NCEMI eTools

NIH Stroke Scale
Score: 0
Answer out of bounds for assessibility
Assessment
 
Level of Consciousness
Alert, keenly responsive 0 points
Obeys, answers or resonds to minor stimulation 1 points
Responds only to repeated stimulation or painful stimulation (excludes reflex response 2 points
Responds only with reflex motor or totally unresponsive 3 points
 
Ask the month, and patient age. Must be exactly right.
Answers both correctly 0 points
Answers one correctly or patient unable to speak due to any reason other than aphasia or coma 1 points
Answers neither correctly, or too stuporous or aphasic 2 points
 
Ask patient to open and close eyes and then grip and release non-paretic hand
Performs both tasks correctly 0 points
Performs 1 task correctly 1 points
Performs neither task correctly 2 points
 
Best Gaze: Only horizontal movements tested. Oculocephalic reflex use is ok, but not calorics
Normal 0 points
Partial gaze palse 1 points
Forced deviation or total gaze paresis not overcome by oculocephalic maneuver 2 points
 
Visual fields tested by confrontation
No visual loss 0 points
Partial hemianopia 1 points
Complete hemianopia 2 points
Bilateral hemianopia (blind from any cause including cortical blindness) 3 points
 
Facial palsy - encourage patient to smile and close eyes, or grimace symmetry
Normal symmetrical movement 0 points
Minor paryalysis (flattened nasolabial fold, asymmetry on smiling) 1 points
Partial paralysis (total or near total lower face paralysis) 2 points
Complete paralysis (absence of facial movement upper/lower face) 3 points
 
Right Arm Motor: Extend right arm palm down at 90 degrees (sitting) or 45 degrees (supine)
No drift - holds for full 10 seconds 0 points
Drifts down before 10 seconds but does not hit bed/support 1 points
Some effort against gravity, but cannot get up to 90 (or 45 if supine) degrees 2 points
No effort against gravity, limb falls 3 points
No movement 4 points
 
Left Arm Motor: Extend left arm palm down at 90 degrees (sitting) or 45 degrees (supine)
No drift - holds for full 10 seconds 0 points
Drifts down before 10 seconds but does not hit bed/support 1 points
Some effort against gravity, but cannot get up to 90 (or 45 if supine) degrees 2 points
No effort against gravity, limb falls 3 points
No movement 4 points
 
Right Leg Motor: Extend right leg and flex at hip to 30 degrees
No drift - holds for full 5 seconds 0 points
Drifts down before 5 seconds but does not hit bed/support 1 points
Some effort against gravity 2 points
No effort against gravity, limb falls 3 points
No movement 4 points
 
Left Leg Motor: Extend left leg and flex at hip to 30 degrees
No drift - holds for full 5 seconds 0 points
Drifts down before 5 seconds but does not hit bed/support 1 points
Some effort against gravity 2 points
No effort against gravity, limb falls 3 points
No movement 4 points
 
Limb ataxia - finger/nose and heel/shin done on both sides. Not ataxia if hemiplegic or unable to comprehend. Ataxia must be out of proportion to any weakness present.
Absent 0 points
Present in 1 limb 1 points
Present in two limbs 2 points
 
Sensory to pinprick.
Normal 0 points
Pinprick less sharp or dull on affected side 1 points
Severe to total sensory loss; patient unaware of being touched 2 points
 
Best language using pictures, naming items, and reading short sentences.
No aphasia 0 points
Some loss of fluency or comprehension 1 points
Severe aphasia - fragmentary communication, listener carries burden of communication 2 points
Mute, global aphasia. NO usable speech OR auditory comprehension 3 points
 
Dysarthria - if not obviously present, have patient read
Normal 0 points
Slurs some words 1 points
So slurred as to be unintelligible, or mute 2 points
 
Extinction/Inattention
No abnormality 0 points
Inattention to any sensory modality or extinction to bilateral simultaneous stimulation in one sensory modality 1 points
Profound hemi-inattention or hemi-inattention to more than one modality. Does not recognize own hand 2 points
Calculate

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