NIH Stroke Scale (NIHSS) – All Test Groups A–F | Patients 1–6 | NIHSS Certification &
Recertification Study Guide 2026 | Stroke Assessment Practice | NIH Stroke Scale
Scoring Review | Level of Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor
Arm & Leg, Limb Ataxia, Sensory, Language, Dysarthria, Extinction & Inattention |
Clinical Stroke Assessment Practice, Scoring Guide & Detailed Explanations
Question 1: A 68-year-old male with sudden onset right-sided weakness is unable to lift his
right arm against gravity but can move it weakly on the bed. How should the examiner score
the motor function of the right arm according to the NIH Stroke Scale?
A. 0 – No drift
B. 1 – Drift
C. 2 – Some effort against gravity
D. 3 – No effort against gravity
CORRECT ANSWER: C. 2 – Some effort against gravity
Rationale: The NIHSS motor arm item is scored as 2 if the limb can move up against gravity but
cannot maintain the position against resistance. A score of 0 means no drift, 1 indicates drift
before 10 seconds, 2 indicates some effort against gravity, and 3 indicates no movement or
gravity eliminated.
Question 2: Which of the following is the most appropriate next step in management for a
patient with acute ischemic stroke who presents within 3 hours of symptom onset and has no
contraindications to thrombolysis?
A. Aspirin 325 mg orally
B. Intravenous alteplase at 0.9 mg/kg
C. Clopidogrel 300 mg loading dose
D. Immediate mechanical thrombectomy
CORRECT ANSWER: B. Intravenous alteplase at 0.9 mg/kg
Rationale: IV alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) is the standard of care for acute
ischemic stroke within 3-4.5 hours of onset. Aspirin is contraindicated within 24 hours of tPA.
Mechanical thrombectomy is for large vessel occlusions and not first-line in all cases.
Question 3: A patient with a recent TIA has a 70% stenosis of the left internal carotid artery.
Which of the following medications has been shown to provide the greatest risk reduction for
recurrent stroke in this patient population?
A. Aspirin
B. Clopidogrel
C. Atorvastatin
D. Carotid endarterectomy
CORRECT ANSWER: D. Carotid endarterectomy
,Rationale: For symptomatic carotid stenosis ≥70%, carotid endarterectomy significantly reduces
the 5-year risk of ipsilateral stroke, more than medical therapy alone. Statins and antiplatelet
agents are adjunctive but not as effective as surgical revascularization for high-grade stenosis.
Question 4: In the clinical assessment of a patient with suspected subarachnoid hemorrhage,
which finding on non-contrast head CT is most characteristic of the condition?
A. Hyperdense middle cerebral artery sign
B. Sulcal effacement
C. Hyperdense blood in the basal cisterns
D. Hypodensity in the lentiform nucleus
CORRECT ANSWER: C. Hyperdense blood in the basal cisterns
Rationale: Subarachnoid hemorrhage appears as hyperdense blood filling the subarachnoid
spaces, particularly the basal cisterns and Sylvian fissures. The hyperdense MCA sign is
associated with acute ischemic stroke, not SAH.
Question 5: What is the most sensitive imaging modality for detecting acute intracranial
hemorrhage in the emergency department?
A. MRI with diffusion-weighted imaging
B. Non-contrast head CT
C. CT angiography
D. Transcranial Doppler
CORRECT ANSWER: B. Non-contrast head CT
Rationale: Non-contrast head CT is the gold standard for acute hemorrhage, with nearly 100%
sensitivity in the first 6 hours. MRI is more sensitive for chronic hemorrhage and ischemia but
takes longer and is less accessible in emergencies.
Question 6: A 72-year-old patient with atrial fibrillation develops sudden aphasia and right
hemiparesis. What is the most appropriate immediate treatment if symptoms began 2 hours
ago?
A. Warfarin 5 mg orally
B. IV heparin bolus
C. IV alteplase
D. Aspirin 325 mg
CORRECT ANSWER: C. IV alteplase
Rationale: The patient is within the 3-hour window for IV alteplase. Atrial fibrillation is a
common cause of cardioembolic stroke, but anticoagulation is not initiated emergently and
aspirin is not first-line in acute stroke.
,Question 7: Which cerebral artery is most commonly occluded in acute ischemic stroke?
A. Anterior cerebral artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. Basilar artery
CORRECT ANSWER: B. Middle cerebral artery
Rationale: The MCA is the most frequently involved vessel in ischemic stroke due to its direct
continuation from the internal carotid artery and its large perfusion territory.
Question 8: Which clinical sign differentiates an upper motor neuron lesion from a lower
motor neuron lesion?
A. Muscle atrophy
B. Fasciculations
C. Hyperreflexia
D. Hypotonia
CORRECT ANSWER: C. Hyperreflexia
Rationale: Upper motor neuron lesions cause hyperreflexia, spasticity, and a positive Babinski
sign. Lower motor neuron lesions cause hyporeflexia, flaccidity, fasciculations, and atrophy.
Question 9: In a patient with acute stroke, which parameter is most critical to monitor to
prevent secondary brain injury?
A. Blood pressure
B. Blood glucose
C. Oxygen saturation
D. Temperature
CORRECT ANSWER: A. Blood pressure
Rationale: Blood pressure management is crucial as extreme hypertension can worsen cerebral
edema and hemorrhage, while hypotension can reduce cerebral perfusion pressure, leading to
secondary infarction.
Question 10: Which of the following is a contraindication to the use of IV tPA in acute
ischemic stroke?
A. Age >80 years
B. History of hypertension
C. Current use of anticoagulation with INR >1.7
D. Glucose >100 mg/dL
, CORRECT ANSWER: C. Current use of anticoagulation with INR >1.7
Rationale: An INR >1.7 is an absolute contraindication due to increased risk of symptomatic
intracranial hemorrhage. Age >80 and prior hypertension are not absolute contraindications.
Question 11: Which stroke subtype is most associated with hypertension and lipohyalinosis of
small penetrating arteries?
A. Large artery atherosclerosis
B. Cardioembolic stroke
C. Lacunar stroke
D. Cryptogenic stroke
CORRECT ANSWER: C. Lacunar stroke
Rationale: Lacunar strokes are caused by occlusion of small penetrating arteries, often due to
lipohyalinosis related to chronic hypertension and diabetes.
Question 12: A 55-year-old with a history of hypertension presents with acute vertigo,
dysarthria, and double vision. Examination reveals nystagmus and ataxia. Where is the most
likely lesion?
A. Cerebellum
B. Brainstem
C. Temporal lobe
D. Occipital lobe
CORRECT ANSWER: B. Brainstem
Rationale: Vertigo, diplopia, dysarthria, nystagmus, and ataxia are classic brainstem stroke
symptoms, often involving the pons or medulla. Cerebellar strokes cause ataxia and vertigo but
typically not diplopia or dysarthria.
Question 13: What is the most appropriate antiplatelet regimen for a patient with a minor
stroke (NIHSS < 3) within the first 24 hours?
A. Aspirin 325 mg daily
B. Clopidogrel 75 mg daily
C. Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days
D. Dipyridamole alone
CORRECT ANSWER: C. Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days
Rationale: The CHANCE and POINT trials support dual antiplatelet therapy for 21-90 days in
minor stroke or high-risk TIA to reduce recurrent stroke risk without significantly increasing
hemorrhage.
Recertification Study Guide 2026 | Stroke Assessment Practice | NIH Stroke Scale
Scoring Review | Level of Consciousness, Best Gaze, Visual Fields, Facial Palsy, Motor
Arm & Leg, Limb Ataxia, Sensory, Language, Dysarthria, Extinction & Inattention |
Clinical Stroke Assessment Practice, Scoring Guide & Detailed Explanations
Question 1: A 68-year-old male with sudden onset right-sided weakness is unable to lift his
right arm against gravity but can move it weakly on the bed. How should the examiner score
the motor function of the right arm according to the NIH Stroke Scale?
A. 0 – No drift
B. 1 – Drift
C. 2 – Some effort against gravity
D. 3 – No effort against gravity
CORRECT ANSWER: C. 2 – Some effort against gravity
Rationale: The NIHSS motor arm item is scored as 2 if the limb can move up against gravity but
cannot maintain the position against resistance. A score of 0 means no drift, 1 indicates drift
before 10 seconds, 2 indicates some effort against gravity, and 3 indicates no movement or
gravity eliminated.
Question 2: Which of the following is the most appropriate next step in management for a
patient with acute ischemic stroke who presents within 3 hours of symptom onset and has no
contraindications to thrombolysis?
A. Aspirin 325 mg orally
B. Intravenous alteplase at 0.9 mg/kg
C. Clopidogrel 300 mg loading dose
D. Immediate mechanical thrombectomy
CORRECT ANSWER: B. Intravenous alteplase at 0.9 mg/kg
Rationale: IV alteplase (tPA) at 0.9 mg/kg (maximum 90 mg) is the standard of care for acute
ischemic stroke within 3-4.5 hours of onset. Aspirin is contraindicated within 24 hours of tPA.
Mechanical thrombectomy is for large vessel occlusions and not first-line in all cases.
Question 3: A patient with a recent TIA has a 70% stenosis of the left internal carotid artery.
Which of the following medications has been shown to provide the greatest risk reduction for
recurrent stroke in this patient population?
A. Aspirin
B. Clopidogrel
C. Atorvastatin
D. Carotid endarterectomy
CORRECT ANSWER: D. Carotid endarterectomy
,Rationale: For symptomatic carotid stenosis ≥70%, carotid endarterectomy significantly reduces
the 5-year risk of ipsilateral stroke, more than medical therapy alone. Statins and antiplatelet
agents are adjunctive but not as effective as surgical revascularization for high-grade stenosis.
Question 4: In the clinical assessment of a patient with suspected subarachnoid hemorrhage,
which finding on non-contrast head CT is most characteristic of the condition?
A. Hyperdense middle cerebral artery sign
B. Sulcal effacement
C. Hyperdense blood in the basal cisterns
D. Hypodensity in the lentiform nucleus
CORRECT ANSWER: C. Hyperdense blood in the basal cisterns
Rationale: Subarachnoid hemorrhage appears as hyperdense blood filling the subarachnoid
spaces, particularly the basal cisterns and Sylvian fissures. The hyperdense MCA sign is
associated with acute ischemic stroke, not SAH.
Question 5: What is the most sensitive imaging modality for detecting acute intracranial
hemorrhage in the emergency department?
A. MRI with diffusion-weighted imaging
B. Non-contrast head CT
C. CT angiography
D. Transcranial Doppler
CORRECT ANSWER: B. Non-contrast head CT
Rationale: Non-contrast head CT is the gold standard for acute hemorrhage, with nearly 100%
sensitivity in the first 6 hours. MRI is more sensitive for chronic hemorrhage and ischemia but
takes longer and is less accessible in emergencies.
Question 6: A 72-year-old patient with atrial fibrillation develops sudden aphasia and right
hemiparesis. What is the most appropriate immediate treatment if symptoms began 2 hours
ago?
A. Warfarin 5 mg orally
B. IV heparin bolus
C. IV alteplase
D. Aspirin 325 mg
CORRECT ANSWER: C. IV alteplase
Rationale: The patient is within the 3-hour window for IV alteplase. Atrial fibrillation is a
common cause of cardioembolic stroke, but anticoagulation is not initiated emergently and
aspirin is not first-line in acute stroke.
,Question 7: Which cerebral artery is most commonly occluded in acute ischemic stroke?
A. Anterior cerebral artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. Basilar artery
CORRECT ANSWER: B. Middle cerebral artery
Rationale: The MCA is the most frequently involved vessel in ischemic stroke due to its direct
continuation from the internal carotid artery and its large perfusion territory.
Question 8: Which clinical sign differentiates an upper motor neuron lesion from a lower
motor neuron lesion?
A. Muscle atrophy
B. Fasciculations
C. Hyperreflexia
D. Hypotonia
CORRECT ANSWER: C. Hyperreflexia
Rationale: Upper motor neuron lesions cause hyperreflexia, spasticity, and a positive Babinski
sign. Lower motor neuron lesions cause hyporeflexia, flaccidity, fasciculations, and atrophy.
Question 9: In a patient with acute stroke, which parameter is most critical to monitor to
prevent secondary brain injury?
A. Blood pressure
B. Blood glucose
C. Oxygen saturation
D. Temperature
CORRECT ANSWER: A. Blood pressure
Rationale: Blood pressure management is crucial as extreme hypertension can worsen cerebral
edema and hemorrhage, while hypotension can reduce cerebral perfusion pressure, leading to
secondary infarction.
Question 10: Which of the following is a contraindication to the use of IV tPA in acute
ischemic stroke?
A. Age >80 years
B. History of hypertension
C. Current use of anticoagulation with INR >1.7
D. Glucose >100 mg/dL
, CORRECT ANSWER: C. Current use of anticoagulation with INR >1.7
Rationale: An INR >1.7 is an absolute contraindication due to increased risk of symptomatic
intracranial hemorrhage. Age >80 and prior hypertension are not absolute contraindications.
Question 11: Which stroke subtype is most associated with hypertension and lipohyalinosis of
small penetrating arteries?
A. Large artery atherosclerosis
B. Cardioembolic stroke
C. Lacunar stroke
D. Cryptogenic stroke
CORRECT ANSWER: C. Lacunar stroke
Rationale: Lacunar strokes are caused by occlusion of small penetrating arteries, often due to
lipohyalinosis related to chronic hypertension and diabetes.
Question 12: A 55-year-old with a history of hypertension presents with acute vertigo,
dysarthria, and double vision. Examination reveals nystagmus and ataxia. Where is the most
likely lesion?
A. Cerebellum
B. Brainstem
C. Temporal lobe
D. Occipital lobe
CORRECT ANSWER: B. Brainstem
Rationale: Vertigo, diplopia, dysarthria, nystagmus, and ataxia are classic brainstem stroke
symptoms, often involving the pons or medulla. Cerebellar strokes cause ataxia and vertigo but
typically not diplopia or dysarthria.
Question 13: What is the most appropriate antiplatelet regimen for a patient with a minor
stroke (NIHSS < 3) within the first 24 hours?
A. Aspirin 325 mg daily
B. Clopidogrel 75 mg daily
C. Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days
D. Dipyridamole alone
CORRECT ANSWER: C. Dual antiplatelet therapy (aspirin + clopidogrel) for 21 days
Rationale: The CHANCE and POINT trials support dual antiplatelet therapy for 21-90 days in
minor stroke or high-risk TIA to reduce recurrent stroke risk without significantly increasing
hemorrhage.
