NIH Stroke Scale Test Group Answer Key | Complete NIHSS Scoring Guide

NIH Stroke Scale Test Group Answer Key |
Complete NIHSS Scoring Guide


1. Official NIHSS Itemized Scoring Guide
The NIHSS assesses 11 distinct clinical domains with
total scores ranging from 0 (Normal) to 42 (Severe).
Docsity
Item Assessment Area Scoring Criteria
0 = Alert; 1 = Not alert,
arousable by minor stimulation;
Level of
2 = Requires repeated/strong
1a Consciousness
stimulation to respond; 3 =
(LOC)
Reflex movements only /
Unresponsive.
0 = Answers both correctly; 1 =
LOC Questions
1b Answers one correctly; 2 =
(Month & Age)
Answers neither correctly.
LOC Commands 0 = Performs both correctly; 1 =
1c (Open/close eyes, Performs one correctly; 2 =
squeeze hand) Performs neither correctly.
0 = Normal; 1 = Partial gaze
2 Best Gaze palsy; 2 = Forced deviation or
total gaze paresis.

, Item Assessment Area Scoring Criteria
0 = No visual loss; 1 = Partial
hemianopia; 2 = Complete
3 Visual Fields
hemianopia; 3 = Bilateral
hemianopia (blind).
0 = Normal; 1 = Minor paralysis;
4 Facial Palsy 2 = Partial paralysis (lower face);
3 = Complete paralysis.
0 = No drift (10 sec); 1 = Drift
before 10 sec, no bed contact; 2
= Drifts to bed; 3 = No effort
5a Motor Arm: Left
against gravity; 4 = No
movement; UN =
Amputation/Fusion.
Motor Arm:
5b Same scale as 5a.
Right
0 = No drift (5 sec); 1 = Drift
before 5 sec, no bed contact; 2 =
Drifts to bed; 3 = No effort
6a Motor Leg: Left
against gravity; 4 = No
movement; UN =
Amputation/Fusion.
Motor Leg:
6b Same scale as 6a.
Right
Limb Ataxia 0 = Absent; 1 = Present in one
7 (Finger-nose, limb; 2 = Present in two or more
heel-shin) limbs; UN = Amputation/Fusion.