NIH stroke scale Exam/13 Questions
and Answers/Distinction Graded
1a- Level of consciousness - -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 and
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.
-1b- LOC questions - -0=answers to questions correctly
1=Answers one questions correctly
2= Answers neither questions correctly
-1c-LOC commands - -0=Performs two tasks correctly
1=Perrforms one task correctly
2=Performs neither task correctly
-2--Best Gaze - -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 paresis not overcome by the oculocephalic
maneuver.
-3--Visual - -0=No visual loss
1=partial hemianopia
2=complete hemianopia
3=bilateral hemianopia (blind including cortical blindness)
-4--Facial Palsy - -0=Normal symmetrical movements
1=Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
2=Partial paralysis (total or near total paralysis of lower face)
3=Complete paralysis of one or both sides (absence of facial movement in
the upper and lower face)
-5--Motor (Arm) - -0=No drift; limbs holds 90 (or 45) degrees for full 10
seconds
1= drift; limbs hold 90 (or 45 degrees), but drifts down before full 10
seconds; does not hit bed or other support
2=Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or
45), drifts down to bed, but has some effort against gravity
3=No effort against gravity, limbs falls.
4=No movement
Untestable=Amputation or joint fusion
and Answers/Distinction Graded
1a- Level of consciousness - -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 and
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.
-1b- LOC questions - -0=answers to questions correctly
1=Answers one questions correctly
2= Answers neither questions correctly
-1c-LOC commands - -0=Performs two tasks correctly
1=Perrforms one task correctly
2=Performs neither task correctly
-2--Best Gaze - -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 paresis not overcome by the oculocephalic
maneuver.
-3--Visual - -0=No visual loss
1=partial hemianopia
2=complete hemianopia
3=bilateral hemianopia (blind including cortical blindness)
-4--Facial Palsy - -0=Normal symmetrical movements
1=Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
2=Partial paralysis (total or near total paralysis of lower face)
3=Complete paralysis of one or both sides (absence of facial movement in
the upper and lower face)
-5--Motor (Arm) - -0=No drift; limbs holds 90 (or 45) degrees for full 10
seconds
1= drift; limbs hold 90 (or 45 degrees), but drifts down before full 10
seconds; does not hit bed or other support
2=Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or
45), drifts down to bed, but has some effort against gravity
3=No effort against gravity, limbs falls.
4=No movement
Untestable=Amputation or joint fusion
