NIH Stroke Scale Answer key Updated Spring 2023.
How to assess Level of Consciousness?
1a. Deteremine if patient is alert, oriented x4
1b. The patient is asked the month and his/her age.
The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients
who do not comprehend the questions will score 2. It is important that only the initial answer be graded
and that the examiner not "help" the patient with verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient does not respond to command,
the task
should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or
two commands)
What are the results?
0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
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.
0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
How to assess best gaze?
Only horizontal eye movements will be tested.
Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If
the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity,
the score will be 1If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1
What are the results?
, 0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze
How to assess visual gaze?
Visual fields (upper and lower quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored.
If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1,
and the results are used to respond to item 11.
What are the results?
0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy?
Ask - or use pantomime to encourage - the patient
to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious
stimuli in the poorly responsive or non-comprehending patient.
What are the results?
0 = Normal symmetrical movements.
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)
How to assess motor arm and leg?
The limb is placed in the appropriate position: extend
the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls
before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but
not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm.
What are the results?
0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
How to assess Level of Consciousness?
1a. Deteremine if patient is alert, oriented x4
1b. The patient is asked the month and his/her age.
The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients
who do not comprehend the questions will score 2. It is important that only the initial answer be graded
and that the examiner not "help" the patient with verbal or non-verbal cue.
1c. The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. If the patient does not respond to command,
the task
should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or
two commands)
What are the results?
0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
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.
0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
How to assess best gaze?
Only horizontal eye movements will be tested.
Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If
the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity,
the score will be 1If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1
What are the results?
, 0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze
How to assess visual gaze?
Visual fields (upper and lower quadrants) are tested by
confrontation, using finger counting or visual threat, as appropriate.
If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored.
If patient is blind from any cause, score 3.
Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1,
and the results are used to respond to item 11.
What are the results?
0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy?
Ask - or use pantomime to encourage - the patient
to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious
stimuli in the poorly responsive or non-comprehending patient.
What are the results?
0 = Normal symmetrical movements.
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)
How to assess motor arm and leg?
The limb is placed in the appropriate position: extend
the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls
before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but
not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm.
What are the results?
0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds.
1 = Drift; limb holds 90 (or 45) degrees, but drifts down before
