Standardizing

the stroke scale

THE

purpose

The NIHSS is widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. However, we often see health care professionals administer the examination or score the scale incorrectly, which can become detrimental to the patient’s clinical outcome.

This online learning module is designed to act as a refresher course for those who have completed their NIHSS certification, as well as to standardize how the examination should be performed and scored when dealing with a stroke patient.

What is NIHSS?

The National Institutes of Health Stroke Scale – a common diagnostic method for quickly assessing the stroke severity.

1

DESIGNED TO STANDARDIZE AND DOCUMENT RELIABLE AND VALID NEURO EXAM

2

USED TO MONITOR CHANGES IN NEUROLOGICAL STATUS

3

IT ALLOWS TO PREDICT FUNCTIONAL RECOVERY AND THE MORTALITY RISK AFTER ISCHEMIC STROKE

*Kasner SE, et al. Stroke 1999;30:1534–1537.
Fonarow GC, et al. J Am Heart Assoc 2012;1:42–50

How to do it?

1

ADMINISTER STROKE SCALE ITEMS IN THE LISTED ORDER

2

DO NOT GO BACK AND CHANGE SCORES

3

SCORES SHOULD REFLECT WHAT THE PATIENT DOES, NOT WHAT THE PHYSICIAN ( NEUROLOGIST ) THINKS THE PATIENT CAN DO

4

THE FIRST ATTEMPT OF THE PATIENT SHOULD BE COUNTED, NOT THE BEST

5

THE PHYSICIAN ( NEUROLOGIST ) SHOULD RECORD ANSWERS WHILE ADMINISTERING THE EXAM

6

WORK AS FAST AS IT IS POSSIBLE

7

THE PATIENT SHOULD NOT BE COACHED, EXCEPT THE CASES WHERE IT IS INDICATED (I.E., REPEATED REQUESTS )

How to score?

11 Items

1

LEVEL OF CONSCIOUSNESS

2

BEST GAZE

3

VISUAL

4

FACIAL PALSY

5

MOTOR ARM

6

MOTOR LEG

7

LIMB ATAXIA

8

SENSORY

9

BEST LANGUAGE

10

DYSARTHRIA

11

EXTINCTION AND INATTENTION

Can You

diagnose?

Watch the following video and take our assessment to see if you are an expert at diagnosing stroke severity, based on the NIHSS method.

Level of consciousness

Footage courtesy of NIH (National Institutes of Health).

ITEM 1A

0 - Alert

1 - Not alert, but arousable

2 - Not alert; requires repeated and painful stimulation

3 - Responds only with reflex movements or autonomic reflexes, or totally unresponsive, flaccid

Level of consciousness - Questions

Footage courtesy of NIH (National Institutes of Health).

ITEM 1B

0 - Answer both questions

1 - Answer one

2 - Answer neither

Level of consciousness - Commands

Footage courtesy of NIH (National Institutes of Health).

ITEM 1C

0 - Performs both tasks correct

1 - Performs one task correct

2 - Performs neither

Best Gaze

Footage courtesy of NIH (National Institutes of Health).

ITEM 2

0 - Normal

1 - Partial gaze palsy

2 - Forced deviation or total gaze palsy

Visual

Footage courtesy of NIH (National Institutes of Health).

ITEM 3

0 - No visual loss

1 - Partial hemianopia

2 - Complete hemianopia

3 - Bilateral hemianopia (blindness)

Facial Palsy

Footage courtesy of NIH (National Institutes of Health).

ITEM 4

0 - Normal

1 - Minor paralysis (flattened nasolabial fold, asymmetry when smiling)

2 - Partial paralysis (total/near total paralysis of lower face)

3 - Complete paralysis, one or both sides (absence of movement in upper/lower face)

Motor Arm (Left Hand)

Footage courtesy of NIH (National Institutes of Health).

ITEM 5A

0 - No drift

1 - Drift (does not hit bed)

2 - Some effort against gravity (drifts to bed)

3 - No effort (limb falls)

4 - No movement

Motor Arm (Right Hand)

Footage courtesy of NIH (National Institutes of Health).

ITEM 5B

0 - No drift

1 - Drift (does not hit bed)

2 - Some effort against gravity (drifts to bed)

3 - No effort (limb falls)

4 - No movement

Motor Leg (Left Leg)

Footage courtesy of NIH (National Institutes of Health).

ITEM 6A

0 - No drift

1 - Drift (does not hit bed)

2 - Some effort against gravity (drifts to bed)

3 - No effort (limb falls)

4 - No movement

Motor Leg (Right Leg)

Footage courtesy of NIH (National Institutes of Health).

ITEM 6B

0 - No drift

1 - Drift (does not hit bed)

2 - Some effort against gravity (drifts to bed)

3 - No effort (limb falls)

4 - No movement

Limb Ataxia

Footage courtesy of NIH (National Institutes of Health).

ITEM 7

0 - Absent

1 - Present in one limb

2 - Present in two limbs

Sensory

Footage courtesy of NIH (National Institutes of Health).

ITEM 8

0 - Normal

1 - Mild - moderate sensory loss (feels less sharp on affected side)

2 - Severe - total sensory loss (not aware of being touched)

Best Language

Footage courtesy of NIH (National Institutes of Health).

ITEM 9

0 - No aphasia

1 - Mild-moderate aphasia (loss of fluency, examiner can identify content from patient response)

2 - Severe aphasia (fragmented expression, examiner cannot identify content from patient response)

3 - Mute, global aphasia

Dysarthria

Footage courtesy of NIH (National Institutes of Health).

ITEM 10

0 - Normal

1 - Mild –moderate dysarthria (some slurring, but speech can be understood)

2 - Severe dysarthria (unintelligible)

Extinction/Inattention

Footage courtesy of NIH (National Institutes of Health).

ITEM 11

0 - No abnormality

1 - Visual, tactile, auditory, spatial, or personal inattention

2 - Profound hemi-inattention or extinction to more than one modality (does not recognize own hand)

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