Examqo › Examqo library › Physical medicine and rehabilitation › Stroke and cognition
Spatial neglect, agnosia, apraxia and cognitive rehabilitation
Spatial neglect is a failure of attention to one side of space — usually the left, after a right parietal lesion — not a failure of vision; so a patient with neglect does not compensate by turning the head as a patient with hemianopia does, and it predicts harder rehabilitation.
Why it matters in the exam
The exam describes a patient who eats from one side of the plate only, shaves half the face or bumps into the door frame, and asks which lesion caused it, how it is diagnosed and how it is treated. The tests: line bisection, cancellation tasks, figure copying and the BIT (Behavioural Inattention Test), which includes conventional tests and everyday tasks; the Catherine Bergego Scale assesses neglect in function. Denial of illness (anosognosia) often accompanies neglect and makes rehabilitation harder.
Treatments divide into "top-down" approaches — cognitive strategies the patient learns consciously, such as visual scanning training with an anchor — and "bottom-up" approaches — sensory stimulation that changes spatial representation without conscious effort, such as prism adaptation, neck muscle vibration and left limb activation. Restorative rehabilitation, which tries to improve the impaired ability, is also distinguished from compensatory rehabilitation, which changes the environment or the way a task is done — for example placing objects on the intact side or using a diary and reminders.
Visual object agnosia (bilateral occipitotemporal lesion): the patient sees but cannot recognise an object by sight, and recognises it by touch. Prosopagnosia — failure to recognise faces (fusiform gyrus). Balint syndrome (bilateral parieto-occipital lesion): simultanagnosia, optic ataxia and oculomotor apraxia. Gerstmann syndrome (left angular gyrus): agraphia, acalculia, finger agnosia and right-left confusion. Ideomotor apraxia (left parietal) — the patient cannot perform a purposeful movement on command or by imitation, although strength is normal. "Utilization behaviour" — compulsive use of objects in the surroundings — indicates a frontal lesion. Executive function is assessed with the BADS, and everyday memory with the RBMT.
Key points
- Neglect — usually left-sided, after a right parietal lesion.
- Tests: line bisection, cancellation and BIT.
- Top-down — conscious scanning; bottom-up — prisms and sensory stimulation.
- Gerstmann — left angular gyrus; Balint — bilateral parieto-occipital.
- BADS for executive function, RBMT for everyday memory.
Summary table
| Syndrome | Lesion site | Clinical clue |
|---|---|---|
| Left neglect | Right (inferior) parietal | Eats from half the plate, ignores the left, does not compensate by head turning |
| Visual object agnosia | Bilateral occipitotemporal | Cannot recognise by sight, recognises by touch |
| Balint | Bilateral parieto-occipital | Sees one detail at a time, reaches inaccurately |
| Gerstmann | Left angular gyrus | Agraphia, acalculia, finger agnosia, right-left confusion |
| Ideomotor apraxia | Left parietal | Cannot imitate a movement on command, normal strength |
| Utilization behaviour | Frontal | Uses any object placed in front of them |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Physical medicine and rehabilitation.
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- AHA/ASA Guidelines for Adult Stroke Rehabilitation and Recovery, 2016 — Spatial neglect and cognitive impairment
- Braddom's Physical Medicine and Rehabilitation, 6th edition (2021) — Cognitive Impairment and Rehabilitation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.