NIH STROKE SCALE

(NIHSS)
Name of Patient: ________________________________ Hospital No: __________________ Patient ID: __________________

Instructions Scale Definition Score

1a. Level of consciousness: The investigator must choose response, even if a full evaluation is prevented by 0 = Alert; keenly responsive.
such obstacles as an endotracheal tube, language barrier, orotracheal trauma/ bandages. A "3" is scored only if the 1 = Not alert; but arousable by minor stimulation to obey, answer, or respond.
patient makes no movement (other than reflexive posturing) in response to noxious stimulation. 2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires
strong or painful stimulation to make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or totally unresponsive,
flaccid, and areflexic.
1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is 0 = Answers both questions correctly.
no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 1 = Answers one question correctly.
2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any 2 = Answers neither question correctly.
cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the
initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.
1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the 0 = Performs both tasks correctly.
non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an 1 = Performs one task correctly.
unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, 2 = Performs neither task correctly.
the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or two
commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step
commands. Only the first attempt is scored.
2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye 0 = Normal.
movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that 1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve but forced deviation or total gaze paresis is not present.
paresis (CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, 2 = Forced deviation, or total gaze paresis not overcome by the
pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a oculocephalic maneuver.
choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will
occasionally clarify the presence of a partial gaze palsy.
4. Facial Palsy: Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows 0 = Normal symmetrical movements.
and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non- 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling).
comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the 2 = Partial paralysis (total or near-total paralysis of lower face).
face, these should be removed to the extent possible. 3 = Complete paralysis of one or both sides (absence of facial movement in the upper
and lower face).
5. Motor Arm: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. Right:
sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does
encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, not hit bed or other support.
beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45)
should record the score as untestable (UN), and clearly write the explanation for this choice. degrees, drifts down to bed, but has some effort against gravity. Left:
3 = No effort against gravity; limb falls.
4 = No movement.
UN = Amputation or joint fusion, explain: _____________________
6. Motor Leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested 0 = No drift; leg holds 30-degree position for full 5 seconds. Right:
supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the 1 = Drift; leg falls by the end of the 5-second period but does not hit bed.
voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort
leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable against gravity. Left:
(UN), and clearly write the explanation for this choice. 3 = No effort against gravity; leg falls to bed immediately.
4 = No movement.
UN = Amputation or joint fusion, explain: ________________
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In 0 = Absent.
case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests 1 = Present in one limb.
are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent 2 = Present in two limbs.
in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner UN = Amputation or joint fusion, explain: _________________________
should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness,
test by having the patient touch nose from extended arm position.
8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in 0 = Normal; no sensory loss.
the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the
examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for affected side; or there is a loss of superficial pain with pinprick, but patient is aware of
hemisensory loss. A score of 2, “severe or total sensory loss,” should only be given when a severe or total loss of being touched.
sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The 2 = Severe to total sensory loss; patient is not aware of
patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is being touched in the face, arm, and leg.
quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item.
9. Best Language: A great deal of information about comprehension will be obtained during the preceding 0 = No aphasia; normal.
sections of the examination. For this scale item, the patient is asked to describe what is happening in the 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of
attached picture, to name the items on the attached naming sheet and to read from the attached list comprehension, without significant limitation on ideas expressed or form of expression.
of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding Reduction of speech and/or comprehension, however, makes conversation about
general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the provided materials difficult or impossible. For example, in conversation about provided
hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item materials, examiner can identify picture or naming card content from patient’s response.
1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or 2 = Severe aphasia; all communication is through fragmentary expression; great need
limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step for inference, questioning, and guessing by the listener. Range of information that can
commands. be exchanged is limited; listener carries burden of communication. Examiner cannot
identify materials provided from patient response.
3 = Mute, global aphasia; no usable speech or auditory comprehension.
10. Dysarthria: If patient is thought to be normal, an adequate sample of speech must be obtained by asking 0 = Normal.
patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be
articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to understood with some difficulty.
producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the
this choice. Do not tell the patient why he or she is being tested. absence of or out of proportion to any dysphasia, or is mute/anarthric.
UN = Intubated or other physical barrier, explain: _________________________
11. Extinction and Inattention (formerly Neglect): Sufficient information to identify neglect may be 0 = No abnormality.
obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral
stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear simultaneous stimulation in one of the sensory modalities.
to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be 2 = Profound hemi-inattention or extinction to more than one modality; does not
taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. recognize own hand or orients to only one side of space.

TOTAL SCORE
Date Assessed: ____ / ____ /____ Time: _______ H Assessed by: ______________________________