Nih Stroke Scale Page 2
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1
2Saint Vincent Hospital
at Worcester Medical Center
NEUROLOGY DEPARTMENT
Cerebrovascular Disease Assessment
Flow Sheet
NIH STROKE SCALE
REASSESS.
INITIAL
SCORE
CATEGORY
DESCRIPTION
SCORE
if indicated
1a. Level of Consciousness
0 = Alert
1 = Drowsy
2 = Stuporous
3 = Coma
1b. LOC Questions (month, age) 0 = Answers Both Correctly
1 = Answers One Correctly
2 = Both Incorrect
1c. LOC Commands
0 = Obeys Both Correctly
1 = Obeys One Correctly
2 = Both Incorrect
(open/close eyes, make fist/let go)
2. Best Gaze
0 = Normal
1 = Partial Gaze Palsy
2 = Forced Deviation
(eyes open; pt. follows finger or face)
3. Visual
0 = No Visual Loss
1 = Partial Hemianopia
(introduce visual stimulus to
2 = Complete Hemianopia
3 = Bilateral Hemianopia
pt.’s visual field quadrants)
4. Facial Palsy
0 = Normal
1 = Minor
2 = Partial
3 = Complete
(show teeth, raise eyebrows,
squeeze eyes shut)
5a. Motor Left Arm
0 = No Drift
1 = Drift
2 = Can’t Resist Gravity
(elevate extremity to 90˚
3 = No Effort Against Gravity
4 = No Movement
9 = Amputation/Joint Fusion
& score drift/movement)
5b. Motor Right Arm
0 = No Drift
1 = Drift
2 = Can’t Resist Gravity
(elevate extremity to 90˚
3 = No Effort Against Gravity
4 = No Movement
9 = Amputation/Joint Fusion
& score drift/movement)
6a. Motor Left Leg
0 = No Drift
1 = Drift
2 = Can’t Resist Gravity
(elevate extremity to 30˚
3 = No Effort Against Gravity
4 = No Movement
9 = Amputation/Joint Fusion
& score drift/movement)
6b. Motor Right Leg
0 = No Drift
1 = Drift
2 = Can’t Resist Gravity
(elevate extremity to 30˚
3 = No Effort Against Gravity
4 = No Movement
9 = Amputation/Joint Fusion
& score drift/movement)
7. Limb Ataxia
0 = Absent
1 = Present in One Limb
2 = Present in Two Limbs
(finger to nose, heel to shin)
8. Sensory
0 = Normal
1 = Partial Loss
2 = Severe Loss
(pinprick to face, arm, trunk
& leg; compare side to side)
9. Best Language
0 = No Aphasia
1 = Mild to Moderate Aphasia
(name items, describes a
2 = Severe Aphasia
3 = Mute
picture, reads sentence)
10. Dysarthria
0 = Normal Articulation
1 = Mild to Moderate Dysarthria
(evaluate speech clarity by pt.
2 = Near to Unintelligible
9 = Intubated or Other Barrier
repeating listed words)
11. Extinction and Inattention 0 = No Neglect
1 = Partial Neglect
2 = Complete Neglect
(use info. from prior testing
to identify neglect or double
simultaneous stimuli testing)
INITIAL SCORE: __________ Practitioner’s Signature: _______________________________________ Date: ___________ Time: ___________
REASSESSMENT SCORE: __________ Practitioner’s Signature: _______________________________________ Date: ___________ Time: ___________
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