NIHSS
1.a. Level of Consciousness
0 Alert
1 Not alert, but arousable with minimal stimulation
2 Not alert, requires repeated stimulation to attend - obtunded
3 Coma
1.b. Questions: Ask patient the month and
their age
0 Answers both correctly
1 Answers one correctly
2 Both incorrect
1.c. Commands: Ask patient to open and close
eyes and
close/open hand
0 Obeys both correctly
1 Obeys one correctly
2 Both incorrect
2. Best gaze (only
horizontal eye movement):
0
1 Partial gaze palsy
2 Forced deviation
3. Visual Field
testing:
0 No visual field loss
1 Partial hemianopia
2 Complete hemianopia
3 Bilateral hemianopia (blind including cortical blindness)
4. Facial Paresis
(Ask patient to show teeth or raise eyebrows and close eyes tightly):
0
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 Function -
Arm (right and left):
0
1 Drift before 10s
2 Some effort against gravity but falls before 10s
3 No effort against gravity
4 No movement
9 Untestable (Joint fused or limb amputated)
Left arm ____
Right arm ____
6. Motor Function -
Leg (right and left):
0
1 Drift before 5s
2 Some effort against gravity but falls before 5s
3 No effort against gravity
4 No movement
9 Untestable (Joint fused or limb amputated)
Right leg ____
Left leg ____
7. Limb Ataxia:
0 No ataxia
1 Present in one limb
2 Present in two limbs - unilat or bilat
8. Sensory (Use
pinprick to test arms, legs, trunk and face -- compare side to side):
0
1 Mild to moderate decrease in sensation
2 Severe to total sensory loss
9. Best Language
(describe picture, name items, read sentences)
0 No aphasia
1 Mild to moderate aphasia
2 Severe aphasia
3 Mute
10. Dysarthria (read several words):
0
1 Mild to moderate slurring of words
2 Near unintelligible or unable to speak
9 Intubated or other physical barrier
11. Extinction and
inattention:
0
1 Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities
2 Severe hemi-inattention or hemi-inattention to more than one modality