NIH Stroke Scale: Difference between revisions
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== Objective  ==
== Objective  ==


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.   
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 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 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" />.  
 
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.  


== Intended Population  ==
== Intended Population  ==


Individuals with Stroke
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 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. A 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>. 
 
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.


The evaluation of stroke severity depends upon the ability of the observer to accurately and consistently assess the patient. Stroke severity may be stratified on the basis of NIHSS scores as follows:<ref name="brott">Brott, T., Adams, H. P., Jr., et al. (1989). "Measurements of acute cerebral infarction: a clinical examination scale." Stroke 20(7): 864-870.</ref>  
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>  


*Very Severe: &gt;25  
*Very Severe: &gt;25  
*Severe: 15 – 24  
*Severe: 15 – 24  
*Mild to Moderately Severe: 5 – 14  
*Mild to Moderately Severe: 5 – 14  
*Mild: 1 – 5
*Mild: 1 – 5'


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== Evidence  ==
== Evidence  ==
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=== 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>. &nbsp;However overall scoring can be inconsistent, proper training is required to use the NIH Stroke Scale 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>.
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)
*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 interrater 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.  
*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 weakness, ataxia, and dysarthria<ref>Kasner, S. E. (2006). "Clinical interpretation and use of stroke scales." Lancet Neurol 5(7): 603-612.</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<ref>Schlegel, D., Kolb, S. J., et al. (2003). "Utility of the NIH Stroke Scale as a predictor of hospital disposition." Stroke 34: 134-137.</ref><ref>Rundek, T., Mast, H., et al. (2000). "Predictors of resource use after acute hospitalization: the Northern Manhattan Stroke Study." Neurology 55: 1180-1187.</ref>  ===


Outcomes related to NIHSS scores at admission:  
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>.
*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


=== Responsiveness<ref name="brott" /> ===
=== Responsiveness ===


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.
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]
[https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf NIH Stroke Assessment Tool PDF]


== References  ==
== References  ==

Latest revision as of 12:07, 12 July 2022

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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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