Decision Rule - NIH Stroke Scale

NIH Stroke Scale

1A: Level of consciousness (may be assessed casually while taking history)

-          Alert; keenly responsive  . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Arouses to minor stimulation . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Requires repeated stimulation to arouse  . . . . . . . . . . . .  [+2 points]

-          Movements to pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Postures or unresponsive . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

1B: Ask month and age

-          Both questions right  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          1 question right  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          0 questions right   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Dysarthric/intubated/trauma/language barrier  . . . . . . .  [+1 point]

-          Aphasic  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

1C: ‘Blink eyes’ & ‘squeeze hands’ (pantomime commands if communication barrier)

-          Performs both tasks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Performs 1 task   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   [+1 point]

-          Performs 0 tasks  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

2: Horizontal extraocular movements (only assess horizontal gaze)

-          Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Partial gaze palsy; can be overcome . . . . . . . . . . . . . . . . .  [+1 point]

-          Partial gaze palsy; corrects with oculocephalic reflex . . .  [+1 point]

-          Forced gaze palsy; cannot be overcome   . . . . . . . . . . . . .  [+2 points]

3: Visual fields

-          No visual loss   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Partial hemianopia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Complete hemianopia   . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Patient is bilaterally blind . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          Bilateral hemianopia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

4: Facial palsy (use grimace if obtunded)

-          Normal symmetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Minor paralysis (flat nasolabial fold, smile asymmetry . .  [+1 point]

-          Partial paralysis (lower face)  . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Unilateral complete paralysis (upper/lower face)  . . . . . .  [+3 points]

-          Bilateral complete paralysis (upper/lower face) . . . . . . . .  [+3 points]

5A: Left arm motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

5B: Right arm motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

6A: Left leg motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

6B: Right leg motor drift (count out loud and use your fingers to show the patient your count)

-          No drift for 10 seconds  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Drift, but doesn’t hit the bed  . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Drift, hits bed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Some effort against gravity   . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          No effort against gravity . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

-          No movement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+4 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

7: Limb ataxia (finger-nose-finger and heel-shin tests)

-          No ataxia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Ataxia in 1 limb  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

-          Ataxia in 2 limbs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Does not understand  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Paralyzed  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Amputation/joint fusion . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

8: Sensation

-          Normal; no sensory loss  . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate loss: less sharp/more dull . . . . . . . . . . . . .  [+1 point]

-          Mild-moderate loss; can sense being touched  . . . . . . . . .  [+1 point]

-          Complete loss; cannot sense being touched at all  . . . . . .  [+2 points]

-          No response and quadriplegic   . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

-          Coma/unresponsive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

9: Language/aphasia (describe the scene; name the items; read the sentences (standard printouts))

-          Normal; no aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

(some obvious changes without significant limitation)

-          Severe aphasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(fragmentary expression, inference needed, cannot identify materials)

-          Mute/global aphasia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

(no usable speech/auditory comprehension)

-          Coma/unresponsive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+3 points]

10: Dysarthria (read the words (standard printouts))

-          Normal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Mild-moderate dysarthria  . . . . . . . . . . . . . . . . . . . . . . . . . .  [+1 point]

(slurring but can be understood)

-          Severe dysarthria  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(unintelligible slurring or out of proportion to dysphagia)

-          Mute/anarthric  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(no usable speech/auditory comprehension)

-          Intubated/unable to test   . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

11: Extinction/inattention

-          No abnormality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [0 points]

-          Visual/tactile/auditory/spatial/personal inattention  . . . .  [+1 point]

-          Extinction to bilateral simultaneous stimulation . . . . . . . .  [+1 point]

-          Profound hemi-inattention  . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

(example: does not recognize own hand)

-          Extinction to >1 modality  . . . . . . . . . . . . . . . . . . . . . . . . . . .  [+2 points]

TOTAL SCORE = [##]

An NIH stroke scale score of 0-4 is consistent with minor stroke. 

An NIH stroke scale score of 5-15 is consistent with moderate stroke. 

An NIH stroke scale score of 16-20 is consistent with moderate-severe stroke. 

An NIH stroke scale score of 21-42 is consistent with severe stroke.

https://www.mdcalc.com/nih-stroke-scale-score-nihss
https://www.mdcalc.com/modified-nih-stroke-scale-score-mnihss
https://www.mdcalc.com/hat-hemorrhage-thrombolysis-score-predicting-post-tpa-hemorrhage
https://www.mdcalc.com/sedan-score-post-tpa-hemorrhage