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NIH Stroke Scale/Score (NIHSS)

Calculates the NIH Stroke Scale for quantifying stroke severity.

INSTRUCTIONS
The NIH Stroke Scale has many caveats buried within it. If your patient has prior known neurologic decits e.g.
prior weakness, hemi- or quadriplegia, blindness, etc. or is intubated, has a language barrier, etc., it becomes
especially complicated. In those cases, consult the NIH Stroke Scale website
(https://stroke.nih.gov/resources/scale.htm). MDCalc's version is an attempt to clarify many of these confusing
caveats, but cannot and should not be substituted for the ocial protocol.
Rules:
Score what you see, not what you think.
Score the rst response, not the best response (except Item 9 - Best Language).
Dont coach.

When to Use Pearls/Pitfalls Why Use

1A: Level of consciousness 0

Alert; keenly responsive
May be assessed casually while taking history
Arouses to minor stimulation +1

Requires repeated stimulation to arouse +2

Movements to Pain +2

Postures or unresponsive +3

1B: Ask month and age Both questions right 0

1 question right +1

0 questions right +2
0 Next Steps
Dysarthric/intubated/trauma/language barrier +1
NIH Stroke Scale
Aphasic Copy Results +2
1C: 'Blink eyes' & 'squeeze hands' Performs both tasks 0
Pantomime commands if communication barrier
Performs 1 task +1

Performs 0 tasks +2

2: Horizontal extraocular movements 0

Normal
Only assess horizontal gaze
Partial gaze palsy: can be overcome +1

Partial gaze palsy: corrects with oculocephalic reflex +1

Forced gaze palsy: cannot be overcome +2

3: Visual elds No visual loss 0

Partial hemianopia +1

Complete hemianopia +2

Patient is bilaterally blind +3

Bilateral hemianopia +3

4: Facial palsy 0
Normal symmetry
Use grimace if obtunded
Minor paralysis (flat nasolabial fold, smile asymetry) +1

Partial paralysis (lower face) +2

Unilateral complete paralysis (upper/lower face) +3

Bilateral complete paralysis (upper/lower face) +3

5A: Left arm motor drift

No drift for 10 seconds 0
Count out loud and use your ngers to show the
patient your count
Drift, but doesn't hit bed +1

Drift, hits bed +2

Some effort against gravity +2

No effort against gravity +3

0 Next Steps
No movement +4
NIH Stroke Scale
Amputation/joint fusion Copy Results 0
5B: Right arm motor drift
No drift for 10 seconds 0
Count out loud and use your ngers to show the
patient your count
Drift, but doesn't hit bed +1

Drift, hits bed +2

Some effort against gravity +2

No effort against gravity +3

points No movement +4

Amputation/joint fusion 0

6A: Left leg motor drift

No drift for 5 seconds 0
Count out loud and use your ngers to show the
patient your count
Drift, but doesn't hit bed +1

Drift, hits bed +2

Some effort against gravity +2

No effort against gravity +3

No movement +4

Amputation/joint fusion 0

6B: Right leg motor drift

No drift for 5 seconds 0
Count out loud and use your ngers to show the
patient your count
Drift, but doesn't hit bed +1

Drift, hits bed +2

Some effort against gravity +2

No effort against gravity +3

No movement +4

Amputation/joint fusion 0

7: Limb Ataxia 0
No ataxia
FNF/heel-shin
0 Ataxia in 1 Limb Next Steps +1
NIH Stroke Scale
Ataxia in 2 Limbs +2
Copy Results

Does not understand 0

 Paralyzed 0

Amputation/joint fusion 0

8: Sensation Normal; no sensory loss 0

Mild-moderate loss: less sharp/more dull +1

Mild-moderate loss: can sense being touched +1

Complete loss: cannot sense being touched at all +2

No response and quadriplegic +2

Coma/unresponsive +2

9: Language/aphasia
Normal; no aphasia 0
Describe the scene; name the words; read the
sentences (see About/Evidence)
Mild-moderate aphasia: some obvious changes, without
signicant limitation +1

Severe aphasia: fragmentary expression, inference

needed, cannot identify materials +2

Mute/global aphasia: no usable speech/auditory

comprehension +3

Coma/unresponsive +3

10: Dysarthria 0
Normal
Read the words (see About/Evidence)
Mild-Moderate Dysarthria: slurring but can be
understood +1

Severe Dysarthria: unintelligble slurring or out of

proportion to dysphasia +2

Mute/anarthric +2

Intubated/unable to test 0

11: Extinction/inattention No abnormality 0

0 Next Steps
Visual/tactile/auditory/spatial/personal inattention +1
NIH Stroke Scale
Extinction to bilateral simultaneous stimulation +1
Copy Results

Profound hemi-inattention (ex: does not recognize own

 hand) +2

Extinction to >1 modality +2

Next Steps Evidence Creator Insights

ADVICE
Consult Neurology immediately (if available) for all patients presenting with ischemic stroke.
Evaluate whether the patient is a potential candidate to receive intravenous thrombolysis (tPA)
(https://www.mdcalc.com/tpa-contraindications-ischemic-stroke).
Consider further imaging including CT, CT angiography and MRI/MRA.

MANAGEMENT
In patients who present with symptoms concerning for ischemic stroke:
Consult Neurology.
Determine the onset of stroke symptoms (or time patient last felt or was observed normal).
Obtain a stat head CT to evaluate for hemorrhagic stroke.
In appropriate circumstances and in consultation with both neurology and the patient, consider IV thrombolysis
(https://www.mdcalc.com/tpa-contraindications-ischemic-stroke) for ischemic strokes in patients with no
contraindications.
Always consider stroke mimics in the differential diagnosis, especially in cases with atypical features (age, risk
factors, history, physical exam), including:
Recrudescence of old stroke from metabolic or infectious stress;
Todds paralysis after seizure;
Complex migraine;
Pseudoseizure, conversion disorder

CRITICAL ACTIONS
The NIHSS is broadly predictive of clinical outcomes, but it is important to recognize that individual cases will vary
and that management decisions must be made in consultation with the patient whenever possible.
Patients with a score of <4 are highly likely to have good clinical outcomes.
Whenever possible, patients with acute stroke should be transferred to a stroke center for their initial evaluation
and treatment, as the holistic care (medical optimization, early initiation of PT and OT, patient and family
0 education and discharge planning) is associated with improved clinical outcomes; some argue Nextthat most of the
Steps
gains in stroke morbidity and mortality are due to these improvements in stroke care.
NIH Stroke Scale
Copy Results
Content Contributors
 Daniel Runde, MD (/contributors/#danielrunde)

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Calculations must be re-checked and should not be used alone to guide patient care, nor should they substitute for clinical

judgment. See our full disclaimer (/disclaimer).
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