APEX NIH Stroke Scale – NIHSS Assessment Study Guide & Practice for Clinical
Training
Instructions: This examination consists of 6 clinical vignettes representing patients
undergoing acute stroke evaluation in a comprehensive stroke center (CSC) in 2026.
Each patient scenario is followed by 3 independent questions assessing specific NIHSS
items. Select the single best NIHSS score for each item based on the clinical findings
provided. All patients underwent non-contrast CT and CTA/CT perfusion imaging per
current AHA/ASA guidelines.
Patient 1: Large Vessel Occlusion with Mild Aphasia
Vignette: A 64-year-old man with atrial fibrillation (on apixaban, last dose 18 hours ago)
arrives within the thrombectomy window. CT perfusion reveals a small ischemic core
with large penumbra in the left MCA territory. He is alert and oriented, but his speech is
hesitant with word-finding pauses; he names "watch" as "that thing for time" and
struggles with sentence construction despite intact comprehension. When instructed to
hold his right arm at 90 degrees while sitting, the limb drifts downward to a 45-degree
position by 8 seconds without hitting the armrest, though he does not attempt to correct
it.
Question 1.1: Based on the vignette above, what is the patient's correct NIHSS score for
Item 1a: Level of Consciousness?
A) 0
B) 1
C) 2
,D) 3
Certified Examiner's Rationale:
Correct Answer: A) 0
The decisive phrase is: "He is alert and oriented."
According to official NIHSS criteria for Item 1a, a score of 0 indicates the patient is alert
and responsive with eyes open spontaneously or to minor stimulation. The patient is
explicitly described as alert with no mention of drowsiness, stupor, or coma.
Option B (1) is incorrect because there is no evidence of "not alert; arousable by minor
stimulation to arouse"—the patient is already awake. Option C (2) applies to obtunded
patients requiring "repeated stimulation" or "strong stimulation" to awaken, which is not
the case here. Option D (3) represents coma with reflex responses only, clearly not
applicable.
Question 1.2: Based on the vignette above, what is the patient's correct NIHSS score for
Item 9: Best Language?
A) 0
B) 1
C) 2
D) 3
Certified Examiner's Rationale:
Correct Answer: B) 1
, The decisive phrases are: "speech is hesitant with word-finding pauses" and "names
'watch' as 'that thing for time'" with "intact comprehension."
According to official NIHSS criteria for Item 9, a score of 1 indicates mild-to-moderate
aphasia characterized by loss of fluency or comprehension difficulties without making
communication impossible. The patient demonstrates circumlocution ("that thing for
time") and hesitancy but can still convey ideas and understand the examiner.
Option A (0) is incorrect because fluent, normal speech is absent. Option C (2) would
require "severe aphasia" where communication is fragmentary and requires extensive
guessing; however, this patient can still name objects (albeit with paraphasic errors) and
comprehends instructions. Option D (3) applies to mute or global aphasia with no
usable speech, which contradicts the described conversational ability.
Question 1.3: Based on the vignette above, what is the patient's correct NIHSS score for
Item 5a: Motor Arm (Right)?
A) 0
B) 1
C) 2
D) 3
Certified Examiner's Rationale:
Correct Answer: B) 1
The decisive phrase is: "the limb drifts downward to a 45-degree position by 8 seconds
without hitting the armrest."
Training
Instructions: This examination consists of 6 clinical vignettes representing patients
undergoing acute stroke evaluation in a comprehensive stroke center (CSC) in 2026.
Each patient scenario is followed by 3 independent questions assessing specific NIHSS
items. Select the single best NIHSS score for each item based on the clinical findings
provided. All patients underwent non-contrast CT and CTA/CT perfusion imaging per
current AHA/ASA guidelines.
Patient 1: Large Vessel Occlusion with Mild Aphasia
Vignette: A 64-year-old man with atrial fibrillation (on apixaban, last dose 18 hours ago)
arrives within the thrombectomy window. CT perfusion reveals a small ischemic core
with large penumbra in the left MCA territory. He is alert and oriented, but his speech is
hesitant with word-finding pauses; he names "watch" as "that thing for time" and
struggles with sentence construction despite intact comprehension. When instructed to
hold his right arm at 90 degrees while sitting, the limb drifts downward to a 45-degree
position by 8 seconds without hitting the armrest, though he does not attempt to correct
it.
Question 1.1: Based on the vignette above, what is the patient's correct NIHSS score for
Item 1a: Level of Consciousness?
A) 0
B) 1
C) 2
,D) 3
Certified Examiner's Rationale:
Correct Answer: A) 0
The decisive phrase is: "He is alert and oriented."
According to official NIHSS criteria for Item 1a, a score of 0 indicates the patient is alert
and responsive with eyes open spontaneously or to minor stimulation. The patient is
explicitly described as alert with no mention of drowsiness, stupor, or coma.
Option B (1) is incorrect because there is no evidence of "not alert; arousable by minor
stimulation to arouse"—the patient is already awake. Option C (2) applies to obtunded
patients requiring "repeated stimulation" or "strong stimulation" to awaken, which is not
the case here. Option D (3) represents coma with reflex responses only, clearly not
applicable.
Question 1.2: Based on the vignette above, what is the patient's correct NIHSS score for
Item 9: Best Language?
A) 0
B) 1
C) 2
D) 3
Certified Examiner's Rationale:
Correct Answer: B) 1
, The decisive phrases are: "speech is hesitant with word-finding pauses" and "names
'watch' as 'that thing for time'" with "intact comprehension."
According to official NIHSS criteria for Item 9, a score of 1 indicates mild-to-moderate
aphasia characterized by loss of fluency or comprehension difficulties without making
communication impossible. The patient demonstrates circumlocution ("that thing for
time") and hesitancy but can still convey ideas and understand the examiner.
Option A (0) is incorrect because fluent, normal speech is absent. Option C (2) would
require "severe aphasia" where communication is fragmentary and requires extensive
guessing; however, this patient can still name objects (albeit with paraphasic errors) and
comprehends instructions. Option D (3) applies to mute or global aphasia with no
usable speech, which contradicts the described conversational ability.
Question 1.3: Based on the vignette above, what is the patient's correct NIHSS score for
Item 5a: Motor Arm (Right)?
A) 0
B) 1
C) 2
D) 3
Certified Examiner's Rationale:
Correct Answer: B) 1
The decisive phrase is: "the limb drifts downward to a 45-degree position by 8 seconds
without hitting the armrest."
