Stroke Scale NIHSS PDF

NIHSS
Checklist

The National Institutes of Health Stroke Scale (NIHSS) is a standardized tool for assessing the severity of
neurological deficits in suspected ischemic stroke. Practitioners who are documenting an NIHSS score
should have completed a certification program (available for free online). The steps of the NIHSS are
summarized here, adapted from the Canadian Best Stroke Practices pocket card (also available online).

o Wash your hands

o Introduce yourself to the patient
o Drape patient appropriately
o Set of vitals

Scale Component Scoring

1a. Level of consciousness 0 = Alert
o Ask a brief question such as “are you 1 = Not alert, rousable with minimal stimulation
comfortable?” or “do you have any pain?” 2 = Not alert, requires repeated stimulation
3 = Not rousable
1b. LOC Questions 0 = Answers both correctly
o “What month is it?” 1 = Answers one correctly
o “How old are you?” 2 = Answers both incorrectly
*Score only first attempt, do not coach
1c. LOC Commands 0 = Does both correctly
o “Open and close your eyes” 1 = Does one correctly
o “Grip and release your hand” 2 = Does neither correctly
*Score only first attempt; do not coach
2. Best gaze 0 = Normal
o Ask patient to follow finger, moving to left 1 = Partial gaze palsy
and right to assess horizontal gaze 2 = Forced deviation or total gaze paresis (i.e.
*If unable to follow commands, move your face NOT overcome by oculocephalic maneuver)
while maintaining eye contact
3. Visual fields 0 = No visual loss
o Use number of fingers, finger movement, or 1 = Partial hemianopsia
visual threat to check upper and lower lateral 2 = Complete hemianopsia
quadrants of visual fields 3 = Bilateral hemianopsia
4. Facial palsy 0 = Normal symmetrical movement
o “Show me your teeth” 1 = Minor paralysis (flattened nasolabial fold,
o “Raise your eyebrows” asymmetry on smiling)
o “Shut your eyes tight” 2 = Partial paralysis (lower face)
*Ask and demonstrate 3 = Complete paralysis
5. Arm motor 0 = No drift
o Ask patient to extend one arm with palms 1= Drift (i.e. falls before 10 seconds)
down to 90° if seated, 45° if supine, and hold 2 = Some effort vs gravity
for 10 seconds 3 = No effort vs gravity
o Repeat with opposite arm 4 = No movement
*Score each limb separately UN = Amputation or joint fusion
Adapted from Heart & Stroke Foundation. “Canadian Best Stroke Practices: Stroke Assessment and Prevention
Pocket Cards.” Accessed November 6, 2017. Available at http://www.strokebestpractices.ca/resources/.

Scale Component Scoring
6. Leg motor 0 = No drift
o Ask supine patient to lift one leg to 30° and 1= Drift (i.e. falls before 5 seconds)
hold for 5 seconds 2 = Some effort vs gravity
o Repeat with opposite leg 3 = No effort vs gravity
*Score each limb separately 4 = No movement
UN = Amputation or joint fusion
7. Limb ataxia 0 = Absent
o “Touch your finger to your nose” 1 = Present in one limb
o “Touch your heel to your shin” 2 = Present in two or more limbs
o Repeat both on opposite side UN = Amputation or joint fusion
8. Sensory 0 = Normal
o Have patient close eyes and tell you if they 1 = Mild-to-moderate sensory loss
can feel pinprick on arms (not hands), legs 2 = Severe-to-total sensory loss
(not feet), trunk, and face *Stuporous/aphasic à 0 or 1
*If decreased LOC, use noxious stimulus *Quadiplegic /comatose patients à 2
9. Best language 0 = No aphasia
o “Describe what you see in this picture” 1 = Mild-to-moderate aphasia
o “Read out these sentences” 2 = Severe aphasia
o “Name the items in this picture” 3 = Mute, global aphasia
*See next page for reference *Intubated patients should be asked to write
*Comatose patients à 3
10. Dysarthria 0 = Normal articulation

o “Read these words” (see next page) 1 = Mild-to-moderate dysarthria
*If visually impaired, ask to repeat words 2 = Severe dysarthria
UN = Intubated or other physical barrier
11. Extinction and Inattention 0 = No abnormality
o Ask patient to close eyes 1 = Visual, tactile, auditory, spatial, or personal
o “Tell me on which side you hear the sound” inattention
while rubbing fingers together near one ear, 2 = Profound hemi-inattention or extinction to
then the other, then both more than one modality
o “Tell me on which side you feel my touch” *Severe vision loss preventing visual double
while touching one side of face/body, then simultaneous stimulation, but no other
the other, then both evidence of extinction/inattention à 0
o Ask patient to look at your nose and then “tell
me on which side you see my fingers moving”
while moving fingers on the far right of their
visual field, then the far left, then both
*Latter two steps can be incorporated into VF and
sensory testing above
The NIHSS is scored out of 42
*Score of <4 is associated with good outcome




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NIHSS

o Wash your hands

Scale Component Scoring

10. Dysarthria 0 = Normal articulation

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