Clinical stroke scales including the NIHSS are less sensitive for right compared to left hemisphere stroke. We hypothesized that adding one of three neglect tests to a brief stroke severity scale would increase diagnostic accuracy for right-hemisphere LVO.

This single-site, observational prospective study occurred from January 2020-June 2022. Research assistants (RAs) were trained using a video and post-training exam on three hemi-neglect tests including line bisection, the “2 and 1” test of visual extinction, and the Eastchester Clap Sign (ECS) which were added to the Emergency Medical Stroke Assessment (EMSA), a previously validated stroke severity scale. RAs, blinded to NIHSS and imaging, assessed ED code stroke patients using the expanded EMSA. A vascular neurologist blinded to EMSA and NIHSS determined LVO status. We calculated Receiver Operator Characteristics Area Under the Curve (AUC) and 95% CI for right-sided LVO.

There was no significant difference in the ability of the EMSA and NIHSS to distinguish between right-hemisphere LVO and non-LVO ischemic stroke. The addition of the 2 and 1 test or Eastchester Clap Sign but not line bisection to the EMSA modestly improved its ability to discriminate between right-hemisphere LVO and non-LVO ischemic stroke.