NIH stroke scale
1a- Level of consciousness - ANS0=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 - ANS0=answers to questions correctly
1=Answers one questions correctly
2= Answers neither questions correctly
1c-LOC commands - ANS0=Performs two tasks correctly
1=Perrforms one task correctly
2=Performs neither task correctly
2--Best Gaze - ANS0=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 - ANS0=No visual loss
1=partial hemianopia
2=complete hemianopia
3=bilateral hemianopia (blind including cortical blindness)
4--Facial Palsy - ANS0=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) - ANS0=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
1a- Level of consciousness - ANS0=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 - ANS0=answers to questions correctly
1=Answers one questions correctly
2= Answers neither questions correctly
1c-LOC commands - ANS0=Performs two tasks correctly
1=Perrforms one task correctly
2=Performs neither task correctly
2--Best Gaze - ANS0=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 - ANS0=No visual loss
1=partial hemianopia
2=complete hemianopia
3=bilateral hemianopia (blind including cortical blindness)
4--Facial Palsy - ANS0=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) - ANS0=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
