NIH Stroke Scale
How to assess Level of Consciousness? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-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? - Correct Answer-
0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy? - Correct Answer-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? - Correct Answer-
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? - Correct Answer-The limb is placed in the appropriate
position: extend
How to assess Level of Consciousness? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-
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? - Correct Answer-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? - Correct Answer-
0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
How to assess facial palsy? - Correct Answer-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? - Correct Answer-
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? - Correct Answer-The limb is placed in the appropriate
position: extend
