Unveiling residual, spontaneous recovery from subtle hemispatial neglect three years after stroke

A common and disabling consequence of stroke is the difficulty in processing contralesional space (i.e., hemispatial neglect). According to paper-and-pencil tests, neglect remits or stabilizes in severity within a few months after a brain injury. This arbitrary temporal limit, however, is at odds with neglect's well-known dependency on task-sensitivity. The present study tested the hypothesis that the putative early resolution of neglect might be due to the insensitivity of testing methods rather than to the lack of spontaneous recovery at later stages. A right hemisphere stroke patient was studied longitudinally for 3 years. According to paper-and-pencil tests the patient showed no symptom of hemispatial neglect 1 month post stroke. Awareness of spatially lateralized visual targets was then assessed by means of computer-based single- and dual-tasks requiring an additional top-down deployment of attention for the parallel processing of visual or auditory stimuli. Errorless performance at computer-based tasks was reached at month 12 and maintained until month 29 after stroke. A bottom-up manipulation was then implemented by reducing target diameter. Following this change, more than 50% of contralesional targets were omitted, mostly under dual-tasking. At months 40 and 41 the same task revealed a significant (but not complete) reduction in the number of contralesional omissions. Ipsilesional targets were, in contrast, still errorless detected. The coupling of a bottom-up (target change) and a top-down (dual-tasking) manipulation revealed the presence of a long-lasting spontaneous recovery from contralesional spatial awareness deficits. In contrast, neither manipulation was effective when implemented separately. After having excluded the potential confound of practice effects, it was concluded that not only the presence but also the time course of hemispatial neglect strongly depends on the degree of attentional engagement required by the task.