The relationships between spatial attention and conscious perception are currently the object of intense debate. Recent evidence of double dissociations between attention and consciousness cast doubt on the time-honored concept of attention as a gateway to consciousness. Here we review evidence from behavioral, neurophysiologic, neuropsychological, and neuroimaging experiments, showing that distinct sorts of spatial attention can have different effects on visual conscious perception. While endogenous, or top-down attention, has weak influence on subsequent conscious perception of near-threshold stimuli, exogenous, or bottom-up forms of spatial attention appear instead to be a necessary, although not sufficient, step in the development of reportable visual experiences. Fronto-parietal networks important for spatial attention, with peculiar inter-hemispheric differences, constitute plausible neural substrates for the interactions between exogenous spatial attention and conscious perception.

Objectives: The lack of agreement regarding assessment methods is responsible for the variability in the reported rate of occurrence of spatial neglect after stroke. The aim of this study was to assess the sensitivity of different tests of neglect after right hemisphere stroke. Methods: Two hundred and six subacute right hemisphere stroke patients were given a test battery including a preliminary assessment of anosognosia and of visual extinction, a clinical assessment of gaze orientation and of personal neglect, and paper and pencil tests of spatial neglect in the peripersonal space. Patients were compared with a previously reported control group. A subgroup of patients (n=69) received a behavioural assessment of neglect in daily life situations. Results: The most sensitive paper and pencil measure was the starting point in the cancellation task. The whole battery was more sensitive than any single test alone. About 85% of patients presented some degree of neglect on at least one measure. An important finding was that behavioural assessment of neglect in daily life was more sensitive than any other single measure of neglect. Behavioural neglect was considered as moderate to severe in 36% of cases. A factorial analysis revealed that paper and pencil tests were related to two underlying factors. Dissociations were found between extrapersonal neglect, personal neglect, anosognosia, and extinction. Anatomical analyses showed that neglect was more common and severe when the posterior association cortex was damaged. Conclusions: The automatic rightward orientation bias is the most sensitive clinical measure of neglect. Behavioural assessment is more sensitive than any single paper and pencil test. The results also support the assumption that neglect is a heterogeneous disorder.

Intraoperative electrical stimulation, which temporarily inactivates restricted regions during brain surgery, can map cognitive functions in humans with spatiotemporal resolution unmatched by other methods. Using this technique, we found that stimulation of the right inferior parietal lobule or the caudal superior temporal gyrus, but not of its rostral portion, determined rightward deviations on line bisection. However, the strongest shifts occurred with subcortical stimulation. Fiber tracking identified the stimulated site as a section of the superior occipitofrontal fasciculus, a poorly known parietal-frontal pathway. These findings suggest that parietal-frontal communication is necessary for the symmetrical processing of the visual scene.

Unilateral spatial neglect is a disabling neurological condition that typically results from right hemisphere damage. Neglect patients are unable to take into account information coming from the left side of space. The study of neglect is important for understanding the brain mechanisms of spatial cognition, but its anatomical correlates are currently the object of intense debate. We propose a reappraisal of the contribution of disconnection factors to the pathophysiology of neglect based on a review of animal and patient studies. These indicate that damage to the long-range white matter pathways connecting parietal and frontal areas within the right hemisphere may constitute a crucial antecedent of neglect. Thus, neglect would not result from the dysfunction of a single cortical region but from the disruption of large networks made up of distant cortical regions. In this perspective, we also reexamined the possible contribution to neglect of interhemispheric disconnection. The reviewed evidence, often present in previous studies but frequently overlooked, is consistent with the existence of distributed cortical networks for orienting of attention in the normal brain, has implications for theories of neglect and normal spatial processing, opens perspectives for research on brain-behavior relationships, and suggests new possibilities for patient diagnosis and rehabilitation.

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The exact anatomical localization of right hemisphere lesions that lead to left spatial neglect is still debated. The effect of confounding factors such as acute diaschisis and hypoperfusion, visual field defects, and lesion size may account for conflicting results that have been reported in the literature. Here, we present a comprehensive anatomical investigation of the gray- and white matter lesion correlates of left spatial neglect, which was run in a sample 58 patients with subacute or chronic vascular strokes in the territory of the right middle cerebral artery. Standard voxel-based correlates confirmed the role played by lesions in the posterior parietal cortex (supramarginal gyrus, angular gyrus, and temporal-parietal junction), in the frontal cortex (frontal eye field, middle and inferior frontal gyrus), and in the underlying parietal-frontal white matter. Using a new diffusion tensor imaging-based atlas of the human brain, we were able to run, for the first time, a detailed analysis of the lesion involvement of subcortical white matter pathways. The results of this analysis revealed that, among the different pathways linking parietal with frontal areas, damage to the second branch of the superior longitudinal fasciculus (SLF II) was the best predictor of left spatial neglect. The group study also revealed a subsample of patients with neglect due to focal lesion in the lateral-dorsal portion of the thalamus, which connects the premotor cortex with the inferior parietal lobule. The relevance of fronto-parietal disconnection was further supported by complete in vivo tractography dissection of white matter pathways in 2 patients, one with and the other without signs of neglect. These 2 patients were studied both in the acute phase and 1 year after stroke and were perfectly matched for age, handedness, stroke onset, lesion size, and for cortical lesion involvement. Taken together, the results of the present study support the hypothesis that anatomical disconnections leading to a functional breakdown of parietal-frontal networks are an important pathophysiological factor leading to chronic left spatial neglect. Here, we propose that different loci of SLF disconnection on the rostro-caudal axis can also be associated with disconnection of short-range white matter pathways within the frontal or parietal areas. Such different local disconnection patterns can play a role in the important clinical variability of the neglect syndrome.

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