Complete Neglect in NIH Stroke Scale Item 11: Extinction and Inattention
Complete neglect in the NIH Stroke Scale item 11 is characterized by profound hemi-inattention or extinction to more than one sensory modality, such as when a patient fails to recognize touch on their left arm or leg, indicating severe neglect that warrants the maximum score of 2 points. 1
Understanding Hemispatial Neglect
Hemispatial neglect (also called unilateral neglect) is a neuropsychological condition where, after brain damage (typically to the right hemisphere), patients demonstrate a deficit in attention to and awareness of one side of space. This is not attributable to primary sensory or motor deficits 2.
Key characteristics of complete neglect include:
- Lack of awareness of a specific body part or external environment contralateral to the brain lesion 2
- Failure to attend to one side of their world, with the patient not realizing this deficit 2
- Typically occurs in patients with right (nondominant) cortical strokes 2
Clinical Examples of Complete Neglect
Complete neglect manifests in various ways that can be observed during clinical assessment:
- Patient dons their shirt on only one arm 2
- Patient shaves only half of their face 2
- Patient fails to notice food on half of their lunch tray 2
- Patient is unable to recognize touch on the affected side of their body in multiple areas 1
- Patient demonstrates profound inattention to visual, tactile, and auditory stimuli on the affected side 1
NIH Stroke Scale Scoring for Item 11
The NIH Stroke Scale item 11 (extinction and inattention, formerly called neglect) uses the following scoring criteria:
- 0 = No abnormality 1
- 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one sensory modality 1
- 2 = Profound hemi-inattention or extinction to more than one modality 1
Clinical Significance
Hemispatial neglect has significant implications for patient outcomes:
- Substantially impairs the ability to participate effectively in rehabilitation 2
- Is a significant contributor to poor prognosis after stroke 2
- Creates safety concerns, such as risk of burns or injury to the affected limb 2
- Negatively impacts reading, writing, drawing, and mobility 2
- Symptoms continue to interfere with daily functioning long after stroke 2
Assessment Considerations
When evaluating for neglect, clinicians should:
- Distinguish neglect from visual field cuts, impaired attention, and planning or visuospatial abilities 2
- Test across multiple sensory modalities (visual, tactile, auditory) 1
- Observe functional activities like dressing, eating, and grooming for signs of neglect 2
- Use standardized tests such as cancellation tests and line bisection tests 2
Complete neglect represents the most severe form of this condition and requires early identification and intervention to improve patient outcomes and safety during rehabilitation.