APEX NIH Stroke Scale (NIHSS) Group A —
Patients 1–6 (COMPLETE) 2025/2026
Introduction
This document provides a complete set of six patient cases for NIH Stroke Scale
(NIHSS) Group A training, aligned with the 2025/2026 American Stroke Association
(ASA) updates. These include refined visual stimuli (e.g., "Precarious Painter" for
language) and animated certification tools, but core scoring criteria remain consistent
with prior validations. Each case features realistic scenarios, full NIHSS scoring, and
rationales referencing ASA guidelines for accurate assessment in acute stroke
evaluation.
Patient [1]: Mild Left Arm Weakness
Clinical Scenario:
A 65-year-old female presents with sudden onset of mild weakness in her left arm
lasting 30 minutes. She is alert, oriented, and follows commands without difficulty. No
facial droop, speech issues, or sensory complaints. Vital signs stable; no ataxia or
neglect noted.
NIH Stroke Scale Scoring:
Category Description Scor
e
1a. Level of Alert, responsive to questions 0
Consciousness
1b. LOC Questions Answers both month and age correctly 0
1c. LOC Commands Performs both close eyes and grip fist tasks 0
2. Best Gaze Normal horizontal and vertical gaze 0
3. Visual Normal visual fields bilaterally 0
, 4. Facial Palsy Symmetric smile and eye closure 0
5a. Motor Arm (Left) Drift but does not hit bed in 10 seconds 1
5b. Motor Arm (Right) Holds arm at 90 degrees without drift 0
6a. Motor Leg (Left) No drift in leg lift 0
6b. Motor Leg (Right) Normal leg lift without drift 0
7. Limb Ataxia No ataxia in finger-nose or heel-shin testing 0
8. Sensory Normal sensation to light touch bilaterally 0
9. Best Language Names objects and describes "Precarious Painter" 0
image clearly
10. Dysarthria Clear, articulate speech 0
11. Extinction and No neglect; attends to both sides 0
Inattention
Total NIHSS Score: 1
Rationale:
This mild lacunar stroke presentation shows isolated upper extremity drift (score 1 on
left motor arm, per ASA 2025 criteria for partial weakness without flaccidity). All other
domains are normal, reflecting minimal hemispheric involvement. ASA guidelines
emphasize precise timing in motor testing (10 seconds) to differentiate drift from no
weakness, supporting tPA eligibility in low scores like this.
Patient [2]: Moderate Aphasia and Gaze Deviation
Clinical Scenario:
A 72-year-old male arrives with acute right facial droop, slurred speech, and difficulty
naming objects. He follows one-step commands but struggles with gaze to the left. Mild
right arm weakness; no leg involvement or sensory loss. Onset 2 hours ago.
NIH Stroke Scale Scoring:
Patients 1–6 (COMPLETE) 2025/2026
Introduction
This document provides a complete set of six patient cases for NIH Stroke Scale
(NIHSS) Group A training, aligned with the 2025/2026 American Stroke Association
(ASA) updates. These include refined visual stimuli (e.g., "Precarious Painter" for
language) and animated certification tools, but core scoring criteria remain consistent
with prior validations. Each case features realistic scenarios, full NIHSS scoring, and
rationales referencing ASA guidelines for accurate assessment in acute stroke
evaluation.
Patient [1]: Mild Left Arm Weakness
Clinical Scenario:
A 65-year-old female presents with sudden onset of mild weakness in her left arm
lasting 30 minutes. She is alert, oriented, and follows commands without difficulty. No
facial droop, speech issues, or sensory complaints. Vital signs stable; no ataxia or
neglect noted.
NIH Stroke Scale Scoring:
Category Description Scor
e
1a. Level of Alert, responsive to questions 0
Consciousness
1b. LOC Questions Answers both month and age correctly 0
1c. LOC Commands Performs both close eyes and grip fist tasks 0
2. Best Gaze Normal horizontal and vertical gaze 0
3. Visual Normal visual fields bilaterally 0
, 4. Facial Palsy Symmetric smile and eye closure 0
5a. Motor Arm (Left) Drift but does not hit bed in 10 seconds 1
5b. Motor Arm (Right) Holds arm at 90 degrees without drift 0
6a. Motor Leg (Left) No drift in leg lift 0
6b. Motor Leg (Right) Normal leg lift without drift 0
7. Limb Ataxia No ataxia in finger-nose or heel-shin testing 0
8. Sensory Normal sensation to light touch bilaterally 0
9. Best Language Names objects and describes "Precarious Painter" 0
image clearly
10. Dysarthria Clear, articulate speech 0
11. Extinction and No neglect; attends to both sides 0
Inattention
Total NIHSS Score: 1
Rationale:
This mild lacunar stroke presentation shows isolated upper extremity drift (score 1 on
left motor arm, per ASA 2025 criteria for partial weakness without flaccidity). All other
domains are normal, reflecting minimal hemispheric involvement. ASA guidelines
emphasize precise timing in motor testing (10 seconds) to differentiate drift from no
weakness, supporting tPA eligibility in low scores like this.
Patient [2]: Moderate Aphasia and Gaze Deviation
Clinical Scenario:
A 72-year-old male arrives with acute right facial droop, slurred speech, and difficulty
naming objects. He follows one-step commands but struggles with gaze to the left. Mild
right arm weakness; no leg involvement or sensory loss. Onset 2 hours ago.
NIH Stroke Scale Scoring:
