Denial of eye closure in acute stroke.

Background and Purpose: Many patients suffering from stroke exhibit denial of illness. As part of this symptom complex we observed denial of eye closure. We therefore aimed to document the frequency and phenomenology of denial of eye closure in acute stroke.
Methods: Denial of eye closure was sought in 43 cases of denial of illness from a series of 400 acute strokes. Subjects underwent a neurological examination, and audiotaped interviews were performed during which they were asked to finger count through their closed eyes and their denial was challenged.
Results: Five of 43 patients with denial of hemiplegia after acute stroke were also found to have denial of eye closure (12%). Denial of eye closure was associated with drowsiness and in all but one patient with disorientation. In the three cases with imaging or autopsy data available, lesions were moderate to large, in the right hemisphere, and involved the frontal lobe. Three subjects confabulated as to what they saw through their closed eyes. One subject mislocalized the hospital closer to her home.
Conclusions: Denial of eye closure occurs in a minority of patients with denial of illness after acute stroke. This phenomenon sheds light on denial as a whole and cannot easily be accounted for by unilateral explanations, such as inattention to one half of the body or loss of sensory input. There are aspects of denial, such as denial of eye closure, mislocalization, and the delusional intensity of beliefs, that can only be understood in cognitive terms.