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Decision

Are symptoms disabling?

(See NIH Stroke Scale in below)

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No→ Admit to stroke unit or ICU

Background

The neurologic examination of an acute stroke patient should assist in localizing the affected vascular territory and evaluating the severity of the neurologic deficit. The most recent AHA/ASA guidelines recommend the use of a standardized stroke severity rating scale that is easily reproducible and allows for monitoring patients’ clinical status throughout care in order to objectively quantify the degree of deficit.

The National Institutes of Health Stroke Scale (NIHSS) is a widely accepted and commonly used scale. It is based on a standardized, stroke-specific, neurologic examination with points awarded for each deficit, up to a maximum of 42 points. A higher score is suggestive of a more-severe stroke. The NIHSS can be performed quickly, and analysis of large cohorts across a diverse group of healthcare providers utilizing the scale demonstrated good accuracy and interrater reliability.

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NIH Stroke Scale

General Principles:

  • Administer stroke scale items in the order listed.
  • Record performance in each category after each subscale exam.
  • Do not go back and change scores.
  • Follow directions provided for each exam technique.
  • Scores should reflect what the patient does, not what the clinician thinks the patient can do.
  • The clinician should record answers while administering the exam and work quickly.
  • Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).

1a. Level of Consciousness

The investigator must choose a response even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

  • 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. Ask Month and Age

The patient is asked the month and his/her age. The answer must be correct – there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not “help” the patient with verbal or non-verbal cues.

  • 0 = Answers both questions correctly.
  • 1 = Answers one question correctly.
  • 2 = Answers neither question correctly.

1c. Close Eyes, Squeeze Hands

The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.

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

2. Horizontal Gaze

Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.

  • 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

3. Visual Fields

Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11.

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

4. Facial Palsy

Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.

  • 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. Arm Drift

The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.

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.

6. Leg Drift

The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice.

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 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.

7. Limb Ataxia: Finger-Nose-Finger, Heel-Shin

This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position.

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

8. Sensation: Pinprick or withdrawal from pain

Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, “severe or total sensory loss,” should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item.

  • 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 to total sensory loss; patient is not aware of being touched in the face, arm, and leg.

9. Best Language: Describe Picture, Read Sentences

A great deal of information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in this picture, to name the items on this sheet and to read from this list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands.

  • 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. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response.
  • 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. Examiner cannot identify materials provided from patient response.
  • 3 = Mute, global aphasia; no usable speech or auditory comprehension.

10. Dysarthria: Read Words

If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from this list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for this choice. Do not tell the patient why he or she is being tested.

  • 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.

11. Extinction and Inattention (Neglect)

Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.

  • 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.

NIH Stroke Scale References:

  1. NIH Stroke Scale Printable Handout – NIH.gov
  2. MD Calc NIH SS

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References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, random-ized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the ref-erence, where available. In addition, the most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528. (Statistical report)
  2. Carandang R, Seshadri S, Beiser A, et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. JAMA. 2006;296(24):2939-2946. (Prospective study; 9152 patients)
  3. Ovbiagele B, Goldstein LB, Higashida RT, et al. Forecasting the future of stroke in the United States: a policy statement from the American Heart Association and American Stroke Association. Stroke. 2013;44(8):2361-2375. (Cost-projection assessment)
  4. National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333(24):1581-1587. (Randomized double-blind trial; 624 patients) DOI: 10.1056/NEJM199512143332401
  5. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015;372(1):11-20. (Randomized trial; 500 patients) DOI: 10.1056/NEJMoa1411587
  6. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295. (Randomized controlled trial; 196 patients)
  7. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med. 2015;372(11):1009-1018. (Randomized controlled trial; 70 patients)
  8. Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med. 2015;372(11):1019-1030. (Randomized controlled trial; 238 patients)
  9. Bracard S, Ducrocq X, Mas JL, et al. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial. Lancet Neurol. 2016;15(11):1138-1147. (Randomized controlled trial; 414 patients)
  10. Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selec-tion by perfusion imaging. N Engl J Med. 2018;378(8):708-718. (Multicenter, randomized, open-label trial, with blinded outcome assessment; 182 patients, 92 to the endovascular-therapy group and 90 to the medical-therapy group).) DOI: 10.1056/NEJMoa1713973
  11. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11-21. (Randomized controlled trial; 206 patients) DOI: 10.1056/NEJMoa1706442
  12. Emberson J, Lees KR, Lyden P, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929-1935. (Review)
  13. Saver JL, Goyal M, van der Lugt A, et al. Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279-1288. (Meta-analysis; 5 trials, 1287 patients)
  14. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e110. (Guidelines)
  15. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418. (Guidelines) DOI: 10.1161/STR.0000000000000211
  16. Demaerschalk BM, Kleindorfer DO, Adeoye OM, et al. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2016;47(2):581-641. (Review)
  17. Schaefer PW, Roccatagliata L, Ledezma C, et al. First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol. 2006;27(1):20-25. (Prospective study; 14 patients)
  18. Campbell BC, Christensen S, Levi CR, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke. 2011;42(12):3435-3440. (Retrospective analysis; 54 patients)
  19. Olivot JM, Mlynash M, Thijs VN, et al. Optimal Tmax threshold for predicting penumbral tissue in acute stroke. Stroke. 2009;40(2):469-475. (Multicenter study; 33 patients)
  20. Broderick JP, Adeoye O, Elm J. Evolution of the modified Rankin Scale and its use in future stroke trials. Stroke. 2017;48(7):2007-2012. (Review)
  21. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363(9411):768-774. (Meta-analysis; 6 randomized placebo-controlled trials)
  22. Wardlaw JM, Murray V, Berge E, et al. Recombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis. Lancet. 2012;379(9834):2364-2372. (Systematic review and meta-analysis; 12 trials)
  23. Wardlaw JM, Murray V, Berge E, et al. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2014(7):CD000213. (Systematic review)
  24. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329. (Randomized double-blind trial; 821 patients) DOI: 10.1056/NEJMoa0804656
  25. Thomalla G, Simonsen CZ, Boutitie F, et al. MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med. 2018;379(7):611-622. (Multicenter randomized controlled trial; 503 patients) DOI: 10.1056/NEJMoa1804355
  26. Lin CB, Peterson ED, Smith EE, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2012;5(4):514-522. (Multivariate analysis; 371,988 patients)
  27. Roffe C, Nevatte T, Sim J, et al. Effect of routine low-dose oxygen supplementation on death and disability in adults with acute stroke: the stroke oxygen study randomized clinical trial. JAMA. 2017;318(12):1125-1135. (Single-blind randomized clinical trial; 8003 patients)
  28. Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis. 2006;22(5-6):389-395. (Comparative study; 11 patients)
  29. Lyden P, Raman R, Liu L, et al. National Institutes of Health Stroke Scale certification is reliable across multiple venues. Stroke. 2009;40(7):2507-2511. (Inter-rater reliability assessment)
  30. Mazya M, Egido JA, Ford GA, et al. Predicting the risk of symptomatic intracerebral hemorrhage in ischemic stroke treated with intravenous alteplase: safe Implementation of Treatments in Stroke (SITS) symptomatic intracerebral hemorrhage risk score. Stroke. 2012;43(6):1524-1531. (Registry analysis; 31,627 patients)
  31. Butcher K, Christensen S, Parsons M, et al. Postthrombolysis blood pressure elevation is associated with hemorrhagic transformation. Stroke. 2010;41(1):72-77. (Randomized controlled trial; 97 patients)
  32. Stead LG, Gilmore RM, Decker WW, et al. Initial emergency department blood pressure as predictor of survival after acute ischemic stroke. Neurology. 2005;65(8):1179-1183. (Observational study; 357 patients)
  33. Alper BS, Foster G, Thabane L, et al. Thrombolysis with alteplase 3 – 4.5 hours after acute ischemic stroke: trial reanalysis adjusted for baseline imbalances. BMJ Evid Based Med. 2020;25(5):168-171. (Reanalysis of randomized placebo-controlled trial; 821 patients)
  34. Cronin CA, Sheth KN, Zhao X, et al. Adherence to Third European Cooperative Acute Stroke Study 3- to 4.5-hour exclusions and association with outcome: data from Get with the Guidelines-Stroke. Stroke. 2014;45(9):2745-2749. (Data analysis; 32,019 patients)
  35. Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. JAMA. 2004;292(15):1823-1830. (Prospective multicenter study; 200 patients)
  36. Fiebach JB, Schellinger PD, Gass A, et al. Stroke magnetic resonance imaging is accurate in hyperacute intracerebral hemorrhage: a multicenter study on the validity of stroke imaging. Stroke. 2004;35(2):502-506. (Prospective multicenter trial; 124 patients)
  37. The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke. 1997;28(11):2109-2118. (Subgroup analyses of data from a randomized double-blind placebo-controlled trial; 312 patients)
  38. Patel SC, Levine SR, Tilley BC, et al. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke. JAMA. 2001;286(22):2830-2838. (Re-evaluation of randomized controlled trial; 624 patients)
  39. Turk AS 3rd, Siddiqui A, Fifi JT, et al. Aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion (COMPASS): a multicentre, randomised, open label, blinded outcome, non-inferiority trial. Lancet. 2019;393(10175):998-1008. (Multicenter randomized open-label blinded outcome noninferiority trial; 15 sites, 270 patients)
  40. Lapergue B, Blanc R, Gory B, et al. Effect of endovascular contact aspiration vs stent retriever on revascularization in patients with acute ischemic stroke and large vessel occlusion: the ASTER randomized clinical trial. JAMA. 2017;318(5):443-452. (Randomized controlled open-label blinded end-point trial; 381 patients )
  41. Goyal M, Menon BK, van Zwam WH, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet. 2016;387(10029):1723-1731. (Meta-analysis; 5 trials, 1287 patients)
  42. Rimmele DL, Thomalla G. Wake-up stroke: clinical characteristics, imaging findings, and treatment option - an update. Front Neurol. 2014;5:35. (Review)
  43. Thomalla G, Rossbach P, Rosenkranz M, et al. Negative fluid-attenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Ann Neurol. 2009;65(6):724-732. (Comparative study; 120 patients)
  44. Thomalla G, Cheng B, Ebinger M, et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4.5 h of symptom onset (PRE-FLAIR): a multicentre observational study. Lancet Neurol. 2011;10(11):978-986. (Multicenter observational study; 543 patients)
  45. Aoki J, Kimura K, Iguchi Y, et al. FLAIR can estimate the onset time in acute ischemic stroke patients. J Neurol Sci. 2010;293(1-2):39-44. (Retrospective study; 333 patients, 389 MRI studies)

Symptoms Disabling
Symptoms Disabling
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