Field cut vs. Neglect following Stroke

Patients frequently present with reduced awareness of their affected side following a stroke or brain injury.  This decreased awareness can be a visual field cut or hemispatial neglect or both. Here are some ways to tell just why your patient cannot find half of the world.

Anatomy of field cut vs. neglect

A stroke with neurological neglect is generally associated with middle cerebral artery strokes. These are the most common strokes. The temporal/parietal lobes tend to be affected in these strokes with hemiplegia also occurring. Because of redundant connection for attention in the left side of the brain (the right side attends to left and right while the left side attends to right, making both sides attending to the right…see photo) left side neglect with right side affected CVAs are more common.

Generally, a true field cut is associated with a posterior cerebral artery stroke with the occipital lobe being affected. This is a stroke that is less common. The patient may not have any other symptoms from the stroke.

Functional differences between field cut and neglect

There are functional differences in patients that have neglect vs field cut.

Patients with a field cuts:

• show awareness of the field cut, they will tell you “I can see on my right side”
• They begin compensations quickly
• Show organized search patterns during cancellation tasks. This means left to right, top to bottom pattern

Patients with neglect present differently

• They may not be aware of the field loss and may not be aware of any of the stroke-related deficits. This lack of insight to their condition is a big hurdle to treatment
• They do not compensate well. This is probably related to the lack of insight.
• Problems with attention in general. Perseveration (unable to shift attention) and distractibility are common.
• Patients with neglect have difficulty with crossing midline. The eyes may not track across the midline to the affected side.  Slow saccades to the affected side.
• Poor search patterns on cancellation tests.  These patients randomly search for targets. It is important to watch how a patient completes cancellation assessments as a patient with a field cut and neglect will have similar looking cancellation tests when completed.
• These patients tend to be oriented (posture and head position) away from the affected side.

Treatment differences of field cut vs neglect

Early resolution of neglect is vital to improving functional status following stroke.  Here are some of my favorite activities for treating neglect:

• Sensory stimulation of the affected side with vibration, weight bearing, and functional electrical stimulation (go read this article. It is fresh and full of ideas)
• Bilateral limb activation activities
• Midline crossing activities
• Prism Adaptation Therapy has been shown to be effective very quickly 
• Saccade activities into the affected side with minimal head movement. Reducing head movement is important in remapping visual space. Hold the patients head still if needed.

Field cuts tend to be a bit easier and are discussed here. Neglect and field cuts are common consequences to stroke and confusion about just what the patient is experiencing can make treatment difficult. I hope this helps!!!