NIH Stroke Scale - Simplified & Added Cranial Nerves
I N /
1 .L C : Is the 0 = A ; keenly responsive N : VIII
patient awake? Are they responsive when 1 = N A ; but arousable by vestibulocochlear
you enter the room? Opening eyes. minor stimulation to obey, answer, or Concerned with
respond hearing and balance,
3 is scored if patient makes no ________ why we make sure
2 = N A ; requires repeated or
movement. they can hear us.
GC : Pt. has eye opening, verbal, and painful stimulation to attend : Alertness
motor response. 3 =
1 . LOC : 0 = Answers both correctly N :
Ask the Month and age/DOB. Answer 1 = Answers 1 correctly. ________
must be correct first time with no help 2 = Answers 0 correctly : Awareness,
from nurse. orientation
1 . LOC C : 0 = performs both correctly N :
Patient open and close eyes. Clench fist 1 = performs 1 task correctly
on both hands (or substitute command if 2 = performs neither task correctly : Ability to
hands can t be used), etc. ________ control motor
*not testing weakness, only if commands responses and follow
are being followed* direction
2. B G : Horizontal and vertical eye 0 = normal N : III, IV, VI
movements. Move pen or finger side to 1 = partial gaze palsy: eyes only Concerned with eye
side, & up and down. move in one direction ________ rotation, movement,
2 = forced deviation: eyes do not and pupillary reaction
Also test pupillary reflex to light. move & are stuck in one position : Eye
movement, pupil
reaction
3. : Visual fields in upper & lower 0 = No visual loss N : Optic II
quadrants. Cover each eye and check 1 = Partial hemianopia Sense of vision in all
other eye for peripheral vision with visual 2 = Complete hemianopia fields.
threat or counting fingers. 3 = Bilateral hemianopia (blind ________
including cortical blindness)
*if patient moves eyes to see fingers, this : Blindness
is scored as normal* over half vision field
4. F : Ask (or use pantomime) 0=N symmetrical movements. N : VII Facial, V
the pt. to smile, raise eyebrows, and 1=M (flattened trigeminal
close eyes. nasolabial fold, asymmetry on smile) Concerned with
2= (total or ________ facial movements
Score symmetry. near-total paralysis of lower face) and facial
3=C (absent expressions
face movements in entire face) : Facial
paralysis
5. M A : Extend arms one at a time 0=N ; holds to time N : Accessory XI
90(45) degree angle and hold for 10 1 = D ; limb holds but drifts without Responsible for
seconds each. hitting bed or support movement of
Drift is scored if falls before 10sec. 2= ; 5a shoulder muscles
limb can not reach 90(45) degree but ______
5 =L A effort against gravity is present : Strength &
5 = A 3=N ; limb 5b motor control in
N= / falls ______ upper limbs
I N /
1 .L C : Is the 0 = A ; keenly responsive N : VIII
patient awake? Are they responsive when 1 = N A ; but arousable by vestibulocochlear
you enter the room? Opening eyes. minor stimulation to obey, answer, or Concerned with
respond hearing and balance,
3 is scored if patient makes no ________ why we make sure
2 = N A ; requires repeated or
movement. they can hear us.
GC : Pt. has eye opening, verbal, and painful stimulation to attend : Alertness
motor response. 3 =
1 . LOC : 0 = Answers both correctly N :
Ask the Month and age/DOB. Answer 1 = Answers 1 correctly. ________
must be correct first time with no help 2 = Answers 0 correctly : Awareness,
from nurse. orientation
1 . LOC C : 0 = performs both correctly N :
Patient open and close eyes. Clench fist 1 = performs 1 task correctly
on both hands (or substitute command if 2 = performs neither task correctly : Ability to
hands can t be used), etc. ________ control motor
*not testing weakness, only if commands responses and follow
are being followed* direction
2. B G : Horizontal and vertical eye 0 = normal N : III, IV, VI
movements. Move pen or finger side to 1 = partial gaze palsy: eyes only Concerned with eye
side, & up and down. move in one direction ________ rotation, movement,
2 = forced deviation: eyes do not and pupillary reaction
Also test pupillary reflex to light. move & are stuck in one position : Eye
movement, pupil
reaction
3. : Visual fields in upper & lower 0 = No visual loss N : Optic II
quadrants. Cover each eye and check 1 = Partial hemianopia Sense of vision in all
other eye for peripheral vision with visual 2 = Complete hemianopia fields.
threat or counting fingers. 3 = Bilateral hemianopia (blind ________
including cortical blindness)
*if patient moves eyes to see fingers, this : Blindness
is scored as normal* over half vision field
4. F : Ask (or use pantomime) 0=N symmetrical movements. N : VII Facial, V
the pt. to smile, raise eyebrows, and 1=M (flattened trigeminal
close eyes. nasolabial fold, asymmetry on smile) Concerned with
2= (total or ________ facial movements
Score symmetry. near-total paralysis of lower face) and facial
3=C (absent expressions
face movements in entire face) : Facial
paralysis
5. M A : Extend arms one at a time 0=N ; holds to time N : Accessory XI
90(45) degree angle and hold for 10 1 = D ; limb holds but drifts without Responsible for
seconds each. hitting bed or support movement of
Drift is scored if falls before 10sec. 2= ; 5a shoulder muscles
limb can not reach 90(45) degree but ______
5 =L A effort against gravity is present : Strength &
5 = A 3=N ; limb 5b motor control in
N= / falls ______ upper limbs
