NIH Stroke Scale
NIH Stroke Scale
Study online at https://quizlet.com/_1fuvxc
1. How to assess 1a. Deteremine if patient is alert, oriented x4
Level of Con-
sciousness? 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 that 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 scored (i.e.,
follows none, one or two commands)
2. What are the re- 0 = Alert; keenly responsive.
sults? 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.
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.
1/6
Page 1 of 6
, NIH Stroke Scale
NIH Stroke Scale
Study online at https://quizlet.com/_1fuvxc
How to assess Only horizontal eye movements will be tested.
best gaze? 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 1
4. What are the re- 0 = Normal.
sults? 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 vi- Visual fields (upper and lower quadrants) are tested by
sual gaze? confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are
scored.
If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is extinction,
patient receives a 1, and the results are used to respond to item 11.
6. What are the re- 0 = No visual loss.
sults? 1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
7. How to assess fa- Ask - or use pantomime to encourage - the patient
cial palsy? to show teeth or raise eyebrows and close eyes. Score symmetry of grimace
in response to noxious stimuli in the poorly responsive or non-comprehending
patient.
8. What are the re- 0 = Normal symmetrical movements.
sults? 1 = Minor paralysis (flattened nasolabial fold, asymmetry on
2/6
Page 2 of 6
NIH Stroke Scale
Study online at https://quizlet.com/_1fuvxc
1. How to assess 1a. Deteremine if patient is alert, oriented x4
Level of Con-
sciousness? 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 that 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 scored (i.e.,
follows none, one or two commands)
2. What are the re- 0 = Alert; keenly responsive.
sults? 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.
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.
1/6
Page 1 of 6
, NIH Stroke Scale
NIH Stroke Scale
Study online at https://quizlet.com/_1fuvxc
How to assess Only horizontal eye movements will be tested.
best gaze? 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 1
4. What are the re- 0 = Normal.
sults? 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 vi- Visual fields (upper and lower quadrants) are tested by
sual gaze? confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are
scored.
If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is extinction,
patient receives a 1, and the results are used to respond to item 11.
6. What are the re- 0 = No visual loss.
sults? 1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
7. How to assess fa- Ask - or use pantomime to encourage - the patient
cial palsy? to show teeth or raise eyebrows and close eyes. Score symmetry of grimace
in response to noxious stimuli in the poorly responsive or non-comprehending
patient.
8. What are the re- 0 = Normal symmetrical movements.
sults? 1 = Minor paralysis (flattened nasolabial fold, asymmetry on
2/6
Page 2 of 6
