Liz Mackey, Stroke Nurse Practitioner, Western Health
Melbourne
Lizzie Dodd, Clinical Practice Consultant, Acute Stroke Unit
Coordinator, The Queen Elizabeth Hospital SA Health
Aims
• Introduction to the National Institutes of Health Stroke Scale
• Common pitfalls of the NIHSS
• Discuss how the NIHSS can be incorporated into practice
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Patient assessment
Communication
Decision making
Stroke trial recruitment
Reporting outcomes
• Case examples
• Training options
National Institutes of Health
Stroke Scale
15-item neurologic examination stroke scale
Ratings for each item are scored with 3 to 5 grades
with 0 as normal, and there is an allowance for
untestable items. Range 0 – 42
• Mild 0-7
• Moderate 8-16
• Severe > 16
The single patient assessment requires less than
10 minutes to complete.
National Institutes of Health Stroke Scale
A trained observer rates the patient’s ability to answer
questions and perform activities.
The evaluation of stroke severity depends upon the
ability of the observer to accurately and consistently
assess the patient
National Institutes of Health Stroke Scale
Evaluates the effect of stroke on:
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Level of consciousness
Extraocular movement
Visual-field loss
Facial symmetry
Motor strength
Ataxia
Sensory loss
Language
Dysarthria
Extinction and Inattention (Neglect)
http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf
Pitfalls of the NIHSS
Three main pitfalls in using the NIHSS:
 Items with poor reliability
 Dominant-hemisphere strokes
 Lessened weighting for posterior circulation strokes
Pitfalls: Items with poor reliability
 The NIHSS contains FOUR items which are widely acknowledged to
have poor reliability
 1a Loss of Consciousness
 4 Facial Palsy
 7 Ataxia
 10 Dysarthria
Potential issues if not scored accurately include:
 Communication difficulties between practitioners
 Decision making errors (eg in thrombolysis or trial recruitment)
 Difficulties assessing patient outcomes
Review clip 1,6,9,12
 https://www.youtube.com/watch?v=awscZzCVaqE&lis
t=PLfvzF_UhY1eZhoSn_uox8Fi3wtdku3x7K&index=13
Pitfalls: dominant hemisphere strokes
 Communication / language impairments in dominant hemisphere
strokes
 Higher scores for more deficits related to language / communication
impairments
 Tendency for dominant hemisphere strokes to receive a higher
rating, approximately 4-points more for the same size stroke,
compared with non-dominant hemisphere strokes.
 Items affected particularly:
 1b LOC Questions,
 1c LOC Commands,
 9 Best language,
 10 Dysarthria
Ref 13, 14
Pitfalls: Posterior circulation
Lessened weighting for vertebrobasilar (posterior circulation)
strokes
Items include:
 1a LOC
 3 Visual fields
 4 Facial palsy
 5&6 Motor
 7 Ataxia
 8 Sensory
 10 Dysarthria
Other elements that provide more
information about the posterior
circulation receive no score e.g.
 diplopia
 dysphagia
 gait instability
 hearing
 nystagmus
Ref 12
Why should we bother doing NIHSS?
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Well-validated, reliable
Time efficient & standardised brief neurological examination
Assesses degree of neurological deficit
Predictor of mortality & functional outcomes (short- and long-term)
Clinical Guidelines for Stroke Management 2010 (NSF p.55)
• “Stroke severity should be assessed & recorded on
admission by a trained clinician using a validated tool
(e.g. NIHSS or SSS)”
• Facilitates:
• Communication (clinicians, patients, care givers)
• Identification of location of infarct
• Early understanding of prognosis
• Selection for interventions / trials
• Identification of potential for complications
Ref 1-9
NIHSS use in everyday clinical practice
Emergency Department
• Who?
• Why?
• Rapid assessment & decision making:
• Location of stroke
• Thrombolysis
• Patient management & prognosis
• Facilitate coordination of care
• Adds to the picture of the stroke subtype
• TACI, PACI, LACI, POCI, haemorrhage
• Trial recruitment
• Communication when referring to other teams
• eg. neurointervention, neurosurgery
• Facilitates communication to patients and families / care givers
NIHSS use in everyday clinical practice
Thrombolysis decision making:
• Baseline differences in NIHSS scores can affect the response of
stroke patients to intravenous tissue plasminogen activator
• Risk of haemorrhage is considerable among patients with high
NIHSS scores:
• US FDA labelling: use intravenous tissue-type plasminogen
activator in patients with NIHSS scores >22 with caution.
Ref 2,10
NIHSS use in everyday clinical practice
Acute Stroke Care Unit
• Who?
• Why?
• Facilitate coordination of care
• Communication of changes
• Recruitment to trials
• When?
• At intervals during acute stay:
• Thrombolysis: NIHSS at 2-hours, 24-hours, discharge
NIHSS use in everyday clinical practice
Follow-up in Outpatient Clinic
• Communication of changes
• Audit of outcomes for thrombolysis
NIHSS use in everyday clinical practice
Stroke trial recruitment
• Most stroke trials require NIHSS to be > 4 or < 26
NIHSS use in reviewing hospital
morbidity & mortality performance
 Growing interest in ensuring stroke severity is accurately quantified
 By scoring stroke costs to health services are potentially more
accurately identified
 i.e. adjustment for stroke severity
Fonarow et al (2014): “Stroke severity has been documented
to be a key mortality risk determinant in acute ischemic stroke.
Prior analyses demonstrated that stroke severity, as quantified by the
NIHSS, was the strongest predictive variable for in-hospital and 30-day
mortality and substantially improved the performance of a model based
on clinical variables without stroke severity”
Ref 2
NIHSS use in reviewing hospital
morbidity & mortality performance
Fonarow et al (2012):
Among hospitals ranked in the top 20% or bottom 20% of performers by the
claims model without NIHSS scores, 26.3% were ranked differently by
the model with NIHSS scores.
Of hospitals initially classified as having “worse than expected” mortality,
57.7% were reclassified to “as expected” by the model with NIHSS scores.
Ref 11
Case examples
(R)
(L)
Large Middle Cerebral Artery Infarct
L) MCA infarct (TACI)
(R)
(L)
Not alert
x age, x month
Does not follow commands
Eyes deviated to left
Homonymous hemianopia
R) facial droop
UL - R) UL no mvmt & L) drift
LL - R) sev weak L) some effort
Absent ataxia
R) Hemiparesis (face,arm)
Non-verbal
Dysarthria = mute
? Inattention
Total = 29
2
2
2
2
2
2
5
5
0
2
3
2
0
Large Middle Cerebral Artery Infarct
L) MCA infarct (TACI)
(R)
(L)
Discussion:
Mild / moderate/ severe?
Prognosis?
Treatment options?
Lacunar Infarct
Alert
R) internal capsule
Age, Month
infarct (LACI)
Follows commands
(R)
(L) Normal gaze
No visual loss
L) minor facial droop
UL - L) UL some effort
LL - L) some effort
No ataxia
L) mild sensory loss face,arm,leg
No aphasia
Mild dysarthria
Image: Stroke July 2012 vol. 43 no. 7 1837-1842 No Inattention
Total = 7
0
0
0
0
0
1
2
2
0
1
0
1
0
Lacunar Infarct
R) internal capsule
infarct (LACI)
(R)
Image: Stroke July 2012 vol. 43 no. 7 1837-1842
(L)
Discussion:
Mild / moderate/ severe?
Prognosis?
Treatment options?
NIHSS Training
FREE training via
https://secure.trainingcampus.net/uas/modules/trees/
windex.aspx?rx=nihss-english.trainingcampus.net
Boehringer Ingelheim training offer
 In hospital group training and accreditation for NIHSS (can be a 2
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hour session or 2 x 1 hour sessions = 1 hour to train + 1 hour for
exam)
BI sponsor paper exams ($25 each), everyone gets booklet ($3
each), a DVD for the department ($50 worth)
The DVD does the teaching
Get sent to the National Stroke Association in Colorado for official
processing and accreditation, certificates will be provided
Benefits are that a group of doctors/nurses can do training in one inhouse session, (no need to do it at home)
Examples of Apps for NIHSS Canopy Medical
Translator
Android
https://itunes.apple.com/us/app/canopy-medicaltranslator/id792808936?mt=8
Boehringer Ingelheim
App
Boehringer Ingelheim
App
References
1. Clinical Guidelines for Stroke Management 2010 (NSF)
2. Fonarow GC, Alberts MJ, Broderick JP, Jauch EC, Kleindorfer DO, Saver JL, Solis P, Suter
R, Schwamm LH. Stroke Outcomes Measures Must Be Appropriately Risk Adjusted To
Ensure Quality Care of Patients: A Presidential Advisory From the American Heart
Association/American Stroke Association Stroke. published online February 12, 2014
3. Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N, RemondaL,
Schroth G, Arnold M, Mattle HP. Predictors of early mortality after acute ischaemic
stroke. Swiss Med Wkly. 2010;140:254-259.
4. Chang KC, Tseng MC, Tan TY, Liou CW. Predicting 3-month mortality among patients
hospitalized for first-ever acute ischemic stroke. J Formos Med Assoc. 2006;105:310-317.
5. Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED,
Fonarow GC, Schwamm LH. Risk score for in-hospital ischemic stroke mortality derived
and validated within the Get With The Guidelines–Stroke Program. Circulation.
2010;122:1496-1504.24. Johnston KC, Connors AF Jr, Wagner DP, Knaus WA, Wang X,
Haley EC Jr. A predictive risk model for outcomes of ischemic stroke. Stroke. 2000;31:448455.
 6. Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, Duhamel
A, Pruvo JP. Early predictors of death and disability after acute cerebralischemic event.
Stroke 1995;26:392-398.
 7. Weimar C, Konig IR, Kraywinkel K, Ziegler A, Diener HC. Age and National
Institutes of Health Stroke Scale score within 6 hours after onset are accurate
predictors of outcome after cerebral ischemia: development and external validation of
prognostic models. Stroke 2004;35:158-162.
 8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P,
McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ,
Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council,
Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and
Council on Clinical Cardiology. Guidelines for the early management of patients with
acute ischemic stroke: a guideline for healthcare professionals from the American
Heart Association/American Stroke Association. Stroke. 2013;44:870-947.
 9. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, PhD;
Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical
practice guideline. Stroke. 2005;36:e100-e143
 10. Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, Hernandez AF,
Peterson ED, Schwamm LH; on behalf of the GWTG-Stroke Steering Committee &
Investigators. Comparison of performance achievement award recognition with
primary stroke center certification for acute ischemic stroke care. J Am Heart Assoc
 11. Fonarow GC, Pan W, Saver J et al “Comparison of 30-Day Mortality Models for
Profiling Hospital Performance in Acute Ischemic Stroke With vs Without Adjustment
for Stroke Severity” JAMA, July 18, 2012—Vol 308, No. 3 257-264
 12. Meyer BC, Lyden PD. "The Modified National Institutes of Health Stroke Scale
(mNIHSS): Its Time Has Come" Int J Stroke. 2009 August ; 4(4): 267–273
 13. Lyden P, Claesson L, Havstad S, AshwoodT, Lu M. Factor analysis of the national
institutes of health stroke scale in patients with large strokes. Arch Neurol.
2004;61:1677-1680.
 14.Woo D, Broderick J, Kothari R, et al.,Group Nr-PSS. Does the national institutes of
health stroke scale favor left hemisphere strokes. Stroke. 1999;30:2355-2359.
Questions... Comments?