NIHSS Visual Field Testing 4 — Questions and Answers
Question 1: A patient has bilateral occipital lobe infarcts from a basilar artery stroke. They are cortically blind but deny being blind (Anton syndrome). How should NIHSS item 3 be scored?
- 0, because the patient denies vision loss
- 1, because they have some residual vision
- 3, because bilateral blindness is present regardless of denial (Correct answer)
- UN, because the patient is not cooperative
Correct answer: 3, because bilateral blindness is present regardless of denial
Objective findings of bilateral blindness are scored 3 even if the patient denies the deficit due to anosognosia (Anton syndrome).
Question 2: The NIHSS specifies that visual fields should be tested by confrontation using finger counting or visual threat. What is the rationale for allowing visual threat as an alternative?
- Visual threat tests the temporal lobe rather than the occipital lobe
- It allows testing in aphasic or unresponsive patients who cannot report seeing fingers (Correct answer)
- Visual threat is more sensitive than finger counting for small scotomas
- It avoids the need to assess both eyes separately
Correct answer: It allows testing in aphasic or unresponsive patients who cannot report seeing fingers
Visual threat allows assessment of grossly intact vs. absent visual fields in patients who are unable to verbally or motorically respond to finger counting.
Question 3: A patient with a right posterior cerebral artery infarct demonstrates left homonymous hemianopia plus macular sparing. How should NIHSS item 3 be scored?
- 0 — normal, because the macula is spared
- 1 — partial loss
- 2 — complete hemianopia (Correct answer)
- 3 — bilateral blindness
Correct answer: 2 — complete hemianopia
Even with macular sparing, a complete left homonymous hemianopia meets criteria for NIHSS score 2 (complete hemianopia).
Question 4: When documenting the NIHSS visual field result in a clinical note, the examiner writes 'VF: 1 (partial loss — right superior quadrantanopia)'. What does this notation correctly convey?
- The patient has a total right visual field loss
- The patient has an incomplete field defect limited to one quadrant (Correct answer)
- The patient is bilaterally blind
- The finding is untestable
Correct answer: The patient has an incomplete field defect limited to one quadrant
A right superior quadrantanopia is an incomplete (partial) field loss restricted to one quadrant, appropriately scored as 1.
Question 5: A patient has monocular vision loss in the right eye from a central retinal artery occlusion that occurred one week before the current stroke. Visual fields in the left eye are full. What is the NIHSS item 3 score for the current stroke?
- 0 — prior baseline (Correct answer)
- 1 — partial loss
- 2 — complete hemianopia
- 3 — bilateral blindness
Correct answer: 0 — prior baseline
The monocular loss is a pre-existing condition unrelated to the acute stroke and is not attributed to the current event; baseline deficits do not contribute to the stroke score.
Question 6: How many total score points can be contributed by NIHSS item 3 (Visual) to the overall NIHSS score?
- Up to 1 point
- Up to 2 points
- Up to 3 points (Correct answer)
- Up to 4 points
Correct answer: Up to 3 points
NIHSS item 3 is scored 0–3, so it can contribute a maximum of 3 points to the total NIHSS score.
Question 7: A clinician is performing NIHSS serial assessments on a patient at 0, 2, and 24 hours post-stroke. On day 1, item 3 was scored 2 (complete hemianopia). At 24 hours the hemianopia has partially resolved to a quadrantanopia. What is the updated score?
- Still 2, because recovery is not scored in NIHSS
- 1 — partial loss reflecting improvement (Correct answer)
- 0 — full recovery assumed
- 3 — maximized due to fluctuation
Correct answer: 1 — partial loss reflecting improvement
The NIHSS reflects the current neurological status at the time of testing; improvement to a quadrantanopia is recorded as 1.
NIHSS Visual Field Testing 4
A patient has bilateral occipital lobe infarcts from a basilar artery stroke.
They are cortically blind but deny being blind (Anton syndrome).
How should NIHSS item 3 be scored?