Validation of Web-Based Star Cancellation and Line Bisection Tests in Hemiplegic Stroke

Development and Validity of Web Based Star Cancellation Test and Line Bisection Test in the Assessment of Visuospatial Neglect in Hemiplegic Stroke Patients

The goal of this observational study is to evaluate the clinical usability and diagnostic performance of newly developed web-based Star Cancellation and Line Bisection tests in assessing visuospatial neglect in hemiplegic stroke patients. It will also compare these digital tests with conventional paper-and-pencil assessments.

The main questions it aims to answer are:

Can the web-based Star Cancellation and Line Bisection tests accurately distinguish between stroke patients with and without visuospatial neglect? Do digital test parameters (such as completion time, search speed, and search patterns) provide additional clinical information beyond conventional test scores? Researchers will compare the results of the web-based tests with standard paper-and-pencil tests to evaluate their diagnostic accuracy and clinical validity.

Participants will:

Complete conventional paper-and-pencil Star Cancellation and Line Bisection tests Perform web-based (digital) versions of the same tests using a tablet and stylus Undergo routine clinical and cognitive assessments as part of standard care Provide demographic and clinical information

Study Overview

• Status: Not yet recruiting
• Conditions: Stroke; Spatial Neglect; Spatial Neglect After Stroke
• Intervention / Treatment: Diagnostic test: Web-Based Star Cancellation Test; Diagnostic test: Web-Based Line Bisection Test

Detailed Description

This study is designed as a cross-sectional, comparative, diagnostic accuracy and methodological validation study to evaluate newly developed web-based (browser-based) Star Cancellation Test (SCT) and Line Bisection Test (LBT) for the assessment of visuospatial neglect in hemiplegic stroke patients.

Visuospatial neglect is a common neuropsychological condition following stroke, particularly after right hemisphere lesions, and is associated with significant functional impairment. In clinical practice, neglect is typically assessed using paper-and-pencil tests such as cancellation tasks and line bisection tests. While these methods are widely used, they rely on manual scoring and provide limited information about the underlying search process and performance dynamics.

The digital tests developed in this study are designed to preserve the core structure and spatial characteristics of conventional assessments while enabling automated scoring and recording of additional performance metrics. These include process-based parameters such as completion time, search speed, search path characteristics, and ineffective or off-target responses. The system operates on a web-based platform without requiring software installation and is accessible through standard consumer devices, aiming to improve standardization, accessibility, and scalability in clinical settings.

Participants will be recruited from patients admitted to a physical medicine and rehabilitation clinic and will be classified into three groups based on independent clinical assessment: (1) stroke patients with visuospatial neglect, (2) stroke patients without visuospatial neglect, and (3) age- and sex-matched healthy controls without neurological disease. The presence of visuospatial neglect will be determined using routine clinical reference standards, including established paper-and-pencil neuropsychological tests and behavioral assessment scales. Digital test results will not be used in diagnostic classification to avoid incorporation bias.

All participants will complete both conventional paper-and-pencil and web-based versions of the Star Cancellation Test and Line Bisection Test under standardized conditions in a quiet clinical environment. To minimize potential order effects such as fatigue or learning, the sequence of test administration will be counterbalanced across participants. Digital assessments will be performed using a tablet device and stylus pen to ensure consistency in motor and spatial interaction.

The primary objective of the study is to evaluate the diagnostic performance of the digital tests in distinguishing between patients with and without visuospatial neglect. Secondary objectives include examining the additional clinical value of process-based digital metrics and assessing the agreement between conventional and digital test outcomes.

Statistical analyses will be conducted to assess diagnostic accuracy using receiver operating characteristic (ROC) curve analysis, including estimation of area under the curve (AUC), sensitivity, and specificity. Multivariate modeling approaches may be applied to explore the contribution of multiple digital parameters to diagnostic classification. Descriptive and correlational analyses will be used to evaluate relationships between digital performance measures and clinical variables.

Data will be collected and stored in a secure and anonymized format. Automated data capture within the digital platform will reduce manual entry errors and improve data completeness. All analyses will be performed using standard statistical software.

This study aims to provide a clinically applicable, accessible, and standardized digital alternative to conventional visuospatial neglect assessment methods, while also contributing novel process-based performance measures to the field.

• Study Type: Observational
• Enrollment (Estimated): 105

Contacts and Locations

• Study Contact: Name: Melisa Zengin, MD; Phone Number: +905414005688; Email: melisazngn@gmail.com

Study Locations

• Turkey (Türkiye)
  • Kadikoy
    • Istanbul, Kadikoy, Turkey (Türkiye), 34722
      • Istanbul Medeniyet University Goztepe Prof Dr Suleyman Yalcin City Hospital
      • Contact: Melisa Zengin, MD; Phone Number: +905414005688; Email: melisazngn@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

The study population consists of adult patients with hemiplegic stroke who are admitted to our physical medicine and rehabilitation clinic, as well as age- and sex-matched healthy control individuals without a history of neurological disease.

Description

Inclusion Criteria:

• Age 18 to 80 years
• First-ever ischemic or hemorrhagic stroke
• Hemiplegia secondary to stroke
• Stroke in the subacute or chronic phase, defined as 1 to 24 months after stroke onset
• Ability to provide written informed consent

Exclusion Criteria:

• History of neurological or severe psychiatric disease before stroke that could significantly affect cognitive function or attention, such as brain tumor, traumatic brain injury, vasculitis, multiple sclerosis, or schizophrenia
• Severe visual field defect not attributable to visuospatial neglect, such as isolated homonymous hemianopia
• Severe upper extremity motor impairment or apraxia preventing interaction with the tablet or stylus pen
• Inability to understand test instructions, cooperate with the assessment, or complete the evaluation process

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Stroke patients with visuospatial neglect; The diagnosis of visuospatial neglect will be established using standard paper-and-pencil neuropsychological assessments routinely applied in clinical practice, including the Star Cancellation Test, Line Cancellation Test, Line Bisection Test, Letter Cancellation Test, figure copying tasks, and clock drawing test, along with the Catherine Bergego Scale. To classify a participant as having visuospatial neglect, pathological findings must be present in at least two of these assessments, with at least one being a performance-based paper-and-pencil test. These assessments are part of routine clinical evaluation in stroke patients.Digital test results will not be used for diagnostic classification.	Diagnostic test: Web-Based Star Cancellation Test; The intervention consists of a web-based Star Cancellation Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Star Cancellation Test is based on the conventional paper-and-pencil version and includes both target and distractor stimuli. In addition to standard scoring, it automatically records performance measures such as the number of omitted targets, laterality index, completion time, search speed, and search path characteristics.; Other Names: Digital Star Cancellation Test; Star Cancellation Test; Diagnostic test: Web-Based Line Bisection Test; The intervention consists of a web-based Line Bisection Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Line Bisection Test follows the conventional paradigm in which participants are asked to mark the midpoint of horizontal lines. In the digital version, line positions vary across trials, and deviation from the true midpoint is calculated automatically, along with measures of variability.; Other Names: Line Bisection Test; Digital Line Bisection Test
Stroke patients without visuospatial neglect	Diagnostic test: Web-Based Star Cancellation Test; The intervention consists of a web-based Star Cancellation Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Star Cancellation Test is based on the conventional paper-and-pencil version and includes both target and distractor stimuli. In addition to standard scoring, it automatically records performance measures such as the number of omitted targets, laterality index, completion time, search speed, and search path characteristics.; Other Names: Digital Star Cancellation Test; Star Cancellation Test; Diagnostic test: Web-Based Line Bisection Test; The intervention consists of a web-based Line Bisection Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Line Bisection Test follows the conventional paradigm in which participants are asked to mark the midpoint of horizontal lines. In the digital version, line positions vary across trials, and deviation from the true midpoint is calculated automatically, along with measures of variability.; Other Names: Line Bisection Test; Digital Line Bisection Test
Control Group; Age- and sex-matched healthy control individuals without a history of neurological disease	Diagnostic test: Web-Based Star Cancellation Test; The intervention consists of a web-based Star Cancellation Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Star Cancellation Test is based on the conventional paper-and-pencil version and includes both target and distractor stimuli. In addition to standard scoring, it automatically records performance measures such as the number of omitted targets, laterality index, completion time, search speed, and search path characteristics.; Other Names: Digital Star Cancellation Test; Star Cancellation Test; Diagnostic test: Web-Based Line Bisection Test; The intervention consists of a web-based Line Bisection Test developed by the study investigators for the assessment of visuospatial neglect. This test is implemented as a browser-based application that can be accessed on standard devices without requiring software installation and is administered using a tablet and stylus pen to ensure consistent interaction. The digital Line Bisection Test follows the conventional paradigm in which participants are asked to mark the midpoint of horizontal lines. In the digital version, line positions vary across trials, and deviation from the true midpoint is calculated automatically, along with measures of variability.; Other Names: Line Bisection Test; Digital Line Bisection Test

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Laterality Index of the Digital Star Cancellation Test	The laterality index is calculated as the proportion of targets identified on the left side relative to the total number of identified targets. It is used to assess spatial bias and distinguish between participants with and without visuospatial neglect.	Baseline (single assessment during study visit)
Mean Deviation in the Digital Line Bisection Test	Mean deviation represents the average distance between the participant's marked midpoint and the true midpoint of horizontal lines. It is used as a quantitative measure of spatial bias.	Baseline (single assessment during study visit)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Omitted Targets in the Digital Star Cancellation Test	The total number of target stars not identified during the digital Star Cancellation Test. This measure reflects incomplete visual exploration.	Baseline (single assessment during study visit)
Completion Time of the Digital Star Cancellation Test	The total time required to complete the digital Star Cancellation Test, recorded automatically by the system.	Baseline (single assessment during study visit)
Search Speed in the Digital Star Cancellation Test	The rate of target identification during the digital Star Cancellation Test, used to characterize visual search efficiency.	Baseline (single assessment during study visit)
Ineffective or Off-Target Responses in the Digital Star Cancellation Test	The number of ineffective or off-target marking attempts recorded during the digital Star Cancellation Test.	Baseline (single assessment during study visit)
Variability of Performance in the Digital Line Bisection Test	The standard deviation of deviations from the true midpoint across lines in the digital Line Bisection Test, used to assess response variability.	Baseline (single assessment during study visit)
Time Spent on Each Side of the Screen in the Digital Star Cancellation Test	The amount of time spent exploring the left and right halves of the screen during the digital Star Cancellation Test, recorded automatically by the system. This measure is used to assess lateralized visual exploration patterns.	Baseline (single assessment during study visit)
Search Path Characteristics in the Digital Star Cancellation Test	Process-based measures describing the pattern of visual search during the digital Star Cancellation Test.	Baseline (single assessment during study visit)

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Participant-Reported Feasibility of the Digital Tests	Feasibility and user experience of the web-based Star Cancellation and Line Bisection tests, assessed using a brief investigator-developed questionnaire administered after completion of the digital assessments.	Baseline (single assessment immediately after test completion)

Collaborators and Investigators

• Sponsor: Istanbul Medeniyet University

Study record dates

Study Major Dates

• Study Start (Estimated): April 15, 2026
• Primary Completion (Estimated): October 15, 2026
• Study Completion (Estimated): December 1, 2026

Study Registration Dates

• First Submitted: April 12, 2026
• First Submitted That Met QC Criteria: April 12, 2026
• First Posted (Actual): April 20, 2026

Study Record Updates

• Last Update Posted (Actual): April 20, 2026
• Last Update Submitted That Met QC Criteria: April 12, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Spatial Neglect; Stroke Rehabilitation; Neuropsychological Testing; Digital Assessment; Visuospatial Neglect; Web-Based Assessment; Star Cancellation Test; Line Bisection Test
• Additional Relevant MeSH Terms: Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Vascular Diseases; Cardiovascular Diseases; Stroke
• Other Study ID Numbers: Neglect Tests

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data will not be shared due to privacy and confidentiality considerations, and because the data were collected for a single-center academic study.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No