Is there a relationship between perseverations and spatial short-term memory deficits in unilateral neglect?

Introduction
Spatial neglect is a multicomponent syndrome characterized by an inability to orient or to respond to stimuli arising in the hemispace contralateral to a brain lesion. According to many authors, spatial neglect can be explained by an attentional deficit, and more specifically by a lateral attentional bias towards the right (magnetic attraction) and/or difficulties in disengaging attention from items to the right side. However, attentional theories are not sufficient to explain some behaviors such as revisiting and perseverations. Recently, it has been suggested that revisiting and perseveration behaviors in visual search tasks shown in parietal neglect could be related to impairments in visuo-spatial working memory (Husain et al., 2001; Malhotra et al., 2005; Malhotra, Mannan, Driver, & Husain, 2004). This hypothesis is supported by studies (1) in which a contrast is made between cancellation tasks with and without visual control, the absence of visual feedback increasing left neglect (omissions) and repeated cancellations (perseverations) towards the ipsilesional space, and (2) in which the Corsi test is administrated in a vertical way.

However, Ronchi et al. (2009) did not confirm the link between impairments in spatial short-term memory and perseverations. Indeed, these authors found no correlation between perseverations in star cancellation and spatial memory performance in the Corsi test. Nevertheless, they did not use a condition without visual feedback, which is considered as involving more spatial short-term memory than a condition with visual feedback. This methodological choice could explain the lack of relationship between short-term memory and perseverations in the Ronchi et al.’s study.
The purpose of our study was to test the hypothesis of a spatial short-term memory deficit being an explanatory factor of perseverations in unilateral neglect.
Methods
We assessed twenty right-damaged patients suffering from left neglect. Neglect signs were evaluated with the Batterie d’Evaluation de la Négligence (BEN) (Azouvi et al., 2002). Twenty healthy older participants matched for age and sociocultural level served as controls.
In order to explore the relationship between perseverations and spatial short-term memory, two different tasks were administrated: a computerized version of the Corsi test and a cancellation task. All tests were computerized and presented on a touchscreen.
The subject’s spatial span corresponded to the longest sequence in which at least three out of four sequences were correctly reproduced. The cancellation task consisted of 32 “O” presented in two conditions: with (visible) and without (invisible) visual feedback. Patients were instructed to cancel out all targets only once. The number of omissions and perseverations was calculated for each participant in both conditions.
Results
Control participants performed better than neglect patients in the Corsi test; eleven neglect patients showed a deficit in spatial short-term memory.
In the cancellation tasks, Wilcoxon matched-pairs signed ranks tests highlighted that perseverations and omissions were greater in the invisible condition for each group. In this condition, neglect patients made more omissions and perseverations (all ps <.05) than control subjects, while in the visible condition there was only a significant difference for the omissions. However, spatial short-term memory did not explain perseverations in invisible condition (R² = .17, F(1,18) = 3.66, p = .07).

Discussion
These findings suggest that a spatial short-term memory deficit cannot be considered as an explanatory factor for the perseveration behavior in unilateral neglect. Moreover, perseverations and omissions were greater in the invisible condition than in the visible one; therefore, the hypothesis of the magnetic attraction is not confirmed either. In the neglect patients’ group, the visual feedback decreases, and even eliminates the neglect symptoms (omissions and perseverations) compared to the invisible condition. In other words, the presence of visual feedback can help patients to explore their visual environment.
We propose that, in the invisible condition, difficulties to plan a visual search could exacerbate both omissions and perseverations, leading to recursive search towards the right side of the space and thus promote failure to explore left space. However, further investigations will be necessary to confirm this hypothesis.