(e.g. hip flex) 4 no movement; patient has no ability to enact voluntary movement in this leg notes default coma score: 8 this is performed for each leg, indicating a maximum possible score of 8 test the non paralyzed leg first if applicable motor leg assessment should be skipped in the case of an amputee, however a note should be made in the score records if patient is unable to understand commands, the investigator should deliver the instructions via demonstration 7. limb ataxia this test for the presence of a unilateral cerebellar lesion, and distinguishes a difference between general weakness and incoordination. the patient should be instructed to first touch his or her finger to the examiner's finger then move that finger back to his or her nose, repeat this movement 3-4 times for each hand. next the patient should be instructed to move his or her heel up and down the shin of his or her opposite leg. this test should be repeated for the other leg as well. score test results 0 normal coordination; smooth and accurate movement 1 ataxia present in 1 limb; rigid and inaccurate movement in one limb 2 ataxia present in 2 or more limbs: rigid and inaccurate movement in both limbs on one side notes if significant weakness is present, score 0 if patient is unable to understand commands or move limbs, score is 0 patient's eyes should remain open throughout this section if applicable, test the un-paretic side first 8. sensory sensory testing is performed via pinpricks in the proximal portion of all four limbs. while applying pinpricks, the investigator should ask whether or not the patient feels the pricks, and if he or she feels the pricks differently on one side when compared to the other side. score test results 0 no evidence of sensory loss 1 mild-to-moderate sensory loss; patient feels the pinprick, however he or she feels as if it is duller on one side 2 severe to total sensory loss on one side; patient is not aware he or she is being touched in all unilateral extremities notes default coma score: 2 the investigator should insure that the sensory loss being detected is a result of the stroke, and should therefore test multiple spots on the body. for patients unable to understand the instructions, the pinprick can be replaced by a noxious stimulus and the grimace can be judged to determine sensory score. 9. language this item measures the patient's language skills. after completing items 1-8, it is likely the investigator has gained an approximation of the patient's language skills; however, it is important to confirm this measurement at this time. the stroke scale includes a picture of a scenario, a list of simple sentences, a figure of assorted random objects, and a list of words. the patient should be asked to explain the scenario depicted in the first figure. next, the patient should read the list of sentences and name each of the objects depicted in the next figure. the scoring for this item should be based on both the results from the test performed in this item in addition to the language skills demonstrated up to this point in the stroke scale. score test results 0 normal; no obvious speech deficit 1 mild-to-moderate aphasia; detectable loss in fluency, however, the examiner should still be able to extract information from patient's speech 2 severe aphasia; all speech is fragmented, and examiner is unable to extract the figure's content from the patients speech. 3 unable to speak or understand speech notes default coma score: 3 patients with visual loss should be asked to identify objects placed in his or her hands this is an exception to recording only the patients first attempt. in this item, the patients best language skills should be recorded 10. speech dysarthria is the lack of motor skills required to produce understandable speech. dysarthria is strictly a motor problem, and is not related to the patient's ability to comprehend speech. strokes that cause dysarthria typically affect areas such as the anterior opercular, medial prefrontal and premotor, and anterior cingulate regions. these brain regions are vital in coordinating motor control of the tongue, throat, lips, and lungs. to perform this item the patient is asked to read from the list of words provided with the stroke scale while the examiner observes the patient's articulation and clarity of speech. score test results 0 normal; clear and smooth speech 1 mild-to-moderate dysarthria; some slurring of speech, however the patient can be understood 2 severe dysarthria; speech is so slurred that he or she cannot be understood, or patients that cannot produce any speech notes default coma score:2 an intubated patient should not be rated on this item, instead make note of the situation in the scoring documents. 11. extinction and inattention (f.k.a. neglect) sufficient information regarding this item may have been obtained by the examiner in items 1–10 to properly score the patient. however, if any ambiguity exist the examiner should test this item via a technique referred to as "double simultaneous stimulation". double simultaneous stimulation is performed by having the patient close his or her eyes and asking him or her to identify the side on which they are being touched by the examiner. during this time, the examiner is alternating between touching the patient on the right and left side. next, the examiner touches the patient on both sides at the same time. this should be repeated on the patients face, arms, and legs. to test extinction in vision, the examiner should hold up one finger in front of each of the patient's eyes and ask the patient to determine which finger is wiggling or if both are wiggling. the examiner should then alternate between wiggling each finger and wiggling both fingers at the same time. score test results 0 normal; patient correctly answers all questions 1 inattention on one side in one modality; visual, tactile, auditory, or spatial 2 hemi-inattention; does not recognize stimuli in more than one modality on the same side. notes default coma score: 2 patient with severe vision loss that correctly identifies all other stimulations scores a 0 usage the nihss was designed to be a standardized and repeatable assessment of stroke patients utilized by large multi-center clinical trials. clinical researchers have widely accepted this scale due to its high scoring consistency, which has been demonstrated in inter-examiner and in test-retest scenarios. clinical research use of the nihss typically involves obtaining a baseline nihss score as soon as possible after onset of stroke symptoms the nihss is then repeated at regular intervals or after significant changes in patient condition. this history of scores can then be utilized to monitor the effectiveness of treatment methods and quantify a patient's improvement or decline. the nihss has also been used in a prospective observational study, to predict 3 month outcomes of patients with undernutrition during hospital stays directly after a stroke. nihss use in tpa eligibility nihss has gained popularity as a clinical tool utilized in treatment planning. tissue plasminogen activator (tpa), a type of thrombolysis, is one of the main options for treatment of acute ischemic strokes (the type of stroke caused by blood clots that are preventing blood flow within a cerebral artery). the effectiveness and risk of tpa is strongly correlated with the delay between stroke onset and tpa delivery ("door-to-needle time"). current standards recommend for tpa to be delivered within 3 hours of onset, while best results occur when treatment is delivered within 90 minutes of onset. since the nihss has been established as a quick and consistent quantifier of stroke severity, many physicians have looked to nihss scores as indicators for tpa treatment. this rapid assessment of stroke severity is targeted to reduce delay of tpa treatment. while some clinical trials have used minimum and maximum nihss scores to determine eligibility for acute treatment such as tpa, guidelines such as those from the american heart association / american stroke association urge against nihss scores being used as the sole reason for declaring a patient as ineligible for tpa treatment. nihss structure in an effort to produce a complete neurological assessment the nihss was developed after extensive research and multiple iterations. the goal of the nihss was to accurately measure holistic neurological function by individually testing specific abilities. nihss total score is based on the summation of 4 factors. these factors are left and right motor function and left and right cortical function. the nihss assesses each of these specific functions by the stroke scale item listed in the chart below. left cortical right cortical right motor left motor loc questions horizontal eye movement right arm motor left arm motor loc commands visual fields right leg left leg language extinction and inattention dysarthria sensory modified national institutes of health stroke scale (mnihss) the modified nih stroke scale (mnihss) is a shortened, validated version of the mnihss. it has been shown to be equally, if not more, accurate than the longer, older nihss. it removes questions 1a, 4, and 7. this makes the mnihss shorter and easier to use. the mnihss predicts patients at high risk of hemorrhage if given tissue plasminogen activator (tpa) and which patients are likely to have good clinical outcomes. the mnihss has also recently been shown to be taken without seeing the patient, and only using medical records. this potentially improves care while in the emergency room and the hospital, but also facilitates retrospective research. accuracy the national institutes of health stroke scale has been repeatedly validated as a tool for assessing stroke severity and as an excellent predictor for patient outcomes. severity of a stroke is heavily correlated with the volume of brain affected by the stroke; strokes affecting larger portions of the brain tend to have more detrimental effects. nihss scores have been found to be reliable predictors of damaged brain volume, with a smaller nihss score indicating a smaller lesion volume. effect of stroke location on nihss prediction of stroke severity the nihss places 7 of the possible 42 points on abilities that require verbal skills; 2 points from the loc questions, 2 points from loc commands, and 3 points from the language item. the nihss only awards 2 points for extinction and inattention. approximately 98% of humans have verbal processing take place in the left hemisphere, indicating that the nihss places more value on deficits in the left hemisphere. this results in lesions receiving a higher (worse) score when occurring in the left hemisphere, compared to lesions of equal size in the right hemisphere. due to this emphasis, the nihss is a better predictor of lesion volume in the strokes occurring within the left cerebral hemisphere. nihss as predictor of patient outcomes the nihss has been found to be an excellent predictor of patient outcomes. a baseline nihss score greater than 16 indicates a strong probability of patient death, while a baseline nihss score less than 6 indicates a strong probability of a good recovery. on average, an increase of 1 point in a patient's nihss score decreases the likelihood of an excellent outcome by 17%. however, correlation between functional recovery and nihss scores was weaker when the stroke was isolated to the cortex. other stroke-related scores abcd² score chads2 score