NIH Stroke Scale

Background

• Intubation or limb pathology making categories not testable should be considered and potentially not scored.
• tPA candidate generally with NIHSS 4 - 22

=Level of Consciousness

1a General

• 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. Questions

• Month and DOB
  • Both correct = 0
  • One correct = 1
  • Zero correct = 2

1c. Commands

• 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

Source

National Institute of Neurologic Disorders and Stroke