NIH Stroke Scale: Difference between revisions

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== Objective<br>  ==


The [http://www.nihstrokescale.org/ National Institutes of Health Stroke Scale] (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.
== Objective  ==


The NIHSS can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients<ref>Spilker J1, Kongable G, Barch C, Braimah J, Brattina P, Daley S, Donnarumma R, Rapp K, Sailor S. Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group. J Neurosci Nurs. 1997 Dec;29(6):384-92.</ref>. The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity. The NIHSS has been shown to be a predictor of both short and long term outcome of stroke patients<ref>H.P. Adams Jr., P.H. Davis, E.C. Leira, K.-C. Chang, B.H. Bendixen, W.R. Clarke, R.F. Woolson, Hansen, MS. [http://www.neurology.org/content/53/1/126.short Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)]. Neurology July 1, 1999 vol. 53 no. 1 126</ref>. Additionally, the stroke scale serves as a data collection tool for planning patient care and provides a common language for information exchanges among healthcare providers.  
The National Institutes of Health Stroke Scale (NIHSS) is a systematic, quantitative assessment tool to measure [[stroke]]-related neurological deficit<ref name=":0">NIH Stroke Scale. Approach to Human Subject Protection and Patient Safety. Available from: https://www.nihstrokescale.org/ (Accessed 12/07/2022)</ref>. In clinical practice it can be used to evaluate and document [[Neurological Assessment|neurological status]] in acute stroke patients, determine appropriate [[Stroke: Physiotherapy Treatment Approaches|treatment]] and assist in standardizing communication between healthcare practitioners<ref name=":1">Spilker J, Kongable G, Barch C, Braimah J, Brattina P, Daley S, Donnarumma R, Rapp K, Sailor S. [https://pubmed.ncbi.nlm.nih.gov/9479660/ Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group.] J Neurosci Nurs. 1997 Dec;29(6):384-92.</ref>. The NIHSS has been shown to be a predictor of both short and long term outcomes of stroke patients<ref>H.P. Adams Jr., P.H. Davis, E.C. Leira, K.-C. Chang, B.H. Bendixen, W.R. Clarke, R.F. Woolson, Hansen, MS. [http://www.neurology.org/content/53/1/126.short Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST)]. Neurology July 1, 1999 vol. 53 no. 1 126</ref><ref>Runde D. [https://pubmed.ncbi.nlm.nih.gov/33112580/ Calculated Decisions: NIH stroke scale/score (NIHSS)]. Emerg Med Pract. 2020 Jul 15;22(7):CD6-CD7. </ref>.


The scale is designed to be a simple, valid, and reliable tool that can be administered at the bedside consistently by physicians, nurses or therapists.  
The NIHSS is designed to be a simple tool that can be administered in less than 10 minutes by physicians, nurses or therapists<ref name=":0" />.  


== Intended Population<br> ==
== Intended Population  ==
 
Acute stroke patients<ref name=":1" />.


== Method of Use  ==
== Method of Use  ==


The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. A trained observer rates the patent’s ability to answer questions and perform activities. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. The single patient assessment requires less than 10 minutes to complete.  
The NIHSS is a 15-item neurological examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of [[Disorders of Consciousness|consciousness]], language, neglect, visual-field loss, extraocular movement, [[Muscle Strength Testing|motor strength]], [[ataxia]], [[dysarthria]], and [[Sensation|sensory loss]]<ref name=":0" />. A trained observer rates the patent’s ability to answer questions and perform activities, without coaching and without making assumptions about what the patient can do<ref>Know Stroke. NIH Stroke Scale. Available from https://www.stroke.nih.gov/resources/scale.htm (Accessed 12/07/2022)</ref>.  


The evaluation of stroke severity depends upon the ability of the observer to accurately and consistently assess the patient.  
Ratings for each item are scored on a 3- to 5-point scale, with 0 as normal, and there is an allowance for untestable items. Scores range from 0 to 42, with higher scores indicating greater severity.


== Reference<br> ==
Stroke severity may be stratified on the basis of NIHSS scores as follows:<ref name="brott">Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. [https://pubmed.ncbi.nlm.nih.gov/2749846/ Measurements of acute cerebral infarction: a clinical examination scale]. 1989. Stroke 20(7): 864-870.</ref>  


Spilker J, Kongable G, Barch C, Braimah J, Brattina P, Daley S, Donnarumma R, Rapp K, Sailor S. [http://www.ncbi.nlm.nih.gov/pubmed/9479660 Using the NIH Stroke Scale to assess stroke patients]. The NINDS rt-PA Stroke Study Group.&nbsp;J Neurosci Nurs. 1997 Dec;29(6):384-92.<br>
*Very Severe: &gt;25
*Severe: 15 – 24
*Mild to Moderately Severe: 5 – 14
*Mild: 1 – 5'
 
{{#ev:youtube|do2CbY_Nm5c}}


== Evidence  ==
== Evidence  ==
Line 28: Line 34:
=== Reliability  ===
=== Reliability  ===


Inter-rater reliability for individual elements of the NIHSS has been shown to be generally good<ref>Josephson SA1, Hills NK, Johnston SC.. NIH Stroke [http://www.ncbi.nlm.nih.gov/pubmed/16888381 Scale reliability in ratings from a large sample of clinicians]. Cerebrovasc Dis. 2006;22(5-6):389-95.</ref><ref>Goldstein LB1, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol. 1989 Jun;46(6):660-2.</ref>. &nbsp;However overall scoring can be inconsistent, proper training is required to use the NIH Stroke Scale acurately<ref>André C. [http://www.ncbi.nlm.nih.gov/pubmed/17903854 The NIH Stroke Scale is unreliable in untrained hands]. J Stroke Cerebrovasc Dis. 2002 Jan-Feb;11(1):43-6.</ref><ref>Lyden P1, Raman R, Liu L, Emr M, Warren M, Marler J. [http://stroke.ahajournals.org/cgi/pmidlookup?view=long&amp;amp;pmid=19520998 National Institutes of Health Stroke Scale certification is reliable across multiple venues]. Stroke. 2009 Jul;40(7):2507-11.</ref><ref>Goldstein LB, Samsa GP.. Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke. 1997 Feb;28(2):307-10.</ref><ref>Lyden P, Raman R, Liu L, Grotta J, Broderick J, Olson S, Shaw S, Spilker J, Meyer B, Emr M, Warren M, Marler J. [http://stroke.ahajournals.org/content/36/11/2446.long NIHSS training and certification using a new digital video disk is reliable]. Stroke. 2005 Nov;36(11):2446-9.</ref>.&nbsp;  
Inter-rater reliability for individual elements of the NIHSS has been shown to be generally good<ref>Josephson SA1, Hills NK, Johnston SC.. NIH Stroke [http://www.ncbi.nlm.nih.gov/pubmed/16888381 Scale reliability in ratings from a large sample of clinicians]. Cerebrovasc Dis. 2006;22(5-6):389-95.</ref>. &nbsp;However, overall scoring can be inconsistent, so proper training is required to use the NIHSS accurately<ref>André C. [http://www.ncbi.nlm.nih.gov/pubmed/17903854 The NIH Stroke Scale is unreliable in untrained hands]. J Stroke Cerebrovasc Dis. 2002 Jan-Feb;11(1):43-6.</ref><ref>Lyden P1, Raman R, Liu L, Emr M, Warren M, Marler J. [http://stroke.ahajournals.org/cgi/pmidlookup?view=long&amp;pmid=19520998 National Institutes of Health Stroke Scale certification is reliable across multiple venues]. Stroke. 2009 Jul;40(7):2507-11.</ref><ref>Lyden P, Raman R, Liu L, Grotta J, Broderick J, Olson S, Shaw S, Spilker J, Meyer B, Emr M, Warren M, Marler J. [http://stroke.ahajournals.org/content/36/11/2446.long NIHSS training and certification using a new digital video disk is reliable]. Stroke. 2005 Nov;36(11):2446-9.</ref>. A simpler, modified version of the NIHSS has been found to have greater inter-rater reliability with equivalent clinical performance<ref>EB Medicine. Current Topics in Acute Stroke Care. Available from https://www.ebmedicine.net/topics/stroke/stroke-imaging-modalities-CRAO/calculators (Accessed 12/07/2022)</ref>.
*A study of 4 patients assessed by 30 physicians and 29 study coordinators, with a space of 3 months between assessments, found that the NIHSS has excellent interrater (ICC = 0.95) and test-retest reliability (ICC = 0.93)<ref>Goldstein LB, Samsa GP. [https://www.ahajournals.org/doi/full/10.1161/01.STR.28.2.307 Reliability of the National Institutes of Health Stroke Scale Extension to Non-Neurologists in the Context of a Clinical Trial.] Stroke. 1997;28:307–310</ref>
*A study of 20 patients rated by 4 clinicians, with each patient subsequently evaluated by 2 independent observers found Adequate to Excellent inter-rater agreement for 9 of the 13 items on the NIHSS (Kappa = 0.32 to 0.79); lowest levels of agreement were found for the [[Facial Palsy|Facial palsy]] (Kappa = 0.22) and limb ataxia (Kappa = -0.16) items<ref>Goldstein LB, Bertels C, Davis JN. [https://pubmed.ncbi.nlm.nih.gov/2730378/ Interrater reliability of the NIH stroke scale]. Arch Neurol. 1989 Jun;46(6):660-2.</ref>.
*4 items have poorly reliability or are redundant (level of consciousness, [[Facial Muscles - Lower Group|facial weakness,]] ataxia, and dysarthria<ref>Kasner SE. [https://pubmed.ncbi.nlm.nih.gov/16781990/ Clinical interpretation and use of stroke scales.] Lancet Neurol. 2006 Jul;5(7):603-12.</ref>.
 
=== Validity ===
 
Outcomes related to NIHSS scores at admission<ref>Schlegel D, Kolb SJ, Luciano JM, Tovar JM, Cucchiara BL, Liebeskind DS, Kasner SE. [https://pubmed.ncbi.nlm.nih.gov/12511764/ Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke]. 2003 Jan;34(1):134-7</ref><ref>Rundek T, Mast H, Hartmann A, Boden-Albala B, Lennihan L, Lin IF, et al. [https://pubmed.ncbi.nlm.nih.gov/11071497/ Predictors of resource use after acute hospitalization: the Northern Manhattan Stroke Study]. Neurology. 2000 Oct 24;55(8):1180-7</ref>:
*Scores of &lt;5; 80% of stroke survivors will be discharged to home.
*Score between 6 and 13 typically require acute inpatient rehabilitation.
*Scores of &gt;14 frequently require long-term skilled care.
 


=== Validity  ===
The validity of the NIHSS is reduced if there is a language barrier, if the patient previously had a neurological deficit or if they are [[Coma|intubated]]<ref>MD Calc. NIH Stroke Scale/Score (NIHSS). Available from: https://www.mdcalc.com/calc/715/nih-stroke-scale-score-nihss (Accessed 12/07/2022)</ref>. Moreover, there was found to be differences between the average NIHSS of patients with a good functional outcome between posterior circulation stroke and anterior circulation stroke<ref>Kazi SA, Siddiqui M, Majid S. [https://pubmed.ncbi.nlm.nih.gov/34137544/ Stroke Outcome Prediction Using Admission Nihss In Anterior And Posterior Circulation Stroke]. J Ayub Med Coll Abbottabad. 2021 Apr-Jun;33(2):274-278</ref>.


=== Responsiveness ===
=== Responsiveness ===


=== Miscellaneous<br> ===
NIHSS scores were compared to infarction size (measured by computed tomography) on 65 patients at 1 week post stroke. 10 items demonstrated an average of 25% change over 7 days. However, changes in limb ataxia and best gaze may have been overstated<ref name="brott" />.


== Links  ==
== Links  ==


[http://www.ninds.nih.gov/doctors/nih_stroke_scale.pdf NIH Stroke Assessment Tool]&nbsp;
[https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf NIH Stroke Assessment Tool PDF]


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) ==
== References ==
<div class="researchbox">
<references /><br>
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=14ipX3fGPZTNtLsU27iTDtvSizTRJVV2bZWI0Zv6bC3cvmZEer|charset=UTF-8|short|max=10</rss>
</div>  
== References<br> ==


<references />
[[Category:Assessment]] [[Category:Outcome Measures]]
[[Category:Neurology]] [[Category:Neurological - Assessment and Examination]] [[Category:Neurological - Outcome Measures]] [[Category:Neurological - Outcome Measures]]
[[Category:Stroke]] [[Category:Stroke - Assessment and Examination]] [[Category:Stroke - Outcome Measures]]
[[Category:Head]] [[Category:Head - Assessment and Examination]] [[Category:Head - Outcome Measures]]
[[Category:Acute Care]]

Latest revision as of 12:07, 12 July 2022

Original Editor - Rachael Lowe

Top Contributors - Admin, Chloe Waller, Adam Vallely Farrell, Kim Jackson, Oyemi Sillo, WikiSysop, Naomi O'Reilly, Garima Gedamkar, Karen Wilson, 127.0.0.1, Tony Lowe and Evan Thomas

Objective[edit | edit source]

The National Institutes of Health Stroke Scale (NIHSS) is a systematic, quantitative assessment tool to measure stroke-related neurological deficit[1]. In clinical practice it can be used to evaluate and document neurological status in acute stroke patients, determine appropriate treatment and assist in standardizing communication between healthcare practitioners[2]. The NIHSS has been shown to be a predictor of both short and long term outcomes of stroke patients[3][4].

The NIHSS is designed to be a simple tool that can be administered in less than 10 minutes by physicians, nurses or therapists[1].

Intended Population[edit | edit source]

Acute stroke patients[2].

Method of Use[edit | edit source]

The NIHSS is a 15-item neurological examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss[1]. A trained observer rates the patent’s ability to answer questions and perform activities, without coaching and without making assumptions about what the patient can do[5].

Ratings for each item are scored on a 3- to 5-point scale, with 0 as normal, and there is an allowance for untestable items. Scores range from 0 to 42, with higher scores indicating greater severity.

Stroke severity may be stratified on the basis of NIHSS scores as follows:[6]

  • Very Severe: >25
  • Severe: 15 – 24
  • Mild to Moderately Severe: 5 – 14
  • Mild: 1 – 5'

Evidence[edit | edit source]

Reliability[edit | edit source]

Inter-rater reliability for individual elements of the NIHSS has been shown to be generally good[7].  However, overall scoring can be inconsistent, so proper training is required to use the NIHSS accurately[8][9][10]. A simpler, modified version of the NIHSS has been found to have greater inter-rater reliability with equivalent clinical performance[11].

  • A study of 4 patients assessed by 30 physicians and 29 study coordinators, with a space of 3 months between assessments, found that the NIHSS has excellent interrater (ICC = 0.95) and test-retest reliability (ICC = 0.93)[12]
  • A study of 20 patients rated by 4 clinicians, with each patient subsequently evaluated by 2 independent observers found Adequate to Excellent inter-rater agreement for 9 of the 13 items on the NIHSS (Kappa = 0.32 to 0.79); lowest levels of agreement were found for the Facial palsy (Kappa = 0.22) and limb ataxia (Kappa = -0.16) items[13].
  • 4 items have poorly reliability or are redundant (level of consciousness, facial weakness, ataxia, and dysarthria[14].

Validity[edit | edit source]

Outcomes related to NIHSS scores at admission[15][16]:

  • Scores of <5; 80% of stroke survivors will be discharged to home.
  • Score between 6 and 13 typically require acute inpatient rehabilitation.
  • Scores of >14 frequently require long-term skilled care.


The validity of the NIHSS is reduced if there is a language barrier, if the patient previously had a neurological deficit or if they are intubated[17]. Moreover, there was found to be differences between the average NIHSS of patients with a good functional outcome between posterior circulation stroke and anterior circulation stroke[18].

Responsiveness[edit | edit source]

NIHSS scores were compared to infarction size (measured by computed tomography) on 65 patients at 1 week post stroke. 10 items demonstrated an average of 25% change over 7 days. However, changes in limb ataxia and best gaze may have been overstated[6].

Links[edit | edit source]

NIH Stroke Assessment Tool PDF

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 NIH Stroke Scale. Approach to Human Subject Protection and Patient Safety. Available from: https://www.nihstrokescale.org/ (Accessed 12/07/2022)
  2. ↑ 2.0 2.1 Spilker J, Kongable G, Barch C, Braimah J, Brattina P, Daley S, Donnarumma R, Rapp K, Sailor S. Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group. J Neurosci Nurs. 1997 Dec;29(6):384-92.
  3. ↑ H.P. Adams Jr., P.H. Davis, E.C. Leira, K.-C. Chang, B.H. Bendixen, W.R. Clarke, R.F. Woolson, Hansen, MS. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology July 1, 1999 vol. 53 no. 1 126
  4. ↑ Runde D. Calculated Decisions: NIH stroke scale/score (NIHSS). Emerg Med Pract. 2020 Jul 15;22(7):CD6-CD7.
  5. ↑ Know Stroke. NIH Stroke Scale. Available from https://www.stroke.nih.gov/resources/scale.htm (Accessed 12/07/2022)
  6. ↑ 6.0 6.1 Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, et al. Measurements of acute cerebral infarction: a clinical examination scale. 1989. Stroke 20(7): 864-870.
  7. ↑ Josephson SA1, Hills NK, Johnston SC.. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis. 2006;22(5-6):389-95.
  8. ↑ André C. The NIH Stroke Scale is unreliable in untrained hands. J Stroke Cerebrovasc Dis. 2002 Jan-Feb;11(1):43-6.
  9. ↑ Lyden P1, Raman R, Liu L, Emr M, Warren M, Marler J. National Institutes of Health Stroke Scale certification is reliable across multiple venues. Stroke. 2009 Jul;40(7):2507-11.
  10. ↑ Lyden P, Raman R, Liu L, Grotta J, Broderick J, Olson S, Shaw S, Spilker J, Meyer B, Emr M, Warren M, Marler J. NIHSS training and certification using a new digital video disk is reliable. Stroke. 2005 Nov;36(11):2446-9.
  11. ↑ EB Medicine. Current Topics in Acute Stroke Care. Available from https://www.ebmedicine.net/topics/stroke/stroke-imaging-modalities-CRAO/calculators (Accessed 12/07/2022)
  12. ↑ Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale Extension to Non-Neurologists in the Context of a Clinical Trial. Stroke. 1997;28:307–310
  13. ↑ Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol. 1989 Jun;46(6):660-2.
  14. ↑ Kasner SE. Clinical interpretation and use of stroke scales. Lancet Neurol. 2006 Jul;5(7):603-12.
  15. ↑ Schlegel D, Kolb SJ, Luciano JM, Tovar JM, Cucchiara BL, Liebeskind DS, Kasner SE. Utility of the NIH Stroke Scale as a predictor of hospital disposition. Stroke. 2003 Jan;34(1):134-7
  16. ↑ Rundek T, Mast H, Hartmann A, Boden-Albala B, Lennihan L, Lin IF, et al. Predictors of resource use after acute hospitalization: the Northern Manhattan Stroke Study. Neurology. 2000 Oct 24;55(8):1180-7
  17. ↑ MD Calc. NIH Stroke Scale/Score (NIHSS). Available from: https://www.mdcalc.com/calc/715/nih-stroke-scale-score-nihss (Accessed 12/07/2022)
  18. ↑ Kazi SA, Siddiqui M, Majid S. Stroke Outcome Prediction Using Admission Nihss In Anterior And Posterior Circulation Stroke. J Ayub Med Coll Abbottabad. 2021 Apr-Jun;33(2):274-278


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