Neurological Concepts in Critical Care

NIH Stroke Scale

nursebob 07/25/10

1.a. Level of Consciousness

SCORE ____

0 Alert
1 Not alert, but arousable with minimal stimulation.
2 Not alert, requires repeated stimulation to attend.
3 Coma
1.b. Ask patient the month and their age:


0 Answers both correctly
1 Answers one correctly
2 Both incorrect
1.c. Ask patient to open and close eyes


0 Obeys both correctly
1 Obeys one correctly
2 Both incorrect
2. Best gaze
(only horizontal eye movement):


0 Normal1 Partial gaze palsy2 Forced deviation
3. Visual Field testing:


0 No visual field loss
1 Partial hemianopia
2 Complete hemianopia
3 Bilateral hemianopia
(blind including cortical blindness)
4. Facial Paresis (Ask patient to show teeth or raise eyebrows and close eyes tightly):



0 Normal symmetrical movement
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 Function - Arm
(right and left):

Right arm ____
Left arm _____


0 Normal
(extends arems 90 (or 45) degrees for 10 seconds without drift)

1 Drift
2 Some effort against gravity
3 No effort against gravity4 No movement

9 Untestable (Joint fused or limb amputated)
6. Motor Function - Leg (right and left):
Right leg ____
Left leg _____


0 Normal (hold leg 30 degrees position for 5 seconds)
1 Drift
2 Some effort against gravity
3 No effort against gravity
4 No movement

9 Untestable (Joint fused or limb amputated)
7. Limb Ataxia

SCORE ____

0 No ataxia
1 Present in one limb
2 Present in two limbs
8. Sensory
(Use pinprick to test arems, legs,trunk and face -- compare side to side)


0 Normal
1 Mild to moderate decrease in sensation

2 Severe to total sensory loss
9. Best Language
(describe picture, name items,
read sentences)


0 No aphasia
1 Mild to moderate aphasia
2 Severe aphasia

3 Mute
10. Dysarthria (read several words)


0 Normal articulation
1 Mild to moderate slurring of words
2 Near unintelligible or unable to speak
9 Intubated or other physical barrier
11. Extinction and inattention



0 Normal
1 Inattention or extinction to bilateral simultaneous stimulation
in one of the sensory modalities

2 Severe hemi-inattention or hemi-inattention to more than one modality

REFERENCE: NIH Stroke Assessment, US Government.

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