NIH Stroke Scale
Definitions
Each Examination is assessed independently
from previous examinations.
A response must be checked for each item, using the following
definitions:
· 1.b.
Level of Consciousness - Questions
· 1.c.
Level of Consciousness - Commands
· 2.
Gaze
· 4.
FacialMovement (Facial Paresis)
· 5.
Motor Function - Arms(Left and Right Arm)
· 6.Motor
Function - Legs (Left and Right Leg)
· 11.
Neglect (Extinction and Inattention)
This global measure of
responsiveness is assessed by the patient's interactions with the physician at
the bedside when the patient is first examined. The physician should stimulate
the patient (by patting or tapping the patient) to determine the best level of
consciousness. On occasion, more noxious stimuli, such as pinching, may be
required to check the level of consciousness.
0 = Alert - Patient
is fully alert and keenly responsive
1 = Drowsy - Patient
is drowsy but can be aroused with minor stimulation. The patient obeys,
answers, and responds to commands
2 = Stuporous - Patient is lethargic but requires repeated stimulation
to attend. The patient may need painful or strong stimuli to respond to or
follow commands.
3 = Coma - Patient
is comatose and responds only with reflexive motor or automatic responses.
Otherwise, the patient is unresponsive.
Level of Consciousness -
Questions is checked by asking the patient to respond to two questions. The
patient is asked the month of the year and his/her age. The answer must be
correct - there is no partial credit for being close (for example, being off by
one year in age). If the patient gives the wrong initial answer but then
corrects it, the answer should still be scored as incorrect. Other measures of
orientation such as time of day, location, etc. are not asked as part of this
examination. If the patient has aphasia, the physician should judge the
responses to questions in light of the language impairment.
0 = Answers BOTH correctly.
1 = Answers ONE correctly.
2 = BOTH incorrect.
The Level of Consciousness -
Commands is checked by asking the patient to follow two commands. The patient
is asked to open and close his/her eyes and then is asked to make a grip (close
and open his/her hand). Only the initial response is scored. If a patient is
aphasic and unable to follow verbal commands, the patient may imitate these
movements (pantomime). For a patient who has hemiparesis, the response in the
unaffected limb should be measured. For example, if the patient has a left
hemiparesis, making a fist with the right hand is a normal response to the
command. If a paralyzed patient does try to move the limb in response to a
command but is unable to form a fist, it is counted as a normal response.
0 = Obeys BOTH correctly
1 = Obeys ONE correctly
2 = BOTH incorrect
The position of the eyes at
rest and movement of the eyes to command are tested. First look at the position
of the eyes at rest. Spontaneous eye movements to the left are right should be
noted. The patient is then asked to look to the left or right. Only horizontal
eye movements are tested. Disorders of vertical gaze, nystagmus,
or skew deviation are not measured. Reflexive eye movements (oculocephalic or oculovestibular)
should be tested in patients who are unable to respond to commands. If a
patient has ocular rotatory problems, such as a
strabismus, but leaves the midline and attempts to look both right and left,
he/she should be considered to have a normal response. If a patient has an
isolated oculorotatory problem, such as an oculomotor (CN III) or abducens
(CN IV) palsy, the score should be 1. If the patient has a conjugate deviation
of the eyes that can be overcome by voluntary or reflexive activity, the score
should be 1. If there is a conjugate lateral deviation that is NOT overcome
with reflexive movements, the score should be 2.
0 =
1 = Partial Gaze Palsy - Patient is unable to move one or both eyes completely
to both directions.
2 = Forced Deviation - The patient has conjugate deviation of the eyes to the
right or left, even with reflexive movements.
Visual fields of both eyes
are examined. In most cases, the physician asks the patient to count fingers in
all four quadrants. Each eye is independently tested. If a patient is unable to
respond verbally, the physician should check responses (attending) to visual
stimuli in the quadrants or have the patient hold up the number of fingers
seen. A quadrantic field cut should be scored 1. The
entire half field (both upper and lower quadrants) should be involved with a
dense field loss to be scored 2. If a patient has severe monocular visual loss
due to intrinsic eye disease and the visual fields in the other eye are normal,
the physician should score the visual fields are normal. If the patient has
monocular blindness due to primary eye disease and the visual fields in the
other, "normal" eye demonstrate a partial or dense visual field
defect, the visual loss should be scored as 1, 2, or 3 as appropriate.
0 = No visual loss
1 = Partial hemianopia - There is a partial visual field defect in both eyes.
Included is a quadrantic field defect or sector field
defect.
2 = Complete hemianopia - There is dense visual field defect in both eyes. A
homonymous hemianopia is included.
3 = Bilateral hemianopia - There are bilateral visual field defects in both
eyes. Cortical blindness is included.
4. Facial Movement (Facial Paresis)
The patient is examined by
looking at the patient's face and noting any spontaneous facial movements. The
facial movements in response to commands are also tested. Such commands may
include asking the patient to grimace or smile, to puff out his/her cheeks, to
pucker, and to close his/her eyes forcefully. If the patient is aphasic and is
unable to follow commands, the physician should have the patient attempt
imitative (pantomime) responses. The facial responses to painful stimuli
(grimace) may substitute for responses to commands in a patient who has
decreased levels of alertness.
0 =
1 = Minor paresis Asymmetrical facial movements or facial asymmetry at rest. This
response may be noted with a spontaneous smile but not with forced facial
movements.
2 = Partial paresis Unilateral "central" facial paresis. Decreased spontaneous
and forced facial movements with changes most prominent at the mouth. Orbital
and forehead musculature movements are normal.
3 = Complete palsy Dysfunction involves forehead, orbital, and circumoral
muscles (the entire distribution of the facial nerve). Deficits may be
unilateral or bilateral (facial diplegia) complete
facial paresis.
5. Motor Function - Arms
(Left and Right)
The patient is asked to
extend his arm outstretched in front of the body at 90 degrees (if sitting) or
at 45 degrees (if supine). The effort is for a full 10 seconds. the physician
should count to ten aloud to encourage the patient to maintain the limb's
position. If a limb is paralyzed, the physician may wish to test any
"normal" limb first. If a patient is aphasic, directions may be
achieved by non-verbal cues or pantomime. Patients may be "helped" by
the physician by placing the limb in the desired position. If the patient has
restricted limb function due to arthritis or non-stroke related limitations,
the physician should attempt to judge the "best" motor response. If
the patient has decreased level of consciousness, an estimate of response to
noxious stimuli should be measured. Volitional motor responses that are
performed well should be graded as 0. If the patient has reflexive responses,
such as flexor or extensor posturing, the response should be scored as 4. The
only indication for scoring this item as 9 - untestable,
is if the limb is missing or amputated, or if the shoulder joint is fused. A patient
with a partial limb amputation should be tested.
0 = No drift
The patient is able to hold the outstretched limb for 10 seconds.
1 = Drift
The patient is able to hold the outstretched limb for 10 seconds but there is
some fluttering or drift of the limb. If the limb falls to an intermediate
position, the score is 1.
2 = Some effort against gravity The patient is not able to hold the outstretched limb
for 10 seconds but there is some effort against gravity.
3 = No effort against gravity The patient is not able to bring the limb off the bed
but there is some effort against gravity. If the limb is raised in the correct
position by the examiner, the patient is unable to sustain the position.
4 = No movement The patient is unable to move the limb. There is no effort against
gravity.
9 = Untestable May be used only if the limb is missing or amputated,
or if the shoulder joint is fused.
6. Motor Function - Leg
(Right and Left)
The supine patient is asked
to hold the outstretched leg 30 degrees above the bed. The limb should be held
in this position for 5 seconds. The physician should count to 5 aloud to
encourage the patient to maintain the limb's position. If the right leg is
paralyzed, the examiner may wish to examine the "normal" left leg
first. If a patient is unable to follow verbal commands, nonverbal cues may be
used, or the limb may be placed in the desired position. If the patient has a
decreased level of consciousness, an estimate of response to noxious stimuli
should be measured. Volitional motor responses that are performed well should
be scored 0. If the patient has reflexive responses, such as flexor or extensor
posturing, the response should be scored 4. The only indication for scoring
this item as 9 - untestable is if the limb is missing
or if the hip joint is fused. Patients with artificial joints or partial limb
amputations should be tested.
0 = No drift
The patient is able to hold the outstretched limb for 5 seconds.
1 = Drift
The patient is able to hold the outstretched limb for 5 seconds but there is
unsteadiness, fluttering, or drift of the limb.
2 = Some effort against gravity The patient is unable to hold the outstretched limb
for 5 seconds but there is some effort against gravity.
3 = No effort against gravity The patient is not able to bring the limb off the bed
but there is effort against gravity. If the limb is placed in the correct
position, the patient is unable to sustain the position.
4 = No movement
The patient is unable to move the limb. There is no effort against gravity.
9 = Untestable May be used only if limb is missing or hip joint is
fused.
This item is aimed at
examining the patient for evidence of a unilateral cerebellar
lesion. It will also detect limb movement abnormalities related to sensory or
motor dysfunction. Limb ataxia is checked by the finger-to-nose and
heel-to-shin tests. The physician should test the "normal" side
first. The movements should be well performed, smooth, accurate, and
non-clumsy. There should not be any dysmetria or dyssynergia. Non-verbal cues may be given to the patient.
If a patient has dysmetria or dyssynergia
in one limb, the score should be 1. If a patient has dysmetria
or dyssynergia in both the arm and leg on one side,
or if there are bilateral signs, the score should be 2. If limb ataxia is
present, the ataxia should be rated as present regardless of the possible
etiology. This item may be scored 9 - untestable only
if there is complete paralysis of the limbs (All Motor Function scores = 4), if
the limb is missing, amputated, or fused, or if the patient is comatose (item
1.a., LOC = 3).
0 = Absent
The patient is able to perform both the finger-to nose and heel-to-shin tasks
well. The movements are smooth and accurate.
1 = Present unilaterally in either arm or leg The patient is able to perform one of the two
required tasks well.
2 = Present unilaterally in both arm and leg or
bilaterally The patient is unable to
perform either task well. Movements are inaccurate, clumsy, or poorly done.
9 = Untestable May be used only if all Motor Function Scores = 4,
limb is missing, amputated, or fused, or if item 1.a., LOC = 3.
The patient is examined with
a pin in the proximal portions of all four limbs and asked how the stimulus
feels. The patient's eyes do not need to be closed. The patient is asked if the
stimulus is sharp or dull and if there is any asymmetry between the right and
left sides. Only sensory loss that can be attributed to stroke should be
counted as abnormal - usually this will be a hemisensory
loss. Sensory loss due to a non-stroke related condition, such as a neuropathy,
should not be graded as abnormal. If a patient has depressed level of consciousness,
neglect, aphasia or is unable to describe the sensory perception, the patient's
non-verbal responses, such as a grimace or withdrawal, should be graded. If the
patient responds to the stimulus, it should be scored 0. The response to the
stimulus on the right and left sides should be compared. If the patient does
not respond to a noxious stimulus on one side, the score should be 2. Patients
with severe depression of consciousness should be examined.
0 = Normal
No sensory loss to pin is detected.
1 = Partial loss Mild to moderate diminution in perception to pin stimulation is
recognized. This may involve more than one limb.
2 = Dense loss
Severe sensory loss so that the patient is not aware of being touched. Patient
does not respond to noxious stimuli applied to that side of the body.
The patient's language will
be tested by having the patient identify standard groups of objects and by
reading a series of sentences. Comprehension of language should be judged as
the physician performs the entire neurologic
examination. The physician should give the patient adequate time to identify
the objects
on the sheet of paper. Only the first response is measured. If the patient
misidentifies the object and later corrects himself, the response is still
considered abnormal. The physician should then give the patient a sheet of
paper with the
series of sentences. The examiner should ask the patient to read at least
three sentences. The first attempt to read the sentence is measured. If the
patient misreads the sentence and later corrects himself, the response is still
considered abnormal. If the patient's visual loss precludes visual
identification of objects or reading, the examiner should ask the patient to
identify objects placed in his/her hand and the examiner should judge the
patient's spontaneous speech and ability to repeat sentences. If the examiner
judges these responses as normal, the score should be 0. If the patient is intubated or is unable to speak, the examiner should check
the patient's writing.
0 = No aphasia The
patient is able to read the sentences well and is able to correctly name the
objects on the sheet of paper.
1 = Mild to moderate aphasia The patient has mild to moderate naming errors, word
finding errors, paraphasias, or mild impairment in
comprehension or expression.
2 = Severe aphasia The patient has severe aphasia with difficulty in reading as well as
naming objects. Patient with either Broca's or Wernicke's aphasia is included here.
3 = Mute
The primary method of
examination is to ask the patient to read and pronounce a standard list of words
from a sheet of paper. If the patient is unable to read the words because of
visual loss, the physician may say the word and ask the patient to repeat it.
If the patient has severe aphasia, the clarity of articulation of spontaneous
speech should be rated. If the patient is mute or comatose (item 9, Best
Language = 3 ) or has an endotracheal tube, this item
can be rated as 9 - untestable.
0 =
1 = Mild to moderate dysarthria
Patient has problems in articulation.
Mild to moderate slurring of words is noted. The patient can be understood but
with some difficulty.
2 = Near unintelligible or worse Patient's speech is so slurred that it is
unintelligible
9 = Untestable May be used only if item 9, Best Language = 3, or if
the patient has an endotracheal tube.
11. Neglect (Extinction and
Inattention)
The presence of neglect is
examined by the patient's ability to recognize simultaneous cutaneous
sensory and visual stimuli from the right and left sides. The visual stimulus
is a standard
picture. The picture is shown to the patient and s/he is asked to describe
it. The physician should encourage the patient to scan the picture and identify
features on both the right and left sides of the picture. The physician should
encourage the patient to compensate for any visual loss. If the patient does
not identify parts of the picture on one side, the result should be considered
abnormal. The physician then assesses the ability to recognize bilateral
simultaneous touch to upper or lower limbs. The test is done by touching the
patient with the patient's eyes closed. The test should be considered abnormal
if the patient ignores sensory stimuli from one side of the body. If the
patient has a severe visual loss and the cutaneous
stimuli are normal, the score should be 0. If the patient has aphasia and is
unable to describe the picture, but does attend to both sides, the score should
be 0.
0 = No neglect
The patient is able to recognize bilateral simultaneous cutaneous
stimuli on the right and left sides of the body and is able to identify images
on the right and left sides of the picture.
1 = Partial neglect The patient is able to recognize either cutaneous
or visual stimuli on both the left and right, but is unable to do both
successfully (unless severe visual loss or aphasia is present).
2 = Complete neglect The patient is unable to recognize either bilateral cutaneous sensory or visual stimuli.
