NIH Stroke Scale

1. 1A - Level of con- sciousness 2. 1B - Ask month and age 3. 1C - "Blink eyes" and "Squeeze hands" 4. 2 - Test hori- zontal extraocu- lar muscles 5. 3 - Test visual fields 6. 4 - Test facial pal- 0 - Alert; keenly responsive 1 - Arouses to minor stimulation 2 - Requires repeated stimulation to arouse 2 - Movements to pain 3 - Postures or unresponsive 0 - Both questions right 1 - One question right 1 - Dysarthric, intubated, trauma, or language barrier 2 - Aphasic 0 - Performs both tasks 1 - Performs one task 2 - Performs neither task 0 - Normal 1 - Partial gaze palsy: can be overcome 1 - Partial gaze palsy: corrects with oculocephalic reflex 2 - Forced gaze palsy: can not be overcome 0 - No visual loss 1 - Partial hemianopia 2 - Complete hemianopia 3 - Patient is bilaterally blind 3 - Bilateral hemianopia 0 - Normal symmetry sy (use grimace if 1 - Minor paralysis (flat nasolabial fold, asymmetric smile) obtunded) 7. 5A - Test left arm motor drift 2 - Partial paralysis (lower face) 3 - Unilateral complete paralysis (upper/lower face) 3 - Bilateral complete paralysis 0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 8. 5B - Test right arm motor drift 9. 6A - Test left leg motor drift 10. 6B - Test right leg motor drift 11. 7 - Test limb atax- ia (Finger-nose, heel-shin) 0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 0 - No ataxia 1 - Ataxia in 1 limb 2 - Ataxia in 2 limbs 0 - Doesn't understand, paralyzed, amputation 12. 8 - Test sensation 0 - Normal 1 - Mild-moderate loss: less sharp/more dull 1 - Mild-moderate loss: can sense being touched 2 - Complete loss: cannot sense being touched 2 - No response and quadriplegic 2 - Coma, unresponsive 13. 9 - Test language/apha- sia (Describe the scene, name 0 - Normal; no aphasia 1 - Mild-moderate aphasia: some obvious changes without significant limitation 2 - Severe aphasia: fragmentary expression, interference words, read the sentences) 14. 10 Test dysarthria (read words: Mama, Tip-top, Fifty-fifty, Thanks, Huckleberry, Baseball player) 15. 11 - Test extinc- tion/inattention needed, cannot identify materials 3 - Mute/global aphasia: no usable speech/auditory com- prehension 3 - Coma, unresponsive 0 - Normal; no dysarthria 1 - Mild-moderate dysarthria: slurring but can be under- stood 2 - Severe dysarthria: unintelligible slurring or out of pro- portion to dysphasia 2 - Mute/anarthric 0 - Intubated/unable to test 0 - No abnormality 1 - Visual/tactile/auditory/spatial/personal inattention 1 - Extinction to bilateral simultaneous stimulation 2 - Profound hemi-inattention (does not recognize own hand) 2 - Extinction to 1 modality 16. What NIHSS mea- measures severity of symptoms of stroke sures 17. NIHSS areas of assessment 18. Grading scale of NIHSS Level of consciousness Vision Extraoccular movements Facial Palsy Limb strength Ataxia Sensation Speech and language 3 or 4 point scale Scores range from 0-42 19. Score of 25 Very severe stroke on NIHSS scale 20. Score of 15-24 Severe stroke on NIHSS scale 21. Score of 5-14 Mild to Moderately Severe stroke on NIHSS scale 22. Score of 1-5 Mild stroke on NIHSS scale