NIH Stroke Scale

1A - Level of consciousness (stimulate, rub, pinch) - ANS-0 - Alert; keenly responsive 1 - not alert, Arouses to minor stimulation 2 - Requires repeated stimulation to arouse 3 - reflex movements only or totally unresponsive; Postures or unresponsive( use painful/noxious stimulus) 1B - Ask month and age - ANS-0 - Both questions right 1 - One question right 1 - Dysarthric, intubated, trauma, or language barrier 2 - Aphasic 1C - "Blink eyes" and "Squeeze hands" (ask pt to close eye, then open, L-hand make fist) - ANS-0 - Performs both tasks 1 - Performs one task 2 - Performs neither task 2 - Best Gaze (Test horizontal extraocular muscles) (position of eyes @ rest, spontaneous moving L or R, follow your finger; tract finger side to side) - ANS-0 - Normal; no visual loss 1 - Partial gaze palsy: can be overcome; partial hemianopia. Partial gaze palsy: corrects with oculocephalic maneuver 2 - complete hemianopia. Forced gaze palsy: can not be overcome occulocephalic maneuver 3- bilateral hemianopia (blind including cortical blindness) 3 - Test visual fields (one hand cover eye, tell pt to look at your eyes/nose and does pt see which hand is moving then do with other eye) - ANS-0 - No visual loss 1 - Partial hemianopia 2 - Complete hemianopia 3 - Patient is bilaterally blind 3 - Bilateral hemianopia 4 - Test facial palsy (use grimace if obtunded) (show me your teeth/gum, lift eyebrows, close eyes as hard as you can)(symmetry of grimace is basis of scoring) - ANS-0 - Normal symmetry 1 - Minor paralysis (flat nasolabial fold, asymmetric smile) 2 - Partial paralysis (lower face) 3 - Unilateral complete paralysis (upper/lower face) 3 - Bilateral complete paralysis