Hemi-spatial neglect rehabilitation using non-invasive brain stimulation: or how to modulate the disconnection syndrome?

Hemi-spatial neglect syndrome is common and sometimes long-lasting. It is characterized by a deficit in the use and awareness of one side of space, most often consecutive to a right hemisphere injury, mainly in the parietal region. Acknowledging the different types and all clinical characteristics is essential for an appropriate evaluation and adapted rehabilitation care management, especially as it constitutes a predictive factor of a poor functional prognosis. Some new approaches have been developed in the last fifteen years in the field of hemi-spatial neglect rehabilitation, where non-invasive brain stimulation (TMS and tDCS) holds an important place. Today's approaches of unilateral spatial neglect modulation via non-invasive brain stimulation are essentially based on the concept of inter-hemispheric inhibition, suggesting an over-activation of the contralesional hemisphere due to a decrease of the inhibiting influences of the injured hemisphere. Several approaches may then be used: stimulation of the injured right hemisphere, inhibition of the hyperactive left hemisphere, or a combination of both. Results are promising, but the following complementary aspects must be refined before a more systematic application: optimal stimulation protocol, individual management according to the injured region, intensity, duration and frequency of care management, delay post-stroke before the beginning of treatment, combination of different approaches, as well as prognostic and efficacy criteria. An encouraging perspective for the future is the combination of several types of approaches, which would be largely facilitated by the improvement of fundamental knowledge on neglect mechanisms, which could in the future refine the choice for the most appropriate treatment(s) for a given patient.