National Institutes of Health
MAXE • SSHIN
NIH NIH Stroke Scale (NIHSS) Certification
S C I E N C E • H E A LT H • H U M A N I T Y
EST. 2026
NIH Stroke Scale (NIHSS) — Certification Examination
CO M P R E H E N S I V E A SS E SS M E N T F O R ST R O K E S E V E R I TY S CO R I N G
INSTITUTION National Institutes of Health (NIH) PROGRAM NIHSS Stroke Certification Program
ACADEMIC YEAR EXAM TITLE NIH Stroke Scale — Certification Exam
TOTAL QUESTIONS 40 Questions FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question. All questions are multiple choice.
▸ Questions cover stroke risk factors, ischemic stroke clinical findings by vascular territory, and NIH Stroke Scale administration
and scoring.
▸ Pay close attention to the specific scoring criteria, limb positioning, and vascular territory correlations.
▸ Correct answers and detailed rationales appear below each question for certification preparation.
▸ A high NIHSS score indicates greater stroke severity — this is critical for treatment decisions.
SECTION I — STROKE RISK FACTORS, VASCULAR TERRITORIES & NIHSS Questions 1
ADMINISTRATION – 40
1. Which of the following is a potentially modifiable stroke risk factor?
A. Age over 65
B. Family history of stroke
C. Hypertension
D. Male gender
CORRECT ANSWER C — Hypertension
RATIONALE Hypertension is the single most important modifiable risk factor for stroke. Potentially modifiable risk factors
include: hypertension, diabetes, atrial fibrillation, dyslipidemia, smoking/tobacco use, physical inactivity,
chronic kidney disease, obesity/weight, diet and nutrition, alcohol use, carotid artery disease, sickle cell
disease, and obstructive sleep apnea. These can be controlled through lifestyle changes and/or medication.
Non-modifiable risk factors include age, gender, race/ethnicity, and family history/genetics. Recognizing
modifiable risk factors is essential for stroke prevention education and risk factor management.
, 2. An ischemic stroke in the anterior cerebral artery (ACA) territory typically presents with:
A. Contralateral weakness of arm and face greater than leg
B. Contralateral weakness of leg greater than arm and face with minimal sensory findings
C. Contralateral visual field deficit with minimal weakness
D. Crossed deficits with ipsilateral cranial nerve deficits and contralateral weakness
CORRECT ANSWER B — Contralateral weakness of leg greater than arm and face with minimal sensory findings
RATIONALE The ACA supplies the medial portions of the frontal and parietal lobes, which include the motor and sensory
homunculus representation for the lower extremity. Therefore, an ACA stroke produces contralateral
weakness and sensory loss predominantly affecting the leg, with relative sparing of the arm and face. This
pattern is distinctive from MCA strokes (arm and face > leg) and PCA strokes (visual field deficits).
Understanding these vascular territory clinical correlations helps localize the stroke based on physical
examination findings, which guides imaging and treatment decisions.
3. Which artery is MOST commonly involved in ischemic stroke, and what is its characteristic presentation?
A. ACA — contralateral leg weakness greater than arm
B. MCA — contralateral weakness and numbness of arm and face greater than leg
C. PCA — contralateral visual field deficit
D. Basilar artery — locked-in syndrome
CORRECT ANSWER B — MCA — contralateral weakness and numbness of arm and face greater than leg
RATIONALE The middle cerebral artery (MCA) is the most commonly affected vessel in ischemic stroke. The MCA supplies
the lateral portions of the frontal, parietal, and temporal lobes, including the motor and sensory cortices for
the face and upper extremity (represented laterally on the homunculus). MCA strokes present with
contralateral hemiparesis and hemisensory loss affecting the face and arm more than the leg. If the dominant
hemisphere (usually left) is affected, aphasia may also be present. This is the classic stroke presentation and
the pattern most frequently tested on NIHSS and stroke certification examinations.
4. A lacunar artery stroke typically presents with:
A. Contralateral visual field deficit
B. Crossed cranial nerve deficits
C. Pure motor or pure sensory findings
D. Locked-in syndrome
CORRECT ANSWER C — Pure motor or pure sensory findings
RATIONALE Lacunar infarcts are small, deep strokes affecting penetrating arteries that supply subcortical structures
(basal ganglia, thalamus, internal capsule, pons). Because these small vessels supply highly localized areas,
lacunar strokes produce well-defined, isolated syndromes: pure motor hemiparesis (internal capsule or
pons), pure sensory stroke (thalamus), ataxic hemiparesis, or sensorimotor stroke. They typically do NOT
cause cortical signs such as aphasia, neglect, or visual field deficits. Lacunar strokes are strongly associated
with hypertension and diabetes. The pure motor or pure sensory presentation is a classic distinguishing
feature from larger cortical strokes.
MAXE • SSHIN
NIH NIH Stroke Scale (NIHSS) Certification
S C I E N C E • H E A LT H • H U M A N I T Y
EST. 2026
NIH Stroke Scale (NIHSS) — Certification Examination
CO M P R E H E N S I V E A SS E SS M E N T F O R ST R O K E S E V E R I TY S CO R I N G
INSTITUTION National Institutes of Health (NIH) PROGRAM NIHSS Stroke Certification Program
ACADEMIC YEAR EXAM TITLE NIH Stroke Scale — Certification Exam
TOTAL QUESTIONS 40 Questions FORMAT Multiple Choice — Select the Single Best
Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question. All questions are multiple choice.
▸ Questions cover stroke risk factors, ischemic stroke clinical findings by vascular territory, and NIH Stroke Scale administration
and scoring.
▸ Pay close attention to the specific scoring criteria, limb positioning, and vascular territory correlations.
▸ Correct answers and detailed rationales appear below each question for certification preparation.
▸ A high NIHSS score indicates greater stroke severity — this is critical for treatment decisions.
SECTION I — STROKE RISK FACTORS, VASCULAR TERRITORIES & NIHSS Questions 1
ADMINISTRATION – 40
1. Which of the following is a potentially modifiable stroke risk factor?
A. Age over 65
B. Family history of stroke
C. Hypertension
D. Male gender
CORRECT ANSWER C — Hypertension
RATIONALE Hypertension is the single most important modifiable risk factor for stroke. Potentially modifiable risk factors
include: hypertension, diabetes, atrial fibrillation, dyslipidemia, smoking/tobacco use, physical inactivity,
chronic kidney disease, obesity/weight, diet and nutrition, alcohol use, carotid artery disease, sickle cell
disease, and obstructive sleep apnea. These can be controlled through lifestyle changes and/or medication.
Non-modifiable risk factors include age, gender, race/ethnicity, and family history/genetics. Recognizing
modifiable risk factors is essential for stroke prevention education and risk factor management.
, 2. An ischemic stroke in the anterior cerebral artery (ACA) territory typically presents with:
A. Contralateral weakness of arm and face greater than leg
B. Contralateral weakness of leg greater than arm and face with minimal sensory findings
C. Contralateral visual field deficit with minimal weakness
D. Crossed deficits with ipsilateral cranial nerve deficits and contralateral weakness
CORRECT ANSWER B — Contralateral weakness of leg greater than arm and face with minimal sensory findings
RATIONALE The ACA supplies the medial portions of the frontal and parietal lobes, which include the motor and sensory
homunculus representation for the lower extremity. Therefore, an ACA stroke produces contralateral
weakness and sensory loss predominantly affecting the leg, with relative sparing of the arm and face. This
pattern is distinctive from MCA strokes (arm and face > leg) and PCA strokes (visual field deficits).
Understanding these vascular territory clinical correlations helps localize the stroke based on physical
examination findings, which guides imaging and treatment decisions.
3. Which artery is MOST commonly involved in ischemic stroke, and what is its characteristic presentation?
A. ACA — contralateral leg weakness greater than arm
B. MCA — contralateral weakness and numbness of arm and face greater than leg
C. PCA — contralateral visual field deficit
D. Basilar artery — locked-in syndrome
CORRECT ANSWER B — MCA — contralateral weakness and numbness of arm and face greater than leg
RATIONALE The middle cerebral artery (MCA) is the most commonly affected vessel in ischemic stroke. The MCA supplies
the lateral portions of the frontal, parietal, and temporal lobes, including the motor and sensory cortices for
the face and upper extremity (represented laterally on the homunculus). MCA strokes present with
contralateral hemiparesis and hemisensory loss affecting the face and arm more than the leg. If the dominant
hemisphere (usually left) is affected, aphasia may also be present. This is the classic stroke presentation and
the pattern most frequently tested on NIHSS and stroke certification examinations.
4. A lacunar artery stroke typically presents with:
A. Contralateral visual field deficit
B. Crossed cranial nerve deficits
C. Pure motor or pure sensory findings
D. Locked-in syndrome
CORRECT ANSWER C — Pure motor or pure sensory findings
RATIONALE Lacunar infarcts are small, deep strokes affecting penetrating arteries that supply subcortical structures
(basal ganglia, thalamus, internal capsule, pons). Because these small vessels supply highly localized areas,
lacunar strokes produce well-defined, isolated syndromes: pure motor hemiparesis (internal capsule or
pons), pure sensory stroke (thalamus), ataxic hemiparesis, or sensorimotor stroke. They typically do NOT
cause cortical signs such as aphasia, neglect, or visual field deficits. Lacunar strokes are strongly associated
with hypertension and diabetes. The pure motor or pure sensory presentation is a classic distinguishing
feature from larger cortical strokes.
