NIH Stroke Scale

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NIH Stroke Scale

  1. 1. NIH Stroke Scale
  2. 2. InstructionsAdminister stroke scale items in the 1a Instructions Level of Consciousness Scale Definitionorder listed. Record performance ineach category after each subscale exam.Do not go back and change scores. Level of Consciousness: The investigator must choose a response if a full evaluation is prevented by such 0 Alert; keenly responsive.Follow directions provided for each Not alert; but arousable by minorexam technique. Scores should reflectwhat the patient does, not what the obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement 1 stimulation to obey, answer, or respond.clinician thinks the patient can do. (other than reflexive posturing) in response toThe clinician should record answers while noxious stimulation. Not alert; requires repeated stimulation to attend, or is 2administering the exam and work quickly.Except where indicated, the patient obtunded and requires strongshould not be coached (i.e., repeated or painful stimulation to makerequests to patient to make a movements (not stereotyped).special effort). Responds only with reflex motor 3 or autonomic effects, or totally unresponsive, flaccid, and areflexic. Score
  3. 3. Level of ConsciousnessInstructions 1b Scale Definition 1c Instructions Level of Consciousness Scale DefinitionLOC Questions:The patient is asked the month and his/herage. The answer must be correct — there is 0 Answers both questions correctly. LOC Commands: The patient is asked to open and close the eyes and then to grip and release 0 Performs both tasks correctly.no partial credit for being close. Aphasic and the non-paretic hand. Substitutestuporous patients who do not comprehend another one-step command if the handsthe questions will score 2. Patients unable cannot be used. Credit is given if anto speak because of endotracheal intubation,orotracheal trauma, severe dysarthria from anycause, language barrier, or any other problem 1 Answers one question correctly. unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, 1 Performs one task correctly.not secondary to aphasia are given a 1. It the task should be demonstrated tois important that only the initial answer be him or her (pantomime), and the result scoredgraded and that the examiner not “help” the (i.e., follows none, one, or two commands). 2 2patient with verbal or non-verbal cues. Patients with trauma, amputation, or Answers neither question correctly. other physical impediments should be Performs neither task correctly. given suitable one-step commands. Only the first attempt is scored. Score Score
  4. 4. Best GazeInstructions 2 Scale Definition 3 Instructions Visual Scale DefinitionBest Gaze:Only horizontal eye movements will be tested.Voluntary or reflexive (oculocephalic) eye 0 Normal. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting 0 No visual loss.movements will be scored, but caloric testing or visual threat, as appropriate. Patients mayis not done. If the patient has a conjugatedeviation of the eyes that can be overcomeby voluntary or reflexive activity, the score 1 Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral 1 Partial hemianopia.will be 1. If a patient has an isolated not present. blindness or enucleation, visual fields in theperipheral nerve paresis (CN III, IV, or VI), remaining eye are scored. Score 1 only if ascore a 1. Gaze is testable in all aphasicpatients. Patients with ocular trauma,bandages, pre-existing blindness, or other clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is 2 Complete hemianopia. Forced deviation, or totaldisorder of visual acuity or fields should betested with reflexive movements, and a choicemade by the investigator. Establishing eye 2 gaze paresis is not overcome by the oculocephalic maneuver. performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 3 Bilateral hemianopia (blind including cortical blindness).contact and then moving about the patientfrom side to side will occasionally clarify thepresence of a partial gaze palsy. Score Score
  5. 5. Facial PalsyInstructions 4 Scale Definition 5 Instructions Motor Arm Scale DefinitionFacial Palsy:Ask — or use pantomime to encourage — thepatient to show teeth or raise eyebrows and 0 Normal symmetrical movements. Motor Arm: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees 0 No drift; limb holds 90 (or 45) degrees for full 10 seconds. Drift; limb holds 90 (or 45) degrees,close eyes. Score symmetry of grimace inresponse to noxious stimuli in the poorlyresponsive or non-comprehending patient. 1 Minor paralysis (flattened nasolabial fold, asymmetry on smiling). (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency 1 but drifts down before full 10 seconds; does not hit bed or other support.If facial trauma/bandages, orotracheal tube, Some effort against gravity; limb in the voice and pantomime, but not noxious 2tape, or other physical barriers obscure stimulation. Each limb is tested in turn, cannot get to or maintain (if cued) 90the face, these should be removed to the beginning with the non-paretic arm. Only (or 45) degrees, drifts down to bed,extent possible. but has some effort against gravity. 2 Partial paralysis (total or near-total in the case of amputation or joint fusion at paralysis of lower face). the shoulder, the examiner should record the score as untestable (UN) and clearly write the 3 No effort against gravity; limb falls. 4 explanation for this choice. No movement. Complete paralysis of one or both 3 sides (absence of facial movement in the upper and lower face). 5b a Left Arm Score UN Amputation or joint fusion, explain: Score 5 Right Arm Score
  6. 6. Motor LegInstructions 6 Scale Definition 7 Instructions Limb Ataxia Scale DefinitionMotor Leg:The limb is placed in the appropriate position:hold the leg at 30 degrees (always tested 0 No drift; leg holds 30-degree position for full 5 seconds. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes 0 Absent.supine). Drift is scored if the leg falls before5 seconds. The aphasic patient is encouraged 1 Drift; leg falls by the end of the 5- second period but does not hit the bed. open. In case of visual defect, ensure testing is done in intact visual field. The finger-using urgency in the voice and pantomime butnot noxious stimulation. Each limb is testedin turn, beginning with the non-paretic leg. 2 Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity. nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia 1 Present in one limb.Only in the case of amputation or joint fusion is absent in the patient who cannot under-at the hip, the examiner should record thescore as untestable (UN) and clearly write theexplanation for this choice. 3 No effort against gravity; leg falls to bed immediately. stand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN) 2 Present in two limbs. 4 No movement. and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm a UN Amputation or joint fusion, explain: position. UN6b Score Amputation or joint fusion, explain: Left Leg6 Right Leg Score Score
  7. 7. SensoryInstructions 8 Scale Definition 9 Instructions Best Language Scale DefinitionSensory:Sensation or grimace to pinprick when tested,or withdrawal from noxious stimulus in the 0 Normal; no sensory loss. Best Language: A great deal of information about comprehension will be obtained during the 0 No aphasia; normal. Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension,obtunded or aphasic patient. Only sensory preceding sections of the examination. For without significant limitation on ideasloss attributed to stroke is scored as abnormal Mild-to-moderate sensory loss; this scale item, the patient is asked to expressed or form of expression. Reductionand the examiner should test as many bodyareas [arms (not hands), legs, trunk, face] patient feels pinprick is less sharp describe what is happening in the attached 1 of speech and/or comprehension, however, makes conversation about provided materials 1 or is dull on the affected side; or picture, to name the items on the attached difficult or impossible. For example, inas needed to accurately check for hemisensory there is a loss of superficial pain naming sheet, and to read from the attached conversation about provided materials,loss. A score of 2, “severe or total sensory with pinprick, but patient is aware list of sentences. Comprehension is judged examiner can identify picture or naming cardloss,” should only be given when a severe from responses here, as well as to all of the content from patient’s response. of being touched.or total loss of sensation can be clearly commands in the preceding general neurological Severe aphasia; all communication isdemonstrated. Stuporous and aphasic patients exam. If visual loss interferes with the tests, through fragmentary expression; great needwill, therefore, probably score 1 or 0. The for inference, questioning, and guessing by ask the patient to identify objects placed inpatient with brainstem stroke who has bilateral Severe or total sensory loss; patient the hand, repeat, and produce speech. The 2 the listener. Range of information that can be exchanged is limited; listener carriesloss of sensation is scored 2. If the patientdoes not respond and is quadriplegic, score 2.Patients in a coma (item 1a=3) are automati- 2 is not aware of being touched in the face, arm, and leg. intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner burden of communication. Examiner cannot identify materials provided from patient response.cally given a 2 on this item. Score must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows 3 Mute, global aphasia; no usable speech or auditory comprehension. Score no one-step commands.
  8. 8. DysarthriaInstructions 10 Scale Definition 11 Instructions Extinction and Inattention Scale DefinitionDysarthria:If patient is thought to be normal, anadequate sample of speech must be obtained 0 Normal. Extinction and Inattention (formerly Neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the 0 No abnormality.by asking patient to read or repeat words from Mild-to-moderate dysarthria; patient has a severe visual loss preventingthe attached list. If the patient has severeaphasia, the clarity of articulation of 1 patient slurs at least some words visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is Visual, tactile, auditory, spatial, or 1 and, at worst, can be understood personal inattention, or extinction tospontaneous speech can be rated. Only if the with some difficulty. normal. If the patient has aphasia but does bilateral simultaneous stimulation inpatient is intubated or has other physical appear to attend to both sides, the score is one of the sensory modalities.barriers to producing speech, the examiner normal. The presence of visual spatial neglectshould record the score as untestable (UN) and Severe dysarthria; patient’s speech or anosagnosia may also be taken as evidence 2clearly write the explanation for this choice. is so slurred as to be unintelligible of abnormality. Since the abnormality isDo not tell the patient why he/she is being in the absence of or out of scored only if present, the item is never Profound hemi-inattention or extinctiontested. proportion to any dysphasia, or is untestable. 2 to more than one modality; does not mute/anarthric. recognize own hand or orients to only one side of space. UN Intubated or other physical barrier, explain: Score Score
  9. 9. You know how. MAMADown to earth. TIP – TOPI got home from work. FIFTY – FIFTYNear the table in the dining room. THANKSThey heard him speak on the HUCKLEBERRYradio last night. BASEBALL PLAYER
  10. 10. www.ninds.nih.gov 1-800-352-9424

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