Nihss Stroke Scale Test A Answers

The National Institutes of Health Stroke Scale (NIHSS) is a standardized, multi-item neurological assessment tool used to evaluate the effect of acute cerebral infarction on levels of consciousness, language, neglect, visual-field loss, extraocular movement, strength, ataxia, and sensory function. Designed as a practical method to provide a quantified measure of the neurological deficit caused by a stroke, it serves as a common language between clinicians and is used extensively in clinical trials and routine clinical practice. Understanding the nuances of the NIHSS and how to accurately score each item is paramount for healthcare professionals involved in stroke care. This article delves into a comprehensive overview of the NIHSS, providing insights into each component and detailing the appropriate responses for accurate scoring.

Understanding the NIHSS: A Comprehensive Guide

The NIHSS is not simply a checklist; it is a detailed assessment that requires training and experience to administer correctly. The scale comprises 11 items, each assessing a specific neurological function. The total score ranges from 0 to 42, with higher scores indicating more severe deficits.

Here's a breakdown of each item and the corresponding scoring:

1A: Level of Consciousness (LOC)

This item assesses the patient's overall alertness and responsiveness. The examiner observes the patient's behavior and attempts to arouse them if they appear drowsy or unresponsive.

• 0 = Alert: The patient is fully alert and spontaneously interacts with the examiner. They are aware of their surroundings and respond appropriately to questions.
• 1 = Drowsy: The patient is not fully alert but can be aroused by a minor stimulus (e.g., calling their name or touching them lightly). They may drift back to sleep if left undisturbed.
• 2 = Stupor: The patient requires repeated stimulation to maintain attention or to respond. This might involve painful stimuli. Their responses may be slow or incomplete.
• 3 = Coma: The patient is unresponsive to all stimuli, including pain. They may exhibit reflexive movements, but there is no purposeful response.

Key Considerations:

• If the patient is intubated or has a language barrier, base the score on observed behaviors and attempts to interact.
• Document the type of stimulus required to elicit a response.

1B: LOC Questions

This item evaluates the patient's ability to answer questions about their current situation. The examiner asks two standard questions:

• What month is it?
• How old are you?

Score 1 point for each incorrect answer. If the patient is unable to speak due to intubation or aphasia, indicate this in the notes.

• 0 = Both correct: The patient correctly answers both questions.
• 1 = One correct: The patient answers one question correctly.
• 2 = Neither correct: The patient answers neither question correctly.

Key Considerations:

• Acceptable answers should be reasonable and accurate. Minor variations in age (e.g., stating they are 50 when they are 49) may be considered correct.
• If the patient is unable to answer due to a language barrier or other communication difficulty, score based on observed behavior and attempts to communicate.

1C: LOC Commands

This item assesses the patient's ability to follow simple commands. The examiner gives two commands:

• Close your eyes.
• Make a fist with your non-paretic hand.

Give the commands one at a time. Score 1 point for each command not performed.

• 0 = Both correct: The patient performs both commands correctly.
• 1 = One correct: The patient performs one command correctly.
• 2 = Neither correct: The patient does not perform either command correctly.

Key Considerations:

• Demonstrate each command before asking the patient to perform it.
• If the patient has a physical limitation (e.g., amputation or paralysis), choose an alternative command that they can perform.

2: Best Gaze

This item assesses the patient's ability to move their eyes horizontally. The examiner observes the patient's eye movements as they follow a finger or object.

• 0 = Normal: The patient has normal horizontal eye movements with no gaze preference.
• 1 = Partial gaze palsy: The patient has partial gaze palsy, meaning they have difficulty moving their eyes in one or both directions but can still achieve some movement.
• 2 = Forced deviation: The patient has a forced deviation of the eyes, meaning they are unable to move their eyes voluntarily and their gaze is fixed in one direction.

Key Considerations:

• Test both horizontal directions (left and right).
• If the patient has a pre-existing gaze palsy, score based on any new deficits.
• If the patient is unable to follow commands, attempt to elicit eye movements using the oculocephalic reflex ("doll's eyes maneuver").

3: Visual Fields

This item assesses the patient's visual fields in each eye. The examiner tests the patient's ability to see objects presented in each visual quadrant.

• 0 = No visual loss: The patient has no visual field loss.
• 1 = Partial hemianopia: The patient has partial hemianopia, meaning they have visual loss in one or more quadrants but not a complete half of their visual field.
• 2 = Complete hemianopia: The patient has complete hemianopia, meaning they have visual loss in half of their visual field (either left or right).
• 3 = Bilateral hemianopia (blindness): The patient is blind due to bilateral hemianopia.

Key Considerations:

• Test each eye separately.
• If the patient is unable to cooperate with formal visual field testing, use confrontation testing.
• If the patient has a pre-existing visual field deficit, score based on any new deficits.

4: Facial Palsy

This item assesses the patient's facial muscle strength and symmetry. The examiner observes the patient's face at rest and during voluntary movements (e.g., smiling, raising eyebrows, and puffing out cheeks).

• 0 = Normal: The patient has normal facial movement with no asymmetry.
• 1 = Minor paralysis: The patient has minor facial weakness, such as slight drooping of the mouth or flattening of the nasolabial fold.
• 2 = Partial paralysis: The patient has moderate facial weakness, with noticeable drooping of the mouth and difficulty closing the eye on the affected side.
• 3 = Complete paralysis: The patient has complete paralysis of one side of the face.

Key Considerations:

• Pay attention to subtle asymmetries.
• If the patient is unable to cooperate with voluntary movements, observe their facial movements during spontaneous expressions (e.g., smiling or crying).
• If the patient has a pre-existing facial palsy, score based on any new deficits.

5: Motor Arm (Left and Right)

These items assess the patient's strength in each arm. The examiner asks the patient to extend each arm to 90 degrees (if sitting) or 45 degrees (if supine) and hold it against gravity for 10 seconds.

• 0 = No drift: The patient holds the arm in the correct position for the full 10 seconds with no drift.
• 1 = Drift: The patient's arm drifts downward before the 10 seconds are up, but they make some effort to resist gravity.
• 2 = Some effort against gravity: The patient can move the arm against gravity but cannot hold it in the correct position.
• 3 = No effort against gravity: The patient cannot move the arm against gravity.
• 4 = No movement: The patient has no movement in the arm.
• UN = Amputation or joint fusion: Use this score if the limb is amputated or has a joint fusion, preventing accurate assessment.

Key Considerations:

• Test each arm separately.
• Encourage the patient to keep their eyes closed during the test to minimize visual compensation.
• If the patient has pain or other limitations, modify the test as needed.
• If the patient releases the arm, but does not drift, give them a second attempt.
• If a patient scores a 4, test for pronator drift by having the patient hold their arms out in front of them, palms up, eyes closed. If the affected arm pronates, score a 4.

6: Motor Leg (Left and Right)

These items assess the patient's strength in each leg. The examiner asks the patient to extend each leg to 30 degrees and hold it against gravity for 5 seconds.

• 0 = No drift: The patient holds the leg in the correct position for the full 5 seconds with no drift.
• 1 = Drift: The patient's leg drifts downward before the 5 seconds are up, but they make some effort to resist gravity.
• 2 = Some effort against gravity: The patient can move the leg against gravity but cannot hold it in the correct position.
• 3 = No effort against gravity: The patient cannot move the leg against gravity.
• 4 = No movement: The patient has no movement in the leg.
• UN = Amputation or joint fusion: Use this score if the limb is amputated or has a joint fusion, preventing accurate assessment.

Key Considerations:

• Test each leg separately.
• Encourage the patient to keep their eyes closed during the test to minimize visual compensation.
• If the patient has pain or other limitations, modify the test as needed.
• If the patient releases the leg, but does not drift, give them a second attempt.

7: Limb Ataxia

This item assesses the patient's coordination in the limbs. The examiner asks the patient to perform finger-to-nose and heel-to-shin tests.

• 0 = Absent: The patient has no ataxia in the limbs.
• 1 = Present in one limb: The patient has ataxia in one limb.
• 2 = Present in two limbs: The patient has ataxia in two limbs.

Key Considerations:

• Test each limb separately.
• If the patient is unable to perform the standard tests, observe their movements during other activities.
• If the patient has weakness that limits their ability to perform the tests, score based on the observed coordination deficits.
• Only score if ataxia is out of proportion to weakness.
• If a patient is unable to understand or follow commands, this item should be scored as a 0.
• If a limb is amputated or a joint fusion is present, score a 0.

8: Sensory

This item assesses the patient's ability to feel light touch or pinprick sensation. The examiner tests sensation in multiple locations on the body, including the face, arms, legs, and trunk.

• 0 = Normal: The patient has normal sensation in all areas tested.
• 1 = Mild to moderate sensory loss: The patient has decreased sensation in one or more areas, but they are still able to perceive the stimulus.
• 2 = Severe to total sensory loss: The patient has a significant loss of sensation or is unable to perceive the stimulus in one or more areas.

Key Considerations:

• Test each side of the body separately.
• Use a consistent stimulus and apply it with equal pressure.
• If the patient has aphasia, observe their responses to the stimulus (e.g., grimacing or withdrawal).
• Only score sensory loss attributed to stroke.

9: Best Language

This item assesses the patient's ability to understand and produce language. The examiner assesses the patient's ability to name objects, describe a picture, and understand commands.

• 0 = No aphasia: The patient has no aphasia and can communicate effectively.
• 1 = Mild to moderate aphasia: The patient has some difficulty with language, but they can still communicate basic needs and ideas.
• 2 = Severe aphasia: The patient has significant difficulty with language, and their communication is severely limited.
• 3 = Mute, global aphasia: The patient is unable to speak or understand language.

Key Considerations:

• Assess both expressive and receptive language skills.
• If the patient has a pre-existing language impairment, score based on any new deficits.
• If the patient is intubated, score based on their ability to communicate nonverbally.
• To assess naming, show the patient a picture of a watch and a key and ask them to name them.
• To assess comprehension, ask the patient to point to items in the room or follow simple commands.
• To assess expressive language, ask the patient to describe a picture.

10: Dysarthria

This item assesses the patient's ability to articulate speech. The examiner listens to the patient's speech and assesses its clarity and ease of production.

• 0 = Normal: The patient's speech is clear and easy to understand.
• 1 = Mild to moderate dysarthria: The patient's speech is slurred or difficult to understand, but they can still be understood with effort.
• 2 = Severe dysarthria: The patient's speech is severely slurred or unintelligible.
• UN = Intubated or other physical barrier: Use this score if the patient is intubated or has another physical barrier that prevents them from speaking.

Key Considerations:

• Listen carefully to the patient's speech and note any abnormalities in articulation, rate, or rhythm.
• If the patient has a pre-existing speech impairment, score based on any new deficits.
• Only score dysarthria due to weakness or incoordination of the muscles of speech.

11: Extinction and Inattention (Neglect)

This item assesses the patient's awareness of stimuli on both sides of their body and in space. The examiner tests the patient's ability to perceive stimuli presented simultaneously on both sides of their body (double simultaneous stimulation).

• 0 = No neglect: The patient has no neglect and is aware of stimuli on both sides of their body.
• 1 = Visual, tactile, auditory, spatial, or personal neglect: The patient neglects stimuli on one side of their body in one or more modalities (visual, tactile, auditory, spatial, or personal).
• 2 = Profound neglect: The patient has profound neglect and is unaware of stimuli on one side of their body in multiple modalities.

Key Considerations:

• Test neglect in multiple modalities (visual, tactile, auditory).
• Use double simultaneous stimulation to assess for extinction (the failure to perceive a stimulus on one side of the body when presented simultaneously with a stimulus on the other side).
• Assess for spatial neglect by asking the patient to bisect a line or draw a clock.
• Assess for personal neglect by observing the patient's grooming and hygiene.
• Only score neglect attributed to stroke.
• If a patient has severe aphasia, this item should be scored as a 0.

Minimizing Errors and Ensuring Accuracy

Accurate scoring of the NIHSS is crucial for clinical decision-making and research purposes. Here are some tips to minimize errors and ensure accuracy:

• Training: Healthcare professionals administering the NIHSS should undergo formal training and certification.
• Standardization: Follow the standardized procedures for each item, as outlined in the NIHSS training manual.
• Practice: Practice administering the NIHSS regularly to maintain proficiency.
• Objectivity: Be objective and avoid making subjective interpretations.
• Consistency: Use consistent methods and stimuli when testing each patient.
• Documentation: Document all findings clearly and concisely.
• Collaboration: Consult with other healthcare professionals when in doubt.
• Re-assessment: Re-assess the patient regularly to monitor changes in their neurological status.
• Consider pre-existing conditions: Always consider pre-existing conditions and adjust scoring accordingly.
• Address limitations: Document any limitations in the examination due to the patient's condition.

Clinical Significance of the NIHSS

The NIHSS score is a valuable tool for:

• Assessing stroke severity: The NIHSS score provides a quantitative measure of the severity of a stroke.
• Guiding treatment decisions: The NIHSS score can help guide treatment decisions, such as the use of thrombolytic therapy.
• Monitoring treatment response: The NIHSS score can be used to monitor the patient's response to treatment.
• Predicting outcomes: The NIHSS score is a predictor of long-term outcomes after stroke, such as functional independence and mortality.
• Stratifying patients in clinical trials: The NIHSS is used to stratify patients in stroke clinical trials.
• Facilitating communication: The NIHSS provides a common language for healthcare professionals involved in stroke care.

Conclusion

The NIHSS is an essential tool for assessing stroke severity, guiding treatment decisions, and predicting outcomes. Accurate scoring requires training, standardization, and practice. By understanding the nuances of each item and following the guidelines outlined in this article, healthcare professionals can ensure the reliability and validity of the NIHSS, ultimately improving the care of patients with stroke. Continuous education and adherence to standardized protocols are paramount to maintaining competency and ensuring the best possible outcomes for stroke patients. The NIHSS, when administered correctly, provides invaluable information for acute stroke management and beyond.