What is the National Institutes of Health (NIH) stroke scale score for item 11 in a patient with left-sided neglect, who does not recognize touch on their left arm or leg?

NIH Stroke Scale Score for Left-Sided Neglect

For a patient with left-sided neglect who does not recognize touch on their left arm or leg, the correct NIH Stroke Scale score for item 11 (Extinction and Inattention) is 2 points. 1

Understanding the NIH Stroke Scale Item 11: Extinction and Inattention

• The NIH Stroke Scale (NIHSS) is a standardized, validated instrument used to assess stroke severity with scores ranging from 0 to 42, where higher scores indicate more severe strokes 1
• Item 11 specifically evaluates extinction and inattention (formerly known as neglect) using the following scoring criteria:
  • 0 = No abnormality
  • 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one sensory modality
  • 2 = Profound hemi-inattention or extinction to more than one modality 1

Clinical Assessment of Neglect

• Unilateral neglect is the lack of awareness of a specific body part or external environment contralateral to the site of the brain lesion and usually occurs in patients with right (nondominant) cortical strokes 1
• When a patient does not recognize touch on their left arm or leg, this represents profound hemi-inattention affecting the tactile sensory modality 1
• This manifestation of neglect involves more than one body part (both arm and leg), indicating severe neglect that warrants the maximum score of 2 points on item 11 1

Clinical Significance of Neglect

• Neglect is a significant contributor to poor prognosis after stroke and substantially impacts an individual's ability to function safely within their environment 1
• When present, neglect should be addressed early in the rehabilitation process due to safety concerns, such as risk of sustaining burns or injury to the affected limb 1
• Patients with neglect may fail to attend to one side of their world, which can be observed when they don clothing on only one arm, shave only half of their face, or fail to notice food on half of their lunch tray 1

Hemispheric Differences in NIHSS Scoring

• The NIHSS has been criticized for favoring left hemisphere strokes by attributing more points to language deficits (7 points) compared to neglect (2 points) 2, 3
• For a given NIHSS score, right hemisphere strokes with neglect tend to have larger lesion volumes than left hemisphere strokes 2, 3
• The correlation between NIHSS scores and lesion volume is lower in patients with neglect compared to those without neglect 3
• Tests of hemispatial neglect may better reflect dysfunction and reperfusion than NIHSS for patients with nondominant (right) hemisphere stroke 4

Age Considerations in Neglect Assessment

• Increasing age in patients with acute right hemispheric stroke significantly increases the odds of unilateral neglect as well as severity of neglect, independently of stroke size or overall NIHSS score 5
• Older patients (>65 years) are 1.83 times more likely to have neglect compared to younger patients, even after adjusting for infarct volume and NIHSS score 5

Rehabilitation Implications

• Several approaches may be considered for treating neglect, including strategy training, gesture training, task practice with and without mental rehearsal 1
• Interventions such as half-field eye patching, visual scanning training, prism adaptation, limb activation, and various forms of brain stimulation have shown efficacy in improving performance on standard neglect tests 1
• Early identification of specific neglect deficits may help identify patients likely to experience chronic disability 6

Remember that accurate assessment and documentation of neglect using the NIHSS is crucial for proper stroke severity classification and appropriate rehabilitation planning.