NIH Stroke Scale/Score (NIHSS)

Special Cases

• Choose a response even if a full evaluation is prevented by such obstacles, such as an endotracheal tube, language barriers, or orotracheal trauma/bandages. 
• A "3" is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

The answer must be correct. There is no partial credit for being close. 

• Score the first response, not the best response.
• Do not "help" the patient with verbal or non-verbal cues.

Special Cases

• Aphasic and stuporous patients who do not comprehend the questions will score a "2".
• Patients unable to speak because of endotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a "1".

Only the first attempt is scored.

Special Cases

• Substitute another one-step command if the hands cannot be used.
• Credit is given if an unequivocal attempt is made but not completed due to weakness.
• If the patient does not respond to command, the task should be demonstrated (pantomime), and the result scored.
• Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. 

Only assess horizontal gaze.

• Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done.
• Gaze is testable in all aphasic patients.

Special Cases

• 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".
• Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity 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 will occasionally clarify the presence of a partial gaze palsy.

Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. 

• Patients may be encouraged.
• If the patient looks at the side of the moving fingers appropriately, this can be scored as normal.
• Score "1" only if a clear-cut asymmetry, including quadrantanopia, is found.

Special Cases

• If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored.
• If patient is blind from any cause, score "3". Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a "1", and the results are used to respond to item 11.

May use pantomime to encourage.

Special Cases

• Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient.
• If facial trauma/bandages, orotracheal tube, tape, or other physical barriers obscure the face, these ought be removed to the extent possible.

Count out loud and use your fingers to show the patient your count.

• Extend the arm (palm down) 90 degrees (if sitting) or 45 degrees (if supine). 
• Drift is scored if the arm falls before 10 seconds.

Special Cases

• The aphasic patient is encouraged using urgency in voice and pantomime, but not noxious stimuli.
• Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).

Count out loud and use your fingers to show the patient your count.

• Extend the arm (palm down) 90 degrees (if sitting) or 45 degrees (if supine). 
• Drift is scored if the arm falls before 10 seconds.

Special Cases

• The aphasic patient is encouraged using urgency in voice and pantomime, but not noxious stimuli.
• Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).

Count out loud and use your fingers to show the patient your count.

• Place the limb in the appropriate position (always test in supine with leg at 30 degrees). 
• Drift is scored if the leg falls before 5 seconds.

Special Cases

• The aphasic patient is encouraged using urgency in voice and pantomime, but not noxious stimuli.
• Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).

Count out loud and use your fingers to show the patient your count.

• Place the limb in the appropriate position (always test in supine with leg at 30 degrees). 
• Drift is scored if the leg falls before 5 seconds.

Special Cases

• The aphasic patient is encouraged using urgency in voice and pantomime, but not noxious stimuli.
• Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).

This item is aimed at finding evidence of a unilateral cerebellar lesion.

• Test with eyes open.
• 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.

Special Cases

• In case of visual defect, ensure testing is done in intact visual field.
• In case of blindness, test by having the patient touch nose from extended arm position.
• Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).

Report of sensation (grimace) to pinprick, or withdrawal from noxious stimulus in the obtunded or aphasic patient.

• Only sensory loss attributed to stroke is scored as abnormal.
• 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 only be given when a severe or total loss of sensation can be clearly demonstrated.
• The patient with brainstem stroke who has bilateral loss of sensation is scored "2".

Special Cases

• Stuporous and aphasic patients will probably score "1" or "0".
• If the patient does not respond and is quadriplegic, score "2".
• Patients in a coma (item 1a = 3) are automatically given a "2" on this item.

Ask patient to 

1. Describe what is happening in the picture 
2. Name items on the naming sheet 
3. Read from the list of sentences

Special cases

• Choose a score for the patient with stupor or limited cooperation.
• A score of "3" should be used only if the patient is mute and follows no one-step commands.
• If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech.
• The intubated should be asked to write.
• The patient in a coma (item 1a = 3) will automatically score "3" on this item.

Ask patient to read or repeat words from the list.

• Do not tell the patient the reason why they are being tested.
• If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated.

Special Case

• The patient is "untestable" only if intubated or has other physical barriers to producing speech.

Identification of neglect may be obtained during the prior testing.

• The presence of visual spatial neglect or anosagnosia may be taken as evidence of abnormality.

Special Cases

• 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 not appear to attend to both sides, the score is normal.

Management considerations for patients presenting with ischemic stroke symptoms:

• Activate stroke protocol (Refer to AHA Guidelines for the Early Management of Patients with Acute Ischemic Stroke)
• Consult Neurology immediately if available
• Determine the onset of stroke symptoms (or the last time patient last felt or was observed normal).
• Obtain a stat head CT to evaluate for hemorrhagic stroke.
• When appropriate (in consultation with both neurology and the patient) consider IV thrombolysis  for ischemic strokes in patients with no contraindications.
• As part of the differential diagnosis, consider stroke mimics, especially in atypical presentations (age, risk factors, history, physical exam).
  • Recrudescence of old stroke from metabolic or infectious stress
  • Todd's paralysis after seizure
  • Complex migraine
  • Pseudoseizure, conversion disorder
• Patients with acute stroke ought to be transferred to a stroke center for their initial evaluation and treatment when possible.
• Holistic stroke care is associated with improved clinical outcomes.
• Patients with a score of < 4 are highly likely to have good clinical outcomes.