STROKE SCA 411 STROKE SCALE QUESTIONS AND ANSWERS ALREADY
Patient | 1
Topic Question Answer Grade
Level |of 1a. |Level |of 0 | = | Alert; | keenly | responsive Correct
|Consciousness |Consciousness: |The
|investigator |must
| choose |a |response,
|even |if |a |full |evaluation
|is |prevented |by |such
|obstacles |as |an
|endotracheal |tube,
|language |barrier,
|orotracheal
|trauma/bandages. |A |3
|is |scored | only | if | the
|patient |makes |no
|movement |(other |than
|reflexive |posturing) |in
|response |to |noxious
|stimulation.
LOC | Questions 1b. | LOC | Questions: | The 0 |= |Answers |both |questions Correct
patient |is |asked |the |correctly
|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.
LOC | Commands 1c. |LOC | Commands: 0 | = | Performs | both | tasks | correctly | Correct
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.
0 |= |Normal Correct
Best |Gaze 2. |Best |Gaze: |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.
Visual 3. |Visual: |Visual |fields 0 |= |No |visual |loss Correct
|(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.
Facial |Palsy 4. |Facial |Palsy: |Ask, |or | scored | if 0 |= |Normal |symmetrical
|use |pantomime |to |movement
|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.
Motor |Arms 5a. |Motor |Arm|Left: |The 0 |= |No |drift, |limb |holds |90
|limb |is |placed |in |the |(or |45) | degrees | for | full | 10
|appropriate |position: | seconds
|extend |the |arms |(palms
|down) |90 |degrees |(if
|sitting) |or |45 |degrees
|(if |supine). | Drift | is
, Correct
Incorrect
Patient | 1
Topic Question Answer Grade
Level |of 1a. |Level |of 0 | = | Alert; | keenly | responsive Correct
|Consciousness |Consciousness: |The
|investigator |must
| choose |a |response,
|even |if |a |full |evaluation
|is |prevented |by |such
|obstacles |as |an
|endotracheal |tube,
|language |barrier,
|orotracheal
|trauma/bandages. |A |3
|is |scored | only | if | the
|patient |makes |no
|movement |(other |than
|reflexive |posturing) |in
|response |to |noxious
|stimulation.
LOC | Questions 1b. | LOC | Questions: | The 0 |= |Answers |both |questions Correct
patient |is |asked |the |correctly
|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.
LOC | Commands 1c. |LOC | Commands: 0 | = | Performs | both | tasks | correctly | Correct
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.
0 |= |Normal Correct
Best |Gaze 2. |Best |Gaze: |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.
Visual 3. |Visual: |Visual |fields 0 |= |No |visual |loss Correct
|(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.
Facial |Palsy 4. |Facial |Palsy: |Ask, |or | scored | if 0 |= |Normal |symmetrical
|use |pantomime |to |movement
|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.
Motor |Arms 5a. |Motor |Arm|Left: |The 0 |= |No |drift, |limb |holds |90
|limb |is |placed |in |the |(or |45) | degrees | for | full | 10
|appropriate |position: | seconds
|extend |the |arms |(palms
|down) |90 |degrees |(if
|sitting) |or |45 |degrees
|(if |supine). | Drift | is
, Correct
Incorrect
