Right Hemisphere Impairments

right hemisphere syndrome (RHS)

collection of symptoms associated with right hemisphere damage (RHD)

• extremely heterogeneous population in terms of severity

etiologies

• any neurologic disorder

  • stroke

  • TBI

  • tumor

  • infectious process

• damage in any part of right hemisphere

site of lesion

not very helpful to talk about with this population

• very few clear patterns of localization of function in right hemisphere

onset

• right and left hemisphere strokes occur at same frequency 

• most commonly used stroke assessment tools do not specifically  assess right hemisphere → leads to underestimating severity of RH stroke 

  • RH stroke may receive less appropriate medical care

symptoms

cognition and communication may be affected

• expressive and receptive challenges

• attention

• memory

• executive functioning

• reading and writing

• visual-perceptual impairment

• auditory-perceptual impairment

no aphasia in RH damage

combined expressive and receptive challenges

• lack of perspective regarding another person’s feelings or pov

• deficits in pragmatics

• challenges in humor

• changes in affect

• deficits in pragmatics

• humor may change

• hypo and hyper-affectivity 

deficits in pragmatics

• topic maintenance

• codeswitching

• inappropriate utterances

• challenges with judging appropriateness of conversational content

• poor eye contact

• poor conversational turn-taking

• failure to interpret non-verbal cues

• problems noticing communication breakdown

• failure to repair communication breakdown

changes in humor

may be related to disinhibition of inappropriate content and preference for more concrete over abstract content 

hypoaffectivity

flat expression of emotion conveyed by reduced prosody and lack of conversational or social initiative

hyperaffectivity

exuberance and incessant talking

receptive challenges 

difficulty stems from cognitive deficits (attention and memory)

• tendency to literally interpret figurative language

• difficulty with inferencing 

do not struggle with lexical and grammatical processing very much 

expressive challenges

• difficulty with discourse coherence (tying content together)

• deficits in the use of prosody

• aprosodia

aprosodia

deficit in ability to

1. discriminate prosodic patterns that signal emotion, grammar, or pragmatics

2. manipulate prosodic patterns to convey emotion, grammar, or pragmatics

expressive and receptive aprosodia may co-occur or on their own

speech may be monotone and slow

attention 

• reduced alertness to environment

• decreased sustained attention or vigilance 

• decreased selective attention 

• decreased alternating attention 

• visual neglect 

• anosognosia  

anosognosia

lack of awareness of illness

memory

• verbal

• nonverbal

• working memory

  • complex sentences

  • instructions

  • carry out specific actions (take medications, turn off stove)

executive functions 

difficulty with 

• reasoning 

• judgement 

• decision-making 

• planning

• self-monitoring 

• sequencing 

• problem-solving

• organization 

reading and writing

reading impairments related to visuospatial problems and cognitive linguistic problems

• impact language that is used

• affect the grapheme to sound relationship

visual-perceptual impairments

• agnosia (can’t recognize objects)

• prosopagnosia (can’t recognize faces)

• difficulty judging spatial relationships

• difficulty drawing and copying figures

• difficulty distinguishing between important and background components of image

auditory-perceptual impairments 

• impairment is processing a interpreting tonla and melodic aspects of speech 

• amusia 

• auditory agnosia 

• sound localization deficit 

amusia

an impairment of processing, remembering, and recognizing music

auditory agnosia

inability to recognize sounds

theories

• theory of mind

• the suppression of deficit hypothesis

theory of mind (ToM)

ability to understand that others have thoughts, feelings, ideas and knowledge that differ from one’s own, and that those impact or drive their behaviors 

• impairments impact intended meaning, efficiency

• adults with RHD can have ToM deficits  

criticism of ToM

suggest it does not help us to understand the nature of pragmatic problems any more than describing the problems themselves does

suppression deficit hypothesis

people with RHS have difficulty with this suppression process, results in irrelevant information remaining active in their mind interfering with comprehension, memory and discourse processing

• normally need to suppress irrelevant info when our brains are activated while reading, listening and thinking

SLP challenges

• RHS symptoms are subtle and harder to describe

• classifying symptoms are challenging

• underdiagnosis attributed to symptoms of RHS less likely to be complained about or noticed

• diagnostic process must be multifaceted (standardized and observation)

challenges of people with RHS

• specialized interdisciplinary rehab services are lacking

• communicative deficits are often invisible

• may have additional medical issues

• decreased insight into impairments

• may have decreased understanding of what intervention may help

what can we do

• ensure active interprofessional RHS screening protocols 

• educate others about RHS and services 

• raise awareness that com/cog challenges are within SLP scope of practice 

• provide education and referral materials 

left hemisphere imapirments

• telegraphic speech

• neologisms

• paraphasias

• agrammatism

right hemisphere impairments

• discourse coherence

• aprosodia

• hypoaffectivity