NIH Stroke Scale

Background

  • Intubation or limb pathology making categories not testable should be considered and potentially not scored.
  • tPA candidate generally with NIHSS 4 - 22

Scale

Level of Consciousness

1a General

  • Alert = 0
  • Not alert, arousable to mild stimulation = 1
  • Not alert, arousable to significant stimulation = 2
  • Not alert; reflexic, autonomic or no response = 3

1b. Questions

  • Month and DOB
    • Both correct = 0
    • One correct = 1
    • Zero correct = 2

1c. Commands

  • Open/close eyes & squeeze/release hand:
    • Both correct = 0
    • One correct = 1
    • Zero correct = 2

2. Best Gaze

  • Horizontal voluntary or oculocephalic reflex:
    • Normal = 0
    • Partial gaze palsy = 1
    • Forced deviation or total gaze palsy = 2

3. Visual Fields

  • Normal = 0
  • Partial hemianopia = 1
  • Complete hemianopia = 2
  • Bilateral hemianopia or cortical blindness = 3

4. Facial Paralysis

  • Normal = 0
  • Minor, flat nasolabial fold = 1
  • Partial or total uni lower paralysis= 2
  • Complete paralysis 1 or both sides (upper & lower) = 3

5. Motor Arm

  • 10 seconds:
    • No drift = 0
    • Some drift = 1
    • Falls, effort against gravity = 2
    • Falls, No effort against gravity = 3
    • No movement = 4

6. Motor Leg

  • 5 seconds:
    • No drift = 0
    • Some drift = 1
    • Falls, effort against gravity = 2
    • Falls, No effort against gravity = 3
    • No movement = 4

7. Limb ataxia

  • Absent = 0
  • One limb = 1
  • Two limb = 2

8. Sensory Loss

  • Arms, legs, trunk:
    • Normal = 0
    • Present but altered = 1
    • Absent = 2

9. Best Language

  • Identification (picture or tactile), repetition, comprehension:
    • No aphasia = 0
    • Mild to moderate = 1
    • Severe = 2
    • Mute/Global aphasia = 3

10. Dysarthria

  • None = 0
  • Mild to moderate = 1
  • Severe = 2

11. Extinction/Inattention

  • Neglect:
    • None = 0
    • Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1
    • Profound hemi-inattention or more than 1 modality = 2

External Links

References

National Institute of Neurologic Disorders and Stroke

See Also