Physical – left upper and lower limb weakness, altered sensation, sensory inattention, reduced proprioception & increased muscle tone
Cognition & perception – executive problems and poor insight into her limitations; mild left sided visual inattention.
Flora’s ability to drive might be affected in the following way as a result of her left-sided inattention:
N.B. Someone with a left hemianopia may have a similar experience, although their problem is visual rather than perceptual. Flora does not have this problem.
Although a hemianopia or quadrantanopia is a DVLA listed medical legal bar to driving and must be declared, DVLA may be able to reconsider its practical effect on driving when the individual is one year post stroke, has medical support that the deficit is static i.e. non-progressive, and they have documented medical support in relation to their ability to compensate for this in everyday life. In this case DVLA may consider the individual as an ‘exceptional case’ and can choose to refer them to Specialist Driving Assessment Service for assessment. Clinically apparent visual inattention is also a DVLA listed medical legal bar to driving. See DVLA guidelines for further information.
The animation shows how Flora’s left-sided inattention prevents her from seeing the animal run into the road until it is too late to avoid a collision with her car
Additional Information
Visual field testing using the recognised confrontational test (outlined below) should help to confirm if the patient does meet the required visual field standards for driving.
The assessor should sit directly in front of the individual being assessed with arms elevated and semi extended and begin by wiggling their right index finger initially horizontally on the right and then separately their left index finger horizontally on the left side of the person’s vision peripherally. This should identify whether the individual has a medical debarring visual field deficit in the horizontal field. It is also important to ascertain whether the individual has vision in their upper and lower visual quadrants and this can be done by again wiggling the index finger in diagonally opposite sides, above and below the midline.
Once you have confirmed that your patient has the legally required visual field of vision for driving, the assessor is required to identify any clinically apparent debarring visual inattention/visual extinction. This is also done using confrontational testing but on this occasion with simultaneous stimulation of both visual fields using the wiggling index fingers. The individual with clinically apparent visual inattention/visual extinction will not respond or may respond inconsistently to stimuli on the contralesional affected side but only in the presence of simultaneous stimuli. Individuals will respond normally when the same stimulus is presented in isolation to the left or right side. On occasion’s patients can respond inconsistently to bilateral stimulation, Azouvi et al. (2006) believe the test identifies the presence of visual inattention/extinction if the individual fails to appreciate contralesional stimuli at least once during a trial of 6, particularly if the individual consistently responds to the unilateral stimulus.
Dr Paresh Malhotra YouTube video illustrates the practical effects of hemispatial visual inattention in two individuals who have suffered strokes. The video demonstrates how to test for visual inattention/extinction using the confrontational test although one individual also has a left-sided hemianopia. It confirms how visual extinction/inattention can still be identified within the intact visual field. (https://www.youtube.com/watch?v=d4FhZs-m7hAto)
