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NIH STROKE SCALE: NINDS TPA TRIAL ASSESSMENT GUIDE
NIH Stroke Scale The NINDS tPA Stroke Trial No--------------------------------
Pt. Date of Birth / /
Hospital ( ------------- )
Date of Exam / /
Interval: 1 □ Baseline 2 □ 2 hours post treatment 3 □ 24 hours post onset of symptoms 6 minutes
4 □ 7–10 days 5 □ 3 months 6 □ Other ( )
Time: : 1 □ am 2 □ pm
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam.
Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect
what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while
administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeat-
ed requests to patient to make a special effort).
IF ANY ITEM IS LEFT UNTESTED, A DETAILED EXPLANATION MUST BE CLEARLY WRITTEN
ON THE FORM. ALL UNTESTED ITEMS WILL BE REVIEWED BY THE MEDICAL MONITOR,
AND DISCUSSED WITH THE EXAMINER BY TELEPHONE.
Instructions Scale Definition Score
1a. Level of Consciousness: The investigator must 0 = Alert; keenly responsive.
choose a response, even if a full evaluation is pre- 1 = Not alert, but arousable by minor stimulation to
vented by such obstacles as an endotracheal tube, obey, answer, or respond.
language barrier, orotracheal trauma/bandages. A 3 is 2 = Not alert, requires repeated stimulation to
scored only if the patient makes no movement (other attend, or is obtunded and requires strong or
than reflexive posturing) in response to noxious painful stimulation to make movements (not
stimulation. stereotyped).
3 = Responds only with reflex motor or autonomic
effects or totally unresponsive, flaccid, areflexic.
1b. LOC Questions: The patient is asked the month 0 = Answers both questions correctly.
and his/her age. The answer must be correct — there 1 = Answers one question correctly.
is no partial credit for being close. Aphasic and 2 = Answers neither question correctly.
stuporous patients who do not comprehend the ques-
tions 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.
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1c. LOC Commands: The patient is asked to open 0 = Performs both tasks correctly
and close the eyes and then to grip and release the
non-paretic hand. Substitute another one-step com- 1 = Performs one task correctly
mand if the hands cannot be used. Credit is given if
an unequivocal attempt is made but not completed 2 = Performs neither task correctly
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, ampu-
tation, or other physical impediments should be
given suitable one-step commands. Only the first
attempt is scored.
Downloaded by JAMES RUTHER ()
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NIH Stroke Scale The NINDS tPA Stroke Trial No--------------------------------
Pt. Date of Birth / /
Hospital ( ------------- )
Date of Exam / /
Interval: 1 □ Baseline 2 □ 2 hours post treatment 3 □ 24 hours post onset of symptoms 6 minutes
4 □ 7–10 days 5 □ 3 months 6 □ Other ( )
Instructions Scale Definition Score
2. Best Gaze: Only horizontal eye movements will 0 = Normal
be tested. Voluntary or reflexive (oculocephalic) eye 1 = Partial gaze palsy. This score is given when
movements will be scored but caloric testing is not gaze is abnormal in one or both eyes, but where
done. If the patient has a conjugate deviation of the forced deviation or total gaze paresis are not
eyes that can be overcome by voluntary or reflexive present.
activity, the score will be 1. If a patient has an isolat- 2 = Forced deviation, or total gaze paresis not over-
ed peripheral nerve paresis (CN III, IV or VI) score a come by the oculocephalic maneuver.
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 occa-
sionally clarify the presence of a partial gaze palsy.
3. Visual: Visual fields (upper and lower quadrants) 0= No visual loss
are tested by confrontation, using finger counting or 1= Partial hemianopia
visual threat as appropriate. Patient must be encour- 2= Complete hemianopia
aged, but if they look at the side of the moving fin- 3= Bilateral hemianopia (blind including cortical
gers appropriately, this can be scored as normal. If blindness)
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.
4. Facial Palsy: Ask, or use pantomime to encourage 0 = Normal symmetrical movement
the patient to show teeth or raise eyebrows and close 1 = Minor paralysis (flattened nasolabial fold,
eyes. Score symmetry of grimace in response to nox- asymmetry on smiling)
ious stimuli in the poorly responsive or non-compre- 2 = Partial paralysis (total or near total paralysis of
hending patient. If facial trauma/bandages, orotra- lower face)
cheal tube, tape or other physical barrier obscures the 3 = Complete paralysis of one or both sides
face, these should be removed to the extent possible. (absence of facial movement in the upper and
lower face)
Downloaded by JAMES RUTHER ()
NIH STROKE SCALE: NINDS TPA TRIAL ASSESSMENT GUIDE
NIH Stroke Scale The NINDS tPA Stroke Trial No--------------------------------
Pt. Date of Birth / /
Hospital ( ------------- )
Date of Exam / /
Interval: 1 □ Baseline 2 □ 2 hours post treatment 3 □ 24 hours post onset of symptoms 6 minutes
4 □ 7–10 days 5 □ 3 months 6 □ Other ( )
Time: : 1 □ am 2 □ pm
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam.
Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect
what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while
administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeat-
ed requests to patient to make a special effort).
IF ANY ITEM IS LEFT UNTESTED, A DETAILED EXPLANATION MUST BE CLEARLY WRITTEN
ON THE FORM. ALL UNTESTED ITEMS WILL BE REVIEWED BY THE MEDICAL MONITOR,
AND DISCUSSED WITH THE EXAMINER BY TELEPHONE.
Instructions Scale Definition Score
1a. Level of Consciousness: The investigator must 0 = Alert; keenly responsive.
choose a response, even if a full evaluation is pre- 1 = Not alert, but arousable by minor stimulation to
vented by such obstacles as an endotracheal tube, obey, answer, or respond.
language barrier, orotracheal trauma/bandages. A 3 is 2 = Not alert, requires repeated stimulation to
scored only if the patient makes no movement (other attend, or is obtunded and requires strong or
than reflexive posturing) in response to noxious painful stimulation to make movements (not
stimulation. stereotyped).
3 = Responds only with reflex motor or autonomic
effects or totally unresponsive, flaccid, areflexic.
1b. LOC Questions: The patient is asked the month 0 = Answers both questions correctly.
and his/her age. The answer must be correct — there 1 = Answers one question correctly.
is no partial credit for being close. Aphasic and 2 = Answers neither question correctly.
stuporous patients who do not comprehend the ques-
tions 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.
Downloaded by JAMES RUTHER ()
,2
1c. LOC Commands: The patient is asked to open 0 = Performs both tasks correctly
and close the eyes and then to grip and release the
non-paretic hand. Substitute another one-step com- 1 = Performs one task correctly
mand if the hands cannot be used. Credit is given if
an unequivocal attempt is made but not completed 2 = Performs neither task correctly
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, ampu-
tation, or other physical impediments should be
given suitable one-step commands. Only the first
attempt is scored.
Downloaded by JAMES RUTHER ()
, 3
NIH Stroke Scale The NINDS tPA Stroke Trial No--------------------------------
Pt. Date of Birth / /
Hospital ( ------------- )
Date of Exam / /
Interval: 1 □ Baseline 2 □ 2 hours post treatment 3 □ 24 hours post onset of symptoms 6 minutes
4 □ 7–10 days 5 □ 3 months 6 □ Other ( )
Instructions Scale Definition Score
2. Best Gaze: Only horizontal eye movements will 0 = Normal
be tested. Voluntary or reflexive (oculocephalic) eye 1 = Partial gaze palsy. This score is given when
movements will be scored but caloric testing is not gaze is abnormal in one or both eyes, but where
done. If the patient has a conjugate deviation of the forced deviation or total gaze paresis are not
eyes that can be overcome by voluntary or reflexive present.
activity, the score will be 1. If a patient has an isolat- 2 = Forced deviation, or total gaze paresis not over-
ed peripheral nerve paresis (CN III, IV or VI) score a come by the oculocephalic maneuver.
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 occa-
sionally clarify the presence of a partial gaze palsy.
3. Visual: Visual fields (upper and lower quadrants) 0= No visual loss
are tested by confrontation, using finger counting or 1= Partial hemianopia
visual threat as appropriate. Patient must be encour- 2= Complete hemianopia
aged, but if they look at the side of the moving fin- 3= Bilateral hemianopia (blind including cortical
gers appropriately, this can be scored as normal. If blindness)
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.
4. Facial Palsy: Ask, or use pantomime to encourage 0 = Normal symmetrical movement
the patient to show teeth or raise eyebrows and close 1 = Minor paralysis (flattened nasolabial fold,
eyes. Score symmetry of grimace in response to nox- asymmetry on smiling)
ious stimuli in the poorly responsive or non-compre- 2 = Partial paralysis (total or near total paralysis of
hending patient. If facial trauma/bandages, orotra- lower face)
cheal tube, tape or other physical barrier obscures the 3 = Complete paralysis of one or both sides
face, these should be removed to the extent possible. (absence of facial movement in the upper and
lower face)
Downloaded by JAMES RUTHER ()
