NIH Stroke Scale Ques & Ans
1.How to assess Level of Consciousness?: 1a. Deteremine if patient is
alert, oriented x4
1b. The patient is asked the month and his/her age.
The answer must be correct - there is no partial credit for being close.
Aphasic and stuporous patients who do not comprehend the questions
will score 2. It is important that only the initial answer be graded and tha
the examiner not "help" the patient with verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient
does not respond to command, the task
should be demonstrated to him or her (pantomime), and the result score
(i.e., follows none, one or two commands)
2.What are the results?: 0 = Alert; keenly
responsive. 1 = Not alert; but arousable by
minor stimulation to obey, answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is obtunded an
requires strong or painful stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or totally
unresponsive, flaccid, and areflexic.
1/
9
, 0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
3.How to assess best gaze?: Only horizontal eye movements will be
tested. Voluntary or reflexive (oculocephalic) eye movements will be
scored, but caloric testing is not done. If the patient has a conjugate
deviation of the eyes that can
be overcome by voluntary or reflexive activity, the score will be 1If a
patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a
4.What are the results?: 0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not
present. 2 = Forced deviation, or total gaze
5.How to assess visual gaze?: Visual fields (upper and lower
quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the
2/
9
1.How to assess Level of Consciousness?: 1a. Deteremine if patient is
alert, oriented x4
1b. The patient is asked the month and his/her age.
The answer must be correct - there is no partial credit for being close.
Aphasic and stuporous patients who do not comprehend the questions
will score 2. It is important that only the initial answer be graded and tha
the examiner not "help" the patient with verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient
does not respond to command, the task
should be demonstrated to him or her (pantomime), and the result score
(i.e., follows none, one or two commands)
2.What are the results?: 0 = Alert; keenly
responsive. 1 = Not alert; but arousable by
minor stimulation to obey, answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is obtunded an
requires strong or painful stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or totally
unresponsive, flaccid, and areflexic.
1/
9
, 0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
3.How to assess best gaze?: Only horizontal eye movements will be
tested. Voluntary or reflexive (oculocephalic) eye movements will be
scored, but caloric testing is not done. If the patient has a conjugate
deviation of the eyes that can
be overcome by voluntary or reflexive activity, the score will be 1If a
patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a
4.What are the results?: 0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not
present. 2 = Forced deviation, or total gaze
5.How to assess visual gaze?: Visual fields (upper and lower
quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the
2/
9
