Neuroscience · Year 2 · from Neuroscience
Case 2: Hemispatial Neglect - Right Parietal Stroke
Patient Presentation
Demographics: 75-year-old female
Chief Complaint: Daughter noticed patient not responding to things on her left side
History of Present Illness: A 75-year-old right-handed woman with hypertension and hyperlipidemia was found by her daughter sitting in her chair, apparently unaware of her left arm which was hanging off the armrest. When approached from the left side, she did not respond until the daughter moved to her right. The patient denies any problem and insists she is "perfectly fine" despite obvious deficits. Symptoms began approximately 2 hours ago.
Physical Examination:
- Vital signs: BP 175/95, HR 82, RR 16
- General: Awake, appears unconcerned; head and eyes deviated toward right
- Neurological:
- Mental status: Alert; oriented to self only; neglects left hemispace; denies any deficit (anosognosia)
- Visual fields: Does not respond to stimuli in left visual field (extinction to double simultaneous stimulation)
- Motor: Left arm 0/5 (does not move, patient unaware); left leg 2/5; right side normal
- Sensory: Does not acknowledge stimuli on left; extinguishes left-sided stimuli when presented simultaneously with right
- Special testing: Line bisection test - marks far to the right of center; clock drawing - numbers crowded on right side; asked to copy figure - omits left half
- NIHSS: 15
Workup:
- CT head without contrast: Early hypodensity in right parietal lobe
- CT angiography: Right MCA M1 occlusion
- CT perfusion: Large penumbra with small core
- MRI (24 hours): Large right parietal and posterior frontal infarct
Diagnosis: Right MCA territory stroke with hemispatial neglect and anosognosia
Treatment:
- IV thrombolysis followed by mechanical thrombectomy (door-to-groin 65 minutes)
- Successful recanalization achieved
- ICU monitoring
- Aggressive secondary prevention
- Intensive rehabilitation focusing on neglect awareness training
- Visual scanning therapy
- Prism adaptation therapy
- Some improvement in neglect at 6 weeks; persistent mild left neglect requiring safety supervision
Clinical Pearl: Hemispatial neglect is a failure of attention to one side of space, most commonly the left side after right parietal lesions. Unlike hemianopia (visual field loss), neglect represents an attentional deficit - patients fail to attend to, explore, or act upon the neglected side even when visual pathways are intact. Anosognosia (unawareness of deficit) often accompanies right hemisphere lesions. Neglect is more common, severe, and persistent after right hemisphere damage because the right hemisphere attends to both hemispaces while the left primarily attends to the right. Neglect profoundly impacts rehabilitation because patients don't recognize their deficits.