NIHSS Visual Field Testing 5 — Questions and Answers
Question 1: Which anatomical lesion is most likely to produce a bitemporal hemianopia that would score 2 on NIHSS item 3?
- Unilateral occipital lobe infarct
- Optic chiasm compression or ischemia (Correct answer)
- Unilateral optic tract lesion
- Bilateral lateral geniculate nucleus lesions
Correct answer: Optic chiasm compression or ischemia
Bitemporal hemianopia is a chiasmal lesion pattern; if it causes complete loss of both temporal fields, it scores 2.
Question 2: A patient with posterior circulation stroke cannot fixate because of oculomotor dysfunction. How should the examiner adapt NIHSS item 3 visual field testing?
- Skip item 3 and mark it UN
- Use a visual threat response to each hemifield independently (Correct answer)
- Test only central vision by holding up one finger
- Wait until oculomotor function recovers
Correct answer: Use a visual threat response to each hemifield independently
Visual threat (blink response to sudden hand movement in each hemifield) can be performed even when the patient cannot fixate voluntarily.
Question 3: An examiner presents two fingers simultaneously in the right and left upper quadrants. The patient reports seeing fingers only on the right. On isolated left field testing, the left upper field is intact. What is the correct NIHSS item 3 score and interpretation?
- 0 — no deficit
- 1 — partial loss due to left visual extinction (Correct answer)
- 2 — complete left hemianopia
- 3 — bilateral blindness
Correct answer: 1 — partial loss due to left visual extinction
Extinction to double simultaneous stimulation with intact fields when tested alone is scored as partial visual loss (1) under NIHSS item 3.
Question 4: A patient with a large left hemisphere MCA stroke is aphasic and cannot follow commands. The examiner performs a visual threat in each hemifield. The patient blinks to threat on the left but not on the right. What NIHSS item 3 score is appropriate?
- 0
- 1
- 2 (Correct answer)
- 3
Correct answer: 2
Absent blink-to-threat in the entire right hemifield indicates complete right hemianopia, scored as 2.
Question 5: The NIHSS item 3 scoring scale is 0–3. Which of the following correctly maps scores to findings?
- 0=normal, 1=quadrantanopia/partial loss, 2=complete hemianopia, 3=bilateral blindness (Correct answer)
- 0=normal, 1=complete hemianopia, 2=partial loss, 3=bilateral blindness
- 0=normal, 1=bilateral blindness, 2=partial loss, 3=complete hemianopia
- 0=normal, 1=monocular blindness, 2=complete hemianopia, 3=bilateral blindness
Correct answer: 0=normal, 1=quadrantanopia/partial loss, 2=complete hemianopia, 3=bilateral blindness
The correct mapping is 0=no loss, 1=partial loss (including quadrantanopia or neglect), 2=complete hemianopia, 3=bilateral blindness.
Question 6: Why might a patient with a right parietal lobe stroke fail confrontation testing in the left visual field even though formal perimetry later shows the left field is actually intact?
- Parietal lesions specifically destroy optic radiations bilaterally
- Hemispatial neglect causes the patient to ignore left-sided stimuli including fingers (Correct answer)
- The right parietal lobe contains the primary visual cortex
- Right parietal lesions cause contralateral optic atrophy
Correct answer: Hemispatial neglect causes the patient to ignore left-sided stimuli including fingers
Right parietal lesions commonly produce left hemispatial neglect, causing patients to fail to attend to left-sided stimuli on confrontation despite intact visual pathways.
Question 7: A patient scores 2 on NIHSS item 3 at admission and 0 at 7-day follow-up. What is the most accurate clinical interpretation?
- The initial score was recorded in error
- Significant neurological recovery has occurred in the visual system (Correct answer)
- The 7-day score should be raised to match the admission score
- Visual scores cannot change over time on the NIHSS
Correct answer: Significant neurological recovery has occurred in the visual system
Improvement from score 2 to 0 reflects genuine neurological recovery, as the NIHSS captures the patient's current status at each time point.
NIHSS Visual Field Testing 5
Which anatomical lesion is most likely to produce a bitemporal hemianopia that would score 2 on NIHSS item 3?