This review illustrates how, after unilateral brain damage, the presence and severity of spatial awareness deficits for the contralesional hemispace depend greatly on the quantity of attentional resources available for performance. After a brief description of neglect and extinction, different frameworks accounting for spatial and non-spatial attentional processes will be outlined. The central part of the review will describe how the performance of brain damaged patients is negatively affected by increased task demands, which can result in the emergence of severe awareness deficits for contralesional space even in patients who perform normally on paper-and-pencil tests. Throughout the review neglect is described as a spatial syndrome that can be exacerbated in the presence and severity by both spatial and non-spatial tasks. The take-home message is that the presence and degree of contralesional neglect and extinction can be dramatically overlooked based on standard paper-and-pencil testing, where patients can easily compensate for their deficits. Only tasks where compensation is made impossible represent an appropriate approach to detect these disabling contralesional deficits of awareness that become subtle in post-acute stroke phases.

Numerical fractions are commonly used to express ratios and proportions (i.e., real numbers), but little is known about how they are mentally represented and processed by skilled adults. Four experiments employed comparison tasks to investigate the distance effect and the effect of the spatial numerical association of response codes (SNARC) for fractions. Results showed that fractions were processed componentially and that the real numerical value of the fraction was not accessed, indicating that processing the fraction's magnitude is not automatic. In contrast, responses were influenced by the numerical magnitude of the components and reflected the simple comparison between numerators, denominators, and reference, depending on the strategy adopted. Strategies were used even by highly skilled participants and were flexibly adapted to the specific experimental context. In line with results on the whole number bias in children, these findings suggest that the understanding of fractions is rooted in the ability to represent discrete numerosities (i.e., integers) rather than real numbers and that the well-known difficulties of children in mastering fractions are circumvented by skilled adults through a flexible use of strategies based on the integer components.

Converging evidence suggests that visuospatial attention plays a pivotal role in numerical processing, especially when the task involves the manipulation of numerical magnitudes. Visuospatial neglect impairs contralesional attentional orienting not only in perceptual but also in numerical space. Indeed, patients with left neglect show a bias towards larger numbers when mentally bisecting a numerical interval, as if they were neglecting its leftmost part. In contrast, their performance in parity judgements is unbiased, suggesting a dissociation between explicit and implicit processing of numerical magnitude. Here we further investigate the consequences of these visuospatial attention impairments on numerical processing and their interaction with task demands. Patients with right hemisphere damage, with and without left neglect, were administered both a number comparison and a parity judgement task that had identical stimuli and response requirements. Neglect patients’ performance was normal in the parity task, when processing of numerical magnitude was implicit, whereas they showed characteristic biases in the number comparison task, when access to numerical magnitude was explicit. Compared to patients without neglect, they showed an asymmetric distance effect, with slowing of the number immediately smaller than (i.e., to the left of) the reference and a stronger SNARC effect, particularly for large numbers. The latter might index an exaggerated effect of number-space compatibility after ipsilesional (i.e., rightward) orienting in number space. Thus, the effect of neglect on the explicit processing of numerical magnitude can be understood in terms of both a failure to orient to smaller (i.e., contralesional) magnitudes and a difficulty to disengage from larger (i.e., ipsilesional) magnitudes on the number line, which resembles the disrupted pattern of attention orienting in visual space.

Recent studies suggest that stimuli with directional meaning can trigger lateral shifts of visuospatial attention when centrally presented as noninformative cues. We investigated covert orienting in healthy participants and in a group of 17 right brain-damaged patients (9 with hemispatial neglect) comparing arrows, eye gaze, and digits as central nonpredictive cues in a detection task. Orienting effects elicited by arrows and eye gaze were overall consistent in healthy participants and in right brain-damaged patients, whereas digit cues were ineffective. Moreover, patients with neglect showed, at the shortest delay between cue and target, a disengage deficit for arrow cueing whose magnitude was predicted by neglect severity. We conclude that the peculiar form of attentional orienting triggered by the directional meaning of arrow cues presents some features previously thought to characterize only the stimulus-driven (exogenous) orienting to noninformative peripheral cues.