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Incidence and Diagnosis of Anosognosia for Hemiparesis Revisited B Baier, H-O Karnath 358 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.036731 on 16 February 2005. Downloaded from PAPER Incidence and diagnosis of anosognosia for hemiparesis revisited B Baier, H-O Karnath ............................................................................................................................... J Neurol Neurosurg Psychiatry 2005;76:358–361. doi: 10.1136/jnnp.2004.036731 Background: In previous studies, the incidence of anosognosia for hemiparesis has varied between 17% and 58% in samples of brain damaged patients with hemiparesis. See end of article for Objective: To determine whether this wide variation might be explained by the different criteria used for authors’ affiliations ....................... diagnosing anosognosia. Methods: 128 acute stroke patients with hemiparesis or hemiplegia were tested for anosognosia for Correspondence to: hemiparesis using the anosognosia scale of Bisiach et al. Prof Hans-Otto Karnath, Results: 94% of the patients who were rated as having ‘‘mild anosognosia’’—that is, they did not Centre of Neurology, Hertie-Institute for Clinical acknowledge their hemiparesis spontaneously following a general question about their complaints— Brain Research, University suffered from, and mentioned, other neurological deficits such as dysarthria, ptosis, or headache. of Tu¨bingen, Hoppe- However, they immediately acknowledged their paresis when they were asked about the strength of their Seyler-Str 3, D-72076 Tu¨bingen, Germany; limbs. Their other deficits clearly had a greater impact. These patients had significantly milder paresis than [email protected] those who denied their disorder even when asked directly about their limbs. Conclusions: Patients who do not mention their paresis spontaneously but do so when questioned about it Received 14 January 2004 directly should not be diagnosed having ‘‘anosognosia.’’ If this more conservative cut off criterion is In revised form 10 June 2004 applied to the data of the present as well as previous studies, a frequency of between 10% and 18% for Accepted 10 June 2004 anosognosia for hemiparesis is obtained in unselected samples of acute hemiparetic stroke patients. The ....................... incidence thus seems smaller than previously assumed. copyright. troke patients with anosognosia for hemiparesis typi- should indeed be regarded ‘‘pathological’’ or whether it is still cally deny their paresis or behave as if the disorder did within the normal range (especially when hemiparesis is not Snot exist. They are convinced that their paretic or plegic the only symptom involved after a stroke). Should patients limb functions normally. They may address their paresis, but who do not mention their paresis but complain sponta- then consider it as harmless and state that, for example, their neously of other deficits be considered as having ‘‘anosog- leg ‘‘is tired’’. Anosognosia is not only found in hemiparesis; nosia for hemiparesis’’? it may also be observed with cortical blindness, hemianopia, To investigate this question we asked how patients with or deafness.12 ‘‘mild’’ anosognosia differ in their clinical variables from Previous studies have shown wide variation in the patients with ‘‘medium’’ or ‘‘severe’’ anosognosia. We further incidence of anosognosia for hemiparesis. Bisiach et al3 asked whether it is possible that patients with ‘‘mild’’ reported that about 33% of right brain damaged patients anosognosia do not acknowledge their paresis spontaneously had medium or severe anosognosia for hemiparesis. Cutting4 because they have other deficits that may have a greater found that 58% of right brain damaged patients had impact subjectively. http://jnnp.bmj.com/ anosognosia for hemiparesis, while Maeshima et al5 reported only 24% with this sign. In a study by Starkstein et al,6 31% of METHODS right and left sided acute stroke patients had anosognosia for We investigated patients with circumscribed right and left hemiparesis. Other studies reported incidences ranging from hemisphere lesions consecutively admitted from a well 17% to 28% for the same disorder.7–9 defined area belonging to the University of Tu¨bingen and We wondered whether this wide variation in the incidence six related community hospitals over a period of six months. might reflect varying criteria for diagnosing anosognosia for We included patients who had developed acute stroke within on September 23, 2021 by guest. Protected hemiparesis. All assessment scales applied in previous the previous 15 days, with left or right sided hemiparesis or studies34710 used a short interview to consider a patient hemiplegia. Lesions were documented by magnetic resonance anosognosic for hemiparesis. However, so far none of the imaging or computed tomography. Patients who were not scales has had general acceptance as the standard procedure. alert, not cooperative, or had severe aphasia were excluded The questionnaires suggested by Bisiach et al3 and by Cutting4 only if their communication abilities did not permit a simple have been widely distributed and frequently used in clinical interview for anosognosia (see below). studies.6891112They both start with a general question about The study group comprised 128 patients with hemiparesis the patient’s complaints. The advantage of Bisiach’s ques- or hemiplegia, 72 with right brain damage and 56 with left tionnaire3 is that it allows classification of the degree of brain damage (table 1). The patients gave informed consent anosognosia into ‘‘mild’’, ‘‘medium’’, and ‘‘severe’’, while the for their participation in the study, which was done in scale of Cutting4 only uses a dichotomous classification accordance with the ethical standards laid down in the 1964 (having anosognosia v not having anosognosia). Declaration of Helsinki. All examinations were carried out According to Bisiach’s scale, ‘‘mild anosognosia’’ for immediately after admission—that is, in the acute phase of hemiparesis is diagnosed when patients do not acknowledge the stroke. their paresis when posed a general question about their The degree of paresis of the upper and lower limbs was symptoms. In this study we ask whether such behaviour scored with the usual clinical ordinal scale, where 0 is no www.jnnp.com Incidence and diagnosis of anosognosia 359 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.036731 on 16 February 2005. Downloaded from Table 1 Demographic and clinical data on all brain damaged patients with hemiparesis or hemiplegia Variable Denial grade 0 Denial grade 1 Denial grade 2 Denial grade 3 Number 99 17 8 4 Sex (M;F) 54;45 6;11 6;2 3;1 Age (years) Median (range) 69 (20 to 100) 70 (45 to 89) 71(51 to 84) 78(54 to 91) Aetiology 84 inf, 15 haem 12 inf, 5 haem 3 inf, 5 haem 3 inf, 1 haem Time since lesion (days) Median (range) 4 (0 to 14) 4 (0 to 11) 3.5 (1 to 15) 3 (0 to 14) Side of lesion Right % present 56 41 75 100 Left % present 44 59 25 0 Paresis of contralesional side % present 100 100 100 100 Arm Median (range) 4 (0 to 4) 3 (0 to 4) 0 (0 to 4) 0 (0 to 1) Leg Median (range) 4 (0 to 4) 3 (0 to 4) 0 (0 to 3) 0 (0 to 3) Visual field defects % present 4 0 13 0 % tnp 3 6 Neglect % present 16 24 75 75 % tnp 13 12 13 25 Extinction Visual % present 19 52 75 75 % tnp 5 6 13 Tactile % present 22 41 75 75 % tnp 4 12 13 Auditory % present 19 18 75 75 % tnp 6 12 13 Aphasia % present 14 24 0 0 MMSE Median (range) 25 (9 to 30) 18.5 (6 to 29) 13.5 (10 to 21) 15.5 (4 to 24) Denial grade 0 to 3 according to the anosognosia scale of Bisiach et al.3 f, female; haem, haemorrhage; inf, infarct; m, male; MMSE, mini-mental state examination13; tnp, testing not possible. trace of movement and 5 is normal movement. Scoring was closed. The auditory mode was tested by rustling a small carried out separately for the proximal (upper arm, thigh) piece of paper near the patient’s left or right ear. Tactile and distal (forearm, lower leg) parts of each limb. Table 1 extinction was investigated by applying fingertips lightly on presents the averaged scores per limb. the dorsal surface of the patient’s left or right hand while the Anosognosia for hemiplegia was examined using a German patient’s arms lay relaxed. If the patient was not able to copyright. translation14 of the anosognosia scale suggested by Bisiach report this gentle unilateral tactile stimulation on the et al3: contralateral hand owing to left sided sensory loss, the examination was repeated using soft pinching applied to N grade 0 (no anosognosia): the disorder is spontaneously the left or right shoulder. Patients were classified as showing reported or mentioned by the patient following a general extinction in the respective mode when they reported >90% question about their complaints; of the unilateral stimuli on each side correctly, but failed to N grade 1: the disorder is reported only following a specific perceive the left stimulus during bilateral stimulation in question about the strength of the patient’s limbs; .50% of the trials. N grade 2: the disorder is acknowledged only after demon- strations through routine techniques of neurological RESULTS examination; Ninety nine (77%) of the 128 brain damaged subjects with N grade 3: no acknowledgement of the disorder can be left or right sided hemiparesis or hemiplegia mentioned their http://jnnp.bmj.com/ obtained. motor deficit spontaneously following a general question about their complaints. Twenty nine patients (23%) were Visual field defects were assessed by standard neurological thus rated as showing mild, medium, or severe ‘‘anosogno- examination. Spatial neglect was diagnosed when the sia’’ for hemiparesis according to the anosognosia scale of patients showed characteristic clinical behaviour such as Bisiach et al.3 Seventeen (59%) of these 29 patients had a orienting towards the ipsilesional side when addressed from denial grade of 1 (that is, they reported their motor the front or the left, and/or ignoring contralesionally located impairment only following a specific question about the people or objects.
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