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Cancer Immunology. Nima Rezaei. Mark Tomlin. Laurence Brunton. Deja Review Pharmacology, Second Edition. Jessica Gleason. Given the importance of attention to sensory and cognitive processing, it is not surprising that attentional disorders are among the most common and most devastating neurological conditions. The main attentional disorders are confusional states, partial domain-specific attentional syndromes, and hemispatial neglect. A confusional state or delirium is a global change in mental status wherein the principal cognitive deficit is a change in the overall attentional tone.
It is the most common disturbance of mental status seen by physicians. Associated symptoms can include incoherent thinking, distractibility, perceptual disturbances including illusions or hallucinations, dyscoordination, delusions, impaired judgement, reduced insight and agitation. Some of these disturbances may arise because of the attentional disorder while others may arise separately 2.
Patients in a confusional state are usually disoriented and their memory is impaired. They may appear to have mild-to-moderate associated cognitive deficits such as an anomia, dysgraphia, dyscalculia, or constructional difficulties 2. The attentional nature of these disturbances may become apparent if the patient is given additional assistance in a task. For example, extra-encoding trials on memory tests may allow the patient with a mild confusional state to overcome partially the apparent amnestic disturbance. Despite wide-spread cognitive disturbances, patients usually have no lateralizing neurological signs and primary motor and sensory functions are generally intact.
When neurological signs occur, they may include a coarse tremor, myoclonus or asterixis as an indicator of the patient's underlying metabolic disarray 2. Focal neurological signs may be seen, however, when the confusional state arises because of intrinsic central nervous system disease e.
The main causes of confusional states can be divided into six major classes, which are listed in Table 1. Referring back to Figure 1 , a confusional state can involve any of the levels of the attention-arousal system. The actual mechanisms of attentional disruptions include multifocal disorders, strategic focal lesions, or interference with neurotransmitter functions particularly cholinergic. As listed in Table 1 , the focal anatomical regions associated with a confusional state include the parahippocampal-fusiform-lingual gyri in either cerebral hemisphere, and right-sided lesions of the posterior parietal and inferior prefrontal cortex.
There have been few functional imaging studies of patients in a confusional state, probably because of the difficulties examining such patients. In a study of 50 patients undergoing cardiac surgery, six were found to have a delirium based on clinical examination Abnormalities were noted in the left temporoparietal region 5 of 9 patients , right temporoparietal region 4 of 9 , frontal cortex on the left 1 of 9 or right 3 of 9 , and the right occipital cortex 2 of 9.
Five of nine patients had two or more areas of involvement. In a single patient study, a SPECT scan demonstrated right parieto-occipital hypoperfusion in a delirious patient 2 , These functional imaging studies are consistent with the concept of a network of brain regions contributing to attention. Damage to any part of this network may produce a confusional state, although some regions e. These syndromes are not well defined because partial attentional impairments tend not to present as separately definable syndromes, rather they are manifest as reduced performance in one or more cognitive domains.
For example, changes in visual-based attention could result in reduced detection of stimuli in the environment, while changes in language-based attention could present as reduced verbal fluency. In both these examples, the clinician must be alert to the possibility of an attentional disruption rather than a visual disorder or an aphasia, respectively. Domain specific attention deficits have been produced in normal individuals using tasks based on the concept of inattentional stimulus processing. Such tasks present subjects with stimuli, which they either attend or ignore.
By examining the difference between the attend and ignore conditions, the effects of attention on domain specific processing can be observed. Rees and colleagues, for example, examined domain-specific attentional effects on letter string and picture processing They found that attention was able to influence, differentially, processing within the visual system for words left occipital activation versus pictures bilateral occipitotemporal activations even when the words and pictures were both presented simultaneously at fixation.
Attention to words also enhanced activations throughout the language system The last attentional disorder to be discussed is hemispatial neglect. This disorder, one of the most clinically dramatic in neurology, is characterized by the inability of the patient to orient towards, respond to, or report on, stimuli on the contralesional side of space Neglect is a multimodal deficit and may affect any or all sensory modalities, motor behaviours or even the internal representations of memories and other thoughts.
Most often, the left hemispace is neglected, as the disorder is more frequent and severe following right hemisphere injury. Clinically, the patient's head and eyes may be directed entirely towards the ipsilesional space usually right. When there is an accompanying motor deficit, the patient may deny any problem with the affected limb anosognosia , may say they are moving the limb normally as it hangs limply at their side, or may fail to recognize the affected limb as their own.
Patients with neglect may fail to groom themselves properly on the neglected side, or may fail to eat food on the neglected side of the dinner plate. It is important to note that basic sensory or motor disorders are not part of the neglect syndrome, although they may be present. The phenomenon of extinction may occur either together or separately from neglect. Extinction is diagnosed by the patient being able to detect stimuli presented separately to either side of space, but only detecting one of the stimuli usually right when they are presented simultaneously.
At times, the deficits associated with neglect are less dramatic and may only be apparent when the patient is asked to perform more specific tests such as bisecting lines or searching for targets among a set of irrelevant stimuli. Numerous theories have been proposed to account for the deficits in neglect. Unfortunately, space constrains any discussion other than just a listing of various theories and their chief proponents. Explanations have included a distortion of internal representations Bisiach , release of asymmetrically opposed attentional vectors Kinsbourne , impaired attention towards the affected hemispace Heilman and colleagues , impaired motor intentional behaviour Heilman , impaired disengagement of the attentional focus from ipsilesional stimuli Posner , distortion of the spatial reference frame Jeannerod, Karnath , multidimensional impairment of selective attention Mesulam , and altered premotor planning behaviours Rizzolatti 32 , Lesion sites causing neglect have been found throughout the network of cortical and subcortical areas responsible for attention.
Typically, the lesions are on the right. Only some functional imaging studies have demonstrated findings consistent with right hemispheric dominance for attention. Some of these studies have shown a greater number of activated regions on the right, while others have shown a larger size of the right-sided activations 19 — However, it can be difficult to show significant hemispheric differences in attentional activation studies personal observations and the true nature of this difference may have to await a finer analysis of the time-course of these activations.
Only a few recent studies have been able to examine directly the deficits of neglect and extinction with functional imaging technology.
Vuilleumier and colleagues studied a patient with neglect due to a right parietal lesion, who had intact visual fields Event-related fMRI was used to show that non-perceived stimuli still activated the visual cortex. When stimuli were occasionally perceived, the visual cortex activations were expanded and activations were also seen in the left parietal cortex. Measures of inter-regional correlations involving frontal, parietal and visual areas also increased when the subject was aware of a stimulus.
This study confirmed both bottom-up and top-down aspects of attentional processing, and was consistent with the theory that attention may be critical for conscious awareness 31 , Numerous recent imaging studies have begun to reveal the multifaceted nature of attentional behaviour and its disturbances.
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More importantly, long-held theories regarding attentional contributions to perceptual processing, motor selection and the internal choice of particular thoughts can now be studied directly. Event-related fMRI, event-related potential studies and newer studies with magneto-encephalography will allow improved spatial and temporal localization of the processes underlying this important aspect of cognition. However, the multimodal and protean nature of the disturbances may make them difficult to recognize.
Identifying this class of disturbances is important when trying to distinguish disorders within a modality versus a partial deficit of attention. For example, in examining patients with memory complaints, it is critical to demonstrate whether the patient has a true amnestic disturbance versus a disorder of attention, as the anatomy and treatment of the associated disorders may be very different. Because of the nature of neglect, i. Oxford University Press is a department of the University of Oxford.
It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Attentional components. Anatomical and behavioural models. Disorders of attention. Key points for clinical practice. Attention and its disorders: Imaging in clinical neuroscience Darren R Gitelman. Oxford Academic.
Google Scholar. Cite Citation. Permissions Icon Permissions. Abstract This chapter focuses on the clinical aspects of attention including anatomy, cognitive neuropsychology, disorders, and functional imaging evidence for the role of attention in cognition. View large Download slide. Table 1. View Large. James W. The Principles of Psychology. Mesulam M-M. Confusional states and spatial neglect. The antimicrobial activity of nanoparticles: present situation and prospects for the future. Int J Nanomedicine.
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