NIHSS-LEVEL 1 EXAM 2024
ACTUAL 50 QUESTIONS AND
ANSWERS
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. Patients unable to speak because of
endotracheal intubation, orotracheal trauma, severe dysarthria from any cause,
language barrier or any other problem not secondary to aphasia are given a 1. It
is important that only the initial answer be graded and that the examiner not help
the patient with verbal or non-verbal cues.
1b. LOC Questions
1-Answers One Question Correctly
The patient is asked to open and close the eyes and then to grip and release the
non-paretic hand. Substitute another one step command if the hands cannot be
used. Credit is given if an unequivocal attempt is made but not completed due to
weakness. If the patient does not respond to command, the task should be
demonstrated to them (pantomime) and score the result (i.e., follows none, one or
two commands). Patients with trauma, amputation, or other physical impediments
should be given suitable one-step commands. Only the first attempt is scored.
1c. LOC Commands
0- Performs both Tasks Correctly
Only horizontal eye movements will be tested.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 1. If a patient has an isolated
peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in all aphasic
patients. Patients with ocular trauma, bandages, pre-existing blindness or other
disorder of visual acuity or fields should be tested with reflexive movements and
, a choice made by the investigator. Establishing eye contact and then moving
about the patient from side to side will occasionally clarify the presence of a
partial gaze palsy.
2. best Gaze
0-Normal
Visual fields (upper and lower quadrants) are tested by confrontation, using
finger counting or visual threat as appropriate. Patient must be encouraged, but if
they look at the side of the moving fingers appropriately, this can be scored as
normal. If there is unilateral blindness or enucleation, visual fields in the
remaining eye are scored. Score 1 only if a clear-cut asymmetry, including
quadrantanopia is found. 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 answer question 11.
3. Visual
0-No Visual Loss
Ask, or use pantomime to encourage the patient 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. If facial trauma/bandages,
orotracheal tube, tape or other physical barriers obscure the face, these should
be removed to the extent possible.
4. Facial Palsy
1-Minor Paralysis (Flattened nasolabial fold, asymmetry on smiling).
The limb is placed in the appropriate position: extend the arms (palms down) 90
degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before
10 seconds. The aphasic patient is encouraged using urgency in the voice and
pantomime, but not noxious stimulation. Each limb is tested in turn, beginning
with the non-paretic arm. Only in the case of amputation or joint fusion at the
shoulder, the examiner should record the score as untestable (UN).
5a. Motor Arm Left
0- No drift, limb holds 90 (or 45) degrees for full 10 seconds.
ACTUAL 50 QUESTIONS AND
ANSWERS
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. Patients unable to speak because of
endotracheal intubation, orotracheal trauma, severe dysarthria from any cause,
language barrier or any other problem not secondary to aphasia are given a 1. It
is important that only the initial answer be graded and that the examiner not help
the patient with verbal or non-verbal cues.
1b. LOC Questions
1-Answers One Question Correctly
The patient is asked to open and close the eyes and then to grip and release the
non-paretic hand. Substitute another one step command if the hands cannot be
used. Credit is given if an unequivocal attempt is made but not completed due to
weakness. If the patient does not respond to command, the task should be
demonstrated to them (pantomime) and score the result (i.e., follows none, one or
two commands). Patients with trauma, amputation, or other physical impediments
should be given suitable one-step commands. Only the first attempt is scored.
1c. LOC Commands
0- Performs both Tasks Correctly
Only horizontal eye movements will be tested.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 1. If a patient has an isolated
peripheral nerve paresis (CN III, IV or VI) score a 1. Gaze is testable in all aphasic
patients. Patients with ocular trauma, bandages, pre-existing blindness or other
disorder of visual acuity or fields should be tested with reflexive movements and
, a choice made by the investigator. Establishing eye contact and then moving
about the patient from side to side will occasionally clarify the presence of a
partial gaze palsy.
2. best Gaze
0-Normal
Visual fields (upper and lower quadrants) are tested by confrontation, using
finger counting or visual threat as appropriate. Patient must be encouraged, but if
they look at the side of the moving fingers appropriately, this can be scored as
normal. If there is unilateral blindness or enucleation, visual fields in the
remaining eye are scored. Score 1 only if a clear-cut asymmetry, including
quadrantanopia is found. 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 answer question 11.
3. Visual
0-No Visual Loss
Ask, or use pantomime to encourage the patient 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. If facial trauma/bandages,
orotracheal tube, tape or other physical barriers obscure the face, these should
be removed to the extent possible.
4. Facial Palsy
1-Minor Paralysis (Flattened nasolabial fold, asymmetry on smiling).
The limb is placed in the appropriate position: extend the arms (palms down) 90
degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before
10 seconds. The aphasic patient is encouraged using urgency in the voice and
pantomime, but not noxious stimulation. Each limb is tested in turn, beginning
with the non-paretic arm. Only in the case of amputation or joint fusion at the
shoulder, the examiner should record the score as untestable (UN).
5a. Motor Arm Left
0- No drift, limb holds 90 (or 45) degrees for full 10 seconds.
