Nih stroke scale group a test answers (patients 1-6) – complete answer key
updated spring
Complete Answer Key: NIHSS Group A Patients 1-6
Patient 1
Item Score Description
1a. LOC 0 Alert, keenly responsive
1b. LOC Questions 0 Answers both correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 0 Normal horizontal eye movements
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis (flattened nasolabial fold)
5a. Left Arm Motor 3 Some effort against gravity; falls
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 1 Drift, does not hit bed
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 1 Ataxia present in one limb
8. Sensory 2 Severe sensory loss
9. Best Language 0 No aphasia, normal
,10. Dysarthria 0 Normal
11. Extinction/Inattention 1 Inattention to one side
Patient 2
Item Score Description
1a. LOC 0 Alert
1b. LOC Questions 2 Answers neither correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 0 Normal
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis
5a. Left Arm Motor 0 No drift
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 0 No drift
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 0 Absent
8. Sensory 1 Mild-to-moderate sensory loss
9. Best Language 2 Severe aphasia
10. Dysarthria 1 Mild-to-moderate
11. Extinction/Inattention 0 No abnormality
,Patient 3
Item Score Description
1a. LOC 0 Alert
1b. LOC Questions 0 Answers both correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 2 Forced deviation cannot be overcome
3. Visual Fields 2 Complete hemianopia on the right side
4. Facial Palsy 3 Complete facial paralysis
5a. Left Arm Motor 0 No drift
5b. Right Arm Motor 4 No movement
6a. Left Leg Motor 0 No drift
6b. Right Leg Motor 4 No movement
7. Limb Ataxia 1 Ataxia in one limb
8. Sensory 1 Mild-to-moderate sensory loss
9. Best Language 0 No aphasia
10. Dysarthria 0 Normal
11. Extinction/Inattention 0 No abnormality
Patient 4
Item Score Description
, 1a. LOC 0 Alert
1b. LOC Questions 1 Answers one correctly
1c. LOC Commands 1 Follows only one command
2. Best Gaze 0 Normal
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis
5a. Left Arm Motor 1 Drift, does not hit bed
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 1 Drift, does not hit bed
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 0 Absent
8. Sensory 0 Normal
9. Best Language 0 No aphasia
10. Dysarthria 0 Normal
11. Extinction/Inattention 0 No abnormality
Patient 5
Item Score Description
1a. LOC 1 Not alert but arousable
1b. LOC Questions 1 Answers one correctly
updated spring
Complete Answer Key: NIHSS Group A Patients 1-6
Patient 1
Item Score Description
1a. LOC 0 Alert, keenly responsive
1b. LOC Questions 0 Answers both correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 0 Normal horizontal eye movements
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis (flattened nasolabial fold)
5a. Left Arm Motor 3 Some effort against gravity; falls
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 1 Drift, does not hit bed
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 1 Ataxia present in one limb
8. Sensory 2 Severe sensory loss
9. Best Language 0 No aphasia, normal
,10. Dysarthria 0 Normal
11. Extinction/Inattention 1 Inattention to one side
Patient 2
Item Score Description
1a. LOC 0 Alert
1b. LOC Questions 2 Answers neither correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 0 Normal
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis
5a. Left Arm Motor 0 No drift
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 0 No drift
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 0 Absent
8. Sensory 1 Mild-to-moderate sensory loss
9. Best Language 2 Severe aphasia
10. Dysarthria 1 Mild-to-moderate
11. Extinction/Inattention 0 No abnormality
,Patient 3
Item Score Description
1a. LOC 0 Alert
1b. LOC Questions 0 Answers both correctly
1c. LOC Commands 0 Performs both correctly
2. Best Gaze 2 Forced deviation cannot be overcome
3. Visual Fields 2 Complete hemianopia on the right side
4. Facial Palsy 3 Complete facial paralysis
5a. Left Arm Motor 0 No drift
5b. Right Arm Motor 4 No movement
6a. Left Leg Motor 0 No drift
6b. Right Leg Motor 4 No movement
7. Limb Ataxia 1 Ataxia in one limb
8. Sensory 1 Mild-to-moderate sensory loss
9. Best Language 0 No aphasia
10. Dysarthria 0 Normal
11. Extinction/Inattention 0 No abnormality
Patient 4
Item Score Description
, 1a. LOC 0 Alert
1b. LOC Questions 1 Answers one correctly
1c. LOC Commands 1 Follows only one command
2. Best Gaze 0 Normal
3. Visual Fields 0 No visual loss
4. Facial Palsy 1 Minor paralysis
5a. Left Arm Motor 1 Drift, does not hit bed
5b. Right Arm Motor 0 No drift
6a. Left Leg Motor 1 Drift, does not hit bed
6b. Right Leg Motor 0 No drift
7. Limb Ataxia 0 Absent
8. Sensory 0 Normal
9. Best Language 0 No aphasia
10. Dysarthria 0 Normal
11. Extinction/Inattention 0 No abnormality
Patient 5
Item Score Description
1a. LOC 1 Not alert but arousable
1b. LOC Questions 1 Answers one correctly
