NIH Stroke Scale
Group A — Patient 1‑6
100% Verified Solutions | Complete Assessment Guide
2026/2027 Certification Cycle
Based on NIHSS Group A Version 5 Official Answer Key
, Table of Contents
Section 1: Introduction to the NIH Stroke Scale (NIHSS)
Section 2: NIHSS Scoring Methodology
Section 3: Patient 1 — Complete Domain Scoring
Section 4: Patient 2 — Complete Domain Scoring
Section 5: Patient 3 — Complete Domain Scoring
Section 6: Patient 4 — Complete Domain Scoring
Section 7: Patient 5 — Complete Domain Scoring
Section 8: Patient 6 — Complete Domain Scoring
Section 9: Quick Reference Summary Table
Section 10: Certification Tips and Common Errors
,Section 1: Introduction to the NIH Stroke Scale (NIHSS)
The National Institutes of Health Stroke Scale (NIHSS) is a systematic, standardized neurological
examination tool developed by the National Institute of Neurological Disorders and Stroke (NINDS) to
quantify the severity of ischemic and hemorrhagic strokes. Originally designed for use in the NINDS
tissue plasminogen activator (tPA) trial in the late 1980s, the NIHSS has become the gold standard for
acute stroke assessment worldwide. It is now a mandatory component of stroke evaluation in emergency
departments, stroke units, and neurocritical care settings across the globe.
The primary purpose of the NIHSS is to provide a rapid, reproducible, and objective measure of
stroke‑related neurological impairment. The scale evaluates 15 domains — including level of
consciousness, language, motor strength, visual fields, sensation, ataxia, and inattention — yielding a
composite score that ranges from 0 (no deficits) to 42 (maximum deficit). The NIHSS score directly
informs critical treatment decisions, most notably eligibility for intravenous thrombolytic therapy
(alteplase/tPA), which must be administered within 4.5 hours of symptom onset. Patients with lower
NIHSS scores (particularly ≤4) may not meet criteria for tPA administration, while higher scores reflect
more severe strokes that may benefit from endovascular thrombectomy in the appropriate clinical
context.
Beyond its role in acute treatment decisions, the NIHSS provides a validated common language for
communication among healthcare providers — from paramedics and emergency physicians to
neurologists, nurses, and rehabilitation therapists. A single numerical score efficiently conveys the
severity of a patient's condition, facilitating handoffs, triage decisions, and consultations. Research has
consistently demonstrated that the admission NIHSS score is one of the strongest predictors of clinical
outcomes, including functional independence, mortality, and recanalization success following reperfusion
therapy.
To ensure accurate and consistent administration, healthcare professionals who assess acute stroke
patients must complete the NIHSS certification program. The certification requires demonstrating 100%
accuracy on all patients in a test group (e.g., Group A, B, C, D, E, or F), with each group consisting of six
patient scenarios presented through video or interactive modules. This guide covers Group A (Patients 1–
6) with 100% verified correct answers and detailed clinical rationales.
, Section 2: NIHSS Scoring Methodology
The NIHSS produces a composite score ranging from 0 to 42, with higher scores indicating more severe
neurological impairment. The scale is divided into 15 distinct domains, each assessing a specific aspect of
neurological function. Individual domain scores typically range from 0 to 2, 3, or 4 depending on the item.
The total score is calculated by summing all individual domain scores (excluding item 1a, which counts 0–
3, and item 5a/5b and 6a/6b, each of which count 0–4, the maximum possible total is 42).
Stroke severity is broadly classified into five tiers based on the total NIHSS score. A score of 0 indicates no
measurable neurological deficit (normal). Scores of 1–4 represent a minor stroke, often associated with
excellent functional recovery. Scores of 5–15 indicate moderate stroke severity, where patients typically
have identifiable focal deficits but retain some functional independence. Scores of 16–20 reflect
moderate‑to‑severe stroke with significant disability. Scores of 21–42 indicate severe stroke with profound
neurological impairment and poor prognosis.
Accurate NIHSS administration requires careful attention to the specific scoring rules for each item.
Common pitfalls include confusing the scoring of item 7 (limb ataxia) — which cannot be scored if motor
weakness prevents adequate testing of coordination — and item 10 (dysarthria), which receives a score of
9 if the patient is intubated. Additionally, item 1b and 1c scores are based on the patient's best response,
even if comprehension appears limited. Inter‑rater reliability is high among certified examiners, with
studies showing kappa values exceeding 0.80 for most items when proper training is completed.
NIHSS Domain Scoring Reference Table
Domain Description Scoring Scale
Evaluates the patient's level of
Level of Consciousness (LOC) – arousal and awareness. 0=Alert,
1a
Responsiveness 1=Not Alert, 2=Obtunded,
3=Unresponsive.
Patient is asked the current
LOC Questions – Month and month and their age. 0=Both
1b
Age correct, 1=One correct,
2=Neither correct.
Patient is asked to open/close
LOC Commands – Open Eyes eyes and grip/release hand.
1c
and Grip/Squeeze Hand 0=Both correct, 1=One correct,
2=Neither correct.
Assesses horizontal eye
movements. Only horizontal eye
Best Gaze – Horizontal Eye
2 movement is scored. 0=Normal,
Movement
1=Partial gaze palsy, 2=Forced
deviation.
Tests visual fields by
confrontation. 0=No visual loss,
3 Visual Fields 1=Partial hemianopia,
2=Complete hemianopia,
3=Bilateral hemianopia.
Observes facial symmetry at rest
and during spontaneous or
4 Facial Palsy prompted grimace. 0=Normal,
1=Minor paralysis, 2=Partial
paralysis, 3=Complete paralysis.
5a Motor Arm – Left Patient holds arms outstretched
for 10 seconds; drift is observed.
Group A — Patient 1‑6
100% Verified Solutions | Complete Assessment Guide
2026/2027 Certification Cycle
Based on NIHSS Group A Version 5 Official Answer Key
, Table of Contents
Section 1: Introduction to the NIH Stroke Scale (NIHSS)
Section 2: NIHSS Scoring Methodology
Section 3: Patient 1 — Complete Domain Scoring
Section 4: Patient 2 — Complete Domain Scoring
Section 5: Patient 3 — Complete Domain Scoring
Section 6: Patient 4 — Complete Domain Scoring
Section 7: Patient 5 — Complete Domain Scoring
Section 8: Patient 6 — Complete Domain Scoring
Section 9: Quick Reference Summary Table
Section 10: Certification Tips and Common Errors
,Section 1: Introduction to the NIH Stroke Scale (NIHSS)
The National Institutes of Health Stroke Scale (NIHSS) is a systematic, standardized neurological
examination tool developed by the National Institute of Neurological Disorders and Stroke (NINDS) to
quantify the severity of ischemic and hemorrhagic strokes. Originally designed for use in the NINDS
tissue plasminogen activator (tPA) trial in the late 1980s, the NIHSS has become the gold standard for
acute stroke assessment worldwide. It is now a mandatory component of stroke evaluation in emergency
departments, stroke units, and neurocritical care settings across the globe.
The primary purpose of the NIHSS is to provide a rapid, reproducible, and objective measure of
stroke‑related neurological impairment. The scale evaluates 15 domains — including level of
consciousness, language, motor strength, visual fields, sensation, ataxia, and inattention — yielding a
composite score that ranges from 0 (no deficits) to 42 (maximum deficit). The NIHSS score directly
informs critical treatment decisions, most notably eligibility for intravenous thrombolytic therapy
(alteplase/tPA), which must be administered within 4.5 hours of symptom onset. Patients with lower
NIHSS scores (particularly ≤4) may not meet criteria for tPA administration, while higher scores reflect
more severe strokes that may benefit from endovascular thrombectomy in the appropriate clinical
context.
Beyond its role in acute treatment decisions, the NIHSS provides a validated common language for
communication among healthcare providers — from paramedics and emergency physicians to
neurologists, nurses, and rehabilitation therapists. A single numerical score efficiently conveys the
severity of a patient's condition, facilitating handoffs, triage decisions, and consultations. Research has
consistently demonstrated that the admission NIHSS score is one of the strongest predictors of clinical
outcomes, including functional independence, mortality, and recanalization success following reperfusion
therapy.
To ensure accurate and consistent administration, healthcare professionals who assess acute stroke
patients must complete the NIHSS certification program. The certification requires demonstrating 100%
accuracy on all patients in a test group (e.g., Group A, B, C, D, E, or F), with each group consisting of six
patient scenarios presented through video or interactive modules. This guide covers Group A (Patients 1–
6) with 100% verified correct answers and detailed clinical rationales.
, Section 2: NIHSS Scoring Methodology
The NIHSS produces a composite score ranging from 0 to 42, with higher scores indicating more severe
neurological impairment. The scale is divided into 15 distinct domains, each assessing a specific aspect of
neurological function. Individual domain scores typically range from 0 to 2, 3, or 4 depending on the item.
The total score is calculated by summing all individual domain scores (excluding item 1a, which counts 0–
3, and item 5a/5b and 6a/6b, each of which count 0–4, the maximum possible total is 42).
Stroke severity is broadly classified into five tiers based on the total NIHSS score. A score of 0 indicates no
measurable neurological deficit (normal). Scores of 1–4 represent a minor stroke, often associated with
excellent functional recovery. Scores of 5–15 indicate moderate stroke severity, where patients typically
have identifiable focal deficits but retain some functional independence. Scores of 16–20 reflect
moderate‑to‑severe stroke with significant disability. Scores of 21–42 indicate severe stroke with profound
neurological impairment and poor prognosis.
Accurate NIHSS administration requires careful attention to the specific scoring rules for each item.
Common pitfalls include confusing the scoring of item 7 (limb ataxia) — which cannot be scored if motor
weakness prevents adequate testing of coordination — and item 10 (dysarthria), which receives a score of
9 if the patient is intubated. Additionally, item 1b and 1c scores are based on the patient's best response,
even if comprehension appears limited. Inter‑rater reliability is high among certified examiners, with
studies showing kappa values exceeding 0.80 for most items when proper training is completed.
NIHSS Domain Scoring Reference Table
Domain Description Scoring Scale
Evaluates the patient's level of
Level of Consciousness (LOC) – arousal and awareness. 0=Alert,
1a
Responsiveness 1=Not Alert, 2=Obtunded,
3=Unresponsive.
Patient is asked the current
LOC Questions – Month and month and their age. 0=Both
1b
Age correct, 1=One correct,
2=Neither correct.
Patient is asked to open/close
LOC Commands – Open Eyes eyes and grip/release hand.
1c
and Grip/Squeeze Hand 0=Both correct, 1=One correct,
2=Neither correct.
Assesses horizontal eye
movements. Only horizontal eye
Best Gaze – Horizontal Eye
2 movement is scored. 0=Normal,
Movement
1=Partial gaze palsy, 2=Forced
deviation.
Tests visual fields by
confrontation. 0=No visual loss,
3 Visual Fields 1=Partial hemianopia,
2=Complete hemianopia,
3=Bilateral hemianopia.
Observes facial symmetry at rest
and during spontaneous or
4 Facial Palsy prompted grimace. 0=Normal,
1=Minor paralysis, 2=Partial
paralysis, 3=Complete paralysis.
5a Motor Arm – Left Patient holds arms outstretched
for 10 seconds; drift is observed.
