NIH Stroke Scale

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