ADDONS / SCALES

NIH Stroke Scale (NIHSS)

Name: NIH Stroke Scale Training - Part 4 - Demo Patient B
Uploaded: 2010-06-10
Duration: 11 min 8 s
Description: NIH Stroke Scale Training - Part 4 - Demo Patient B - Department of Health and Human Services - - National Institute of Neurological Disorders and Stroke...

Created 27/09/2022, last revision 31/01/2023

→ NIHSS protocol

→ NIHSS online protocol (MDCALC)

NIHSS is a standardized neurological scale developed to help physicians objectively assess the severity of ischemic stroke
scoring rules must be strictly followed to ensure reproducibility
variants of NIHSS have been introduced:
- modified NIHSS
  - some items are easier to score; data show higher reproducibility compared to the original NIH score
  - still never became popular
- NIHSS-8

Basic principles of NIHSS assessment

administer items in the order listed, do not go back and change scores
follow the instructions provided for each item
score what the patient does, not what the clinician thinks he/she could do
always assess the first response, not the best response (except for item 9 – Best Language)
- if, for example, a patient answers a question about his/her age incorrectly at first and then corrects himself/herself, the answer should be assessed as incorrect. This is essential because otherwise, it is not possible to account for all types of verbal and nonverbal cues and ensure reproducibility
never assist/coach the patient during the examination (unless the instructions explicitly allow this)
some items are only scored if they are present
- for example, ataxia is scored as absent in a plegic patient
older deficits are also scored, except for sensory impairment

Clinical implications

NIHSS is NOT a guide to select tPA-suitable patients – tPA should be used regardless of severity → see IVT contraindication
NIHSS indicates the severity of a stroke and has been shown to correlate with the size of the infarction and higher risk of hemorrhage
- NIHSS of >20 was associated with a 17% rate of intracranial hemorrhage with tPA compared with a 3% hemorrhage rate in patients with a score of <10 (The NINDS t-PA Stroke Study Group 1997).
NIHSS can predict large vessel occlusion (LVO)
- higher NIHSS means a higher probability of LVO; low NIHSS, however, doesn’t exclude LVO!
- some cut-off values for predicting LVO have been reported
  - NIHSS scores ≥ 9 within 3 hours after symptom onset and NIHSS scores ≥ 7 within >3 to 6 hours (Heldner, 2013)
baseline NIHSS may predict clinical outcomes
- a retrospective review of 1281 patients with ischemic stroke found that each 1-point increase in the NIHSS decreased the likelihood of an excellent outcome by 24% at 7 days and 17% at 3 months (Adams 1999).
- patients with moderate (6-13 points) or severe (>14 points) NIHSS scores were 3 times more likely to be placed in a nursing home after discharge and 8 times more likely to require rehabilitation therapy (Rundek 2000).
- patients with a score of ≤ 4 are highly likely to have good clinical outcomes regardless of treatment

National Institute of Health Stroke Scale (NIHSS)
1a. Level of Consciousness the investigator must choose a response if a complete evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages a 3 is scored only if the patient does not move (other than reflexive posturing) in response to a noxious stimulation	0 – alert; keenly responsive 1 – not alert; arousable by mild stimulation to obey or respond 2 – not alert; requires repeated stimulation to arouse, requires intense or painful stimulation to make escape movements 3 – coma, reflex postures or totally unresponsive
1b. LOC – Answers the patient is asked about the month and his/her age the answer must be correct – there is no partial credit for being close aphasic and stuporous patients who do not comprehend the questions will score 2 patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1 only the initial answer is scored; no verbal or nonverbal cues are allowed	0 – answers both questions correctly 1 – answers 1 question correctly or severe dysarthria/mechanical or language barrier 2 = answers neither question correctly, aphasia, coma
1c. LOC – Tasks the patient is asked to open and close the eyes and then to grip and release the non-paretic hand (or other tasks) credit is given if a clear attempt is made but not completed due to weakness if the patient does not respond to the command, the task should be demonstrated (pantomime), and the result scored (i.e., follows none, one, or two commands) patients with trauma, amputation or other physical disabilities should be given appropriate one-step commands only the first attempt is scored	0 – performs both tasks correctly 1 – performs one task correctly 2 = performs neither task correctly, coma
2. Best gaze only horizontal eye movements are tested voluntary or reflexive (oculocephalic) eye movements are scored, not caloric testing patients with an isolated peripheral nerve paresis (CN III, IV, or VI) score 1 patients with ocular trauma, coma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements	0 – normal 1 – isolated peripheral paresis or partial gaze palsy in one or both eyes; can be overcome by the oculocephalic maneuver 2 – forced deviation or total gaze paresis; cannot be overcome
3. Visual fields test by side confrontation, use finger counting or visual threat (blink reflex) as appropriate include double simultaneous stimulation as well; if there is extinction, the patient receives a 1, and the results are used for item 11 with unilateral blindness, visual fields in the fellow eye are scored score 1 only if there is a clear-cut asymmetry, including quadrantanopia if the patient is blind from any cause, score 3	0 – normal 1 – partial hemianopia, extinction 2 – complete hemianopia 3 – bilateral hemianopia or blindness (including cortical blindness)
4. Facial palsy ask or use pantomime to encourage the patient to show teeth or raise eyebrows, and close eyes assess the symmetry of the grimace in response to noxious stimuli in the poorly responsive or noncomprehending patient if facial trauma/bandages, orotracheal tube, tape, or other physical barriers obscure the face, these should be removed to the extent possible	0 – normal 1 – mild paralysis (flattened nasolabial fold, asymmetry when smiling) 2 – partial paralysis (total or near-total paralysis of the lower face) 3 – uni- or complete bilateral paralysis (absence of facial movement in the upper and lower face), coma

5. Motor arm extend the arms (palms down) 90 degrees (sitting position) or 45 degrees (supine position) drift is scored if the arm falls before 10 seconds the aphasic patient is encouraged to use urgency in the voice and pantomime, but not noxious stimulation start with the non-paretic arm in the case of amputation or shoulder fusion, the examiner should record the score as untestable (UN) and write the explanation	0 – no drift; limb holds 90 (or 45) degrees for full 10 seconds 1 – drift before full 10 seconds; arm does not hit the bed or other support 2 – some effort against gravity; limb fails to reach or maintain (if cued) 90 (or 45) degrees, drifts down to bed 3 – no effort against gravity; arm falls to bed immediately 4 – no movement UN = Amputation or joint fusion, explain
6. Motor leg hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds the aphasic patient is encouraged to use urgency in the voice and pantomime but not noxious stimulation start with the non-paretic leg in the case of amputation or hip fusion, the examiner should record the score as untestable (UN) and write the explanation	0 – no drift; leg holds 30-degree position for the whole 5 seconds 1 – drift by the end of 5 seconds, but the leg does not hit the bed 2 – some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity 3 – no effort against gravity; leg falls to bed immediately, some movement on the surface of the bed 4 – no movement UN = amputation or joint fusion, explain
7. Limb ataxia test with eyes open. the finger-nose-finger and heel-shin tests are performed on both sides ataxia is scored only if disproportionate to the weakness ataxia is scored as 0 in a patient who cannot understand, is paralyzed, or is in a coma in the case of blindness, test by having the patient touch the nose from the extended arm position	0 – absent / paralyzed / does not understand / coma 1 – present in one limb 2 – present in two limbs UN = Amputation or joint fusion, explain
8. Sensory a sensation of pinprick or withdrawal from the noxious stimulus in the obtunded or aphasic patient is tested only sensory loss attributed to stroke is scored as abnormal stuporous and aphasic patients will probably score 1 or 0 bilateral loss of sensation due to brainstem stroke is scored as 2 if the patient is unresponsive, quadriplegic or in a coma, score 2	0 – normal 1 – mild-to-moderate sensory loss; pinprick less sharp/more dull or a loss of superficial pain with a pinprick, but the patient can sense being touched 2 – severe or complete sensory loss; the patient is unaware of being touched, coma/unresponsive

9. Best Langauge the patient is asked to name the items on the attached naming sheet and to read from the list of sentences the patient is asked to describe the attached picture the intubated patient is asked to write the patient in a coma (item 1a=3) will automatically score 3	0 – no aphasia 1 – mild-to-moderate aphasia; loss of fluency or ability to understand, without significant limitation 2 – severe aphasia with fragmentary expression; the great need for inference, questioning, and guessing by the listener 3 – global aphasia – no usable speech/auditory comprehension, coma/unresponsive
10. Dysarthria an adequate speech sample must be obtained if the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated if the patient is intubated or has other physical barriers to speech, the examiner should record the score as untestable (UN) and write the explanation	0 – normal 1 – mild-to-moderate dysarthria; patient slurs at least some words, can be understood 2 – severe dysarthria (unintelligible slurring out of proportion to dysphasia), anarthria, mutism, coma UN – intubated / other physical barrier – explain
11. Extinction and Inattention (formerly neglect) sufficient information to identify neglect may be obtained during the prior testing test simultaneous sensitivity and visual field, search for anosognosia if the patient has severe vision loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal the item is never untestable	0 – no abnormality 1 – neglects 1 modality – visual, tactile, auditory, spatial, or personal inattention, or extinction to simultaneous bilateral stimulation in any of the sensory modalities 2 – neglects >1 modality, profound hemi-inattention (fails to recognize own hand or orients to only one side of space), coma

Scoring patients in coma (item 1a = 3)
1a Level of consciousness 1b LOQ questions (answers) 1c LOC questions (tasks) 2 Best gaze 3 Visual fields 4 Facial palsy 5-6 Arm and leg motor drift (left and right) 7 Limb Ataxia 8 Sensory 9 Best language (aphasia) 10 Dysarthria 11 Extinction and Inattention (neglect)	3 2 2 test oculocephalic maneuver test blink reflex 3 16 0 2 3 2 2