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562 5Journal of Neurology, Neurosurgery, and Psychiatry 1992;55:562-565

Directional hypokinesia in spatial hemineglect: case study
G Bottini, R Sterzi, G Vallar


Abstract A patient with an ischaemic lesion involving the right frontal lobe and basal ganglia showed left spatial hemineglect in visuomotor exploratory tasks, requiring the use of the right unaffected hand. Her performancewas, however, entirely preserved, with no evidence of neglect, when she was required to identify targets among distractors in both the left and right halves of space, and in the Wundt-Jastrow illusion test. The latter tasks do not require any arm movement in extrapersonal space. In this patient spatial hemineglect may be explained in terms of defective organisation of movements towards the lefthalf-space (directional hypokinesia). The frontal lesion of the patient may be the neural correlate of this selective disorder. This pattern of impairment may be contrasted with the typical deficit found in patients with right brain damage with perceptual neglect. One case had a defective performance both in visuomotor and in purely perceptual tasks. Patients with spatial hemineglect typically failto explore the half-space contralateral to the

head and eyes. Neurological examination revealed a left hypotonic hemiplegia with enhanced left tendon reflexes and a left Babinski sign, and a severe left hypoaesthesia for touch, pinprick and proprioceptive stimulations. On confrontation, the patient could accurately detect single left- and right-sided visual stimuli, but showed left extinction onbilateral simultaneous stimulation. The patient was aware of her motor deficits and did not show personal neglect for her left limbs. Blood pressure was 130/180 mm Hg, pulse 80/min, and temperature 36°C. Respiration was regular at a normal rate. Routine blood and urine examination gave normal results. ECG, chest x-ray and perfusion lung scan confirmed pulmonary embolism. A CT performed a weekafter stroke onset, showed a right corticosubcortical hypodense area involving the dorso-lateral frontal regions and the basal ganglia, and extending posteriorly into the anterior parietal cortex. Two weeks later a second CT revealed haemorrhagic infarction (fig 1).

side of the cerebral lesion. This exploratory deficit may be due to their inability to plan and initiate movements towards theneglected halfspace, even when the unaffected ipsilateral hand is used. This premotor deficit (directional hypokinesia) may be distinguished from the perceptual aspects of spatial hemineglect.1-3 We report a patient with right brain damage with a frontal lesion, who showed a dissociation between hypokinetic and perceptual aspects of spatial hemineglect. This pattern of performance is contrasted with thebehaviour of a second patient with a temporo-parietal lesion and a perceptual visuo-spatial neglect.
Divisione di Neurologia, Ospedale di Niguarda, Milan G Bottini
R Sterzi Istituto di Clinica

Case Reports

Neurologica, UniversitA di Milano, Milan, Italy
Dr Vailar, Istituto di Clinica Neurologica, Universita di Milano, Via F Sforza 35, 20122, Milan, Italy Received 18 March 1991and in revised form 12 September 1991. Accepted 28 October 1991

G Vallar Correspondence


A 49 year old right handed housekeeper with five years of schooling was admitted to hospital for suspected pulmonary thromboembolism and right inferior limb thrombophlebitis. She had had no previous psychiatic or neurological disease. On admission the patient was treated with heparin, amoxicillinand ranitidine. Two days later she suddenly developed a left hemiplegia. A few minutes after the onset of symptoms the patient was alert and cooperative, with a steady rightward deviation of the

Neuropsychological assessment Baseline tests. The patient was examined two weeks after the onset of stroke. She had a left hemiplegia, hypoaesthesia and visual extinction, while she recovered from the...