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Images in Neurology
January 27, 2020

Horizontal and Vertical Boundaries of Hemineglect—The Puzzling Case of a Crossword Puzzle

Author Affiliations
  • 1Perception and Eye Movement Laboratory, Departments of Neurology and Biomedical Research, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
  • 2Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
JAMA Neurol. 2020;77(3):390-391. doi:10.1001/jamaneurol.2019.4814

A 65-year-old woman had a right-hemispheric ischemic stroke in the territory of the middle cerebral artery (Figure 1). After short-term treatment, the patient was transferred to the neurorehabilitation clinic. Neurological examination results showed left-sided hemiparesis with dysarthria and left-sided visual hemineglect but no visual field defects. The patient had always been an avid crossword puzzle solver, and she resumed this hobby during her first neurorehabilitation days. An example page of her crossword puzzle book is depicted in Figure 2A. The first immediately observable phenomenon was a typical performance pattern for severe visual hemineglect: the entire left side of the page, as well as a small portion of the paracentral right side, were left completely unsolved. However, a closer inspection revealed a second novel and puzzling phenomenon: in the right, paracentral page portion, the patient solved only vertical words, whereas in a more peripheral, right page portion, she solved both vertical and horizontal words. This was also evident by analyzing performance according to the 39 crossword columns (Figure 2A). The first word, a vertical one, was solved at column 22. In columns 22 to 29, exclusively vertical words were solved (in dark shading in wFigure 2A). Only at column 30, the patient started solving horizontal words (in light shading in Figure 2A). Interestingly, in the right paracentral page portion, the patient did not solve horizontal words even when their starting cell coincided with the one of an already solved vertical word, suggesting a high selectivity of the vertical dimension in this page portion. Indeed, the analysis of the horizontal and vertical items of the crossword puzzle with the same starting cell (Figure 2B), revealed a median (interquartile range) starting position of 27.5 (4) for vertical words and 36 (10) for horizontal words.

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