We sought to design a Virtual Reality (VR) program integrating commercially available eye and hand tracking to autonomously and accurately assess components of the National Institutes of Health Stroke Scale (NIHSS).

The rising demand for remote care has highlighted the limitations of current approaches to remote neurological examinations, creating a need for tools that can improve reliability of remote care. VR headsets have recently incorporated eye and hand tracking functionality but have not been evaluated for clinical use.

We designed a Unity™-based VR program for the Pico™ Neo 3 Pro Eye headset with Tobii™ eye tracking and Ultraleap™ hand tracking, which connected to an iPad application for test administration. The program included assessments of level of consciousness (LOC) questions, LOC commands, best gaze, visual fields, motor arm, limb ataxia, and hemispatial inattention. Subjects included patients with stroke diagnosis within 72 hours of symptoms and healthy controls. Patients with baseline severe vision loss or dementia that compromised their participation were excluded. We compared VR headset performance to in-person NIHSS by a vascular neurologist. Results were dichotomized as normal or abnormal to assess congruence.

We evaluated 10 healthy controls and 12 patients, of which 2 (16.6%) failed initial eye calibration and were excluded from analysis. Median NIHSS was 2 (IQR 1-2.5) at enrollment. Congruence between in-person and VR testing were as follows: 100% for LOC questions, 95% for LOC commands, 100% for best gaze, 90% for visual fields, 80% for motor arm left, 70% for motor arm right, 78% for limb ataxia, and 100% for hemispatial inattention.

The results of this small pilot study suggest utilization of VR headsets with eye and limb tracking technology is feasible to enhance remote evaluation in patients with recent stroke. Congruence between in-person and remote assessment of elements of the NIHSS was good to excellent.