NCEMI eTools

NIH Stroke Scale

Score: 0 Answer out of bounds for assessibility
Assessment

Level of Consciousness

	Alert, keenly responsive 0 points
	Obeys, answers or resonds to minor stimulation 1 points
	Responds only to repeated stimulation or painful stimulation (excludes reflex response 2 points
	Responds only with reflex motor or totally unresponsive 3 points

Ask the month, and patient age. Must be exactly right.

	Answers both correctly 0 points
	Answers one correctly or patient unable to speak due to any reason other than aphasia or coma 1 points
	Answers neither correctly, or too stuporous or aphasic 2 points

Ask patient to open and close eyes and then grip and release non-paretic hand

	Performs both tasks correctly 0 points
	Performs 1 task correctly 1 points
	Performs neither task correctly 2 points

Best Gaze: Only horizontal movements tested. Oculocephalic reflex use is ok, but not calorics

	Normal 0 points
	Partial gaze palse 1 points
	Forced deviation or total gaze paresis not overcome by oculocephalic maneuver 2 points

Visual fields tested by confrontation

	No visual loss 0 points
	Partial hemianopia 1 points
	Complete hemianopia 2 points
	Bilateral hemianopia (blind from any cause including cortical blindness) 3 points

Facial palsy - encourage patient to smile and close eyes, or grimace symmetry

	Normal symmetrical movement 0 points
	Minor paryalysis (flattened nasolabial fold, asymmetry on smiling) 1 points
	Partial paralysis (total or near total lower face paralysis) 2 points
	Complete paralysis (absence of facial movement upper/lower face) 3 points

Right Arm Motor: Extend right arm palm down at 90 degrees (sitting) or 45 degrees (supine)

	No drift - holds for full 10 seconds 0 points
	Drifts down before 10 seconds but does not hit bed/support 1 points
	Some effort against gravity, but cannot get up to 90 (or 45 if supine) degrees 2 points
	No effort against gravity, limb falls 3 points
	No movement 4 points

Left Arm Motor: Extend left arm palm down at 90 degrees (sitting) or 45 degrees (supine)

	No drift - holds for full 10 seconds 0 points
	Drifts down before 10 seconds but does not hit bed/support 1 points
	Some effort against gravity, but cannot get up to 90 (or 45 if supine) degrees 2 points
	No effort against gravity, limb falls 3 points
	No movement 4 points

Right Leg Motor: Extend right leg and flex at hip to 30 degrees

	No drift - holds for full 5 seconds 0 points
	Drifts down before 5 seconds but does not hit bed/support 1 points
	Some effort against gravity 2 points
	No effort against gravity, limb falls 3 points
	No movement 4 points

Left Leg Motor: Extend left leg and flex at hip to 30 degrees

	No drift - holds for full 5 seconds 0 points
	Drifts down before 5 seconds but does not hit bed/support 1 points
	Some effort against gravity 2 points
	No effort against gravity, limb falls 3 points
	No movement 4 points

Limb ataxia - finger/nose and heel/shin done on both sides. Not ataxia if hemiplegic or unable to comprehend. Ataxia must be out of proportion to any weakness present.

	Absent 0 points
	Present in 1 limb 1 points
	Present in two limbs 2 points

Sensory to pinprick.

	Normal 0 points
	Pinprick less sharp or dull on affected side 1 points
	Severe to total sensory loss; patient unaware of being touched 2 points

Best language using pictures, naming items, and reading short sentences.

	No aphasia 0 points
	Some loss of fluency or comprehension 1 points
	Severe aphasia - fragmentary communication, listener carries burden of communication 2 points
	Mute, global aphasia. NO usable speech OR auditory comprehension 3 points

Dysarthria - if not obviously present, have patient read

	Normal 0 points
	Slurs some words 1 points
	So slurred as to be unintelligible, or mute 2 points

Extinction/Inattention

	No abnormality 0 points
	Inattention to any sensory modality or extinction to bilateral simultaneous stimulation in one sensory modality 1 points
	Profound hemi-inattention or hemi-inattention to more than one modality. Does not recognize own hand 2 points

Calculate