NIH Stroke Scale

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1.a. Level of Consciousness

0
Alert
1
Not alert, but arousable with minimal stimulation
2
Not alert, requires repeated stimulation to attend
3
Coma

1.b. Ask patient the month and their age

0
Answers both correctly
1
Answers one correctly
2
Both incorrect

1.c. Ask patient to open and close eyes

0
Obeys both correctly
1
Obeys one correctly
2
Both incorrect

2. Best Gaze (only horizontal eye movement)

0
Normal
1
Partial gaze palsy
2
Forced deviation

3. Visual Field Testing

0
No visual field loss
1
Partial hemianopia
2
Complete hemianopia
3
Bilateral hemianopia (blind including cortical blindness)

4. Facial Paresis (Ask patient to show symmetrical movement
teeth or raise eyebrows and close eyes tightly)

0
Normal
1
Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
2
Partial paralysis (total or near total paralysis of lower face)
3
Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)

5. Motor Function - Arm (right and left)
(extends arms 90 (or 45) degrees for 10 seconds without drift)

0
Normal
1
Drift
2
Some effort against gravity
3
No effort against gravity
4
No movement
9
Untestable (Joint fused or limb amputated)

6. Motor Function - Leg (right and left) -
(hold leg 30 degrees position for 5 seconds)

0
Normal
1
Drift
2
Some effort against gravity
3
No effort against gravity
4
No movement
9
Untestable (joint fused or limb amputated)

7. Limb Ataxia

0
No ataxia
1
Present in one limb
2
Present in two limbs

8. Sensory (Use pinprick to test arms, legs, trunk and face -
compare side to side)

0
Normal
1
Mild to moderate decrease in sensation
2
Severe to total sensory loss

9. Best Language (describe picture, name items, read sentences)

0
No aphasia
1
Mild to moderate aphasia
2
Severe aphasia
3

Mute

10. Dysarthria (read several words)

0
Normal articulation
1
Mild to moderate slurring of words
2
Near unintelligible or unable to speak
9
Intubated or other physical barrier

11. Extinction and Inattention

0
Normal
1
Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities
2
Severe hemi-inattention or hemi-inattention to more than one modality
Last Updated ( Friday, 13 March 2009 13:14 )