Nihss Stroke Scale Test A Answers

NIHSS Stroke Scale Test: A Comprehensive Guide to Scoring and Interpretation

The National Institutes of Health Stroke Scale (NIHSS) is the gold standard, quantifiable tool used by healthcare professionals worldwide to rapidly assess and document the neurological status of a patient with suspected acute stroke. Its precise and consistent application is not merely an academic exercise; it directly influences acute treatment decisions, such as eligibility for life-saving thrombolytic therapy or mechanical thrombectomy, and provides a critical baseline for monitoring neurological change. Understanding the correct answers for each item on the NIHSS—what constitutes a score of 0, 1, or 2—is fundamental for any clinician involved in stroke care. This article provides a detailed, item-by-item breakdown of the NIHSS, clarifying the scoring criteria to ensure accurate, reliable, and clinically meaningful assessments.

The Critical Role of the NIHSS in Acute Stroke Management

Before diving into the specific test items, it is essential to understand why precise scoring matters. The NIHSS generates a total score ranging from 0 (no stroke symptoms) to 42 (maximally severe stroke). This numerical value is a powerful predictor of short-term and long-term outcomes. A higher baseline NIHSS score correlates strongly with larger infarct volumes, increased risk of hemorrhagic transformation, poorer functional recovery, and higher mortality. Furthermore, in the hyper-acute window, a significant improvement or deterioration in the NIHSS score (often defined as a change of 4 or more points) can signal treatment success or complication, respectively. Therefore, the "answers" are not about passing a test; they are about capturing the true, objective severity of a patient's neurological deficit at a single point in time.

Detailed Item-by-Scale Breakdown: The "Answers" Explained

The NIHSS is administered in a specific order. The examiner must follow this sequence and use the exact wording of the commands and questions provided in the official scale to maintain standardization.

1. Level of Consciousness (LOC)

This is a two-part assessment.

• 1a. LOC Questions: The patient is asked the month and their age. Score 0 if both answers are correct. Score 1 if one answer is correct. Score 2 if neither is correct. A patient who is unable to speak due to dysarthria or aphasia but who clearly understands the question and can write or nod the correct answer should be scored 0.
• 1b. LOC Commands: The patient is instructed to open and close their eyes, then grip and release the non-paretic hand. Score 0 if both commands are performed correctly. Score 1 if one command is performed correctly. Score 2 if neither is performed correctly. Again, comprehension is key. A patient who cannot speak but follows the command perfectly scores 0.

2. Best Gaze

This tests horizontal eye movement. The examiner assesses for "forced gaze deviation" or "gaze preference"—the eyes resting in a deviated position at baseline, which the patient cannot overcome voluntarily.

• Score 0: Normal, smooth pursuit in both directions.
• Score 1: Forced gaze deviation or partial gaze palsy. The patient may have difficulty moving eyes fully to one side, but the deviation is not "forced" (i.e., they can overcome it with a vestibulo-ocular reflex test like the "doll's eyes" maneuver if the brainstem is intact).
• Score 2: Forced gaze deviation. The eyes are "locked" in a deviated position and cannot be moved horizontally by command or by the vestibulo-ocular reflex. This is a sign of a large hemispheric or pontine lesion.

3. Visual Fields

Using the confrontation method (waving fingers in each quadrant), the examiner tests all four quadrants of each eye.

• Score 0: No visual field defect.
• Score 1: Partial hemianopia—a defect in one or more quadrants on one side.
• Score 2: Complete hemianopia—loss of vision in an entire half of the visual field in both eyes.
• Score 3: Bilateral blindness or bilateral visual field defects (e.g., homonymous hemianopia in both eyes, or complete blindness from ocular causes). This score is rare but indicates profound bilateral post-chiasmal pathology.

4. Facial Palsy

The examiner asks the patient to show teeth, raise eyebrows, and close eyes tightly. Observe for symmetry.

• Score 0: Normal symmetrical movement.
• Score 1: Mild asymmetry. A "smile" may be slightly flattened on the paretic side, or forehead wrinkling may be slightly reduced.
• Score 2: Moderate to complete paralysis. The affected side of the face shows no movement—the smile is grossly asymmetric, the eye does not close, and the nasolabial fold is flattened.

5. Motor Arm

The patient holds each arm outstretched, palms up, at 90 degrees (if sitting) or 45 degrees (if supine) for 10 seconds. The examiner observes for downward drift before the 10 seconds.

• Score 0: No drift; arm holds position.
• Score 1: Drift. The arm drifts down but does not hit the bed or support surface before 10 seconds.
• Score 2: Some effort against gravity. The arm can achieve position but drifts down and hits support before 10 seconds.
• Score 3: No effort against gravity. The arm falls immediately and cannot be held up at all.
• Score 4: No movement. The patient cannot even initiate the movement.
• Important: Test the non-paretic arm first. If the patient is unable to follow commands due to aphasia but appears to try, score based on observed

movement. If the arm is plegic, it will not move at all; if it is weak, it will drift.

6. Motor Leg

The patient holds each leg outstretched for 5 seconds. The examiner observes for downward drift before the 5 seconds.

• Score 0: No drift; leg holds position.
• Score 1: Drift. The leg drifts down but does not hit the bed before 5 seconds.
• Score 2: Some effort against gravity. The leg can achieve position but drifts down and hits support before 5 seconds.
• Score 3: No effort against gravity. The leg falls immediately and cannot be held up at all.
• Score 4: No movement. The patient cannot even initiate the movement.

7. Limb Ataxia

The examiner tests finger-to-nose and heel-to-shin movements in each limb.

• Score 0: No ataxia. Movements are smooth and accurate.
• Score 1: Mild ataxia. There is mild dysmetria or incoordination, but the patient can still complete the task.
• Score 2: Severe ataxia. The patient cannot perform the task at all due to profound incoordination.

8. Sensory

The examiner tests light touch, pinprick, and proprioception in each limb.

• Score 0: No sensory loss. The patient correctly identifies all stimuli.
• Score 1: Mild sensory loss. The patient has some difficulty identifying stimuli but can still do so with concentration.
• Score 2: Severe sensory loss. The patient cannot identify stimuli in one or more limbs.

9. Language

The examiner assesses the patient's ability to speak, understand, read, and write.

• Score 0: Normal. The patient can speak fluently, understand speech, read, and write.
• Score 1: Mild aphasia. The patient has some difficulty with speech or comprehension but can still communicate basic needs.
• Score 2: Severe aphasia. The patient cannot speak or understand speech at all.

10. Extinction and Inattention

The examiner tests for neglect or extinction by simultaneously touching both sides of the body.

• Score 0: No neglect or extinction. The patient correctly identifies stimuli on both sides.
• Score 1: Mild neglect or extinction. The patient has some difficulty identifying stimuli on one side but can still do so with concentration.
• Score 2: Severe neglect or extinction. The patient cannot identify stimuli on one side at all.

Conclusion

The NIH Stroke Scale is a valuable tool for assessing the severity of stroke and guiding treatment decisions. By systematically evaluating each component, clinicians can quickly identify the extent of neurological impairment and tailor interventions accordingly. While the scale is not perfect, it provides a standardized framework for communication among healthcare providers and helps ensure that patients receive timely and appropriate care.