2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in _____ effort against gravity. the case of amputation or joint fusion at the shoulder, the examiner should record the 3 = No effort against gravity; limb falls. score as untestable (UN), and clearly write 4 = No movement. the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 5a. Left arm 5b. Right arm 6. Motor leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The 0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. _____ 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and clearly write the explanation for this choice. 4 = No movement. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding 0 = Absent. _____ evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, 1 = Present in one limb. 2 = Present in two limbs. ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests UN = Amputation or joint fusion, explain:________________ are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 38/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 8. Sensory: Sensation or grimace to pinprick 0 = Normal; no sensory loss. when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial Only sensory loss attributed to stroke is scored as abnormal and the examiner pain with pinprick, but patient is aware of being touched. should test as many body areas (arms [not hands], legs, trunk, face) as needed to 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly and leg. _____ demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 9. Best language: A great deal of 0 = No aphasia; normal. _____ information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes the items on the attached naming sheet and to read from the attached list of sentences. conversation about provided materials Comprehension is judged from responses here, as well as to all of the commands in difficult or impossible. For example, in conversation about provided materials, the preceding general neurological exam. If examiner can identify picture or naming card content from patient's response. visual loss interferes with the tests, ask the patient to identify objects placed in the 2 = Severe aphasia; all communication is through fragmentary expression; great need hand, repeat, and produce speech. The intubated patient should be asked to write. for inference, questioning, and guessing by the listener. Range of information that can The patient in a coma (item 1a=3) will automatically score 3 on this item. The be exchanged is limited; listener carries burden of communication. Examiner cannot examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 39/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate patient is mute and follows no one-step identify materials provided from patient commands. response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be normal, an adequate sample of speech must 0 = Normal. 1 = Mild-to-moderate dysarthria; patient be obtained by asking patient to read or slurs at least some words and, at worst, can be understood with some difficulty. repeat words from the attached list. If the patient has severe aphasia, the clarity of 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence articulation of spontaneous speech can be rated. Only if the patient is intubated or has _____ of or out of proportion to any dysphasia, or is mute/anarthric. other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an UN = Intubated or other physical barrier, explanation for this choice. Do not tell the patient why he or she is being tested. explain:________________ 11. Extinction and inattention (formerly 0 = No abnormality. neglect): Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. 2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. _____ both sides, the score is normal. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. _____ Adapted from: 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. Graphic 61698 Version 8.0 https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 40/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Stroke outcome at three months in the placebo group of the NINDS trial Percent with favorable outcome Baseline NIHSS score (three-month NIHSS score = 0 or 1) Age <60 y 0-9 42 10-14 18 15-20 27 >20 12 Age 61-68 y 0-9 37 10-14 25 15-20 25 >20 0 Age 69-75 y 0-9 54 10-14 27 15-20 0 >20 0 Age >75 y 0-9 36 10-14 15 15-20 6 >20 0 NIHSS: National Institutes of Health Stroke Scale. Adapted from: NINDS t-PA Stroke Study Group, Stroke 1997; 28:2119. Graphic 81859 Version 4.0 https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 41/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Cerebral autoregulation in hypertension Schematic representation of autoregulation of cerebral blood flow in normotensive and hypertensive subjects. In both groups, initial increases or decreases in mean arterial pressure are associated with maintenance of cerebral blood flow due to appropriate changes in arteriolar resistance. More marked changes in pressure are eventually associated with loss of autoregulation, leading to a reduction (with hypotension) or an elevation (with marked hypertension) in cerebral blood flow. These changes occur at higher pressures in patients with hypertension, presumably due to arteriolar thickening. Thus, aggressive antihypertensive therapy will produce cerebral ischemia at a higher mean arterial pressure in patients with underlying hypertension. Redrawn from: Kaplan NM. Management of hypertensive emergencies. Lancet 1994; 344:1335. Based on data from: Strandgaard S, Paulson OB. Cerebral blood ow and its pathophysiology in hypertension. Am J Hypertens 1989; 2:486. Graphic 57676 Version 5.0 https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 42/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Options to treat hypertension before and during reperfusion therapy for acu te ischemic stroke Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mmHg* Labetalol 10 to 20 mg intravenously over 1 to 2 minutes, may repeat one time; or Nicardipine 5 mg/hour intravenously, titrate up by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; when desired blood pressure reached, adjust to maintain proper blood pressure limits; or Clevidipine 1 to 2 mg/hour intravenously, titrate by doubling the dose every 2 to 5 minutes, maximum 21 mg/hour, until desired blood pressure reached ; or Other agents (hydralazine, enalaprilat, etc) may also be considered If blood pressure is not maintained at or below 185/110 mmHg, do not administer alteplase Management to maintain blood pressure at or below 180/105 mmHg during and after acute reperfusion therapy* Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours If systolic blood pressure is >180 to 230 mmHg or diastolic is >105 to 120 mmHg: Labetalol 10 mg intravenously followed by continuous infusion 2 to 8 mg/min; or Nicardipine 5 mg/hour intravenously, titrate up to desired effect by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour; or Clevidipine 1 to 2 mg/hour intravenously, titrate by doubling the dose every 2 to 5 minutes, maximum 21 mg/hour, until desired blood pressure reached If blood pressure is not controlled or diastolic blood pressure >140 mmHg, consider intravenous sodium nitroprusside Different treatment options may be appropriate in patients who have comorbid conditions that may benefit from acute reductions in blood pressure, such as acute coronary event, acute heart failure, aortic dissection, or preeclampsia/eclampsia. Clevidipine has been included as part of the 2018 guidelines for the early management of patients with acute ischemic stroke [1] . Reference: 1. Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e46. Adapted with permission. Stroke. 2013: 44:870-947. Copyright 2013 American Heart Association, Inc. https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 43/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Graphic 50725 Version 15.0 https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 44/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Indications for mechanical thrombectomy to treat patients with acute ischemic IV: intravenous; tPA: tissue plasminogen activator (alteplase or tenecteplase); CTA: computed tomography an artery occlusion; MT: mechanical thrombectomy; ASPECTS: Alberta Stroke Program Early CT Score; NIHSS: Na tomography; MRI: magnetic resonance imaging; mRS: modified Rankin Scale; MCA: middle cerebral artery; IC recovery. Patients are not ordinarily eligible for IV tPA unless the time last known to be well is <4.5 hours. However, im that is diffusion positive and FLAIR negative) is an option at expert stroke centers to select patients with wake associated UpToDate topics for details. Usually assessed with MRA or CTA, less often with digital subtraction angiography. There is intracranial arterial occlusion of the distal ICA, middle cerebral (M1/M2), or anterior cerebral (A1/A2 MT may be a treatment option for patients with acute ischemic stroke caused by occlusion of the basilar ar stroke centers, but benefit is uncertain. [1] Based upon data from the Aurora study . Reference: https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 45/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate 1. Albers GW, Lansberg MG, Brown S, et al. Assessment of Optimal Patient Selection for Endovascular Thrombectomy Beyond 6 Hou Neurol 2021; 78:1064. Graphic 117086 Version 3.0 https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 46/47 7/5/23, 12:11 PM Initial assessment and management of acute stroke - UpToDate Contributor Disclosures Jamary Oliveira-Filho, MD, MS, PhD No relevant financial relationship(s) with ineligible companies to disclose. Michael T Mullen, MD Grant/Research/Clinical Trial Support: NINDS [Asymptomatic carotid disease]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. Jonathan A Edlow, MD, FACEP No relevant financial relationship(s) with ineligible companies to disclose. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/initial-assessment-and-management-of-acute-stroke/print 47/47