NIH Stroke Scale & Training

The NIH stroke scale it used to identify the severity of stroke like symptoms, and should be scored on the patient's initial presentation, without coaching or duplication. It is important to be consistent when scoring all patients, and identify all deficits. 

NIH stroke scale scores patients 0-42, with higher scores indicating increased severity.

Training for appropriate use of the NIH stroke scale is free, at http://nihss-english.trainingcampus.net/

iPhone applications, such as StatCoder, are available and free.

Level of Consciousness

• First, identify if the patient is alert, arousable to verbal stimuli, arousable to repeated stimuli or painful stimuli, or if the patient is unresponsive.
  
• Second, ask two questions are asked to identify LOC; the patient's age, and the current month. If they respond with their date of birth, this is incorrect. 
• Third, ask the patient to open and close their eyes, then grip and release the non-affected hand. Remeber to not coach the patient, however you can repeat the command twice, and pantomine gripping while asking. 

Best Gaze

• Test horizontal gaze only. Note the eye position at rest, and then have the patient follow a horizontal target. If the patient has partially abnormal gaze, or abnormal gaze in a single eye, they score 1. If they are unable to overcome paresis, this is a 2. You can also identify eye movement palsy by watching the patient track people or items in the room. 

Visual Testing

• Upper and lower quadrants should be tested by confrontation (finger movements or counting) in each eye. Ensure the patient is looking ahead when testing peripheral vision. If the patient has poor LOC, bilateral confrontational/threat can be used to test. If any loss of vision corrects with bilateral testing, then the score is 1. If hemianopia is present in monocular and binocular testing, this is a 2. If there is complete bilateral blindness, this is scored as a 3. 

Facial Palsy

• Score symmetry of grimace in poorly responsive patients, or your normal motor exam of the facial nerve. Complete paralysis of one or both sides is a 3, partial paralysis is a 2, and minor flattening of the nasolabial fold, or an asymetric smile, is a 1.  

Motor Arms

• Test motor drift over 10 seconds in the appropriate position. You can place arms in the appropriate position prior to starting, and any immediate 'dip' of the arm is not to be scored. Only score gradual drift over the time period. Each limb should be tested separately. Score each arm 0-4, no drift, minimal drift, effort against gravity but drifts completely down to bed, or no movement

Motor Legs

• Test motor drift over 10 seconds in the appropriate position. You can place legs in the appropriate position prior to starting, and any immediate 'dip' of the leg is not to be scored. Only score gradual drift over the time period. Each limb should be tested separately. Score each leg 0-4, no drift, minimal drift, effort against gravity but drifts completely down to bed, or no movement

Limb Ataxia

• Identify any unilateral cerebellar lesion by testing finger-nose and heel-shin tests, while using the visual fields that are not affected. 

Sensory Testing

• Test for sensory loss to pinprick or noxious stimuli. 

Best Language

• Have the patient describe what is happening in a photo, and ask the patient to name items on a naming sheet. Comprehension and ability to express ideas are both being tested. 

Dysarthria

• Separate from language and comprehension, aphasia should be tested separately, and scorred 1 for mild slurring, and 2 for severe slurring that inhibits communication. 

Extinction & Inattention

• Extinction of sensation or other stimuliation during bilateral stimuliation i.e. sensation, auditory testing, spatial awareness, or personal inattention. If the patient has profound inattention, i.e. cannot identify his/her own hand, this is scored as a 2.