NIH Stroke Scale

Instructions

Scale Definition

1a. Level of consciousness: The investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, or orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

0 = Alert; keenly responsive

1 = Not alert, but arousable by minor stimulation to obey, answer, or respond

2 = Not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped)

3 = Responds only with reflex motor or autonomic effects or is totally unresponsive, flaccid, or areflexic

1b. Level of consciousness questions: The patient is asked the month and his/her age. The answer must be correct; no partial credit is given for being close. Aphasic and stuporous patients who do not comprehend the questions are given a score of 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not due to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or nonverbal cues.

0 = Answers both questions correctly

1 = Answers one question correctly

2 = Answers neither question correctly

1c. Level of consciousness commands: The patient is asked to open and close the eyes and then to grip and release the nonparetic hand. Substitute another one-step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed because of weakness. If the patient does not respond to command, the task should be demonstrated to him/her (pantomime) and the result scored (ie, follows none, one, or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.

0 = Performs both tasks correctly

1 = Performs one task correctly

2 = Performs neither task correctly

2. Best gaze: Only horizontal eye movements are tested. Voluntary or reflexive (oculocephalic) eye movements are scored, but caloric testing is not performed. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV, or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, or pre-existing blindness or other disorder of visual acuity or fields should be tested with reflexive movements and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side occasionally clarifies the presence of a partial gaze palsy.

0 = Normal

1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present.

2 = Forced deviation, or total gaze paresis not overcome is by the oculocephalic maneuver

3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate. The patient must be encouraged, but if he/she looks at the side of the moving fingers appropriately, this can be scored as normal. If is the patient has unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If the patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, the patient receives a 1 and the results are used to answer question 11.

0 = No visual loss

1 = Partial hemianopia

2 = Complete hemianopia

3 = Bilateral hemianopia (blind including cortical blindness)

4. Facial palsy: Ask or use pantomime to encourage the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or noncomprehending patient. If facial trauma/bandages, orotracheal tube, tape, or other physical barrier obscures the face, these should be removed to the extent possible.

0 = Normal symmetrical movements

1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling)

2 = Partial paralysis (total or near-total paralysis of lower face)

3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)

5. Motor arm: The limb is placed in the appropriate position: extend the arms (palms down) 90° (if sitting) or 45° (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the nonparetic arm. The examiner should record the score as untestable (UN) only in the case of amputation or joint fusion at the shoulder and clearly write the explanation for this choice.

0 = No drift; limb holds 90° (or 45°) for full 10 seconds

1 = Drift; limb holds 90° (or 45°), but drifts down before full 10 seconds; does not hit bed or other support

2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90° (or 45°), drifts down to bed, but has some effort against gravity

3 = No effort against gravity; limb falls

4 = No movement

UN = Amputation or joint fusion

5a. Left Arm

5b. Right Arm

6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30° (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the nonparetic leg. The examiner should record the score as untestable (UN) only in the case of amputation or joint fusion at the shoulder and clearly write the explanation for this choice.

0 = No drift; leg holds 30° position for full 5 seconds

1 = Drift; leg falls by the end of the 5-second period but does not hit 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

4 = No movement

UN = Amputation, joint fusion

6a. Left Leg

6b. Right Leg

7. Limb ataxia: This step is aimed at finding evidence of a unilateral cerebellar lesion. Test with the patient’s eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion may the item be scored as untestable (UN), and the examiner must clearly write the explanation for not scoring. In case of blindness test by touching nose from extended arm position.

0 = Absent

1 = Present in one limb

2 = Present in two limbs

UN = Amputation or joint fusion

8. Sensory: Sensation or grimace to pinprick when tested or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal, and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," should be given only when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brain stem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in coma (item 1a=3) are automatically given a 2 on this item.

0 = Normal; no sensory loss.

1 = Mild to moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side or there is a loss of superficial pain with pinprick but patient is aware he/she is being touched

2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg

9. Best language:  A great deal of information about comprehension is obtained during the preceding sections of the examination. The patient is asked to describe what is happening in the given picture (see https://www.ninds.nih.gov/sites/default/files/migrate-documents/nih_stroke_scale_booklet_508c.pdf), to name the items on the given naming sheet, and to read from the given list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological examination. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in coma (question 1a=3) will automatically score 3 on this item. The examiner must choose a score in the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-stepcommands.

0 = No aphasia; normal

1 = Mild to moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression; reduction of speech and/or comprehension, however, makes conversation about provided material difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card from patient's response

2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response

3 = Mute; global aphasia; no usable speech or auditory comprehension

10. Dysarthria:  If patient is thought to be normal, an adequate sample of speech must be obtained by asking the patient to read or repeat words from a given list. (https://www.ninds.nih.gov/sites/default/files/migrate-documents/nih_stroke_scale_booklet_508c.pdf). If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barrier to producing speech may the item be scored as untestable (UN), and the examiner must clearly write an explanation for not scoring. Do not tell the patient why he/she is being tested.

0 = Normal

1 = Mild to moderate; patient slurs at least some words and, at worst, can be understood with some difficulty

2 = Severe; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric

UN = Intubated or other physical barrier

11. Extinction and inattention (formerly neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.

0 = No abnormality

1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities

2 = Profound hemi-inattention or hemi-inattention to more than one modality; does not recognize own hand or orients to only one side of space

Score

Description

0

No stroke

1-4

Minor stroke

5-15

Moderate stroke

15-20

Moderate/severe stroke

21-42

Severe stroke