NIH Stroke Scale
The Good, The Bad, and The Ugly
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NIHSS
Level of consciousness
•
•
•
•
Alert
Drowsy
Stupor
Coma
0 points
1 point
2 points
3 points
NIHSS
Questions Month/Age
• Answer both correctly
• Answers one correctly
• None are correct
0 points
1 point
2 points
NIHSS
Response to 2 Commands
• Follows 2 command correctly
• Follows 1 command correctly
• Cannot follow either command
0 points
1 point
2 points
NIHSS
Best Gaze
• Normal
• Partial gaze to one side
• Forced gaze to one side
0 points
1 point
2 points
NIHSS
Visual Fields
•
•
•
•
No visual loss
Partial hemianopsia
Complete hemianopsia
Bilateral visual loss
0 points
1 point
2 points
3 points
NIHSS
Facial Motor Function
•
•
•
•
No weakness
0 points
Minor unilateral weakness
1 point
Partial unilateral weakness
2 points
Complete uni or bilateral weakness 3 points
NIHSS
Upper Extremity Motor Function
(Right and Left Scored Independently)
•
•
•
•
•
Normal
Drift
Some effort against gravity
No effort against gravity
No movement
0 points
1 point
2 points
3 points
4 points
NIHSS
Lower Extremity Motor Function
(Right and Left Scored Independently)
•
•
•
•
•
Normal
Drift
Some effort against gravity
No effort against gravity
No movement
0 points
1 point
2 points
3 points
4 points
NIHSS
Extremity Ataxia
(Cannot Be Tested in Presence of Paresis)
• No ataxia
• Ataxia in 1 extremity
• Ataxia in 2 extremities
0 points
1 point
2 points
NIHSS
Sensory Loss
• Normal
• Mild to moderate loss
• Severe to total loss
0 points
1 point
2 points
NIHSS
Language
•
•
•
•
No aphasia
Mild to moderate aphasia
Severe aphasia
Mute
0 points
1 point
2 points
3 points
NIHSS
Articulation (Dysarthia)
• Normal
• Mild to moderate
• Severe
0 points
1 point
2 points
NIHSS
Extinction/Inattention
• No abnormality
• Extinction to one modality
• Extinction to 2 modalities
0 points
1 point
2 points
The Good
• Reliable
– Interrater reliability confirmed
• Valid
• Time efficient
– Original trial had a 6 minute average
– Cell phone with video capability takes 38
seconds longer than bedside examination
The Bad
• Tendency to favor speech/language function
over higher integrated sensory function
– L MCA infarcts average 4 points higher than R
MCA infarcts
• Some items represent redundancy
– Ataxia with gross motor function
– Dysarthria with aphasia
• Too often ataxia is over represented
The Ugly
• Brainstem/cerebellar function overly
minimized
• Not a good scale for the “dizzy plus” patient