NIH Stroke Scale

The fifteen scored items, in order, with the NINDS wording — and a running total as you go.

— Nothing scored yet 15 to go

1aLevel of Consciousness

Choose a response even if a full evaluation is prevented by an endotracheal tube, a language barrier or orotracheal trauma. Score 3 only if the patient makes no movement other than reflexive posturing in response to noxious stimulation.

1bLOC Questions

Ask the month and the patient’s age. The answer must be correct — there is no partial credit. Aphasic and stuporous patients who do not comprehend score 2. Patients unable to speak because of intubation, orotracheal trauma, severe dysarthria, a language barrier or any problem not secondary to aphasia are given a 1. Grade only the first answer.

1cLOC Commands

Ask the patient to open and close the eyes, then to grip and release the non-paretic hand. Substitute another one-step command if the hands cannot be used. Credit an unequivocal attempt not completed due to weakness. Demonstrate if there is no response. Only the first attempt is scored.

2Best Gaze

Only horizontal eye movements. Score voluntary or reflexive (oculocephalic) movement; no caloric testing. A conjugate deviation that can be overcome scores 1, as does an isolated peripheral nerve paresis (CN III, IV or VI). Gaze is testable in all aphasic patients.

3Visual

Upper and lower quadrants by confrontation, using finger counting or visual threat. Score 1 only for a clear-cut asymmetry, including quadrantanopia. Blind from any cause scores 3. Do double simultaneous stimulation here; extinction scores 1 and is carried to item 11.

4Facial Palsy

Ask, or pantomime, to show teeth or raise eyebrows and close eyes. In the poorly responsive patient, score symmetry of grimace to noxious stimuli.

5aMotor Arm — Left

Extend the arms (palms down) 90 degrees if sitting or 45 if supine. Drift is scored if the arm falls before 10 seconds.

5bMotor Arm — Right

Extend the arms (palms down) 90 degrees if sitting or 45 if supine. Drift is scored if the arm falls before 10 seconds.

6aMotor Leg — Left

Hold the leg at 30 degrees, always tested supine. Drift is scored if the leg falls before 5 seconds.

6bMotor Leg — Right

Hold the leg at 30 degrees, always tested supine. Drift is scored if the leg falls before 5 seconds.

7Limb Ataxia

Finger-nose-finger and heel-shin on both sides, eyes open. Score ataxia only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralysed.

8Sensory

Sensation or grimace to pinprick, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only loss attributed to stroke is abnormal. A brainstem stroke with bilateral loss scores 2, as does an unresponsive quadriplegic patient. A patient in a coma (item 1a = 3) is automatically given 2.

9Best Language

Ask the patient to describe the picture, name the items on the naming sheet and read the sentences. The intubated patient should be asked to write. A patient in a coma (item 1a = 3) automatically scores 3. Use a score of 3 only if the patient is mute and follows no one-step commands.

10Dysarthria

Read or repeat words from the list. If there is severe aphasia, rate the clarity of spontaneous speech. Do not tell the patient why they are being tested.

11Extinction and Inattention

Formerly Neglect. Severe visual loss with normal cutaneous stimuli scores 0. Aphasia with attention to both sides scores 0. Visual spatial neglect or anosagnosia counts as abnormal. Scored only if present, so this item is never untestable.

Administer the items in the order listed, score what the patient does rather than what they could do, and do not go back and change a score. An untestable item is recorded as UN and left out of the total rather than counted as zero.

A scoring aid, not the medical record and not a medical device. Nothing is sent anywhere — it stays in this browser, so do not enter anything that identifies a patient. Wording from NIH Stroke Scale, NINDS (stroke.nih.gov).