Hemiagnosia in Stroke Survivors

A stroke can result in a variety of long-term and short-term outcomes. One of the more challenging consequences of a stroke is a group of symptoms referred to as visual-spatial neglect, hemispatial neglect, or hemiagnosia.

Neglect is the more common term used to describe a stroke survivor's lack of attention to or lack of awareness of one side of their body or one side of their environment. Neglect may be sensory, motor, visual or auditory. In addition, sometimes patients do not recognize their deficits (anosognosia) or even that one side of their body actually belongs to them (asomatognosia).

Neglect usually develops after a stroke that damages the parietal lobe of the brain, but sometimes can also occur with involvement of the frontal lobe or deep structures in the brain, such as the thalamus.

Neglect most often occurs after a stroke that affects the non-dominant side of the brain—more often the right side. Usually, language is not severely affected by neglect because language function is located on the dominant side of the brain.

There are differences between strokes on the right side of the brain and strokes on the left side of the brain, and these differences are more difficult to predict for people who are left-handed.

• Sensation: Neglect can impact awareness of sensation in the left arm and/or the left leg, mostly noticed when you touch the patient on both sides of the body at the same time. In some cases, a stroke survivor may feel sensation on the impaired side, but when asked to describe the location, they might point to the other (wrong) side.
• Vision: Sometimes stroke survivors neglect everything that is on one side of vision, even when there is no actual loss of vision. It can be particularly challenging to unravel whether a stroke survivor also has loss of peripheral vision in addition to visual neglect. Stroke survivors with visual neglect may blink when an object is nearing their eye (because they saw the object) but they cannot identify the object or remember seeing it.
• Sound: Often, a stroke survivor may neglect sounds coming from the neglected side or may have trouble figuring out where the sounds are coming from.
• Awareness of surroundings: Stroke survivors who suffer from neglect may not notice objects or people on one side of the room.

This lack of awareness can range in severity, affecting different stroke survivors differently. For some stroke survivors, hemispatial neglect is frustrating because it makes it difficult to locate objects on the left side of the room, for example.

However, when a stroke is severe, the stroke survivor may not be aware of hemispatial neglect and may not even care. Some stroke survivors may see only the right side of the room but inaccurately perceive that they are seeing the whole room. The lack of awareness that there is a problem makes everyday function extremely challenging.

Typically, stroke survivors may be confused about the area of neglect and may alternate between progress and regression during recovery.

Generally, a stroke survivor with hemispatial neglect is unaware of the problem. Depending on several factors, some stroke survivors may be able to understand the significance of the neglect, while some may not believe that there is any neglect at all—and may insist that they are moving an arm or a leg when they are not.

Neglect often improves gradually, although some stroke survivors continue to experience neglect for years. There are a few treatment approaches that can help with neglect. These include:

• Rehabilitation: Therapy after a stroke includes a variety of techniques. Mirror therapy is one of the techniques used for some people recovering from visual-spatial neglect.
• Medication: So far there has been some research into medications that can help with visual-spatial neglect, and some results look promising. But, currently, medication is not considered the most beneficial approach to this problem.
• Non-invasive brain stimulation: As with medication, there is research into this approach. So far, there is not strong evidence supporting the use of electrical therapy for this problem, but research is ongoing.

Neglect is one of the most troublesome stroke consequences for loved ones. Stroke survivors with neglect may be more content and less upset about the stroke because of their lack of awareness. But between the difficulty finding things and the inability to fully cooperate with rehabilitation, a stroke survivor's neglect can be emotionally stressful for the caregiver.

• Be patient: Neglect is a real neurological deficit. It is not a behavioral problem, denial, forgetfulness, or uncooperativeness. A stroke survivor with the symptom of neglect cannot help it.
• Offer help: Try to help your loved one who is recovering from stroke by physically assisting them to turn around and look at the room from the other side. This can help get your loved one better oriented to their surroundings. Build the action of turning around and looking from the other side into the regular routine and habits for your loved one. They might not be able to overcome neglect, but might be able to remember a habit such as "always turn around when you are looking for something."
• Pay attention to safety: Your loved one might not complain of pain, temperature changes, or discomfort on the neglected side. Check for injuries, sharp objects, or anything else that could harm the neglected side.

Neglect is one of the most unusual and difficult to understand the consequences of stroke. Hemiagnosia is much more noticeable and upsetting for caregivers than for the stroke survivor. When you have a loved one who is dealing with visual-spatial neglect after a stroke, stroke care can be especially demanding. Understanding neglect is your most important step in coping with those challenges.