Acute Care 32: NIH Stroke Scale (Abbreviated)
The
NIH Stroke Scale is a relatively reproducible and standardized
evaluation tool used to help estimate the severity of a patient’s
stroke and to monitor the patient’s progression of improvement or
deterioration over time.
| Category | Description | Score |
| 1a.
Level of Consciousness (LOC) (Alert, drowsy, etc.) |
Alert Drowsy Stuporous Coma |
0 1 2 3 |
| 1b.
LOC Questions (Month, age) |
Answers
both correctly Answers 1 correctly Incorrect |
0 1 2 |
| 1c.
LOC Commands (Open, close eyes; make fist, let go) |
Obeys
both correctly Obeys 1 correctly Incorrect |
0 1 2 |
| 2.
Best Gaze (Eyes open – patient follows examiner's finger or face) |
Normal Partial gaze palsy Forced deviation |
0 1 2 |
| 3.Visual (Introduce visual stimulus/threat to patient's visual field quadrants) |
No
visual loss Partial hemianopia Complete hemianopia Bilateral hemianopia |
0 1 2 3 |
| 4.
Facial Palsy (Show teeth, raise eyebrows, and squeeze eyes shut) |
Normal Minor Partial Complete |
0 1 2 3 |
| 5a.
Motor Arm – Left (Elevate extremity to 90° and score drift/movement) |
No
drift Drift Can't resist gravity No effort against gravity No movement Amputation, joint fusion (explain) |
0 1 2 3 4 9 |
| 5b.
Motor Arm – Right (Elevate extremity to 90° and score drift/movement) |
No
drift Drift Can't resist gravity No effort against gravity No movement Amputation, joint fusion (explain) |
0 1 2 3 4 9 |
| 6a.
Motor Leg – Left (Elevate extremity to 30° and score drift/movement) |
No
drift Drift Can't resist gravity No effort against gravity No movement Amputation, joint fusion (explain) |
0 1 2 3 4 9 |
| 6b.
Motor Leg – Right (Elevate extremity to 30° and score drift/movement) |
No
drift Drift Can't resist gravity No effort against gravity No movement Amputation, joint fusion (explain) |
0 1 2 3 4 9 |
| 7.
Limb Ataxia (Finger-nose, heel down shin) |
Absent Present in 1 limb Present in 2 limbs |
0 1 2 |
| 8.
Sensory (Pin prick to face, arm, trunk, and leg – compare side to side) |
Normal Partial loss Severe loss |
0 1 2 |
| 9.
Best Language (Name items, describe a picture, and read sentences) |
No
aphasia Mild to moderate aphasia Severe aphasia Mute |
0 1 2 3 |
| 10.
Dysarthria (Evaluate speech clarity by patient repeating listed words) |
Normal
articulation Mild to moderate dysarthria Near to unintelligible or worse Intubated or other physical barrier |
0 1 2 9 |
| 11.
Extinction and Inattention (Use information from prior testing to identify neglect or double simultaneous stimuli testing) |
No
neglect Partial neglect Complete neglect |
0 1 2 |
Level of Stroke Severity: 0=no stroke; 1-4=minor stroke; 5-15=moderate stroke; 15-20=moderate/severe stroke; 21-42=severe stroke.
Strokes with scores greater than 4 may be considered for treatment with tPA.
References
- The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 7: the era of reperfusion: section 2: acute stroke. Circulation. 2000;102(8 suppl):I204-I216.