Unconscious activation of visual cortex in the damaged right hemisphere of a parietal patient with extinction

Visual extinction is a sign classically associated with right parietal damage. The patient can see a single stimulus presented in the ipsilesional or contralesional visual field, but is characteristically unaware of the same contralesional stimulus during simultaneous stimulation of both fields. The ipsilesional stimulus is said to 'extinguish' the contralesional stimulus from awareness during bilateral stimulation, perhaps due to a pathological bias in attention towards the ipsilesional side. Recent psychophysical evidence suggests that, although extinguished stimuli are not consciously seen, they may undergo residual processing and exert implicit effects on performance. However, the neural structures mediating such residual processing for extinguished stimuli remain unknown. Here we studied the neural activity evoked by an extinguished visual stimulus, using event-related functional MRI (fMRI), in a patient with circumscribed right inferior parietal damage and profound left-sided extinction. Monochrome objects (faces or houses) were presented in the left or right field, either unilaterally or bilaterally on each trial, with the patient indicating by button press whether he saw an object on the left, the right or on both sides. He usually saw only the right object on bilateral trials, yet the fMRI data showed activation of visual cortex contralateral to the extinguished left stimulus on these trials (compared with right-only stimulation), in both striate and early extrastriate areas of the right hemisphere. This activity had a similar location and time-course to that resulting from a single stimulus in the left versus right visual field. Cortical pathways involved in the normal processing of a single seen stimulus can thus still be activated by an unseen, extinguished stimulus after right parietal damage. Comparison of fMRI responses for faces versus houses revealed some category-specific activation for extinguished stimuli in right fusiform regions, but only at low statistical threshold. These results are discussed in terms of theoretical accounts for parietal extinction and, more generally, for the neural substrates of visual awareness.