National Institutes of HealthStrokeScaleThe National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS)isatool usedbyhealthcareproviderstoobjectivelyquantifytheimpairmentcaused by a stroke. The NIH is composed of !! items, each of "hich scores aspecific ability bet"een a # and $. %or each item, a score of # typically indicatesnormal function in that specific ability, "hile a hi&her score is indicative of somelevel of impairment.'!( The individual scores from each item are summed in orderto calculate a patient)s total NIH score. The ma*imum possible score is $+, "iththe minimum score bein& a #.'+(',(Score [3]Stroke Severity# No troke ymptoms#-$ .inor troke/-!/ .oderate troke!0-+# .oderate to evere troke+!-$+ evere trokePerforming the scaleThrou&hout the NIH it is important that the e*aminer does not coach or help"ith the assi&ned task. The e*aminer may demonstrate the commands to patientsthat areunable tocomprehendverbal instructions, ho"ever thescoreshouldreflect the patient)s o"n ability. It is acceptable for the e*aminer to physically helpthe patient &et into position to be&in the test, but the e*aminer must not providefurther assistance "hile the patient is attemptin& to complete the task. %or eachitemthee*aminershouldscorethepatient)sfirst effort, andrepeatedattemptsshould not affect the patient)s score. 1n e*ception to this rule e*ist in the lan&ua&eassessment (Item 2) in "hich the patient)s best effort should be scored.'!( ome ofthe items contain 34efault 5oma cores3, these scores are automatically assi&nedto patients that scored a , in item !a.1. Level of Consciousness6evel of consciousness testin& is divided into three sections. The first 675 itemstest for the patient)s responsiveness. The second675itemis basedonthepatient)s ability to ans"er questions that are verbally presented by the e*aminer.Thefinal 675sub-sectionis basedonthepatient)s abilitytofollo"verbalcommands to perform simple task. 1lthou&h this item is broken into three parts,each sub-section is added to the final score as if it is its o"n item.',(! L"C #es$onsivenesscores for this item are assi&ned by a medical practitioner based on the stimulirequired to arouse patient. The e*aminer should first assess if the patient is fullyalert to his or her surroundin&s. If the patient is not completely alert, the e*aminershould attempt a verbal stimulus to arouse the patient. %ailure of verbal stimuliindicates an attempt to arouse the patient via repeated physical stimuli. If none ofthese stimuli are successful in elicitin& a response, the patient can be consideredtotally unresponsive.',(Score %est #esults# 1lert8 9esponsive!Not alert8 :erbally arousable or aroused by minor stimulation to obey,ans"er, or respond.+ Not alert8 7nly responsive to repeated or stron& and painful stimuli, Totally unresponsive8 9esponds only "ith refle*es or is arefle*icNotes If patients scores a , in this factor, the default coma scores should be used"hen applicable&! L"C 'uestions;atient is verbally asked his or her a&e and for the name of the current month.',(Score %est #esults# 5orrectly ans"ers both questions! 5orrectly ans"ers one question+ 4oes not correctly ans"er either questionNotes 4efault 5oma core< + The patient must ans"er each question !##= correct "ithout help to &etcredit ;atients unable to speak are allo"ed to "rite the ans"er 1phasicpatients or patients in astuporousstate "ho are unable tounderstand the commands receive a score of + ;atients that are unable to talk due to trauma, dysarthria, lan&ua&e barrier,or intubation are &iven a score of !C! L"C Comman(sThe patient is instructed to first open and close his or her eyes and then &rip andrelease his or her hand',(Score %est #esults# 5orrectly performs both tasks! 5orrectly performs ! task+ 4oes not correctly perform either taskNotes 5ommands can only be repeated once. The hand &rip command can be replaced "ith any other simple one stepcommand if the patient cannot use his or her hands. 1 patient)s attempt is re&arded as successful if an attempt is made but isincomplete due to "eakness Ifthepatient doesnot understandthecommand, thecommandcanbevisually demonstrated to him or her "ithout an impact on his or her score ;atients "ith trauma,amputations, or other physical impediments can be&iven other simple one-step commands if these commands are notappropriate). Hori*ontal +ye ,ovement1ssesses ability for patient to track a pen or fin&er from side to side only usin& hisor her eyes. This is desi&ned to assess motor ability to &a>e to"ards thehemisphereopposite of injury. This itemis tested because5onju&ated eyedeviation is present in appro*imately +#= of stroke cases. 5?4 is more commonsin ri&ht hemispheric strokes and typically in lesions effectin& thebasal &an&liaand temporoparietal corte*. 4ama&e to these areas can result in decreased spatialattention and reduced control of eye movements.'$(Score %est #esults# Normal8 1ble to follo" pen or fin&er to both sides!;artial &a>e palsy8 &a>e is abnormal in one or both eyes, but &a>e is nottotallyparaly>ed. ;atient can&a>eto"ardshemisphereofinfarct, butcan)t &o past midline+ Total &a>e paresis8 &a>e is fi*ed to one sideNotes If patient is unable to follo"the command to track an object, theinvesti&ator can make eye contact "ith the patient and then move side toside. The patient)s &a>e palsy can then be assessed by his or her ability tomaintain eye contact. Ifpatient isunabletofollo"anycommands, assessthehori>ontal eyemovement viatheoculocephalicmaneuver. This is donebymanuallyturnin& the patient)s head from midline to one side and assessin& the eye)srefle* to return to a midline position. If the patient has isolated peripheral nerve paresis assi&n a score of !3. -isual fiel( test1ssess the patient)s vision in each visual fields. ?ach eye is tested individually, bycoverin& one eye and then the other. ?ach upper and lo"er quadrant is tested byaskin& the patient to indicate ho" many fin&ers the investi&ator is presentin& ineach quadrant. The investi&ator should instruct the patient to maintain eye contactthrou&hout this test, andnot allo"thepatient toreali&nfocus to"ards eachstimulus. @ith the first eye covered, place a random number of fin&ers in eachquadrant and ask the patient ho" many fin&ers are bein& presented. 9epeat thistestin& for the opposite eye.',(Score %est #esults# No vision loss!;artialhemianopiaorcompletequadrantanopia8 patient reco&ni>esnovisual stimulus in one specific quadrant+5omplete hemianopia8 patient reco&ni>es no visual stimulus in one halfof the visual field, Ailateral Alindness, includin& blindness from any causeNotes If patient is non-verbal, he or she can be allo"ed to respond by holdin& upthe number of fin&ers the investi&ator is presentin& If patient is not responsive the visual fields can be tested by visual threat,this involves the investi&ator movin& an object to"ards the eye andobservin& the patient)s response... /acial Palsy%acial palsy is partial or complete paralysis of portions of the face. Typically thisparalysis is most pronouncedinthelo"er half of onefacial side. Ho"ever,dependin& on lesion location the paralysis may be present in other facial re&ions.@hile inspectin& the symmetry of each facial e*pression the e*aminer should firstinstruct patient to sho" his or her teeth (or &ums). econd, the patient should beasked to squee>e his or her eyes closed as hard as possible. 1fter reopenin& his orher eyes, the patient is then instructed to raise his or her eyebro"s.'/(Score %est #esults# Normal and symmetrical movement!.inorparalysis8 function is less than clearly normal, such as flattenednasolabial fold or minor asymmetry in smile+ ;artial paralysis8 particularly paralysis in lo"er face,5omplete facial Hemiparesis, total paralysis in upper and lo"er portionsof one face sideNotes If the patient is unable to understand verbal commands,the instructionsshould be demonstrated to the patient. ;atients incapable of comprehendin&ancommands maybetestedbyapplyin& ano*iousstimulus and observin& for any paralysis in theresultin& &rimace.0. ,otor rm@ith palm facin& do"n"ards, have the patient e*tend one arm 2# de&rees out infront if the patient is sittin&,and $/ de&rees out in front if the patient is lyin&do"n. If necessary, help the patient &et into the correct position. 1s soon as thepatient)s arm is in position the investi&ator should be&in verbally countin& do"nfrom !# "hile simultaneously countin& do"n on his or her fin&ers in full vie" ofthe patient. 7bserve to detect any do"n"ard arm drift prior to the end of the !#seconds. 4o"n"ard movement that occurs directly after the investi&ator placesthe patient)s arm in position should not be considered do"n"ard drift. 9epeat thistest for the opposite arm. This item should be scored for the ri&ht and left armindividually, denoted as item /a and /b.',(Score %est #esults#Noarmdrift8 thearmremains intheinitial positionfor thefull !#seconds!4rift8 the arm drifts to an intermediate position prior to the end of thefull !# seconds, but not at any point relies on a support+6imitedeffort a&ainst &ravity8 thearmis abletoobtainthestartin&position, but drifts do"n from the initial position to a physical supportprior to the end of the !# seconds,No effort a&ainst &ravity8 the arm falls immediately after bein& helped tothe initial position, ho"ever the patient is able to move the arm in someform (e.&. shoulder shru&)$No movement8 patient has no ability to enact voluntary movement in thisarmNotes 4efault 5oma core< B Test the non paraly>ed arm first if applicable core should be recorded for each arm separately, resultin& in a ma*imumpotential score of B. .otor 1rmassessment shouldbeskippedinthecaseof anamputee,ho"ever a note should be made in the scorin& of the amputation. If patient is unable tounderstand commands, the investi&ator shoulddeliver the instructions via demonstration1. ,otor Leg@iththepatient inthesupine position, onele&is placed,#de&rees abovehori>ontal. 1s soon as the patient)s le& is in position the investi&ator should be&inverbally countin& do"n from / "hile simultaneously countin& do"n on his or herfin&ers in full vie" of the patient. 7bserve any do"n"ard le& drift prior to the endof the / seconds. 4o"n"ard movement that occurs directly after the investi&atorplaces thepatient)s le&inpositionshouldnot beconsidereddo"n"arddrift.9epeat this test for the opposite le&. cores for this section should be recordedseparately as 0a and 0b for the left and ri&ht le&s respectively.',(Score %est #esults# No le& drift8 the le& remains in the initial position for the full / seconds!4rift8 the le& drifts to an intermediate position prior to the end of the full/ seconds, but at no point touches the bed for support+6imitedeffort a&ainst &ravity8 the le&is able toobtainthe startin&position, but drifts do"n from the initial position to a physical supportprior to the end of the / seconds,No effort a&ainst &ravity8 the le& falls immediately after bein& helped tothe initial position, ho"ever the patient is able to move the le& in someform (e.&. hip fle*)$No movement8 patient has no ability to enact voluntary movement in thisle&Notes 4efault 5oma core< B This is performed for each le&, indicatin& a ma*imum possible score of B Test the non paraly>ed le& first if applicable .otor le&assessment shouldbe skippedinthe case of anamputee,ho"ever a note should be made in the score records If patient is unable tounderstand commands, the investi&ator shoulddeliver the instructions via demonstration2.Lim3 ta4iaThistest forthepresenceofaunilateralcerebellarlesion, anddistin&uishesadifference bet"een &eneral "eakness and incoordination. The patient should beinstructed to first touch his or her fin&er to the e*aminer)s fin&er then move thatfin&er back to his or her nose, repeat this movement ,-$ times for each hand. Ne*tthe patient should be instructed to move his or her heel up and do"n the shin ofhis or her opposite le&. This test should be repeated for the other le& as "ell.',(Score %est #esults# Normal coordination8 smooth and accurate movement! 1ta*ia present in ! limb8 ri&id and inaccurate movement in one limb+1ta*iapresent in+ormorelimbs< ri&idandinaccuratemovement inboth limbs on one sideNotes If si&nificant "eakness is present, score # If patient is unable to understand commands or move limbs, score is # ;atient)s eyes should remain open throu&hout this section If applicable, test the un-paretic side first5.Sensoryensorytestin&isperformedviapinpricksinthepro*imalportionofall fourlimbs. @hile applyin& pinpricks, the investi&ator should ask "hether or not thepatient feels the pricks, and if he or she feels the pricks differently on one side"hen compared to the other side.',(Score %est #esults# No evidence of sensory loss!.ild-to-.oderate sensory loss8 patient feels the pinprick, ho"ever he orshe feels as if it is duller on one side+evere to total sensory loss on one side8 patient is not a"are he or she isbein& touched in all unilateral e*tremitiesNotes 4efault 5oma core< + Theinvesti&atorshouldinsurethat thesensorylossbein&detectedisaresult of the stroke, and should therefore test multiple spots on the body. %or patients unabletounderstandtheinstructions, thepinprickcanbereplaced by a no*ious stimulus and the &rimace can be jud&ed todetermine sensory score.6.LanguageThis item measures the patient)s lan&ua&e skills. 1fter completin& items !-B it islikelytheinvesti&ator has &ainedanappro*imationof thepatient)s lan&ua&eskills8 ho"ever it isimportant toconfirmthismeasurement at thistime. Thestroke scale includes a picture of a picture of a scenario, a list of simple sentences,a fi&ure of assorted random objects, and a list of "ords. The patient should beasked to e*plain the scenario depicted in the first fi&ure. Ne*t, he or she shouldread the list of sentences and name each of the objects depicted in the ne*t fi&ure.Thescorin&for this itemshouldbebasedonboththeresults fromthetestperformed in this item in addition to the lan&ua&e skills demonstrated up to thispoint in the stroke scale.',(Score %est #esults# Normal8 no obvious speech deficit!.ild-to-moderate aphasia8 detectable loss in fluency, ho"ever, thee*aminer should still be able to e*tract information from patient)s speech+evereaphasia8 all speechisfra&mented, ande*aminer isunabletoe*tract the fi&ure)s content from the patients speech., Cnable to speak or understand speechNotes 4efault 5oma core< , ;atients "ith visual loss should be asked to identify objects placed in hisor her hands This is an e*ceptionto recordin&only thepatientsfirst attempt.In thisitem, the patients best lan&ua&e skills should be recorded17.S$eech4ysarthria is the lack of motor skills required to produce understandable speech.4ysarthria is strictly a motor problem, and is not related to the patient)s ability tocomprehend speech. trokes that cause dysarthria typically effect areas such astheanterior opercular, medial prefrontal andpremotor, andanterior cin&ulatere&ions. These brain re&ions are vital in coordinatin& motor control of the ton&ue,throat, lips, and lun&s.'0( To perform this item the patient is be asked to read fromthe list of "ords provided "ith the stroke scale "hile the e*aminer observes thepatients articulation and clarity of speech.',(Score %est #esults# Normal8 clear and smooth speech!.ild-to-moderate dysarthria8 some slurrin& of speech, ho"ever thepatient can be understood+evere dysarthria8 speech is so slurred that he or she cannot beunderstood, or patients that cannot produce any speechNotes 4efault 5oma coree stimuli in more than one modalityon the same sideNotes 4efault 5oma core< + ;atient "ith severe vision loss that correctly identifies all otherstimulations scores a #8sageTheNIH"as desi&nedtobeastandardi>edandrepeatableassessment ofstroke patients utili>ed by lar&e multi-center clinical trials.'D(5linical researchershave "idely accepted this scale due to hi&h levels of score consistency.5onsistencyofNIHscoreshasbeendemonstratedininter-e*aminer andintest-retest scenarios.'B(5linical researchuse of the NIHtypicallyinvolvesobtainin&a baseline NIHscore as soonas possible after onset ofstrokesymptoms '2('!#( The NIH is then repeated at re&ular intervals or after si&nificantchan&es in patient condition. This history of scores can then be utili>ed to monitorthe effectiveness of treatment methods and quantify a patientEs improvement ordecline.'!!('!+( The NIH has also been used in a prospective observational study,to predict , month outcomes of patients "ith undernutrition durin& hospital staysdirectly after a stroke.'!,(NIHSS use in tP eligi3ilityNIHhas&ainedpopularityasaclinical tool utili>edintreatment plannin&..inimumandma*imumNIHscores havebeenset for multipletreatmentoptions in order to assist physicians in choosin& an appropriate treatment plan.'2('!#( Tissueplasmino&enactivator(t;1), atypeofThrombolysisiscurrentlytheonly proven treatment for acute ischemicstrokes. Ischemic strokes are the resultof blood clots that are preventin& blood flo" "ithin a cerebral blood vessel. The&oal of t;1 treatment is to break up the clotsthat are occludin& the vessel, andrestorecerebral bloodflo". Treatment "itht;1has beensho"ntoimprovepatient outcome in some studies and to be harmful in others. The effectivenessand risk of t;1 is stron&ly correlated "ith the delay bet"een stroke onset and t;1delivery. 5urrent standards recommend for t;1 to be delivered "ithin , hours ofonset, "hile best results occur "hen treatment is delivered "ithin 2# minutes ofonset.'!$(ince the NIH has been established as a quick and consistentquantifierof stroke severity,manyphysicianshavelookedtoNIHscores asindicators for t;1 treatment.'!/( This rapid assessment of stroke severity is tar&etedto reduce delay of t;1 treatment. ome hospitals use an NIH of less than / toe*cludepatientsfromt;1 treatment, ho"everthe1mericanHeart1ssociationur&es a&ainst NIH scores bein& used as the sole reason for declarin& a patientas ineli&ible for t;1 treatment.'!0(NIHSS structureInaneffort toproduce a complete neurolo&ical assessment the NIH"asdeveloped after e*tensive research and multiple iterations. The &oal of the NIH"as to accurately measure holistic neurolo&ical function by individually testin&specific abilities. NIH total score is based on the summation of $ factors. Thesefactors are left and ri&ht motor function and left and ri&ht cortical function. TheNIH assesses each of these specific functions by the stroke scale item listed inthe chart belo".'!D(Left Cortical #ight Cortical #ight ,otor Left ,otor675 FuestionsHori>ontal ?ye.ovement9i&ht 1rm.otor6eft 1rm.otor6755ommands:isual %ields 9i&ht 6e& 6eft 6e&6an&ua&e?*tinction andInattention4ysarthriaensory,o(ifie( National Institutes of Health Stroke ScaleThe .odified NIH troke cale (mNIH) is a shortened, validated version ofthemNIH. It hasbeensho"ntobeequally, ifnot more, accuratethanthelon&er, older NIH. It removes questions !1, $, and D. This makes the mNIHshorter and easier to use. The mNIH predicts patients at hi&h risk ofhemorrha&e if &iven Tissue plasmino&en activator(t;1) and "hich patients arelikelytohave&oodclinical outcomes.'!B(ThemNIHhasalsorecentlybeensho"ntobetaken"ithoutseein&thepatient, andonlyusin&medical records.This potentially improves care "hile in the emer&ency room and the hospital, butalso facilitates retrospective research.'!2(ccuracyThe National Institutes of Health troke cale has been repeatedly validated as atool for assessin& stroke severity and as an e*cellent predictor for patientoutcomes.'+#('+!('++(everityofastrokeisheavilycorrelated"iththevolumeofbrain affected by the stroke, strokes effectin& lar&er portions of the brain tend tohavemoredetrimentaleffects.'+,(NIHscoreshavebeenfound to be reliablepredictorsofdama&edbrainvolume, "ithasmallerNIHscoreindicatin&asmaller lesion volume'+$(+ffect of stroke location on NIHSS $re(iction of stroke severity4ue to the NIHEs focus on cortical function, patients sufferin& from a corticalstroke tend to have hi&her ("orse) baseline scores. The NIH places D of thepossible $+ points on abilities that require verbal skills8 + points from the 675questions, + points from 675 commands, and , points from the 6an&ua&e item.The NIH only a"ards + points for e*tinction and inattention.'+/( 1ppro*imately2B=of humans have verbal processin& take place in the left hemisphere,indicatin& that the NIH places more value on deficitsin the left hemisphere.This results in lesions receivin& a hi&her ("orse) score "hen occurrin& in the lefthemisphere, compared to lesions of equal si>e in the ri&ht hemisphere. 4ue to thisemphasis, the NIHis a better predictor of lesion volume in the strokesoccurrin& "ithin the left cerebral hemisphere.'!0(NIHSS as $re(ictor of $atient outcomesThe NIH has been found to be an e*cellent predictor of patient outcomes. 1baselineNIHscore&reaterthan!0indicatesastron&probabilityofpatientdeath, "hile a baseline NIH score less than 0 indicates a stron& probability of a&oodrecovery.7navera&e, anincreaseof!point inapatientEsNIHscoredecreases the likelihood of an e*cellent outcome by !D=.'+0( Ho"ever, correlationbet"een functional recovery and NIH scores "as "eaker "hen the stroke "asisolated to the corte*.'+$(