NIH Stroke Scale

 

NIH STROKE SCALE ITEM

 

Scoring Definitions

 

Score

1a. ˆำŽฏƒŒƒxƒ‹

0=alert and responsive
1=arousable to minor stimulation
2=arousable only to painful stimulation
3=reflex reponses or unarousable

 

1b. Žฟ–โ‚ษ‘ฮ‚ท‚้ˆำŽฏƒŒƒxƒ‹
--Ask pt’s age and month.
Must be exact.

0=Both correct
1=One correct (or dysarthria, intubated, foreign lang)
2=Neither correct

 

1c. ŽwŽฆ‚ษ‘ฮ‚ท‚้ˆำŽฏƒŒƒxƒ‹
--open/close eyes, grip and release non-paretic hand, (Other 1-step commands or mimic ok)

0=Both correct (ok if impaired by weakness)
1=One correct
2=Neither correct

 

2. ’Ž‹
--Horizontal EOM by voluntary or Doll’s.

0=Normal
1=partial gaze palsy; abnl gaze in 1 or both eyes
2=Forced eye deviation or total paresis which cannot be overcome by Doll’s.

 

3. Ž‹–์
--Use visual threat if nec.
If monocular, score field of good eye.

0=No visual loss
1=Partial hemianopia, quadrantanopia, extinction
2=Complete hemianopia
3=Bilateral hemianopia or blindness

 

4. Š็–ส–ƒแƒ
--If stuporous, check symmetry of grimace to pain.

0=Normal
1=minor paralysis, flat nlf, asymm smile
2=partial paralysis (lower face=UMN)
3=complete paralysis (upper & lower face)

 

5. ถ‰E‚ฬใŽˆ‚ฬ‰^“ฎ
--arms outstretched 100 deg (sitting) or 45 deg (supine) for 10 secs. Encourage best effort. Circle paretic arm in score box

0=No drift x 10 secs
1=Drift but doesn’t hit bed
2=Some antigravity effort, but can’t sustain
3=No antigravity effort, but even miminal mvt counts
4=No movement at all
X=unable to assess due to amputation, fusion, fx, etc.

L or R

6. ถ‰E‚ฬ‰บŽˆ‚ฬ‰^“ฎ
--raise leg to 30 deg supine x 5 secs.

0=No drift x 5 secs
1=Drift but doesn’t hit bed
2=Some antigravity effort, but can’t sustain
3=No antigravity effort, but even miminal mvt counts
4=No movement at all
X=unable to assess due to amputation, fusion, fx, etc.

L or R

7. ŽlŽˆŽธ’ฒ
--check finger-nose-finger ; heel-shin; and score only if out of proportion to paralysis

0=No ataxia (or aphasic, hemiplegic)
1=ataxia in upper or lower extremity
2= ataxia in upper and lower extremity
X=unable to assess due to amputation, fusion, fx, etc.

L or R

 8. ŠดŠo
--Use safety pin. Check grimace or withdrawal if stuporous. Score only stroke-related losses.

0=Normal
1=mild-mod unilateral loss but pt aware of touch (or aphasic, confused)
2=Total loss, pt unaware of touch. coma, bilateral loss

 

9. ŒพŒ๊
--Descr ibe cookie jar picture, name objects, read sentences. May use repeating, writing, stereognosis

0=Normal
1=mild-mod aphasia; (diff but partly comprehensible)
2=severe aphasia; (almost no info exchanged)
3=mute, global aphasia, coma. no 1 step commands

 

10. \Œ๊แŠQ
--read list of words

0=Normal
1=mild-mod; slurred but intelligible
2=severe; unintelligible or mute
X=intubation or mech barrier

 

11.ŠดŠoแŠQ/–ณŽ‹
-- simultaneously touch patient on both hands, show fingers in both vis fields, ask about deficit, left hand.

 0=Normal, none detected. (vis loss alone)
1=Neglects or extinguishes to double simult stimulation in any modality (vis, aud, sens, spatial, body parts)
2=profound neglect in more than one modality

 

ŽQlFhttp://www.stanford.edu/group/neurology/stroke/nihss.html