NIHSS Extinction and Inattention 3 — Questions and Answers
Question 1: A patient closes their eyes and the examiner touches both hands simultaneously. The patient reports only feeling the right hand being touched. On single stimulation, both hands are felt correctly. The NIHSS Item 11 score is:
- 0
- 1 (Correct answer)
- 2
- 3
Correct answer: 1
Tactile extinction on double simultaneous stimulation with intact single-stimulus perception yields a score of 1.
Question 2: Which of the following is NOT an acceptable method of eliciting information for NIHSS Item 11?
- Finger wiggling in both visual fields simultaneously
- Touching both hands at the same time
- Presenting loud sounds to both ears simultaneously
- Asking the patient to solve a mathematical problem (Correct answer)
Correct answer: Asking the patient to solve a mathematical problem
Mathematical problem-solving is not part of the NIHSS neglect assessment; sensory and visual simultaneous stimulation are used.
Question 3: In the context of NIHSS Item 11, what does 'inattention' refer to?
- Inability to follow verbal commands
- Failure to attend to one side of space without a primary sensory loss (Correct answer)
- Reduced level of consciousness
- Inability to sustain attention on any task
Correct answer: Failure to attend to one side of space without a primary sensory loss
Inattention in Item 11 means the patient neglects one hemi-space despite having intact basic sensory pathways when tested alone.
Question 4: A patient with a left MCA stroke does not look toward the right side of the room and does not respond to touch on the right arm during simultaneous bilateral stimulation, but does feel each arm individually. What is the Item 11 score?
- 0 — normal
- 1 — single modality extinction
- 2 — multi-modal neglect (Correct answer)
- 2 — because the left MCA is affected
Correct answer: 2 — multi-modal neglect
Multi-modal neglect (visual and tactile) scores 2 regardless of which hemisphere is affected.
Question 5: Why is double simultaneous stimulation used rather than single-side stimulation in NIHSS Item 11?
- It is faster to perform
- It unmasks extinction that single stimulation would miss (Correct answer)
- It tests the brainstem reticular system
- It evaluates both sides with a single maneuver
Correct answer: It unmasks extinction that single stimulation would miss
Simultaneous bilateral stimulation creates competition between hemispheres, revealing extinction that is absent on unilateral testing.
Question 6: A comatose patient is being assessed with NIHSS. For Item 11 (Extinction and Inattention), the score should be:
- 0 — skipped for comatose patients
- 1 — assumed mild neglect
- 2 — profound neglect is assumed given unresponsiveness (Correct answer)
- Scored based on best observed response to noxious stimulation
Correct answer: 2 — profound neglect is assumed given unresponsiveness
In a comatose or unresponsive patient, Item 11 is scored 2 because neglect cannot be excluded and the patient fails all behavioral responses.
Question 7: Which scenario would correctly receive an NIHSS Item 11 score of 0?
- Patient identifies only right finger when both are wiggled simultaneously
- Patient ignores left food tray after right hemisphere stroke
- Patient correctly identifies simultaneous touch on both hands and both visual fields (Correct answer)
- Patient has mild left arm neglect only when distracted
Correct answer: Patient correctly identifies simultaneous touch on both hands and both visual fields
Correct bilateral identification in all tested modalities with no signs of neglect or extinction yields a score of 0.
NIHSS Extinction and Inattention 3
A patient closes their eyes and the examiner touches both hands simultaneously.
The patient reports only feeling the right hand being touched.
On single stimulation, both hands are felt correctly.
The NIHSS Item 11 score is: