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NIH Stroke Scale (NIHSS) Exam, 2026/2027
Edition, All Test Groups A–F & Patients 1–6 with
Complete Answer Key and Clinical Rationales
GROUP A – PATIENT 1: Mild Left MCA Stroke
Clinical Scenario: Patient: 68-year-old male Chief Complaint: "My right hand feels
clumsy and my speech is a bit off." Time Since Onset: 2 hours 15 minutes Medical
History: Hypertension, hyperlipidemia, former smoker (quit 5 years ago) Medications:
Lisinopril, atorvastatin
Physical Examination Findings:
Level of Consciousness: Alert, oriented to person, place, and time. Follows all commands
appropriately.
Language: Mild word-finding difficulty noted when naming objects. Comprehension
intact. Can repeat phrases with occasional paraphasic errors.
Cranial Nerves:
• Gaze: Full horizontal eye movements, no deviation
• Visual fields: Full to confrontation
• Facial movement: Slight flattening of right nasolabial fold, forehead wrinkling
preserved
Motor:
• Right arm: Mild drift after 10 seconds (does not hit bed)
• Right leg: Mild drift after 10 seconds (does not hit bed)
• Left limbs: Normal strength
Coordination: No dysmetria or ataxia in any limbs
, 2
Sensation: Slight decreased sensation to pinprick on right hand compared to left (patient
reports it feels "duller")
Neglect: No extinction on double simultaneous stimulation
NIHSS Scoring Answer Key – Patient 1
Table
Item Finding Score Rationale
1A Alert, keenly 0 Patient is fully alert and responsive with no delay in response
responsive to verbal or tactile stimulation.
1B Answers both 0 Oriented to month and age. Both answers accurate.
questions
correctly
1C Obeys both 0 Opens and closes eyes, grips and releases hand on command
commands without hesitation.
correctly
2 Normal 0 Full horizontal eye movements; no gaze preference or forced
deviation.
3 No visual loss 0 Visual fields intact to confrontation bilaterally.
4 Minor facial 1 Flattening of right nasolabial fold with preserved forehead
weakness movement (central VII pattern).
5A Right arm: Drift; 1 Right arm drifts down within 10 seconds but does not hit bed.
does not hit bed Left arm holds 10 seconds without drift (score 0).
5B Left arm: No 0 Left arm holds 90° (or 45°) position for full 10 seconds
drift without drift.
, 3
Item Finding Score Rationale
6A Right leg: Drift; 1 Right leg drifts down within 5 seconds but does not hit bed.
does not hit bed Left leg holds 5 seconds without drift (score 0).
6B Left leg: No drift 0 Left leg holds 30° position for full 5 seconds without drift.
7 Absent 0 No ataxia observed in finger-to-nose or heel-to-shin testing on
either side.
8 Mild-to- 1 Patient reports right hand pinprick as "dull" compared to left;
moderate aware of being touched but perception is decreased.
sensory loss
9 Mild-to- 1 Some obvious loss of fluency or facility of comprehension
moderate without significant limitation on ideas expressed or form of
aphasia expression. Word-finding pauses and occasional paraphasic
errors.
10 Normal 0 Articulation clear; no slurred speech.
11 No neglect 0 No extinction to simultaneous stimulation; no neglect on
visual or tactile testing.
Total NIHSS Score: 5/42 Stroke Severity: Mild (NIHSS 1–5) Group Designation: A
(Mild Stroke)
GROUP B – PATIENT 2: Moderate Left MCA Stroke with Aphasia
Clinical Scenario: Patient: 74-year-old female Chief Complaint: Family reports "She
can't speak properly and seems confused." Time Since Onset: 4 hours 30 minutes
Medical History: Atrial fibrillation (on warfarin, INR 2.8), diabetes mellitus type 2, prior
TIA 3 years ago Medications: Warfarin, metformin, insulin
NIH Stroke Scale (NIHSS) Exam, 2026/2027
Edition, All Test Groups A–F & Patients 1–6 with
Complete Answer Key and Clinical Rationales
GROUP A – PATIENT 1: Mild Left MCA Stroke
Clinical Scenario: Patient: 68-year-old male Chief Complaint: "My right hand feels
clumsy and my speech is a bit off." Time Since Onset: 2 hours 15 minutes Medical
History: Hypertension, hyperlipidemia, former smoker (quit 5 years ago) Medications:
Lisinopril, atorvastatin
Physical Examination Findings:
Level of Consciousness: Alert, oriented to person, place, and time. Follows all commands
appropriately.
Language: Mild word-finding difficulty noted when naming objects. Comprehension
intact. Can repeat phrases with occasional paraphasic errors.
Cranial Nerves:
• Gaze: Full horizontal eye movements, no deviation
• Visual fields: Full to confrontation
• Facial movement: Slight flattening of right nasolabial fold, forehead wrinkling
preserved
Motor:
• Right arm: Mild drift after 10 seconds (does not hit bed)
• Right leg: Mild drift after 10 seconds (does not hit bed)
• Left limbs: Normal strength
Coordination: No dysmetria or ataxia in any limbs
, 2
Sensation: Slight decreased sensation to pinprick on right hand compared to left (patient
reports it feels "duller")
Neglect: No extinction on double simultaneous stimulation
NIHSS Scoring Answer Key – Patient 1
Table
Item Finding Score Rationale
1A Alert, keenly 0 Patient is fully alert and responsive with no delay in response
responsive to verbal or tactile stimulation.
1B Answers both 0 Oriented to month and age. Both answers accurate.
questions
correctly
1C Obeys both 0 Opens and closes eyes, grips and releases hand on command
commands without hesitation.
correctly
2 Normal 0 Full horizontal eye movements; no gaze preference or forced
deviation.
3 No visual loss 0 Visual fields intact to confrontation bilaterally.
4 Minor facial 1 Flattening of right nasolabial fold with preserved forehead
weakness movement (central VII pattern).
5A Right arm: Drift; 1 Right arm drifts down within 10 seconds but does not hit bed.
does not hit bed Left arm holds 10 seconds without drift (score 0).
5B Left arm: No 0 Left arm holds 90° (or 45°) position for full 10 seconds
drift without drift.
, 3
Item Finding Score Rationale
6A Right leg: Drift; 1 Right leg drifts down within 5 seconds but does not hit bed.
does not hit bed Left leg holds 5 seconds without drift (score 0).
6B Left leg: No drift 0 Left leg holds 30° position for full 5 seconds without drift.
7 Absent 0 No ataxia observed in finger-to-nose or heel-to-shin testing on
either side.
8 Mild-to- 1 Patient reports right hand pinprick as "dull" compared to left;
moderate aware of being touched but perception is decreased.
sensory loss
9 Mild-to- 1 Some obvious loss of fluency or facility of comprehension
moderate without significant limitation on ideas expressed or form of
aphasia expression. Word-finding pauses and occasional paraphasic
errors.
10 Normal 0 Articulation clear; no slurred speech.
11 No neglect 0 No extinction to simultaneous stimulation; no neglect on
visual or tactile testing.
Total NIHSS Score: 5/42 Stroke Severity: Mild (NIHSS 1–5) Group Designation: A
(Mild Stroke)
GROUP B – PATIENT 2: Moderate Left MCA Stroke with Aphasia
Clinical Scenario: Patient: 74-year-old female Chief Complaint: Family reports "She
can't speak properly and seems confused." Time Since Onset: 4 hours 30 minutes
Medical History: Atrial fibrillation (on warfarin, INR 2.8), diabetes mellitus type 2, prior
TIA 3 years ago Medications: Warfarin, metformin, insulin
