tasks with the right hand, such as writing or using
chopsticks. The remaining 11 cases were all right-
handed (Table 1).
In addition to neuropsychological examinations
such as visual field (confrontation test), motor pa-
ralysis and sensory disturbance, the following neu-
ropsychological tests were performed.
Unilateral spatial neglect
The following diagnostic tests were conducted to
judge the degree of unilateral spatial neglect:
Line bisection test. The patient was asked to bisect
a 20 cm line down on a standard letter-size (A4,
2Ox26cm) sheet of white paper. The same task
given to 34 controls (1 1 men, 23 women; mean age:
57.9 & 13.24 years) revealed a standard mean error
of only 2.00 2.10 mm. The standard for task fail-
ure was therefore set at an error of 1 6 . 5 mm or
twice the mean error of the controls. Abnormalities
were assessed, as follows: 6.5 mm to 13 mm as mild,
13mm to 19.5 mm as moderate, and more than
19.5 mm as severe.
Cancellation task. Based on Albert’s method (7),we
prepared a sheet of white A4 paper (20 x 26 cm) with
40 lines drawn thereon and asked patients to mark
the lines. Oversight of less than one fourth of A4
paper was assessed as mildly abnormal, less than
half left oversight as moderately abnormal and ad-
ditional partial oversight of the right half as severely
abnormal.
Right unilateral spatial neglect
Figure copying. This entailed a picture of a flower and
perspective drawing of a 3-D object.
Controls were asked to perform tasks (b) (c) as
well, and no anomalies were observed.
Anosognosia and hemiasomatognosia
All assessments were made by only one physician
(SM) by Mori’s method (14).
The examiner asked questions such as, “What
feels funny?” “Is there anything wrong with your leg
or hand?” “Can you move your right leg or hand?”
(the examiner indicates the patient’s right leg or
hand) “Is it hard to see things on the right side?” The
patient’s responses were recorded. Patients who
either were not aware of or who denied having visual
problems were classified as anosognosic for visual
field defect. Testing of this nature was not possible
for the 11 cases with aphasia.
Disregard for one side of the body (hemiasomatog-
nosia) was observed by daily monitoring of patients
in the hospital. For example, it was classified as
abnormal if patients disregarded one side of the face
or body while shaving, applying make-up, arranging
hair or washing the face, etc.
Aphasia
Aphasia was diagnosed using the SLTA (Standard
Language Test for Aphasia) (15) which is the most
widely used in Japan. Results were evaluated ac-
cording to the scale devised by Hasegawa et al. (16)
based on degrees of severity ranging from O j l O (most
severe) to lOjl0 (mildest).
Apraxia
By evaluating the patient’s performance on a stan-
dardized test of higher motor functions (17), we were
able to judge attendant signs of apractognosia. Test
involved buccofacial praxis such as clucking with the
tongue and clearing the throat, ritual praxis such as
bowing (in greeting), use of everyday objects includ-
ing a comb and toothbrush, and dressing oneself.
We evaluated each case for the above neuropsy-
chological elements, then divided cases for compari-
son into a non-right-handed group, and a right-
handed group. All cases were examined by CT, and
the lesion site was classfied for correlations with
handedness.
Results
Neurological symptoms
We investigated the neurological and neuropsycho-
logical findings of the patients.
Initial neurological findings included, 18 cases of
419
Table 1, Clinical features and progress of the right unilateral spatial neglect
&
8'
P,
Handedness Neurological deficits Neuropsychological deficits z
Prognosis of unilateral g
Duration V S motor paresis Type of B I C D A A H L C F
Age after F aphasia F M spatial neglect
No. /Sex PH FH Etiology onset D I upper lower severity A A A A H N A B L C (observation period)

1 56/M LR t t infarction 7 wks - t severe severe - - - t t t N V t t t t remained 9 months post onset

2 7l/M LR t t infarction 7 wks t t severe severe - - - t t t t t t t t remained 9 months post onset
3 75/F LR t t hemorrhage 7 wks t t severe severe - - - t t t t t t t t remained 6 months post onset
4 70/M LR t t hemorrhage 24 wks t t moderate moderate T 1/10 t - t t N E N E t t t t remained 6 months post onset
5 54/M LR t t infarction 12 wks t t severe severe T 2/10 t - t t NENE t t t t remained 6 months post onset
6 7 1/M LR t t infarction 16 wks t t severe severe T Oil0 t t t t N E N E t t t t remained 9 months post onset
7 49/M LR t t hemorrhage 7wks t t mild mild B 6/10 - - t t N E N E t t + t relrlained 6 months post onset
8 54/M LR t - hemorrhage 20wks t t mild mild W 3/10 t t t t N E N E t t t t remained 9 months post onset
9 57/F L - t hemorrhage 7 wks - - severe moderate B 2/10 t - t t N E N E t t t t disappeared within 3 months
10 7 1/M R - - infarction 12 wks t t severe severe T Oil0 t t t t NENE - t t t disappeared within 5 months
11 69/F R - infarction 2 wks t t severe severe T Oil0 t t t t N E N E - t t t disappeared within 2 months
12 59/F R - hemorrhage 4 wks t t severe severe C 6/10 t t t t N E N E - t t t disappeared within 3 months
13 44/M R - hemorrhage 3 wks t t severe severe B 1/10 t t t t NENE - t t t disappeared within 2 months
14 55/F R - hemorrhage 2 wks t t severe mild T 2/10 t t t t NENE - t t t disappeared within 2 months
15 55/F R - hemorrhage 8 wks t t severe severe B 2/10 t t t t N E N E - t t t disappeared within 6 months
16 65/M R - hemorrhage Zwks t - - - G - - t - N P t - t t t disappeared within 3 weeks
17 77/M R - hemorrhage 3wks t - - - G t t t - N P t - t t t disappeared within 4 weeks
18 62/F R - hemorrhage 1 wks t - - - G t t t - N P t - t t t disappeared within 3 weeks
19 48/M R - hemorrhage Zwks t - - - G t - t - N P t - t t t disappeared within 4 weeks
20 54/M R - hemorrhage 0.5 wks t - - - AG - - t - N P t - t t t disappeared within 2 weeks

PH: Past history of corrective training T: total aphasia BF A: bucco-facial apraxia

FH: Family history of the left-haders B: Broca's syndrome IM A ideomotor apraxia
W Wernicke's aphasia C A: constructional apraxia
V FD: visual, field defect C: conduction aphasia D A: dressing apraxia
S I: sensory impairment G: Gerstmann's syndrome A H: anosognosia for hemiparesis
AG: agraphia A V anosognosia for visual field defect
NE: not examined for aphasia H A: Hemiasomatognosia
NP: no paresis
NV: no visual field defect L B: line bisection
C L: cancellation task
F C: figure copying

right homonymous hemianopsia, 15 cases of right
hemiparesis involving the face, and 14 cases in which
sensory impairment for the right side.
Neuropsychological findings included, in addition
to right unilateral spatial neglect, 12 cases of apha-
sia (four Broca, one Wernicke, one Conduction, and
four Total aphasias), four cases of Gerstmann’s syn-
drome, and one case of pure agraphia. There were
also ten cases of ideomotor apraxia, 14 cases of
bucco-facial apraxia, 20 cases of constructional
apraxia, and 15 cases with dficulty in dressing. The
breakdown for anosognosia in the eight cases with-
out aphasia was three cases of anosognosia for
hemiplegia and eight cases of anosognosia for visual
field defect. There were nine cases in hemiasomatog-
nosia for the right side of the body was observed
(Table 1).
In studying the relationship between handedness
and neurological symptoms, we discovered that 6 of
the 11 cases in the right-handed group had severe
aphasia, while four had Gerstmann’s syndrome and
one had pure agraphia. The six cases with severe
aphasia were also marked by severe hemiplegia, uni-
lateral sensory dysfunction, hemianopsia, bucco-
facial apraxia, ideomotor apraxia, constructional
apraxia and difficulty with dressing. There was no
clearly defined paralysis or sensory impairments in
the four cases with Gerstmann’s syndrome and one
case with pure agraphia, but hemianopsia and
anosognosia for visual field defect were observed.
Three of these cases also showed signs of bucco-
facial apraxia and two of these cases showed ideo-
motor apraxia. All five cases had some construc-
tional apraxia, but none of these patients had
difficulty with dressing.
Meanwhile, all nine cases in the non-right-handed
group had hemiplegia, with unilateral sensory dys-
function in eight cases and hemianopsia in seven
cases. Moderate-to-severe aphasia was present in
six cases. No aphasia was observed in the other
three cases. Of the six cases of aphasia, four showed
bucco-facial apraxia, and two ideomotor apraxia.
The three cases with no aphasia were marked by
anosognosia for visual field defect and/or hemiple-
gia, but there was neither bucco-facial apraxia nor
ideomotor apraxia. In all nine cases, we found uni-
lateral personal neglect, constructional apraxia and
difficulty with dressing.
Qualitative differences and prognosis in unilateral spatial neglect
We investigated qualitative differences and progno-
sis in unilateral spatial neglect between handedness,
sex, age and etiology.
In comparison to the right-handed group, the non-
right-handers exhibited a greater degree of unilateral
neglect. In line bisection, among the cases of none-
Right unilateral spatial neglect
right-handers, “mild” and “moderate” was null; and
“severe”, 9, while among the cases of right-handers,
“mild” was nil; “moderate”, 4; “severe”, 7. In can-
cellation task, among the cases of none-right-
handers, “mild” was 1; “moderate”, 2; and “severe”,
6, while among the cases of right-handers, “mild”
was 2; “moderate”, 4; “severe”, 5 . In figure copying,
among the cases of none-right-handers, “mild” was
null; “moderate”, 1; and “severe”, 8, while among
the cases of right-handers, “mild” was 1;“moderate”,
4; “severe”, 6.
On picture problems, they made marked omis-
sions on the right side (Fig. la). The right-handers,
conversely, disregarded the right side of figures to a
lesser extent, and errors on picture tests for the most
part were limited to distortions of the right side
(Fig. lb). In 12 cases, symptoms of right unilateral
spatial neglect disappeared within six months. In
another eight cases, however, symptoms persisted
for more than six months. In particular, the eight
non-right-handed patients who had been trained in
the past to use the right hand suffered from right
unilateral spatial neglect well past six months. The
other one patient who had not received such cor-
rective training were free of symptoms within six
months. By contrast, symptoms in the right-handed
group disappeared within two weeks to six months
after admission.
Sex, age, etiology, handedness, focal lesion were
compared between the group in which right unilat-
eral spatial neglect disappeared (disappeared group)
!.lode1
Case 2 care 1 rare 7
Fig. l a . Figure copying by non-right-handed group
case 10 Case 13 Cane 16
Fig. Ib. Figure copying by right-handed group
421
Maeshima et al.
and the other group in which right unilateral spatial
neglect remained (remained group) (Chi-square).
While the number of non-right handers was signifi-
cantly larger in the disappeared group than the re-
mained group, there were no significant relations
between sex, age, and etiology.
As to responsible lesion, the number of non-right
handers was also significantly larger i i the remained
group than in the disappeared group, but there were
no significant relation between responsible lesion.
Prognosis in the other neurological symptoms
Anosognosia faded within two weeks to three months
regardless of handedness or corrective training. All
nine cases with right hemiasomatognosia belonged
to the non-right-handed group. Hemiasomatognosia
of the right side eventually disappeared in one case
(Case 9) in which unilateral spatial neglect also irn-
proved. All six total aphasics did not improve ap-
parently. Though their aphasic symptoms still re-
mained, another six cases improved generally,
regardless of handness or corrective training.
Lesion site
Fig. 2 shows a superposition of CT images at initial
examination. Extensive infarctions were seen in the
area of the brain supplied by the left middle cerebral
artery (five cases) and the area supplied by the left
posterior and left middle cerebral arteries (one case).
There were nine cases of hemorrhage in the left basal
ganglia, and five of subcortical hemorrhage in the left
parietal and occipital lobes. The nine cases in the
non-right-handed group were broken down into four
of cerebral infarction, all in the left temporal, parietal
and occipital lobes or the area extending from the
f
C T lesion in non-right-handed group
CT lesion in right-handed group
Fig. 2. CT lesion in non-right-handed group (upper), in right-
handed group (lower)
422
frontal lobe. Sites of cerebral hemorrhage in the other
five cases were in the left putamen, capsula interna
or thalamus, and the area extending from the parietal
lobe (Fig. 2). In the right-handed group, there were
two cases of infarction with lesions found in an ex-
tensive area extending from the left frontal lobe
through the temporal, parietal and occipital lobes.
Of another 9 cases of cerebral hemorrhage, 4 were
found in a wide area centered on the left putamen,
and the other 5 were of subcortical hemorrhage in
the left parietal and occipital lobes (Fig. 2). As to
focal lesion, the number of non-right handers was
also significantly larger in the remained group than
in the disappeared group, but there were no signifi-
cant relations between handedness and focal lesion.
Discussion
Nine of the 20 cases covered in our study were also
not right-handed, indicating that handedness possi-
bly affects changes in laterality pertaining to higher
cortical function. In Cases 1, 2 and 3 , extensive le-
sions in the left hemisphere had damaged portions
of the language centers; however, there was no apha-
sia, ideomotor apraxia or bucco-facial apraxia. The
symptoms, including unilateral spatial neglect, per-
sonal neglect, and anosognosia, are those associated
with the non-dominant hemisphere. As a conse-
quence, we were led to assume that functions nor-
mally belonging to the dominant hemisphere in these
three cases were operating from the right hemisphere
and that certain visuo-spatial cognitive functions
which are normally assigned to the non-dominant
hemisphere were located in the left hemisphere.
Cases 4-9 were marked by right unilateral spatial
neglect, hemiasomatognosia and aphasia. In five of
six cases there was also bucco-facial apraxia. The
speculation in these six cases is that, in addition to
language centers, the left hemisphere was also the
site of certain functions associated with the non-
dominant hemisphere which relate to visuo-spatial
perception, perception of physical space and control
of bucco-facial praxis. Ideomotor apraxia seen in
only two cases may indicate a strong probability that
dominant hemispheric functions related to engrams
of limb movements were relegated to the opposite
side (right side). Also, despite the fact that all nine
of these non-right-handed patients suffered from le-
sions in the left hemisphere, their mistakes in figure
copying tasks were notably closer to errors of uni-
lateral omission made by right-handed right-
hemispheric lesion cases rather than overall distor-
tions.
A review of prognosis in these cases of right uni-
lateral spatial neglect shows that lesions were com-
paratively limited in Case 9 where symptoms disap-
peared after three months and recovery from aphasia

progressed simultaneously. Based on these observa-
tions, it does not seem unreasonable to assume that
the part of the brain responsible for spatial neglect
was not the site directly damaged by the lesion.
However, symptoms also disappeared within several
months despite the presence of extensive lesions
throughout the right hemisphere. Perhaps this signi-
fies that a lesser degree of strict lateralization of vi-
sual spatial functions makes it easier for the oppo-
site hemisphere to take over tasks. In the eight cases
where symptoms persevered for a longer period we
also saw greater lateralization into the left hemi-
sphere. This may be due from more direct damage
occurring in the area of the cerebrum that controls
these processes. Whatever the reason, it is of par-
ticular interest in terms of laterality of visuo-spatial
perception to note that these were patients who had
been constrained in childhood to use the right hand
for activities such as holding chopsticks or writing.
In three of nine cases there was no aphasia what-
ever, leading us to speculate that language function
in these cases might reside in the right hemisphere.
In summary, it seems probable that the lateraliza-
tion of such higher cortical functions as visuo-spatial
perception into the right and left hemispheres be-
come precisely reversed in non-right-handed patients
(mirror image), or that some areas overlap (anom-
alous patterns).
In the 11 cases where left-handedness was not a
factor, we found a consistent pattern of hemispheric
dominance: aphasia was present in 6 cases, Gerst-
mann’s syndrome in 4, and pure agraphia in 1. Ma-
nifestations of right unilateral spatial neglect, mostly
ideomotor apraxia and bucco-facial apraxia, disap-
peared within six months after onset. In these cases,
it is thought that dominant-hemisphere functions
such as language and limb praxis are sited as usual
in the left hemisphere, and the temporary appear-
ance of right unilateral spatial neglect is due to some
other factor. However, the fact that even such right-
handed patients are prone to occasional unilateral
omissions implies that the accepted qualitative dif-
ferences between the hemispheres are insufficient to
explain all phenomena. We must also consider the
possibility that lateralization of visuo-spatial func-
tion is not absolute. Four of the patients with Ger-
stmann’s syndrome and one of the patients with
pure agraphia also suffered from right unilateral spa-
tial neglect accompanied by hemianopsia and
anosognosia for visual field defect: however, symp-
toms were temporary and disappeared in a few
weeks. What is more, these symptoms were not ac-
companied by the classic signs of dysfunction in the
non-dominant hemisphere such as personal neglect
and difficulty with dressing. The pattern we have just
described concurs well with the theory of sensory
impairments proposed by Batterby et al. (18). In
Right unilateral spatial neglect
other words, unilateral spatial neglect is a form of
perceptual impairment that arises when elemental
perceptual disorders such as hemianopsia are com-
pounded by slight deterioration in attention and
arousal functions. The six right-handed patients with
severe aphasia also suffered from complications of
hemianopsia, hemiplegia and sensory impairment.
These observations lead us to believe that right uni-
lateral spatial neglect might be caused by a similar
mechanism. The difference is that symptoms persist
for several months longer when the area affected by
lesions is large and deterioration of arousal func-
tions and inattention are long. This also suggests the
possibility that the mechanism by which right uni-
lateral spatial neglect appears in purely right-handed
cases is different from that for cases in which left-
handedness is a factor. It has been reported that the
severe cases of unilateral spatial neglect are more
frequently seen in men than in women, and that
laterality for visuo-spatial perception is hgher (19).
In this study, there were no noticeable differences
between sex, age, and etiology. The number of the
cases in which right unilateral spatial neglect re-
mained was much larger in men. This seemed to be
because the number of non-right handers was larger
in men among the subjects studied.
Lesion sites thought to be responsible in cases of
left unilateral spatial neglect include, in addition to
the right temporo-parieto-occipital junction (20, 21),
the right frontal lobe (22), the right occipital lobe
(23), the right thalamus (24, 25), and right basal gan-
glia (26). Cases of right unilateral spatial neglect
have been reported as being caused by lesions in the
left temporo-parieto-occipital junction (1, 27), the
left occipital lobe (20), the left basal ganglia (20) and
the left frontal lobe (28), in addition to the frequently-
mentioned left parietal and temporal regions. CT
images of the 20 cases in this study showed that in
6 there were infarctions in the area supplied by the
left middle cerebral artery, ranging extensively across
the left temporal, parietal, occipital and frontal lobes.
In another nine cases there was extensive hemor-
rhagmg in the area extending from the left basal
ganglia through the capsula interna and thalamus.
Also, in five cases there was subcortical hemorrhag-
ing in the left parietal and occipital lobes. From these
observations, we confirmed that although lesions
may be seen in either hemisphere, the sites respon-
sible for appearance of unilateral spatial neglect all
fall in the parietal and occipital lobes, which are
regions generally-cited in connection with such dis-
orders. When we compared right-handers with non-
right-handers, we found that lesions are more com-
monly located in the parietal and temporal lobes.
Only in a few cases were lesions found to be re-
stricted to a small area in the parietal and occipital
lobes.
423
Maeshima et al.

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