NIH Stroke Scale
Background
- Intubation or limb pathology making categories not testable should be considered and potentially not scored.
- tPA candidate generally with NIHSS 4 - 22
Scale
Level of Consciousness
1a General
- Alert = 0
- Not alert, arousable to mild stimulation = 1
- Not alert, arousable to significant stimulation = 2
- Not alert; reflexic, autonomic or no response = 3
1b. Questions
- Month and DOB
- Both correct = 0
- One correct = 1
- Zero correct = 2
1c. Commands
- Open/close eyes & squeeze/release hand:
- Both correct = 0
- One correct = 1
- Zero correct = 2
2. Best Gaze
- Horizontal voluntary or oculocephalic reflex:
- Normal = 0
- Partial gaze palsy = 1
- Forced deviation or total gaze palsy = 2
3. Visual Fields
- Normal = 0
- Partial hemianopia = 1
- Complete hemianopia = 2
- Bilateral hemianopia or cortical blindness = 3
4. Facial Paralysis
- Normal = 0
- Minor, flat nasolabial fold = 1
- Partial or total uni lower paralysis= 2
- Complete paralysis 1 or both sides (upper & lower) = 3
5. Motor Arm
- 10 seconds:
- No drift = 0
- Some drift = 1
- Falls, effort against gravity = 2
- Falls, No effort against gravity = 3
- No movement = 4
6. Motor Leg
- 5 seconds:
- No drift = 0
- Some drift = 1
- Falls, effort against gravity = 2
- Falls, No effort against gravity = 3
- No movement = 4
7. Limb ataxia
- Absent = 0
- One limb = 1
- Two limb = 2
8. Sensory Loss
- Arms, legs, trunk:
- Normal = 0
- Present but altered = 1
- Absent = 2
9. Best Language
- Identification (picture or tactile), repetition, comprehension:
- No aphasia = 0
- Mild to moderate = 1
- Severe = 2
- Mute/Global aphasia = 3
10. Dysarthria
- None = 0
- Mild to moderate = 1
- Severe = 2
11. Extinction/Inattention
- Neglect:
- None = 0
- Loss of 1 modality (visual, tactile, auditory, spatial, personal) = 1
- Profound hemi-inattention or more than 1 modality = 2
External Links
References
National Institute of Neurologic Disorders and Stroke
See Also
- CVA (Main) for VAN score
- tPA in Stroke