Star Cancellation Test

Background

The Star Cancellation Test is a popular paper-and-pencil diagnostic tool for visual neglect (aka unilateral spatial neglect); a common condition after a stroke or brain injury where a patient fails to pay attention to or process stimuli on one side of their visual field.

Martin Albert published "A Simple Test of Visual Neglect" (Albert's Test) in 1973. He placed 40 short, black lines randomly across an unlined sheet of paper and asked patients to cross them out, a testing procedure that has become known as a 'cancellation test'. Albert's simple test was highly successful in finding patients suffering from severe neglect but routinely missed those with mild to moderate brain damage.

The Star Cancellation Test, developed by Barbara Wilson and colleagues in 1987, increased the complexity of the visual display by adding a heterogeneous mix of distractors to it. Specifically, the test asks a patient to cross out ('cancel') all the little stars that they can find amongst a sea of large stars, letters and words. While patients with severe neglect fail simple tests such as the Albert's Test, the inclusion of distractors increases the cognitive load and helps to successfully unmask mild to moderate unilateral spatial neglect that might otherwise go undetected. This more complex design provided clinicians with a more sensitive tool capable of assessing more moderate spatial neglect that Albert's original 1973 test could miss.

The Millisecond Star Cancellation Test adapts the paper and pencil administration of the task to a computerized environment. The re-created stimulus page is presented in the middle of the screen (Note that the script can be set to run the original page size if needed) and participants are asked to select the little star-targets with the mouse or fingers (on touchscreens). Additionally, the Millisecond Star Cancellation Test allows the visualization of the search strategy at task conclusion by highlighting the trail from selected location with a blue line as well as marking each location with a visitation number. Correctly selected locations are referenced in green; incorrect locations are referenced in red. A screenshot of the search path is taken automatically for future analyses.

Alternative cancellation tasks to diagnose visual neglect include the Bells Cancellation Test and the Apples Cancellation Test; the only cancellation test that allows the differential diagnoses of egocentric and allocentric neglect.

Task Procedure

Before working on the actual Star Cancellations Test, participants watch a computer animation select two of the 56 little stars on the page. These demonstration targets are located roughly in the center of the visual field. The remaining page consists of 27 targets on the left and 27 targets on the right as well as 52 large stars, 13 letters and 10 short words. Participants are asked to select all the little stars they can within 5 minutes and ignore all the other items. Once they press the Start button, the test begins (the two practice items are highlighted with a yellow circle). Anytime participants select an item via mouse click or touch, a blue circle appears around the selected screen location. The test is over if the allotted time is up, or if participants submit their responses via the Submit button.

What it Measures

The Star Cancellation Test is a measure visual neglect.

Psychological domains

• Visuospatial Attention: The ability to consciously direct and shift focus across near-extrapersonal space (the area within arm's reach).
• Selective Attention: The capacity to focus strictly on relevant target stimuli (the small stars) while actively ignoring irrelevant environmental noise.
• Focused Attention: The mental stamina required to remain locked onto a single, repetitive task over a continuous period without becoming distracted.
• Visual Search and Scanning: The systematic strategy used to look through an environment.

Main Performance Metrics

• Laterality Index: Relative number of targets found on the left side to the total number of targets found; measure of Visual Neglect
• Accuracy Score: Analysis of the number of targets not selected; measure of Selective Attention
• Execution Time: Analysis of the execution time of the search; measure of Processing Time

Psychiatric Conditions

The following patient groups are routinely tested with the Star Cancellation Test

• Traumatic Brain Injury (TBI)
• Stroke
• Brain Tumors or Infections

References

Search Google Scholar for peer-reviewed, published research using the Inquisit Star Cancellation Test.

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Wilson, B., Cockburn, J., Halligan, P. (1987). Development of a behavioral test of visuospatial neglect. Arch Phys Med Rehabil, 68, 98-101.

Bailey, M. J., Riddoch, M. J., Crome, P. (2004). Test-retest stability of three tests for unilateral visual neglect in patients with stroke: Star Cancellation, Line Bisection, and the Baking Tray Task.

Tanaka, T., Sugihara, S., Nara, H., Ino, S., & Ifukube, T. (2005). A preliminary study of clinical assessment of left unilateral spatial neglect using a head mounted display system (HMD) in rehabilitation engineering technology. Journal of Neuroengineering and Rehabilitation, 2(1), 31–31. https://doi.org/10.1186/1743-0003-2-31

NURMI, L., KETTUNEN, J., LAIHOSALO, M., RUUSKANEN, E.-I., KOIVISTO, A.-M., & JEHKONEN, M. (2010). Right hemisphere infarct patients and healthy controls: Evaluation of starting points in cancellation tasks. Journal of the International Neuropsychological Society, 16(5), 902–909. https://doi.org/10.1017/S1355617710000792

Di Luca, S., Pesenti, M., Vallar, G., & Girelli, L. (2013). Numbers reorient visuo-spatial attention during cancellation tasks. Experimental Brain Research, 225(4), 549–557. https://doi.org/10.1007/s00221-012-3393-0