NIH Stroke Scale (NIHSS) – Neurological Assessment Study Guide & Scoring
Practice
Patient 1 (Group A): Right Hemisphere, Moderate-Moderately Severe
Clinical Vignette: A 74-year-old right-handed man with history of hypertension and atrial
fibrillation presents with sudden onset left-sided neglect and weakness. Last seen
normal 90 minutes ago. His wife noted he was "staring to the right" and ignored food on
the left side of his plate.
Instruction: You are to administer the NIH Stroke Scale to this patient based on the
observed deficits.
Video Description: The patient opens his eyes to loud voice but does not consistently
make eye contact and requires repetition of questions (1a=1). When asked the month
and his age, he answers correctly but only after a 5-second delay for each (1b=1). When
asked to open and close his eyes and make a fist, he opens his eyes but does not make
a fist despite three repetitions of the command (1c=2). On best gaze testing, his eyes
are deviated to the right and do not cross midline with oculocephalic maneuver (2=2).
He turns his head to the right when instructed to look left (3=1). There is flattening of
the left nasolabial fold with symmetric forehead wrinkling; the smile is clearly
asymmetric with left droop (4=1). On motor arm testing, the right arm is held steadily for
10 seconds. The left arm drifts down to the bed within 3 seconds (5a-L=2). On motor leg
testing, the right leg remains in position. The left leg drifts down but does not hit the bed
within 10 seconds (6a-L=1). On finger-to-nose and heel-to-shin testing, the left limbs
show incoordination that is not clearly out of proportion to weakness (7=1). To pinprick
on the right arm and leg, the patient responds appropriately. On the left arm and leg, he
says "dull" and shows decreased grimacing compared to right (8=1). Language testing
reveals fluent speech with normal comprehension and repetition; however, he
, consistently misses items on the left side of the visual field when naming (9=0).
Articulation is normal (10=0). On extinction testing, he recognizes unilateral stimuli on
either side but only reports right-sided stimulation during bilateral simultaneous testing
on face, arm, and leg (11=2).
Question: Based on the observed findings described, what is the correct total NIHSS
score for this patient?
A) 12
B) 13
C) 14
D) 15
E) 16
Answer & Justification:
Correct Total Score: 14
Item-by-Item Breakdown:
1a. LOC Questions: 1 (Not alert; opens eyes to loud voice)
1b. LOC Commands: 1 (Answers both correctly but slowly)
1c. LOC: 2 (Performs neither task correctly—opens eyes but doesn't make fist)
2. Best Gaze: 2 (Forced deviation, not overcome by oculocephalic)
3. Visual Fields: 1 (Partial gaze palsy/hemineglect behavior)
4. Facial Palsy: 1 (Mild left lower facial weakness)
5a. Motor Arm - Right: 0 (No drift)
5b. Motor Arm - Left: 2 (Falls before 5 seconds)
6a. Motor Leg - Right: 0 (No drift)
6b. Motor Leg - Left: 1 (Some effort against gravity, drifts)
7. Limb Ataxia: 1 (Present in one limb)
8. Sensory: 1 (Mild-to-moderate loss on left)
9. Best Language: 0 (Normal)
10. Dysarthria: 0 (Normal)
11. Extinction/Inattention: 2 (Profound hemi-inattention on multiple modalities)
Sum: 1+1+2+2+1+1+0+2+0+1+0+0+1+0+0+2 = 14
Practice
Patient 1 (Group A): Right Hemisphere, Moderate-Moderately Severe
Clinical Vignette: A 74-year-old right-handed man with history of hypertension and atrial
fibrillation presents with sudden onset left-sided neglect and weakness. Last seen
normal 90 minutes ago. His wife noted he was "staring to the right" and ignored food on
the left side of his plate.
Instruction: You are to administer the NIH Stroke Scale to this patient based on the
observed deficits.
Video Description: The patient opens his eyes to loud voice but does not consistently
make eye contact and requires repetition of questions (1a=1). When asked the month
and his age, he answers correctly but only after a 5-second delay for each (1b=1). When
asked to open and close his eyes and make a fist, he opens his eyes but does not make
a fist despite three repetitions of the command (1c=2). On best gaze testing, his eyes
are deviated to the right and do not cross midline with oculocephalic maneuver (2=2).
He turns his head to the right when instructed to look left (3=1). There is flattening of
the left nasolabial fold with symmetric forehead wrinkling; the smile is clearly
asymmetric with left droop (4=1). On motor arm testing, the right arm is held steadily for
10 seconds. The left arm drifts down to the bed within 3 seconds (5a-L=2). On motor leg
testing, the right leg remains in position. The left leg drifts down but does not hit the bed
within 10 seconds (6a-L=1). On finger-to-nose and heel-to-shin testing, the left limbs
show incoordination that is not clearly out of proportion to weakness (7=1). To pinprick
on the right arm and leg, the patient responds appropriately. On the left arm and leg, he
says "dull" and shows decreased grimacing compared to right (8=1). Language testing
reveals fluent speech with normal comprehension and repetition; however, he
, consistently misses items on the left side of the visual field when naming (9=0).
Articulation is normal (10=0). On extinction testing, he recognizes unilateral stimuli on
either side but only reports right-sided stimulation during bilateral simultaneous testing
on face, arm, and leg (11=2).
Question: Based on the observed findings described, what is the correct total NIHSS
score for this patient?
A) 12
B) 13
C) 14
D) 15
E) 16
Answer & Justification:
Correct Total Score: 14
Item-by-Item Breakdown:
1a. LOC Questions: 1 (Not alert; opens eyes to loud voice)
1b. LOC Commands: 1 (Answers both correctly but slowly)
1c. LOC: 2 (Performs neither task correctly—opens eyes but doesn't make fist)
2. Best Gaze: 2 (Forced deviation, not overcome by oculocephalic)
3. Visual Fields: 1 (Partial gaze palsy/hemineglect behavior)
4. Facial Palsy: 1 (Mild left lower facial weakness)
5a. Motor Arm - Right: 0 (No drift)
5b. Motor Arm - Left: 2 (Falls before 5 seconds)
6a. Motor Leg - Right: 0 (No drift)
6b. Motor Leg - Left: 1 (Some effort against gravity, drifts)
7. Limb Ataxia: 1 (Present in one limb)
8. Sensory: 1 (Mild-to-moderate loss on left)
9. Best Language: 0 (Normal)
10. Dysarthria: 0 (Normal)
11. Extinction/Inattention: 2 (Profound hemi-inattention on multiple modalities)
Sum: 1+1+2+2+1+1+0+2+0+1+0+0+1+0+0+2 = 14
