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