spatial neglect

definition of spatial neglect

Spatial neglect is perception disorder in which individuals fail to attend to or respond to stimuli on one side of space, despite intact primary sensory pathways. Unlike hemianopia, in which visual field loss is recognized by the patient, information reaches the visual cortex in neglect, but conscious awareness does not register it. This arises from impaired functional connectivity between regions in the parietal, temporal, and frontal lobes, particularly following right hemisphere injury

Domains of spatial neglect

• Visuospatial

  • Failure to attend to visual stimuli on one side.

• Auditory

  • Ignoring sounds coming from contralesional space.

• Sensorimotor

  • Reduced initiation or use of the limb despite intact motor ability.

• Representational

  • Impaired mental imagery or spatial memory of the neglected side.

spaces of spatial neglect

• Personal Space

  • The body surface itself.

• Peripersonal Space

  • Within arm’s reach.

• Extrapersonal Space

  • Far space beyond reach.

clinical impact of neglect

Increased length of hospital stay

• Higher fall risk

• Lower likelihood of discharge home

• Persistent symptoms in 30–60% at one-year post-stroke

• Decreased functional independence and safety

intervention evidence

• Evidence remains inconsistent.

• Many interventions do not produce large clinical changes.

• Raises the question: is the underlying problem assessment rather than treatment?

  • Mirror therapy – some benefit

  • Prism adaptation – mixed evidence

  • rTMS – promising but variable

    • short term intervention 

    • $$$

  • tDCS – inconclusive

  • Robot-assisted training – improves midline perception, limited generalization

  • Behavioural cueing – limited evidence

    • reorientation

  • pharphacological 

    • guafacine - helps attention and memory 

  • VR 

    • helpful in VR space but not sure of help in real life scenario 

spatial neglect assessments

• Over 105 terms and ~300 tools exist; no standard approach.

• Many assessments sample only one domain/space.

• Standard stroke guidelines require assessment but provide no specific test

recommendation.

• Underdiagnosis is common, contributing to poor outcomes.

Common assessment tests

• star cancellation test

• line bisection test

• Bell’s test 

• Catherine Bergego Scale

Star Cancellation Test

• Patient crosses out all small stars on the page.

• Strengths: quick screen of visuospatial neglect.

• Limitations: addresses one domain and one space only.

Line Bisection test

• Patient bisects horizontal lines.

• Strengths: simple, familiar in clinical settings.

• Limitations: insensitive to mild or non-visual neglect.

Bell’s test

• Cancellation-type task similar limitations to Star test

Catherine Bergego Scale

• The CBS is the only assessment tool that captures all domains (visual, auditory, sensorimotor, representational)and all spaces (personal, peripersonal, extrapersonal).

• It evaluates neglect during 10 functional tasks.

  • • Limb awareness

    • Dressing

    • Collisions

    • Grooming

    • Meals

    • Managing personal belongings

    • Gaze orientation

    • Auditory attention

    • Navigation

    • Cleaning after meals

CBS Scoring

• 0 No neglect

  • no spatial bias

• 1 Mild neglect

  • prefers right space; occasional omissions

• 2–3 Moderate to severe neglect

  • consistent omissions or inability to explore left

elements of a comprehensive assessment 

• Domains (visual, auditory, sensorimotor, representational)

• Spaces (personal, peripersonal, extrapersonal)

• Functional tasks (e.g., CBS)