NIH Stroke Scale and Neuro Assessment

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Introduction   

According to the Centers for Disease Control and Prevention (CDC), approximately 795,000 people in the United States have a stroke every year. Strokes may occur at any age, although the risk of a stroke increases with age. This single neurological event is the leading cause of long-term disability, and heightens the risk of additional health complications, often in conjunction with the long-term burdens of rising medical costs, decreased quality of life, and shortened life spans.  

Stroke treatment protocols are activated, based on time of onset, location and type of stroke, as well as severity of stroke. The use of approved, standardized assessment tools streamlines these treatment protocols and facilitates rapid communication between all levels of providers. 

The National Institutes of Health Stroke Scale (NIHSS) is the gold standard for rapid stroke assessment and intervention. Accompanied by various ongoing neurological assessments, the client who had a stroke is afforded the best treatment guidelines. This course will overview various assessments of the client who had a stroke and discuss treatment options, as well as prevention strategies for future risk reduction (specific to stroke risk reduction, although applicable to various chronic health conditions).  

Definition 

The NIHSS (National Institutes of Health) Stroke Scale was developed in 1989, and consists of a 15-item impairment scale. Each item is scored, with the final score range of 0-42 points. Used in the evaluation of strokes, the NIHSS scores are thought to be reflective of the clinical outcomes. Total scores less than 4 indicate favorable outcomes, while scores greater than 21 indicate severe strokes. NIHSS scores of greater than 22 are at greater risk of hemorrhagic conversion, if given tPA (tissue plasminogen activator) protocol. (3,4,5)  

NIHSS Overview 

NIHSS Scoring and Interpretation 

The severity of a stroke may be determined by the objective scoring of the NIHSS. As the total scores may range anywhere from 0-42, the following ranges reflect stroke severity and are often used to guide treatment protocols. (6,7) 

Scores as follows: 

Ideally, the NIHSS is completed in less than 10 minutes, and is considered an objective, formal method to assess the severity of a stroke.  

The NIHSS is routinely performed at various stages throughout the acute care of a client who is experiencing a stroke as well as during stages of the client’s ongoing rehabilitation and recovery (8): 

• Initial evaluation (and ongoing at various timed intervals) in the emergency department setting  
• Prior to the initiation of any reperfusion therapy (to have a baseline score with which to evaluate the effect of the therapy) 
• During reperfusion treatment, usually at timed intervals (for example, every 2 hours x 24 hours, then every 4 hours ongoing throughout hospital stay) 
• Ongoing neurological assessments per plan of care 
• Anytime the client’s current neurological condition has changed  

NIHSS Assessment Findings 

The NIHSS measures a client’s brain function, and includes an assessment of the following abilities (9): 

• Level of consciousness  
• Visual ability 
• Sensation ability (detecting touch) 
• Independent movement (movement upon verbal request) 
• Capacity of speech and language  

NIHSS Benefits and Challenges 

The reliability / validity of the NIHSS is challenging when the acute neurological client has the following situations; these “outliers” that affect the overall scoring must be taken into account and documented appropriately so as not to negatively influence treatment options: 

• The existence of any language barrier (to include, but not limited to foreign languages and sign language) 
• Previous / preexisting neurological deficits (to include previous stroke, as well as known traumatic brain injuries) 
• Client is currently on ventilator/ intubated/sedated per protocol  

The NIHSS relativity is highly regarded in the treatment and stabilization of acute neurological injuries due to the following reasons: 

• The assessment form is objective and standardized, which allows all healthcare providers to streamline treatments and monitor client progress. 
• The assessment total scores have been proven to predict accuracy in the projected stroke outcomes and thus, can be used to navigate post stroke management guidelines 
• The NIHSS has a high inter-rater reliability, meaning that various healthcare professionals (in multiple clinical practices) are using the forms and obtaining similar scores, which adds another layer of consistency in stroke management care continuum. 
• The NIHSS offers versatility; it has been successfully used in research studies, clinical trials, and even virtual/ telehealth settings to accurately assess a client who had a stroke and align them with the most appropriate treatments. 

See attached NIHSS sample. 

The National Institutes of Health Stroke Scale (NIHSS) is a 15-item neurological examination that evaluates several areas that may be affected by an acute stroke. 

• Level of consciousness (is the client alert, oriented, and able to follow a simple command?) 
• Best gaze (is the client able to follow an object with their eyes?) 
• Visual field (is the client able to see things there are not in their direct field of vision/ placed directly in front of them?) 
• Facial palsy (is the client able to move their facial muscles appropriately?) 
• Motor arm (can the client hold their arm up without drifting for 10 seconds; does the arm drift downwards toward the bed?) 
• Motor leg (can the client hold their leg up at a 30-degree angle for at least five seconds; does the leg fall toward the bed?) 
• Limb ataxia (can the client touch their finger to their nose; can they run their heel down their shin on each side?) 
• Sensory (does the client react/ can they feel a pinprick to their face, arms, trunk of their body, and their legs?) 
• Best language (how does the client express themselves; can they express their ideas without difficulty?) 
• Dysarthria (does the client have any slurring of their speech?) 
• Extinction and inattention (is the client aware/ attentive to their current environment?) 

Language Assessment Tools in Stroke Scale 

In addition to the physical assessment part of the NIHSS, there are also four pages of images and words to further determine the location and extent of a stroke. 

At first glance, these images and words may not “make sense” when viewed objectively. They do, however, provide critical insights into the location and severity of the suspected stroke. The following is a brief overview of each section.  

In the first two images, there are a series of objects. The client is asked to describe (name) each object. In doing so, the client is being evaluated in several areas: cognition, communication, any obvious language deficits.  

The drawback of this section is that there are concerns that variables such as client age, demographics, and geographical locations may affect outcomes in this area. For example, depending on where the client has lived, they may have never even seen cacti. The feather in the image has been described as a bird feather, but also a feather writing quill. The glove has been described as a glove, as well as a mitten. 

In the “kitchen” image, there are several objects and situations occurring. The client is asked to describe what they see. The simple identification of objects, as well as the scenarios occurring (“the sink is overfull and flooding; the boy is about to fall of the stool”) allow to further assess a client’s speech, object identification, and ability to actually comprehend (and articulate) the various occurrences in the image. 

Image 1. NIHSS Language Assessment “Series of objects” image

Image 2. NIHSS Language Assessment “Kitchen scene” image 

The following two photos are the most recent updates to the NIHSS. These updates/ new additions in objects were found to be more contemporary, and less biased in content than previous samples when tested among healthy research participants (regardless of their age, sex, or ethnicity, or demographics). (10,11) 

Image 3. NIHSS Language Assessment updated images (10,11) 

Ability to Communicate 

In the following two sections, the client is asked to read the words and sentences out loud (see images 4 and 5). Several assessments are occurring as the client reads the words. The purpose of the words, and fragmented sentences are to assess for potential injury to the speech center of brain. These words and sentences are unrelated and are not meant to represent a story. They serve to challenge speech comprehension and the actual ability to form words (thus, evaluating muscle function related to speaking). The assessments occurring are an evaluation of comprehension and language ability, (and may also further evaluate a suspected injury to the visual field (vision loss/partial or full vision field loss). (12) 

The abnormal findings 

• Loss of language ability (can the client actually form the words/ read the words out loud, and read them in order?) 
• Loss of comprehension (can the client perform the requested task?) 
• Aphasia/ dysphagia assessment (comprehension of words being read; ability to read words; guessing and questioning of words) 
• Anarthria/ dysarthria assessment (difficulty in actually forming words/ speaking due to injury of the muscles used to speak; slurring of words) 

Image 4. NIHSS Speech comprehension and communication challenge: Random words 

Image 5. NIHSS Speech comprehension and communication challenge: Fragmented sentences 

Neurological Assessment Overview 

Components of a Neurological Assessment 

A neurological examination is done to assess a client’s motor and sensory skills, reflexes and nerve function. In addition, this examination can also test for balance and coordination as well as overall mental status. The extent of a neurological examination can be affected by many factors, including (but not limited to) preexisting comorbid conditions, acute illness or injury and the chronological age of the client. These factors must be acknowledged, in written form, within the assessment findings so as to not negatively impact outcomes that are based on “total scores” (such as the NIHSS stroke scale). (13) 

A neurological examination may be done for any of the following reasons: 

• During routine physical examination, annual wellness and preventive screenings 
• To evaluate the progression of a known neurodegenerative condition 
• To assess extent of injury after acute trauma (concussion, stroke) 
• To evaluate any new onset of changes in balance, behavior, coordination, mood or cognition  

The following areas will be evaluated during a neurological examination, dependent on presenting symptoms and medical complaints: 

• Mental status examination, to include level of alertness, orientation to surroundings, ability to communicate, speech patterns 
• Motor function, balance, coordination, symmetry in strength 
• Sensory perception to touch, temperature 
• Reflex evaluation 

A neurovascular assessment, in comparison, is done when there is a concern regarding a compromised blood flow to an area. Such compromise, left untreated, could lead to a permanent injury or death. Neurovascular assessments are often used to assess injuries of the musculoskeletal system (limb extremities fractures, including crush trauma injuries) but can also be utilized in a variety of cases including spinal surgery, complicated plastic surgery, and even the (nonsurgical) placement of a plaster cast. (14) 

The “6 Ps” of a neurovascular assessment are as follows: 

• Pain-pain extent and location  
• Paresthesia-numbness or tingling of extremity 
• Pulselessness-absence of pulse (by palpation with secondary assessment by doppler if necessary) 
• Pallor-paleness or discoloration of skin 
• Paralysis-inability to move the extremity 
• Poikilothermia- skin temperature (inability to maintain core body temperature) 

Cranial Nerve Assessment 

There are twelve sets of cranial nerves. They are responsible for sending electrical impulses (signals) from your brain to other parts of your body, including your face, head, neck and torso. These impulses are responsible for both sensory and motor function. (15,16) 

Two sets of cranial nerves (the olfactory and the optic nerve) are located in the cerebrum, the largest part of the brain, and are positioned above the brain stem. The remaining ten sets of cranial nerve are located in the brain stem and connect with the spinal cord. (15,16) 

The twelve cranial nerves are as follows: 

Two well-known mnemonics for remembering the names of the cranial nerves in order: (17) 

On old Olympus/s towering top, a Finn and German viewed some hops. 

Ooh, ooh, ohh to touch and feel very good velvet. Such heaven.  (or alternate ->Ah, Heaven) (S= Spinal accessory; A= Accessory) 

Cranial Nerve Testing, Clinical Signs/Symptoms, and Pathology of Abnormal Findings 

• CN1. Olfactory Nerve: Testing of this nerve is done to assess a client’s sense of smell. Cover one nostril while assessing the ability to smell/detect a smell with the unobstructed nostril, then repeat the process on the other nostril. The loss of smell, known as anosmia, may occur as the result of certain (non-neurological) infections or allergies, as well as due to the presence of nasal polyps. A reduced sense of smell, known as hyposmia, however, is considered a common symptom in early Parkinson’s disease, as well as some lesions located at the base of the skull (such as a meningioma which is a slow growing tumor). (18,19,20) 

• CN 2. Optic Nerve: Testing of this nerve will involve as assessment of both visual acuity and visual fields, with each eye being tested separately.  The pupillary light reflex (how does the pupil react to having light shined into it) will evaluate the ability to constrict and a fundoscopic examination will evaluate the actual optic disk. (18,19,20) 

Papillary edema and retinal hemorrhages can indicate increasing intracranial pressure and brain hemorrhage while the failure of pupils to react appropriately to light may indicate lesions of the optic nerve pathway.  Monocular blindness and cuts in the visual field may indicate pseudobulbar neuritis or pressure resulting from a pituitary tumor. (18,19,20) 

• CN 3, 4, and 6 Oculomotor, Trochlear, and Abducens Nerves: These three cranial nerves are all involved in eye muscle movement. The client is asked to follow the hand movements of the evaluator with only their eyes, as they draw an invisible letter “H” in front of them. Abnormal findings would range from a disconjugate gaze (eyes moving in different direction), involuntary eye movements (side to side, or up and down), and double vision.  The inability to perform this task may indicate a wide variety of conditions, ranging from increasing intracranial pressure, brain infarct, and even optic neuritis, suggestive of early Multiple Sclerosis. (18,19,20) 

• CN 5 Trigeminal Nerve: Assessment of this nerve involves asking the client to clench their jaw. As this nerve is involved in the ability to bite and chew (mastication), a noted weakness of this muscle would indicate possible nerve inflammation/ impairment. This nerve also supplies the sensation to the face, so sensory deficits in touch may indicate to further assess the possibility of nerve inflammation. (18,19,20) 

• CN 7 Facial Nerve: Assessment of this nerve involves asking the client to perform several movements, such as raising their eyebrows, closing their eyes very tightly, smiling and blowing up (puffing out) their cheeks. Deficits/ nerve impairment or inflammation are suspected when there is weakness on one side of the face, or the lower half of the face. There should be noted symmetry on both sides of the face. (18,19,20) 

• CN 8 Vestibulocochlear Nerve: Assessment of this nerve is done by whispering words behind the clients and rubbing fingers or hair together very close to the clients’ ear. The client should be asked if they can hear the sounds/ whispered words. If a hearing deficit is suspected, further testing can be used to differentiate between sensorineural hearing loss and conductive hearing loss. (18,19,20) 

• CN 9 and 10 Glossopharyngeal and Vagus Nerve: Assessment of this nerve is done by actively listening to the client’s speech and checking for hoarseness of voice or nasal speech. A swallow test can also be done, and the client is observed for any coughing or gurgling speech after swallowing sips of water. The client should also be asked to open their mouth wide and say “ah” while the provider observes for any asymmetry of the palatal arch (and deviation of the uvula to one side versus its usual centered position). (18,19,20) 

A swallow test is a standard assessment on a client with suspected stroke. It involves having the client takes sips of water and observing for difficulty in swallowing. Many facilities keep the client “NPO” until a swallow test is performed. (18,19,20) 

• CN 11 Spinal Accessory Nerve: Assessment of this nerve is done by asking the client to turn their head to each side, against resistance of the providers hand, and to shrug their shoulders.  The accessory nerve provides movement to muscles in the neck and shoulder, as well as to structures in the throat, including the larynx. (18,19,20) 

• CN 12 Hypoglossal Nerve: Assessment of this nerve involves inspection of the tongue inside the mouth, as well as asking the client to stick out their tongue. This cranial nerve is involved in the motor component of the tongue involving speech, swallowing and chewing of food. (18,19,20) 

Cranial Nerve Palsies  

The term palsy is used to indicate a paralysis of a cranial nerve, which results in some element of muscle weakness and movement irregularities. 

The following examples offer a brief overview of some cranial nerve palsies.  

• Oculomotor palsy or third nerve palsy is a condition in which one eye stays positioned/ fixed and gives the appearance that the client is looking down or out to the side.  
• Trochlear nerve palsy or fourth nerve palsy is a condition that causes double vision vertically as well as difficulty for that client in attempting to look downward. 
• Trigeminal neuralgia is a condition that affects the fifth cranial nerve and can cause severe facial pain, similar to electrical shocks.  
• Abducens nerve palsy or sixth nerve palsy is a condition that causes strabismus (or misalignment of the eyes) as well as double vision. 
• Facial nerve palsy or Bell’s palsy is a condition affecting the facial nerve, and usually results in temporary drooping of one side of the face. 

Cranial nerves pairs with anatomical sensory functions in outline diagram. Labeled educational collection with neurology brain system and how nerve relay information to human body vector illustration.[/caption]

Babinski Reflex 

The Babinski Reflex was discovered by neurologist Joseph Babinski in 1896. 

The Babinski reflex (also known as the plantar reflex) is a normal reflex present in infants and children roughly up to the age of two years old (although it may disappear within the first year of life). The reflex is absent in adults. (21,22) 

In evaluating for a Babinski reflex, the examiner will firmly stroke the sole of the foot, which should cause the big toe to move upward or toward the top surface of the foot, while the other toes fan out.  The occurrence of this reflex in an adult indicates some level of dysfunction (damage) of the brain or spinal cord. (21,22) 

A normal / negative Babinski sign (in an adult) would be the toes curling downward during the testing, or the foot remaining still.  

A positive Babinski sign would be (in an adult) would be the big toe lifting and the other toes spreading out.  

If an adult tests positive for a Babinski sign, it indicates there is damage to some aspect of the central nervous system that controls movement. The following conditions may “test positive” for the Babinski sign: (21,22) 

• Brain tumors 
• Meningitis 
• Multiple Sclerosis 
• Alzheimer’s dementia  
• Amyotrophic lateral sclerosis (ALS or Lou Gehrig disease) 
• Strokes 
• Spinal Cord Injury 

Acute Stroke Management 

Emergency Treatment for Acute Stroke 

Emergency stroke treatment interventions, based on initial and ongoing NIHSS, type of stroke and client stability, and preexisting medical conditions may include the following (23,24,25): 

• Activase tissue plasminogen activator thrombolytic (tPA) IV (intravenous) within first 3 hours of stroke onset or 
• Activase tissue plasminogen activator thrombolytic (tPA) IA (intraarterial) within 3-6 hours of stroke onset for anterior circulation stroke infarct  
• Craniotomy to remove blood clots, halt hemorrhagic bleeding, and reduce intracranial pressure increases through coiling, endovascular embolization, and surgical clipping of aneurysm. 
• Blood pressure stabilization measures (client-specific)  
• Secondary prevention measures (client-specific) 

For more information on Activase (rPA) administration, click on the following (healthcare professional) website: https://www.activase.com/ais/dosing-and-administration/dosing.html 

Self-Management Strategies 

In a very generic sense, unrelated to any specific neurological condition, the following self-management behaviors are recommended for any/all clients who have experienced (or are living with) the aforementioned conditions. As many neurology-based health conditions are chronic, and manageable, but not curable, the self-management guidelines pivot from traditional care plans aimed at restoring a client back to “former self” (pre-illness status) to maximizing current abilities/ stabilization (“the new normal”). (26,27) 

Self-management behaviors:  

• Medication adherence/ compliance to manage symptoms 
• Monitoring symptoms and reporting changes in health to client care provider team to reduce risk factors 
• Lifestyle assessment and modifications as indicated (proper nutrition, routine physical activity, sleep hygiene practices, stress management) 
• Physical activity / therapy to maintain current mobility and strength 
• Mental health support groups, counseling services as indicated for client/ family members 
• Interdisciplinary healthcare team to monitor disease progress, reduce risk factors, preventive wellness examination, and routine medical care 
• Meaningful and purposeful goals that add quality to daily life (these will be client specific, such as maximal independence, stabilization of disease process) 
• Ongoing education regarding the normal progression of a disease process, including end of life services when applicable 

https://www.neurologylive.com/view/understanding-approval-once-nightly-sodium-oxybate-pediatric-narcolepsy-anne-marie-morse 

Secondary Stroke Prevention / Risk Reduction 

The following are secondary prevention guidelines to treat the underlying causes of strokes (to lower the risk of recurrent stroke) (28). In stroke specific cases, there should also be a dedicated focus in reducing the risk of recurrent stroke.  

Guidelines that should be taken into consideration: 

• Antihypertensive therapies (preexisting history of hypertension) 
• Hyperlipidemia therapies (statin therapies in high-risk individuals) 
• Hyperglycemia therapies (preexisting diabetes medical condition) 
• Physical inactivity therapies (preexisting lifestyle behaviors versus post stroke limited mobility) 
• Proper nutritional therapies (to address any preexisting metabolic conditions {prediabetes, diabetes, metabolic syndrome} as well as to maintain optimal nutrition post stroke) 
• Lifestyle behavioral assessment and intervention. If the client has a history of alcohol and nicotine usage prior to stroke, client should be assessed for possible substance withdrawal in the acute phase of rehabilitation (and treated accordingly) 
• Antiplatelet and anticoagulant therapies if applicable (*may be contraindicated in cases of hemorrhagic stroke conditions) 

Stroke-Related Research Findings 

According to the American Heart Association, who released an overview of both heart disease and strokes in 2024, “strokes account for approximately 1 in every 21 deaths in the United States, with a person dying from a stroke every 3 minutes 14 seconds”. Despite advances in medicine occurring worldwide, this potentially catastrophic “event” continues to increase in strength. Thus, so does the ongoing research to find ways of improving detection, lowering risks, and positively influencing health outcomes. (29,30) 

The NIH Stroke Net, created by NINDS, is a data management center linked to over 500 stroke hospitals in the United States alone, and is conducting research studies and clinical trials in all facets of stroke management from the acute phase to rehabilitation therapies. Landmark trials included the DEFUSE 3 Trial, which improved outcomes in stroke management by showing the benefits to clients that received thrombectomies up to 16 hours after the onset of a stroke. Another funded trial was MISTIE lll trial, which is pioneering the way for the use of TPA with minimally invasive surgery to remove the stroke causing clot formation. (29,30) 

For more information on the above-mentioned clinical trials: 

• DEFUSE 3 trials
• MISTIE111 trials

Conclusion

The treatment of neurological clients is indeed complex. The need for objective data collection, free of bias and evaluator self-interpretation, is detrimental in determining treatment throughout the stroke care continuum (from emergency care to rehabilitation and beyond). The development of neurological assessment tools, such as the NIHSS, affords all levels of healthcare professionals the skillset to collect necessary assessments in streamlined fashion, as well as communicate these findings in universally acceptable terms (“NIHSS score is…..”) to all members of the clients medical team.  

The NIHSS certification is offered through the professional education hub at the American Heart Association. For more information, check the following link:  

https://education.heart.org/productdetails/nih-stroke-scale-test-group-a  

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