NIH Stroke Scale

Aka: NIH Stroke Scale

1. See Also
   1. Cerebrovascular Accident
2. Criteria
   1. Assess Level of Consciousness (0-3 points)
      1. Alert: 0
      2. Alerts to voice: 1
      3. Alerts to pain: 2
      4. Unresponsive: 3
   2. Assess Orientation (0-2 points)
      1. Current Month (1 point if fails)
      2. Patient's own Age (1 point if fails)
   3. Follow Commands (0-2 points)
      1. Open and close eyes (1 point if fails)
      2. Make fist and release (1 point if fails)
   4. Follow my finger (0-2 points)
      1. Normal: 0
      2. Partial gaze palsy: 1
      3. Forced deviation: 2
   5. Visual field (0-3 points)
      1. No visual loss: 0
      2. Partial Hemianopsia: 1
      3. Complete Hemianopsia: 2
      4. Bilateral Hemianopsia: 3
   6. Facial palsy (0-3 points)
      1. Testing: Show teeth, Raise eyebrows, Squeeze eyes shut
      2. Normal symmetric movements: 0
      3. Minor paralysis: 1
      4. Partial paralysis: 2
      5. Complete paralysis: 3
   7. Motor: Left Arm (0-4 points)
      1. Testing: Elevation limb to 90 degrees for 10 seconds
      2. No drift: 0
      3. Drifts (within 10 seconds): 1
      4. Unable to get to and maintain full limb elevation: 2
      5. Unable to move against gravity (limb falls): 3
      6. No movement: 4
   8. Motor: Right Arm (0-4 points)
      1. Testing: Elevation limb to 90 degrees for 10 seconds
      2. No drift: 0
      3. Drifts (within 10 seconds): 1
      4. Unable to get to and maintain full limb elevation: 2
      5. Unable to move against gravity (limb falls): 3
      6. No movement: 4
   9. Motor: Left Leg (0-4 points)
      1. Testing: Elevation limb to 30 degrees for 5 seconds
      2. No drift: 0
      3. Drifts (within 5 seconds): 1
      4. Unable to get to and maintain full limb elevation: 2
      5. Unable to move against gravity (limb falls): 3
      6. No movement: 4
   10. Motor: Right Leg (0-4 points)
       1. Testing: Elevation limb to 30 degrees for 5 seconds
       2. No drift: 0
       3. Drifts (within 5 seconds): 1
       4. Unable to get to and maintain full limb elevation: 2
       5. Unable to move against gravity (limb falls): 3
       6. No movement: 4
   11. Coordination or limb ataxia (0-2 points)
       1. Testing: Finger-nose-finger, Heel-knee-shin
       2. Absent: 0
       3. Present in one limb: 1
       4. Present in both limbs: 2
   12. Sensory (0-2 points)
       1. Test: Pin prick to face, arm, trunk, and legs
       2. Normal: 0
       3. Mild to moderate sensory loss (reduced, dull): 1
       4. Severe or total sensory loss (unaware of touch): 2
   13. Aphasia or Best Language (0-3 points)
       1. Test: Name items, Describe picture, Read sentences
       2. No Aphasia: 0
       3. Mild to moderate Aphasia: 1
       4. Severe Aphasia: 2
       5. Global Aphasia (Mute): 3
   14. Dysarthria (0-2 points)
       1. Normal articulation: 0
       2. Mild to moderate Dysarthria: 1
       3. Severe Dysarthria (nearly unintelligible): 2
       4. Intubated or other physical barrier: N/A
   15. Extinction and Inattention or Neglect (0-2 points)
       1. Testing: Bilateral simultaneous stimulation using one or more sensory modalities (vision, touch, hearing)
       2. No abnormality: 0
       3. Inattention or extinction to single sensory modality: 1
       4. Profound inattention or extinction or to multiple sensory modalities: 2
3. Interpretation
   1. Score 0
      1. No Stroke Symptoms
   2. Score 1-4
      1. Minor Stroke
   3. Score 5-15
      1. Moderate Stroke
   4. Score 16-20
      1. Moderate to Severe Stroke
   5. Score 21-42
      1. Severe Stroke
4. Resources
   1. Stroke-Site
      1. http://www.stroke-site.org
5. Reference
   1. Spilker (2000) Stroke Intervent 2:7-14
   2. (2000) Circulation 102(suppl I):I-204 to I-216