NIHSS

Stroke severity

1a: Level of Consciousness (LOC)

• 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.

1b: LOC Questions

The patient is asked the month and his/her age.

• 0 = Answers both questions correctly.
• 1 = Answers one question correctly / Endotracheal intubation / Dysarthria.
• 2 = Answers neither question correctly / Aphasia.

1b: LOC Commands

The patient is asked to open and close the eyes and then to grip and release the non-paretic hand.

• 0 = Performs both tasks correctly.
• 1 = Performs one task correctly.
• 2 = Performs neither task correctly.

2: Best Gaze

Test horizontal eye movements.

• 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 paresis is not overcome by the oculocephalic maneuver.

3: Visual

Visual field testing by confrontation.

• 0 = No visual loss.
• 1 = Partial hemianopia.
• 2 = Complete hemianopia.
• 3 = Bilateral hemianopia (blind including cortical blindness).

4: Facial Palsy

Show teeth, raise eyebrows, close eyes.

• 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).

5: Motor Arm

The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). 5a = left arm; 5b = right arm.

• 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 full 10 seconds; does not hit bed or other support.
• 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity.
• 3 = No effort against gravity; limb falls.
• 4 = No movement.
• UN = Amputation or joint fusion, explain why untestable.

6: Motor Leg

The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). 6a = left leg; 6b = right leg.

• 0 = No drift; leg holds 30-degree position for full 5 seconds.
• 1 = Drift; leg falls by the end of the 5- second period but does not hit the bed.
• 2 = Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity.
• 3 = No effort against gravity; leg falls to bed immediately.
• 4 = No movement.
• UN = Amputation or joint fusion, explain why untestable.

7: Limb Ataxia

This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open.

• 0 = Absent.
• 1 = Present in one limb.
• 2 = Present in two limbs.
• UN = Amputation or joint fusion, explain why untestable.

8: Sensory

Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient.

• 0 = Normal; no sensory loss.
• 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched.
• 2 = Severe or total sensory loss; patient is not aware of being touched in the face, arm, and leg.

9: Best Language

• 0 = No aphasia; normal.
• 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible.
• 2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication.
• 3 = Mute, global aphasia; no usable speech or auditory comprehension (or patient in coma).

10: Dysarthria

• 0 = Normal.
• 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty.
• 2 = Severe dysarthria; patient’s speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric.
• UN = Intubated or other physical barrier, explain why untestable.

11: Extinction and Inattention

(formerly called Neglect)

• 0 = No abnormality.
• 1 = Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities.
• 2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.

Reference

NINDS.NIH.gov

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