Neglect

Victor W Mark MD (Dr. Mark of the University of Alabama at Birmingham has no relevant financial relationships to disclose.)
Originally released November 15, 1997; last updated September 21, 2016; expires September 21, 2019

This article includes discussion of neglect, amorphosynthesis, dyschiria, hemi-inattention, hemineglect, hemispatial neglect, unilateral neglect, unilateral spatial neglect, visual neglect, visuospatial neglect, anosognosia, and extinction. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Unilateral spatial neglect, or “neglect” for short, commonly follows the acute onset of focal hemispheric brain disease. It is identified by a bias of spatial attention that is usually toward the side of brain injury, thus neglect for the opposite side of space. This article indicates that neglect is distinct from other hemibody deficits of movement (hemiparesis) or perception (hemianopia, hemianesthesia) because the spatial deficit can be overcome by cuing or increasing motivation, such as through reward. Nonetheless, the disorder commonly signifies a profound impairment in recovery of self-care abilities. Significant and selective unilateral spatial errors can emerge following disorders after either “pure” hemianopia or, more perplexing, the complex regional pain syndrome (CPRS), which can follow limb trauma.

Key points

 

• Neglect is a common consequence of focal brain injury.

 

• Neglect is easily assessed with bedside evaluations.

 

• Neglect commonly predicts impaired recovery of self-care after brain injury, although it is not yet clear whether functional impairment is primarily from neglect itself or from other, concurrent cognitive deficits.

 

• Neglect tends to improve in most persons following acute brain injury, but chronically can remain in a small proportion of patients.

 

• No standard of rehabilitation care has thus far been developed for neglect.

Historical note and terminology

Neglect appears to have not received the same scrutiny in the 19th century as the aphasias, agnosias, and apraxias. Late 19th century experiments in laboratory mammals induced asymmetric behavior that could not be accounted for by hemiblindness or hemiparesis (Bianchi 1895; Fishman 1995; Pearce 1995). In the 1880s, Loeb obtained asymmetric responses to bilateral simultaneous stimulation (extinction) in animals, which was quickly confirmed in humans by Oppenheim (Benton 1956). In 1865, Prevost reported that Vulpian had found contralesional conjugate eye deviation following brain injury in humans (Goodwin and Kansu 1986), which if not precisely neglect, is closely related. Jackson reported a British patient whose right hemisphere tumor was associated with a right-to-left reading approach to an eye chart, which the patient could not explain (Jackson 1876). In the early part of the 20th century, Zingerle described neglect as a disorder of spatial representations (Zingerle 1913). Poppelreuter, and then Brain, emphasized the role of spatial attention in the underlying deficit in neglect (Poppelreuter 1917; Brain 1941). In the 1950s, Denny-Brown introduced the notion of "amorphosynthesis," meaning that patients with neglect were unable to synthesize contralateral stimuli into coherent percepts (Denny-Brown and Banker 1954). Systematic theoretical approaches to neglect emerged in the 1970s.

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