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*For medical professional reading reference only, don't underestimate the "ignore" thing! In the National Institutes of Health Stroke Scale (NIHSS) score, the score for "neglect" symptoms is listed as the last item
.
Don't underestimate the "ignoring" score, there is a lot of knowledge behind it
.
At the 2022 International Stroke Conference (ISC 2022), Associate Professor Dawn Mayer explained the concept, pathophysiological mechanism and scoring rules of the "neglect" score in detail
.
See if you also have some neglect? Is your understanding of "ignoring" really correct? Neglect is an umbrella term for a class of clinical symptoms characterized by an attention deficit in which the patient cannot locate, report, or respond to stimuli located in the space opposite the brain lesion
.
For example, with neglect due to damage to the right side of the brain, the patient will be unable to pay attention to, or be unresponsive to, stimuli on the left side
.
Figure 1 shows a small test performed in several categories of patients with left-sided neglect
.
Figure 1 Test results of patients with neglected symptoms on the left side (speaker PPT) Patient A draws only the right side; Patient B draws the clock and draws only the right side; Patient C can only circle the object on the right side; D Ask the patient to mark the mark to In the middle position, the patient marker is to the right; patient E is only filled to the right
.
Neglect is usually manifested in two types: (1) Hemispatial neglect: The patient neglects the space opposite to the lesion, which can be manifested as visual, tactile, auditory, and olfactory neglect
.
(2) Extinction: Patients are stimulated unilaterally one by one, and the patient can perceive it, but when both sides are stimulated at the same time, the patient can only feel the stimulation on one side
.
Therefore, when we use the word "neglect", we should understand that neglect is a phenomenon, and we must know what type of specific clinical manifestations it represents
.
Neglect symptoms are most commonly seen in stroke in one cerebral hemisphere, although symptoms of neglect can also be seen in other neurological disorders
.
And stroke neglect caused by right middle cerebral artery disease is more frequent
.
About 50% to 80% of patients with right middle cerebral artery stroke can see symptoms of neglect in the acute phase, and up to 50% of patients can see symptoms 6 months after stroke
.
Therefore, during the whole rehabilitation process of stroke patients, attention should be paid to the follow-up examination of this symptom
.
Although the symptoms of neglect are mainly related to the lesions of the cortex, it is generally believed to be related to the lesions of the parietal lobe, but in fact, the lesions of the temporal and frontal lobes can also be seen
.
Anatomical and Pathophysiological Mechanisms of "Neglect" Neglect is a heterogeneous group of symptoms, and the exact anatomical site of neglect is still debated
.
Through neuroimaging studies, it is now known that the development of neglect symptoms may not be related to only one anatomical site, but may be related to the disruption of attention-related brain network function
.
Studies have shown that in patients with neglect symptoms, there is an imbalance in the brain network between the bilateral hemispheres of the brain.
After a stroke in the right cerebral hemisphere, the left hemisphere is overactivated, causing the patient's attention and eye movements to be biased to the right, which is clinically manifested.
For the neglect of the left space
.
So what brain networks are involved in this pathophysiological process? There are two main networks, the dorsal attentional network (DAN) and the ventral attentional network (VAN) (Figure 2)
.
DAN is distributed in both cerebral hemispheres and is critical for spatial attention
.
For example, is the body standing or lying down? Which is left and which is right? DAN enables individuals to decide where in space their attention should be placed
.
VAN is mainly distributed in the right cerebral hemisphere, which is also the reason why neglect mostly occurs in the right cerebral hemisphere
.
VAN plays an important role in maintaining attention and vigilance and reorienting attention
.
Both brain networks underlie neglect symptoms
.
DAN determines spatial attention; with lesions in the right cerebral hemisphere, patients can temporarily pay attention to left stimuli, but this stimulus cannot be maintained, which indicates the attention maintenance effect of VAN
.
In addition, these two networks are also the basis for the rehabilitation of neglected patients to overcome the symptoms of neglect
.
Figure 2 Detailed explanation of the "ignored" score in the NIHSS score of DAN and VAN (speaker PPT) First of all, it needs to be clear that the important point of NIHSS score is to score what you see (You score what you see) without guessing (You don't 't have to make inferences) to ensure consistent scoring
.
In the NIHSS score for neglect, if the patient is comatose (3 points for the level of consciousness in item 1a) and cannot be checked for neglect, the neglect item is scored as 2 points
.
If the patient can cooperate, record what you see
.
If the patient has severe partial neglect, such as walking around the room looking only to the right and never to the left, not paying attention to anything on the left, such as showing the patient his left hand that the patient thinks is not his own, 2 points
.
A score of 0 is completely normal
.
A score of 1 was assigned to patients whose symptoms and examination were between 0 and 2
.
Negligence can be examined with double simultaneous stimulation, which further gives the neglect score in the NIHSS score
.
Bilateral simultaneous stimulation includes tactile, visual, auditory, and spatial stimulation
.
Taking tactile examination as an example, ask the patient to close his eyes, give the patient tactile stimulation from the left, right, and bilateral sides at the same time, and ask the patient to tell which side the stimulation comes from
.
In addition, visual field defects may be confused with visual neglect, which have completely different pathophysiological mechanisms
.
The pathophysiological mechanism of visual field defect is the damage of visual pathway, and visual neglect is the damage of brain network function related to attention in patients
.
Visual field defects follow the principle of no vertical midline, but visual neglect does not follow this principle, mainly manifesting as a spatial gradient of symptoms
.
During the examination, it is necessary to pay attention to whether the patient has visual defects.
Ignoring symptoms can be combined with tactile, auditory and other stimuli to comprehensively judge
.
Table 1 Neglect score in NIHSS After reading today's push, I hope that in the future clinical work, the "neglect" is the last score of the NIHSS score, and don't ignore it
.
●After so many years, have you used your NIHSS score correctly? ｜2022 ISC ●Gaze, visual field defect, see how international experts use NIHSS score ●NIHSS score in practice: limb movement and ataxia, listen to what the experts say?
.
Don't underestimate the "ignoring" score, there is a lot of knowledge behind it
.
At the 2022 International Stroke Conference (ISC 2022), Associate Professor Dawn Mayer explained the concept, pathophysiological mechanism and scoring rules of the "neglect" score in detail
.
See if you also have some neglect? Is your understanding of "ignoring" really correct? Neglect is an umbrella term for a class of clinical symptoms characterized by an attention deficit in which the patient cannot locate, report, or respond to stimuli located in the space opposite the brain lesion
.
For example, with neglect due to damage to the right side of the brain, the patient will be unable to pay attention to, or be unresponsive to, stimuli on the left side
.
Figure 1 shows a small test performed in several categories of patients with left-sided neglect
.
Figure 1 Test results of patients with neglected symptoms on the left side (speaker PPT) Patient A draws only the right side; Patient B draws the clock and draws only the right side; Patient C can only circle the object on the right side; D Ask the patient to mark the mark to In the middle position, the patient marker is to the right; patient E is only filled to the right
.
Neglect is usually manifested in two types: (1) Hemispatial neglect: The patient neglects the space opposite to the lesion, which can be manifested as visual, tactile, auditory, and olfactory neglect
.
(2) Extinction: Patients are stimulated unilaterally one by one, and the patient can perceive it, but when both sides are stimulated at the same time, the patient can only feel the stimulation on one side
.
Therefore, when we use the word "neglect", we should understand that neglect is a phenomenon, and we must know what type of specific clinical manifestations it represents
.
Neglect symptoms are most commonly seen in stroke in one cerebral hemisphere, although symptoms of neglect can also be seen in other neurological disorders
.
And stroke neglect caused by right middle cerebral artery disease is more frequent
.
About 50% to 80% of patients with right middle cerebral artery stroke can see symptoms of neglect in the acute phase, and up to 50% of patients can see symptoms 6 months after stroke
.
Therefore, during the whole rehabilitation process of stroke patients, attention should be paid to the follow-up examination of this symptom
.
Although the symptoms of neglect are mainly related to the lesions of the cortex, it is generally believed to be related to the lesions of the parietal lobe, but in fact, the lesions of the temporal and frontal lobes can also be seen
.
Anatomical and Pathophysiological Mechanisms of "Neglect" Neglect is a heterogeneous group of symptoms, and the exact anatomical site of neglect is still debated
.
Through neuroimaging studies, it is now known that the development of neglect symptoms may not be related to only one anatomical site, but may be related to the disruption of attention-related brain network function
.
Studies have shown that in patients with neglect symptoms, there is an imbalance in the brain network between the bilateral hemispheres of the brain.
After a stroke in the right cerebral hemisphere, the left hemisphere is overactivated, causing the patient's attention and eye movements to be biased to the right, which is clinically manifested.
For the neglect of the left space
.
So what brain networks are involved in this pathophysiological process? There are two main networks, the dorsal attentional network (DAN) and the ventral attentional network (VAN) (Figure 2)
.
DAN is distributed in both cerebral hemispheres and is critical for spatial attention
.
For example, is the body standing or lying down? Which is left and which is right? DAN enables individuals to decide where in space their attention should be placed
.
VAN is mainly distributed in the right cerebral hemisphere, which is also the reason why neglect mostly occurs in the right cerebral hemisphere
.
VAN plays an important role in maintaining attention and vigilance and reorienting attention
.
Both brain networks underlie neglect symptoms
.
DAN determines spatial attention; with lesions in the right cerebral hemisphere, patients can temporarily pay attention to left stimuli, but this stimulus cannot be maintained, which indicates the attention maintenance effect of VAN
.
In addition, these two networks are also the basis for the rehabilitation of neglected patients to overcome the symptoms of neglect
.
Figure 2 Detailed explanation of the "ignored" score in the NIHSS score of DAN and VAN (speaker PPT) First of all, it needs to be clear that the important point of NIHSS score is to score what you see (You score what you see) without guessing (You don't 't have to make inferences) to ensure consistent scoring
.
In the NIHSS score for neglect, if the patient is comatose (3 points for the level of consciousness in item 1a) and cannot be checked for neglect, the neglect item is scored as 2 points
.
If the patient can cooperate, record what you see
.
If the patient has severe partial neglect, such as walking around the room looking only to the right and never to the left, not paying attention to anything on the left, such as showing the patient his left hand that the patient thinks is not his own, 2 points
.
A score of 0 is completely normal
.
A score of 1 was assigned to patients whose symptoms and examination were between 0 and 2
.
Negligence can be examined with double simultaneous stimulation, which further gives the neglect score in the NIHSS score
.
Bilateral simultaneous stimulation includes tactile, visual, auditory, and spatial stimulation
.
Taking tactile examination as an example, ask the patient to close his eyes, give the patient tactile stimulation from the left, right, and bilateral sides at the same time, and ask the patient to tell which side the stimulation comes from
.
In addition, visual field defects may be confused with visual neglect, which have completely different pathophysiological mechanisms
.
The pathophysiological mechanism of visual field defect is the damage of visual pathway, and visual neglect is the damage of brain network function related to attention in patients
.
Visual field defects follow the principle of no vertical midline, but visual neglect does not follow this principle, mainly manifesting as a spatial gradient of symptoms
.
During the examination, it is necessary to pay attention to whether the patient has visual defects.
Ignoring symptoms can be combined with tactile, auditory and other stimuli to comprehensively judge
.
Table 1 Neglect score in NIHSS After reading today's push, I hope that in the future clinical work, the "neglect" is the last score of the NIHSS score, and don't ignore it
.
●After so many years, have you used your NIHSS score correctly? ｜2022 ISC ●Gaze, visual field defect, see how international experts use NIHSS score ●NIHSS score in practice: limb movement and ataxia, listen to what the experts say?
