Hemineglect after stroke is an attention problem in which a person may miss people, objects, or even part of their own body on the side opposite the brain injury, despite intact sensory systems. Also called hemispatial neglect or spatial neglect, it can look startlingly ordinary: lunch remains on the left half of the plate, the left sleeve stays empty, or every number on a drawn clock crowds onto the right. It is not a choice or simple inattention, and it deserves prompt assessment by a stroke care team.
What hemineglect after stroke actually means
Hemispatial neglect is an attention syndrome. The brain receives sensory input from the contralesional side—the side opposite the lesion—but the person does not reliably notice or respond to it. Neglect can involve more than sight: hearing, touch, and smell on the affected side may also be missed even though the sensory pathways themselves are intact.
Left neglect is far more common than right neglect, occurring five to 10 times more often. The reason lies in how spatial attention is organized: the right parietal brain is dominant for this task. A right-hemisphere injury can leave the left side of space poorly represented in attention.
After a right hemisphere stroke, spatial neglect is reported in about 33% to 82% of people, depending on the assessment and study. About two-thirds recover spontaneously during the first weeks to months after an acute right-hemisphere stroke. Recovery, however, is not a reason to overlook the condition. Neglect has a stronger negative effect on functional outcome than age, sex, hemiparesis, hemianopsia, or baseline cognitive function, and its presence in the first 10 days after stroke predicts poorer functional recovery at one year more strongly than hemiparesis or hemianopsia alone.
Why a right hemisphere stroke can make the left side disappear
The most common cause is a stroke in the right middle cerebral artery territory that damages the temporoparietal junction and posterior parietal cortex. Within the right parietal lobe, the angular gyrus and temporoparietal junction are central areas for spatial attention. Damage there can produce left neglect.
The right hemisphere directs attention to both sides of space, while the left hemisphere directs attention chiefly to the right. That asymmetry helps explain why a right hemisphere stroke more often produces neglect: after right-sided damage, the intact left hemisphere cannot fully compensate. A disrupted balance between the hemispheres’ attention networks can also maintain neglect after a right-hemisphere stroke.
Spatial neglect is not limited to one spot in the brain. Lesions involving the right frontal eye field, superior temporal lobe, thalamus, or basal ganglia can also cause it. For a patient or family, the practical point is that neglect can follow damage in several brain areas; identifying it is a task for the stroke care team.
How spatial neglect shows up beyond a missed plate
Everyday omissions often reveal the problem before a formal test does. A person may shave or apply makeup only to the right side of the face, leave food on the left side of the plate, or not put the left arm into a sleeve. On a clock-drawing task, the left half may be blank while the numbers compress on the right.
- Reading: Neglect dyslexia can cause a person to read only the right portion of a word. “Whitehouse,” for example, may become “house,” or reading may begin in the middle of a sentence.
- Writing: With neglect dysgraphia, writing can drift to the right and letters on the left may be omitted.
- Memory and imagery: Neglect can affect an imagined scene. In a classic 1978 experiment, patients describing Milan’s Piazza del Duomo from opposite directions repeatedly described the right half of the imagined square and omitted the left.
- Safety: People with right-hemisphere stroke fall about twice as often as those with left-hemisphere stroke. A missed open cabinet door, cord, or piece of furniture can turn a spatial problem into a fall risk.
Symptoms may become more apparent with fatigue. A person who scans the room fairly well early in the day may miss more on the left when tired. This fluctuation is useful practical information for rehabilitation planning and for families arranging more demanding activities.
Why some people do not know they are missing half of space
Some people with neglect have anosognosia, a lack of awareness of their deficit. They may not recognize their paralysis or their spatial neglect, even when missed information is obvious to someone nearby. The term was introduced by neurologist Joseph Babinski in 1914.
Absent insight is not stubbornness. It can make rehabilitation participation and learning compensatory strategies more difficult because the person does not experience the problem in the same way a caregiver or therapist does. In an extreme related phenomenon, somatoparaphrenia, a person may deny that the left arm or leg belongs to them.
Clinicians can assess awareness by comparing the person’s own report with a therapist’s observations. The Catherine Bergego Scale includes a standardized self-rating form for this purpose. A gap between those ratings can help the team understand not just what is missed, but whether the person recognizes the impact.
How clinicians test hemispatial neglect in clinic and daily life
Assessment does not rest on one paper exercise. Clinicians combine structured tests with observation of daily tasks because a person can perform differently on a quiet page than while dressing, navigating, or eating. The tests below identify different aspects of spatial attention.
| Assessment | What the person does | What can indicate neglect |
|---|---|---|
| Line bisection test | Marks the midpoint of a horizontal line, for example a 20-centimeter line. | With left neglect, the mark shifts significantly to the right. |
| Star Cancellation Test | Finds 56 small stars among 52 large stars, 13 letters, and 10 words. | Fewer than 44 of 54 target stars canceled suggests neglect; administration takes under five minutes. |
| Bells Test | Finds 35 bells among 280 distractors arranged in seven columns. | Misses in the far-left column suggest milder neglect; misses extending to the middle column suggest more severe neglect. |
| Behavioural Inattention Test | Completes six conventional subtests and nine behavioral tasks, such as reading a menu or dialing a telephone. | Shows how paper-based findings relate to everyday activities. |
| Catherine Bergego Scale | Is rated across 10 daily-life items, each scored from 0 to 3. | A maximum score of 30 captures effects on grooming, dressing, eating, navigation, collisions, and other daily tasks. |
Clinicians also look for extinction. A visual, tactile, or auditory stimulus on the left may be recognized when presented alone, then missed when a second stimulus appears on the right at the same time. In this situation, the brain receives the left-sided input but cannot give it priority against the ipsilesional stimulus.
Rehabilitation combines practiced scanning with brain-based adaptation
Treatment is individualized to the person’s deficits, awareness, stamina, and daily goals. There is no approved medication for neglect; medication approaches including levodopa, bromocriptine, and amphetamines have had conflicting results and can sometimes worsen neglect. Rehabilitation therefore focuses on specific ways to improve attention and function.
Prism adaptation can shift attention without a verbal strategy
In prism adaptation therapy, a person wears prism glasses that shift vision 11.4 degrees to the right (20 diopters) while repeatedly pointing to visual targets. The motor system adapts, producing a leftward after-effect that can direct attention toward the left. Because this method works implicitly, the person does not have to consciously remember to “look left,” a useful feature when cognitive impairment or anosognosia is present.
A standardized Kessler Foundation protocol uses 20-minute sessions with roughly 100 to 150 target movements, repeated over 10 to 15 treatment days. In a multicenter study across 16 U.S. rehabilitation clinics, more prism adaptation sessions were associated with greater improvement in neglect measured by the Catherine Bergego Scale and with better functional rehabilitation outcomes.
Visual scanning training makes leftward search a deliberate skill
Visual scanning training is a top-down approach. A therapist asks the person to direct gaze leftward, using color markers, light cues, or a strip along the left edge of a page as an anchor. Practice can progress from looking only a few degrees past the midline to turning fully left, often with a head turn. This is a learned strategy, unlike the implicit after-effect of prism adaptation.
Mirror therapy and emerging approaches
Mirror therapy places a mirror at the body’s midline so the person sees movement of the right arm as a reflection. It is used to reduce neglect symptoms. Neck muscle vibration, caloric vestibular stimulation, transcranial direct-current stimulation, and repetitive transcranial magnetic stimulation are also being explored; neck muscle vibration has shown sustained improvement for up to two months.
Common misunderstandings can delay useful support
- “It is just a vision problem.” Neglect is an attention syndrome. It may affect vision, hearing, touch, smell, and even mental imagery, although sensory pathways are intact.
- “They are deliberately ignoring that side.” The missed side may not enter awareness at all. Anosognosia can further limit recognition of the problem.
- “A normal-looking conversation rules it out.” Neglect may become clear during meals, dressing, reading, navigation, or when two stimuli compete at once.
- “Saying ‘look left’ is enough.” The concept of left may itself be impaired. Concrete cues and structured therapy are more useful than repeated verbal correction.
- “Improvement means safety planning can stop.” Symptoms can worsen with fatigue, and missed hazards can still increase fall risk.
Family tips that make daily routines safer
Families can support rehabilitation without turning every interaction into a correction. Put visitors, a television, family photos, or a vase on the neglected side to create meaningful reasons to orient that way. Rather than repeatedly saying “look left,” use the placement of familiar objects as a cue.
- Keep essential items—such as glasses, a call bell, and an emergency alert—on the non-neglected side so they are not missed when urgently needed.
- Reduce background noise and other distractions for important tasks. Scanning is easier in a low-stimulation environment.
- Check the neglected side for open cabinet doors, cords, protruding furniture, and hot drinks on a tray. These hazards may not be noticed.
- Plan therapy and demanding activities for the person’s more alert times of day, since cognitive fatigue can intensify neglect.
These steps support safety; they do not replace an individualized assessment. A new concern after stroke, or a sudden change in attention or safety, warrants urgent medical evaluation. For ongoing symptoms, ask the stroke care team about a functional neglect assessment and rehabilitation plan.
Frequently Asked Questions
What is hemineglect?
Hemineglect, also called hemispatial or unilateral spatial neglect, is an attention syndrome in which a person misses stimuli on the side opposite a brain injury despite intact sensory systems. Left neglect after a right-hemisphere stroke is the most common pattern.
Which brain lobe is involved in spatial neglect?
The right parietal lobe is a core area for spatial attention, especially the angular gyrus and temporoparietal junction. Right middle cerebral artery strokes that damage the temporoparietal junction or posterior parietal cortex are a common cause, although other regions can also be involved.
Do people with neglect know they have it?
Not always. Anosognosia is a lack of awareness of a deficit and can make it harder to participate in rehabilitation or learn compensatory strategies. Clinicians can compare a person’s self-rating with therapist observations on the Catherine Bergego Scale.
How is hemineglect tested?
Testing may include line bisection, cancellation tests such as the Star Cancellation Test or Bells Test, extinction testing, the Behavioural Inattention Test, and the Catherine Bergego Scale. A clinician uses both structured tasks and daily-life observations.
Can hemineglect improve after stroke?
About two-thirds of people with neglect after an acute right-hemisphere stroke recover spontaneously in the first weeks to months. Rehabilitation may include prism adaptation, visual scanning training, mirror therapy, and practical safety strategies tailored to the individual.
