Reference no: EM133333020

Case Study: Mrs S., an intelligent woman in her sixties, has suffered a massive stroke, affecting the deeper and back portions of her right cerebral hemisphere. She has perfectly preserved intelligence - and humor.She sometimes complains to the nurses that they have not put dessert or coffee on her tray. When they say, 'But, Mrs S., it is right there, on the left', she seems not to understand what they say, and does not look to the left. If her head is gently turned, so that the dessert comes into sight, in the preserved right half of her visual field, she says, 'Oh, there is it - it wasn't there before'. She has totally lost theidea of 'left', with regard to both the world and her own body. Sometimes she complains that her portions are too small, but this is because she only eats from the right half of the plate - it does not occur to her that it has a left half as well. Sometimes, she will put on lipstick, and make up the right half of her face, leaving the left half completely neglected: it is almost impossible to treat these things, because her attention cannot be drawn to them ('hemi-inattention' - see Battersby 1956) and she has no conception that they are wrong. She knows it intellectually, and can understand, and laugh; but it is impossible for her to know it directly.Knowing it intellectually, knowing it inferentially, she has worked out strategies for dealing with her imperception. She cannot look left, directly, she cannot turn left, so what she does is to turn right - and right through a circle. Thus she requested, and was given, a rotating wheelchair. And now if she cannot find something which she knows should be there, she swivels to the right, through a circle, until it comes into view. She finds this signally successful if she cannot find her coffee or dessert. If her portions seem too small, she will swivel to the right, keeping her eyes to the right, until the previously missed half now comes into view; she will eat this, or rather half of this, and feel less hungry than before. But if she is still hungry, or if she thinks on the matter, and realizes that she may have perceived only half of the missing half, she will make a second rotation till the remaining quarter comes into view, and, in turn, bisect this yet again. This usually suffices - after all, she has now eaten seven-eighths of the portion - but she may, if she is feeling particularly hungry or obsessive, make a third turn, and secure another sixteenth of her portion (leaving, of course, the remaining sixteenth, the left sixteenth, on her plate). 'It's absurd,' she says. 'I feel like Zeno's arrow - I never get there. It may look funny, but under the circumstances what else can I do?'

It would seem far simpler for her to rotate the plate than rotate herself. She agrees, and has tried this - or at least tried to try it. But it is oddly difficult, it does not come naturally, whereas whizzing round in her chair does, because her looking, her attention, her spontaneous movements and impulses, are all now exclusively and instinctively to the right.

Especially distressing to her was the derision which greeted her when she appeared only half made- up, the left side of her face absurdly void of lipstick and rouge. 'I look in the mirror,' she said, 'and do all I see.' Would it be possible, we wondered, for her to have a 'mirror' such that she would see the left side of her face on the right? That is, as someone else, facing her, would see her. We tried a video system, with camera and monitor facing her, and the results were startling, and bizarre. For now, using the video screen as a 'mirror', she did see the left side of her face to her right, an experience confounding even to a normal person (as anyone knows who has tried to shave using a video screen), and doubly confounding, uncanny, for her, because the left side of her face and body, which she now saw, had no feeling, no existence, for her, in consequence of her stroke. 'Take it away!' she cried, in distress and bewilderment, so we did not explore the matter further. This is a pity because, as R. L. Gregory also wonders, there might be much promise in such forms of video feedback for such patients with hemi-inattention and left hemi-field extinction. The matter is so physically, indeed metaphysically, confusing that only experiment can decide.

Postscript

Computers and computer games (not available in 1976, when I saw Mrs S.) may also be invaluable to patients with unilateral neglect in monitoring the 'missing' half, or teaching them to do this themselves;

I have recently (1986) made a short film of this. I could not make reference, in the original edition of this book, to a very important book which came out almost simultaneously: Principles of Behavioral Neurology (Philadelphia: 1985), edited by M. Marsel Mesulam. I cannot forbear quoting Mesulam's hen the neglect is severe, the patient may behave almost as if one half of the universe had abruptly ceased to exist in any meaningful form.... Patients with unilateral neglect behave not only as if nothing were actually happening in the left hemispace, but also as if nothing of any importance could be expected to occur there.

Questions:

What part of the brain would you suspect is involved?
What treatment approach would you recommend?
How should this treatment approach be executed in a treatment session? Any challenges you envision in executing the treatment?
How might the principle of neuroplasticity factor into your treatment plans?