or limited cooperation but a score of 3 should be used only if the 2 = Severe aphasia; all patient is mute and follows no one step commands. For children communication is through age 2 years to 6 years (or older children with premorbid language skills <6 year level), score this item based on observations of fragmentary expression; great need for inference, language comprehension and speech during the examination. questioning, and guessing by The patient with brain stem stroke who has bilateral loss of the listener. Range of sensation is scored 2. If the patient does not respond and is quadriplegic score 2. Patients in coma (item 1a = 3) are arbitrarily information that can be exchanged is limited; listener given a 2 on this item. carries burden of communication. Examiner cannot identify materials provided from patient 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 0 = Normal. must be obtained by asking patient to read or repeat words from 1 = Mild to moderate; patient the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the slurs at least some words and, at worst, can be understood patient is intubated or has other physical barrier to producing with some difficulty. speech, may the item be scored "9", and the examiner must 2 = Severe; patient's speech is clearly write an explanation for not scoring. Do not tell the patient why he/she is being tested. so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. 9 = Intubated or other physical barrier, explain. 11. Extinction and inattention (formerly neglect): Sufficient information to identify neglect may be obtained during 0 = No abnormality. the prior testing. If the patient has a severe visual loss preventing 1 = Visual, tactile, auditory, visual double simultaneous stimulation, and the cutaneous stimuli spatial, or personal inattention or extinction to are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The bilateral simultaneous presence of visual spatial neglect or anosognosia may also be stimulation in one of the taken as evidence of abnormality. Since the abnormality is scored sensory modalities. only if present, the item is never untestable. 2 = Profound hemi-inattention or hemi-inattention to more than one modality. Does not https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 47/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate recognize own hand or orients to only one side of space. Table S1. Language testing items for PedNIHSS: Repetition Each of 4 word-repetition tasks is presented: a. Stop b. Stop and go c. If it rains we play inside d. The President lives in Washington Reading Each of 3 items is presented for the child to read (see separate "Reading items figure for PedNIHSS"). Adjust expectations according to child's age/school level. Name Pictures are presented of a clock, pencil, skateboard, shirt, baseball, and bicycle (see separate "Picture naming figure for PedNIHSS"). Fluency and word finding The Cookie theft picture is presented and the child is asked to describe what he/she sees (see separate "Cookie theft picture for NIHSS and PedNIHSS"). NIHSS: National Institutes of Health Stroke Scale; PedNIHSS: Pediatric National Institutes of Health Stroke Scale. Reproduced with permission from: Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42:613. Copyright 2011 Lippincott Williams & Wilkins. Graphic 76120 Version 2.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 48/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Reading items figure for PedNIHSS Words to test reading for Item 9 (Best language) of PedNIHSS. Reproduced with permission from: Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42:613. Copyright 2011 Lippincott Williams & Wilkins. Graphic 83404 Version 4.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 49/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Picture naming figure for PedNIHSS Pictures to test naming for Item 9 (Best language) of PedNIHSS. Reproduced with permission from: Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42:613. Copyright 2011 Lippincott Williams & Wilkins. Graphic 83405 Version 4.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 50/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Cookie theft picture for NIHSS and PedNIHSS Cookie theft picture to test story-telling for Item 9 Best language of NIHSS and PedNIHSS. Reproduced with permission from: Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42:613. Copyright 2011 Lippincott Williams & Wilkins. Graphic 83406 Version 4.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 51/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Canadian Neurological Scale Patient Name: Rater Name: Date: Time: Mentation Score Level consciousness Alert 3.0 Drowsy 1.5 Orientation Oriented 1.0 Disoriented/NA 0.0 Speech Normal 1.0 Expressive deficit 0.5 Receptive deficit 0.0 TOTAL: Motor functions (no comprehension deficit) Weakness Score Face None 0.5 Present 0.0 Arm: proximal None 1.5 Mild 1.0 Significant 0.5 Total 0 Arm: distal None 1.5 Mild 1.0 Significant 0.5 Total 0 Leg None 1.5 Mild 1.0 Significant 0.5 Total 0 TOTAL: Motor response (comprehension deficit) Score https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 52/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Face Symmetrical .5 Asymmetrical 0 Arms Equal 1.5 Unequal 0 Legs Equal 1.5 Unequal 0 TOTAL: Reproduced with permission from: C t R, Hachinski VC, Shurvell BL, et al. The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke 1986; 17:731. Copyright 1986 Lippincott Williams & Wilkins. Graphic 55644 Version 9.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 53/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Barthel Index Activity Score Feeding 0 = Unable 5 = Needs help cutting, spreading butter, etc, or requires modified diet 10 = Independent Bathing 0 = Dependent 5 = Independent (or in shower) Grooming 0 = Needs to help with personal care 5 = Independent face/hair/teeth/shaving (implements provided) Dressing 0 = Dependent 5 = Needs help but can do about half unaided 10 = Independent (including buttons, zips, laces, etc) Bowels 0 = Incontinent (or needs to be given enemas) 5 = Occasional accident 10 = Continent Bladder 0 = Incontinent, or catheterized and unable to manage alone 5 = Occasional accident 10 = Continent Toilet use 0 = Dependent 5 = Needs some help, but can do something alone 10 = Independent (on and off, dressing, wiping) Transfers (bed to chair and back) https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 54/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate 0 = Unable, no sitting balance 5 = Major help (one or two people, physical), can sit 10 = Minor help (verbal or physical) 15 = Independent Mobility (on level surfaces) 0 = Immobile or <50 yards 5 = Wheelchair independent, including corners, >50 yards 10 = Walks with help of one person (verbal or physical) >50 yards 15 = Independent (but may use any aid; for example, stick) >50 yards Stairs 0 = Unable 5 = Needs help (verbal, physical, carrying aid) 10 = Independent Total (0-100): The Barthel ADL Index: Guidelines The index should be used as a record of what a patient does, not as a record of what a patient could do The main aim is to establish degree of independence from any help, physical or verbal, however minor and for whatever reason The need for supervision renders the patient not independent Patient performance should be established using the best available evidence provided by the patient, family, friends and caregivers; direct observation and common sense are also important, but direct testing is not needed Usually the patient's performance over the preceding 24 to 48 hours is important, but occasionally longer periods will be relevant Middle categories imply that the patient supplies over 50 percent of the effort Use of aids to be independent is allowed ADL: activities of daily living. References: 1. Mahoney FI, Barthel D. Functional evaluation: The Barthel Index. Maryland State Medical Journal 1965; 14:56. Used with permission. 2. Loewen SC, Anderson BA. Predictors of stroke outcome using objective measurement scales. Stroke 1990; 21:78. 3. Gresham GE, Phillips TF, Labi ML. ADL status in stroke: Relative merits of three standard indexes. Arch Phys Med Rehabil 1980; 61:355. 4. Collin C, Wade DT, Davies S, Horne V. The Barthel ADL Index: A reliability study. Int Disability Study 1988; 10:61. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 55/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Graphic 77371 Version 3.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 56/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Modified Rankin Scale Score Description 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance 3 Moderate disability; requiring some help, but able to walk without assistance 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent, and requiring constant nursing care and attention 6 Dead Reproduced with permission from: Van Swieten JC, Koudstaa PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604. Copyright 1988 Lippincott Williams & Wilkins. Graphic 75411 Version 13.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 57/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate 2 ABCD score 2 The ABCD score can be used to estimate the risk of ischemic stroke in the first two days after TIA. The score is tallied as follows: Age: 60 years 1 point <60 years 0 points Blood pressure elevation when first assessed after TIA: Systolic 140 mmHg or diastolic 90 mmHg 1 point Systolic <140 mmHg and diastolic <90 mmHg 0 points Clinical features: Unilateral weakness 2 points Isolated speech disturbance 1 point Other 0 points Duration of TIA symptoms: 60 minutes 2 points 10 to 59 minutes 1 point <10 minutes 0 points Diabetes: Present 1 point Absent 0 points Data from: Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and re nement of scores to predict very early stroke risk after transient ischaemic attack. Lancet 2007; 369:283. Graphic 62381 Version 3.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 58/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Contributor Disclosures Larry B Goldstein, MD, FAAN, FANA, FAHA No relevant financial relationship(s) with ineligible companies to disclose. 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. 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/use-and-utility-of-stroke-scales-and-grading-systems/print 59/59