Can We Improve Detection of Hemi-Neglect and Right-Sided Large Vessel Occlusion Stroke?
Logan Hilton1, Shaila Kamal2, Melissa Gazi2, Mark Beasley2, Kristen Sandefer2, Sana Somani3, Shannon Stephens2, Ronald Lazar2, Toby Gropen2
1Banner University Neurosciences Institute, 2University of Alabama At Birmingham, 3Medstar Washington Hospital Center
Objective:
To explore the additive value of three simple tests of hemi-neglect to discriminate between right-hemisphere large vessel occlusion (LVO) stroke and non-LVO stroke. 
Background:

Clinical stroke scales including the NIHSS are less sensitive for right compared to left hemisphere stroke. We hypothesized that adding one of three neglect tests to a brief stroke severity scale would increase diagnostic accuracy for right-hemisphere LVO.

Design/Methods:

This single-site, observational prospective study occurred from January 2020-June 2022. Research assistants (RAs) were trained using a video and post-training exam on three hemi-neglect tests including line bisection, the “2 and 1” test of visual extinction, and the Eastchester Clap Sign (ECS) which were added to the Emergency Medical Stroke Assessment (EMSA), a previously validated stroke severity scale. RAs, blinded to NIHSS and imaging, assessed ED code stroke patients using the expanded EMSA. A vascular neurologist blinded to EMSA and NIHSS determined LVO status. We calculated Receiver Operator Characteristics Area Under the Curve (AUC) and 95% CI for right-sided LVO.

Results:
Of the 602 tested patients, 260 had acute ischemic stroke (AIS), and 166 were alert and non-aphasic. Of right-sided AIS (n=90), 22 (24%) had LVO. The AUC (95% CI) of EMSA vs. NIHSS for discrimination between right-sided LVO and non-LVO AIS was 0.71 (0.58-0.84) vs. 0.74 (0.61-0.87), p=0.59. EMSA plus line bisection, 2 and 1 test, or ECS resulted in AUCs of [0.74 (0.61-0.87), p=0.07], [0.75 (0.62-0.87), p=0.02] and [0.76 (0.64-0.88), p=0.003] respectively, with p-values showing comparisons vs. EMSA.
Conclusions:

There was no significant difference in the ability of the EMSA and NIHSS to distinguish between right-hemisphere LVO and non-LVO ischemic stroke. The addition of the 2 and 1 test or Eastchester Clap Sign but not line bisection to the EMSA modestly improved its ability to discriminate between right-hemisphere LVO and non-LVO ischemic stroke.

10.1212/WNL.0000000000211979
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