TARGETED TREATMENT FOR SPATIAL NEGLECT AFTER CEREBELLAR STROKE: A CASE REPORT

F. Aloba¹, T. Kesar², Q. Lin³, A. Barrett³

¹Emory University, Graduate Neuroscience Program & School of Medicine, Department of Physical Therapy, Atlanta, United States, ²Emory University, Emory University School of Medicine, Department of Physical Therapy, Atlanta, Georgia, United States, ³Emory University, School of Medicine, Department of Neurology, Atlanta, GA, United States

Background: Physical Therapy best practice involves selecting evidence-based, domain-specific stroke treatments, including cognitive treatments for problems that affect mobility such as spatial neglect. Spatial neglect, a deficit after a stroke, is defined as asymmetric spatial performance causing functional disability. Spatial neglect is traditionally regarded as a cortical syndrome, however, left cerebellar injury may also result in spatial neglect symptoms, but researchers suggest that cerebellar spatial neglect does not improve with PAT. Therefore, we prospectively followed a patient with a cerebellar lesion and evidence of chronic spatial neglect and applied Prism Adaptation Therapy (PAT) to evaluate its effects on spatial neglect deficits.

Purpose: The purpose ofthis case study was to learn whether applying a targeted and evidence-based spatial neglect treatment, prism adaptation therapy (PAT) in a subject with a cerebellar stroke, would show clinical improvement.

Methods: In this case study, we evaluated CD, a 59-year-old right-handed man, who had an ischemic left cerebellar and right occipital lobes stroke (April 2020). In December 2020, neurologic examination revealed left homonymous hemianopsia, memory deficit, and left sided arm (4/5 muscle strength) and leg weakness (4-/5 muscle strength). He was then referred for neuropsychological testing for spatial neglect due to complaints of bumping into objects in the left space. In January 2021, functional mobility and neuropsychological testing revealed that he was in the normal range in the Behavioral Inattention Test-conventional (BIT-c) (140/146). He was at least Modified Independent for all Functional Independence Measures (FIM)with no assistive device, except two (Memory (Minimum Assist), and Problem solving (Supervision). However, the Catherine Bergego Scale (CBS) spatial neglect assessment with predictive validity to identify limitations in daily life independence, revealed asymmetric gaze orientation, limb awareness, grooming, navigation, and collisions(adjusted score = 13.3; moderate spatial neglect).He received ten sessions of prism adaptation therapy per clinical protocol and demonstrated visuomotor adaptation.

Results: We performed post-PAT reassessment.There was objective spatial neglect improvement (post-PAT CBS = 4.3; mild spatial neglect, improvement in gaze orientation, grooming, and collisions domains),and self-reported improved navigation and reduced collisions post PAT. The subject also maintained the normal range post-PAT on a paper and pencil spatial neglect measure, BIT-c (138/146).

Conclusions: CD had chronic spatial neglect 8 months after cerebellar stroke, which improved after receiving PAT.Other authors suggested that the cerebellum critically mediates PAT effect therefore individuals with lesions in cerebellum may not respond to PAT. However, improvements seen in subject CD after PAT suggests individuals with cerebellar lesions can show improvements in spatial bias in response to PAT, this is because fronto-subcortical white matter connections, or connections through a collicular-cortical system may actually mediate PAT response.

Implications: In conclusion, this case report supports spatial cognitive evaluation by rehabilitation clinicians, and the trialing PAT in individuals with cerebellar lesions and spatial neglect whether at acute or chronic stages. Further studies should include people with and without cerebellar lesions or with lesions affecting different cerebellar regions who show a range of spatial neglect symptoms.

Funding acknowledgements: This study was supported by VHA, Atlanta GA/1I21RX003760-01."A biomarker for personalized care in post-stroke spatial neglect". (PI:A.M. Barrett) 2021-2023.

Keywords:
Stroke
Spatial Neglect
Prism Adaptation Therapy

Topics:
Neurology: stroke
Disability & rehabilitation
Neurology

Did this work require ethics approval? Yes

Institution: Emory University, Atlanta Georgia, United States of America

Committee: Emory University Institutional Review Board

Ethics number: STUDY00002235