Using stroke scales to assess the patient
– Rankin and NIHSS
Dr Jonathan Birns
Consultant in Stroke Medicine, Geriatrics and General Medicine
Guy’s & St Thomas’ NHS Foundation Trust
Alive and
independent
100
80
Alive but
dependent
60
Dead
40
20
0
Thrombolysis
Differences/1000:
Control
141 extra alive and independent
130 fewer dependent survivors
To save 1 patient from disablement NNT is 7
(P<0.01)
(P<0.01)
Outcome measures/Stroke scales
• Pathology
• Impairment - abnormality of structure/function
• Disability - functional consequence of impairment
• Handicap - social consequence of impairment
• QOL
• Survival
Outcome measures/Stroke scales
• Valid
• Reliable
• Reproducible
• Relevant
• Practical
• Sensitive
• Communicable
Modified Rankin Scale
• measures the degree of disability or
dependence in the daily activities of people
who have suffered a stroke.
• originally introduced in 1957 by Rankin
(Rankin J. Cerebral vascular accidents in patients over the age of 60. II.
Prognosis. Scott Med J. 1957. 2: 200–15)
• modified by Lindley et al in 1994
(Lindley RI, Waddell F, Livingstone M et al. Can simple questions assess
outcomes after stroke?. Cerebrovasc Dis. 1994. 4: 314–24)
3 simple questions (Lindley et al. 1994)
No
Is the patient alive?
6
Dead
Yes
5
Does the patient require help from
anybody for everyday activities?
Yes
4
Poor
3
No
Yes
Has the stroke left the patient with any problems?
2
Indifferent
1
No
Good
0
Modified Rankin Scale
0 - No symptoms.
1 - No significant disability.
Able to carry out all usual activities, despite some symptoms.
2 - Slight disability.
Able to look after own affairs without assistance, but unable to carry
out all previous activities.
3 - Moderate disability.
Requires some help, but able to walk unassisted.
4 - Moderately severe disability.
Unable to attend to own bodily needs without assistance, and unable
tto walk unassisted.
5 - Severe disability.
Requires constant nursing care and attention, bedridden, incontinent.
6 - Dead.
mRS 0-3
mRS 4-6
National Institutes of Health Stroke Scale (NIHSS)
• 15-item neurologic examination stroke scale
• Used to evaluate the effect of acute cerebral infarction on:
–
–
–
–
–
–
–
–
–
level of consciousness
extraocular movement
visual-field loss
motor strength
ataxia
sensory loss
language
dysarthria
neglect
National Institutes of Health Stroke Scale (NIHSS)
• Provides a quantitative measure of stroke-related neurologic
deficit
• Originally designed as a research tool
• Now widely used as a clinical assessment tool
• May serve as a measure of stroke severity
• Valid for predicting lesion size, short and long term
outcome
• Provides a common language for information exchanges
among healthcare providers
National Institutes of Health Stroke Scale (NIHSS)
• Designed to be:
–
–
–
–
Simple
Valid
Reliable
Administered at the bedside consistently by:
• Physicians
• Nurses
• Therapists
• Should take <10 minutes to complete
NIHSS Instructions
• Administer NIHSS items in order
• Record performance in each category after assessment
• Do not go back and change scores
• Do not repeat assessments within NIHSS
• Range: 0-42
1a Level of consciousness
1b Level of consciousness questions
What is the month?
How old are you?
1c Level of consciousness commands
Open and close
the eyes.
Grip and release the
non-paretic hand.
2 Best gaze
3 Visual fields
4 Facial palsy
5 Motor - Arm
6 Motor - Leg
7 Limb ataxia
8 Sensory
9 Language
10 Dysarthria
11 Extinction and inattention
NIHSS
i NIHSS
i NIHSS
NIHSS
NIHSS Category
Pre-thrombolysis
Time… after thrombolysis
LOC Ia
0
0
LOC Ib
2
0
LOC Ic
2
0
Gaze
0
0
Visual fields
2
0
Facial palsy
2
0
Motor – right arm
3
0
Motor – left arm
0
0
Motor – right leg
3
0
Motor – left leg
0
0
Ataxia
0
0
Sensory
2
0
Language
3
0
Dysarthria
0
0
Extinction
2
0