NIH Stroke Scale: Difference between revisions
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'''1a. Level of consciousness''' | '''1a. Level of consciousness''' | ||
Alert = 0<br> | Alert = 0<br> | ||
Not alert, arousable to mild stimulation = 1 | Not alert, arousable to mild stimulation = 1 | ||
Not alert, arousable to significant stimulation = 2 | Not alert, arousable to significant stimulation = 2 | ||
Not alert; reflexic, autonomic or no response = 3 | Not alert; reflexic, autonomic or no response = 3 | ||
'''1b. Level of Consc. Questions:''' Month and DOB | '''1b. Level of Consc. Questions:''' Month and DOB | ||
Both correct = 0 | Both correct = 0 | ||
One correct = 1 | One correct = 1 | ||
Zero correct = 2 | Zero correct = 2 | ||
'''1c. Level of Consc. Command:''' Open/close eyes & squeeze/release hand | '''1c. Level of Consc. Command:''' Open/close eyes & squeeze/release hand | ||
Both correct = 0 | Both correct = 0 | ||
One correct = 1 | One correct = 1 | ||
Zero correct = 2 | Zero correct = 2 | ||
'''2. Best Gaze:''' Horizontal voluntary or oculocephalic reflex | '''2. Best Gaze:''' Horizontal voluntary or oculocephalic reflex | ||
Normal = 0 | Normal = 0 | ||
Partial gaze palsy = 1 | Partial gaze palsy = 1 | ||
Forced deviation or total gaze palsy = 2 | Forced deviation or total gaze palsy = 2 | ||
'''3. Visual Fields''' | '''3. Visual Fields''' | ||
Normal = 0 | Normal = 0 | ||
Partial hemianopia = 1 | Partial hemianopia = 1 | ||
Complete hemianopia = 2 | Complete hemianopia = 2 | ||
Bilateral hemianopia or cortical blindness = 3 | Bilateral hemianopia or cortical blindness = 3 | ||
'''4. Facial Paralysis''' | '''4. Facial Paralysis''' | ||
Normal = 0 | Normal = 0 | ||
Minor, flat nasolabial fold = 1 | Minor, flat nasolabial fold = 1 | ||
Partial or total uni lower paralysis= 2 | Partial or total uni lower paralysis= 2 | ||
Complete paralysis 1 or both sides (upper & lower) = 3 | Complete paralysis 1 or both sides (upper & lower) = 3 | ||
'''5. Motor Arm''' (10 seconds) | '''5. Motor Arm''' (10 seconds) | ||
No drift = 0 | No drift = 0 | ||
Some drift = 1 | Some drift = 1 | ||
Falls, effort against gravity = 2 | Falls, effort against gravity = 2 | ||
Falls, No effort against gravity = 3 | Falls, No effort against gravity = 3 | ||
No movement = 4 | No movement = 4 | ||
'''6. Motor Leg''' (5 seconds) | '''6. Motor Leg''' (5 seconds) | ||
No drift = 0 | No drift = 0 | ||
Some drift = 1 | Some drift = 1 | ||
Falls, effort against gravity = 2 | Falls, effort against gravity = 2 | ||
Falls, No effort against gravity = 3 | Falls, No effort against gravity = 3 | ||
No movement = 4 | No movement = 4 | ||
'''7. Limb ataxia''' | '''7. Limb ataxia''' | ||
Absent = 0 | Absent = 0 | ||
One limb = 1 | One limb = 1 | ||
Two limb = 2 | Two limb = 2 | ||
'''8. Sensory Loss''' (arms, legs, trunk) | '''8. Sensory Loss''' (arms, legs, trunk) | ||
Normal = 0 | Normal = 0 | ||
Present but altered = 1 | Present but altered = 1 | ||
Absent = 2 | Absent = 2 | ||
'''9. Best Language:''' identification (picture or tactile), repetition, comprehension | '''9. Best Language:''' identification (picture or tactile), repetition, comprehension | ||
No aphasia = 0 | No aphasia = 0 | ||
Mild to moderate = 1 | Mild to moderate = 1 | ||
Severe = 2 | Severe = 2 | ||
Mute/Global aphasia =3 | Mute/Global aphasia =3 | ||
'''10. Dysarthria''' | '''10. Dysarthria''' | ||
None = 0 | None = 0 | ||
Mild to moderate = 1 | Mild to moderate = 1 | ||
Severe = 2 | Severe = 2 | ||
1'''1. Extinction/Inattention '''(neglect) | 1'''1. Extinction/Inattention '''(neglect) | ||
None = 0 | None = 0 | ||
Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1 | Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1 | ||
Profound hemi-inattention or more than 1 modality = 2 | Profound hemi-inattention or more than 1 modality = 2 | ||
*Intubation or limb pathology making categories not testable should be considered and potentially not scored. | *Intubation or limb pathology making categories not testable should be considered and potentially not scored. | ||
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*tPA candidate generally with NIHSS 4 - 22 | *tPA candidate generally with NIHSS 4 - 22 | ||
Source: National Institute of Neurologic Disorders and Stroke | Source: National Institute of Neurologic Disorders and Stroke | ||
Fink 04/06/2012 | Fink 04/06/2012 | ||
Revision as of 00:35, 7 April 2012
1a. Level of consciousness
Alert = 0
Not alert, arousable to mild stimulation = 1
Not alert, arousable to significant stimulation = 2
Not alert; reflexic, autonomic or no response = 3
1b. Level of Consc. Questions: Month and DOB
Both correct = 0
One correct = 1
Zero correct = 2
1c. Level of Consc. Command: Open/close eyes & squeeze/release hand
Both correct = 0
One correct = 1
Zero correct = 2
2. Best Gaze: Horizontal voluntary or oculocephalic reflex
Normal = 0
Partial gaze palsy = 1
Forced deviation or total gaze palsy = 2
3. Visual Fields
Normal = 0
Partial hemianopia = 1
Complete hemianopia = 2
Bilateral hemianopia or cortical blindness = 3
4. Facial Paralysis
Normal = 0
Minor, flat nasolabial fold = 1
Partial or total uni lower paralysis= 2
Complete paralysis 1 or both sides (upper & lower) = 3
5. Motor Arm (10 seconds)
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
6. Motor Leg (5 seconds)
No drift = 0
Some drift = 1
Falls, effort against gravity = 2
Falls, No effort against gravity = 3
No movement = 4
7. Limb ataxia
Absent = 0
One limb = 1
Two limb = 2
8. Sensory Loss (arms, legs, trunk)
Normal = 0
Present but altered = 1
Absent = 2
9. Best Language: identification (picture or tactile), repetition, comprehension
No aphasia = 0
Mild to moderate = 1
Severe = 2
Mute/Global aphasia =3
10. Dysarthria
None = 0
Mild to moderate = 1
Severe = 2
11. Extinction/Inattention (neglect)
None = 0
Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1
Profound hemi-inattention or more than 1 modality = 2
- Intubation or limb pathology making categories not testable should be considered and potentially not scored.
- tPA candidate generally with NIHSS 4 - 22
Source: National Institute of Neurologic Disorders and Stroke
Fink 04/06/2012