29/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The Los Angeles Motor Scale (LAMS) Facial droop Absent 0 Present 1 Arm drift Absent 0 Drifts down 1 Falls rapidly 2 Grip strength Normal 0 Weak grip 1 No grip 2 From: Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identi es ischemic stroke patients harboring persisting large arterial occlusions. Stroke 2008; 39:2264. DOI: 10.1161/STROKEAHA.107.508127. Copyright 2008 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 130951 Version 1.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 30/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Cincinnati Stroke Triage Assessment Tool (C-STAT) Score Symptom NIHSS equivalent 1 on NIHSS item for Gaze 2 points Conjugate gaze deviation 1 on NIHSS item for Level of consciousness 1b and 1c 1 point Incorrectly answers at least one of two level of consciousness questions on NIHSS (age or current month) and does not follow at least one of two commands (close eyes, open and close hand) 2 on the NIHSS item for Motor arm 1 point Cannot hold arm (either right, left, or both) up to 10 seconds before arm(s) falls to bed NIHSS: National Institutes of Health Stroke Scale. From: Katz BS, McMullan JT, Sucharew H, et al. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke 2015; 46:1508. DOI: 10.1161/STROKEAHA.115.008804. Copyright American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 130949 Version 1.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 31/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The FAST-ED scale and its correspondence to the NIHSS NIHSS FAST-ED Item score source score Facial palsy Normal or minor paralysis 0 0 to 1 Partial or complete paralysis 1 2 to 3 Arm weakness No drift 0 0 Drift or some effort against gravity 1 1 to 2 No effort against gravity or no movement 2 3 to 4 Speech changes Absent 0 0 Mild to moderate 1 1 Severe, global aphasia, or mute 2 2 to 3 Eye deviation Absent 0 0 Partial 1 1 Forced deviation 2 2 Denial/neglect Absent 0 0 Extinction to bilateral simultaneous stimulation in only 1 sensory modality 1 1 Does not recognize own hand or orients only to one side of the 2 2 body FAST-ED: Field Assessment Stroke Triage for Emergency Destination; NIHSS: National Institutes of Health Stroke Scale. From: Lima FO, Silva GS, Furie KL, et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47:1997. DOI: 10.1161/STROKEAHA.116.013301. Copyright 2016 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 32/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Graphic 130950 Version 1.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 33/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate National Institutes of Health Stroke Scale (NIHSS) Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (ie, repeated requests to patient to make a special effort). Instructions Scale definition Score 1a. Level of consciousness: The investigator must choose a response if a full 0 = Alert; keenly responsive. 1 = Not alert; but arousable by minor stimulation to obey, answer, or respond. evaluation is prevented by such obstacles as an endotracheal tube, language barrier, 2 = Not alert; requires repeated stimulation orotracheal trauma/bandages. A 3 is scored to attend, or is obtunded and requires only if the patient makes no movement (other than reflexive posturing) in response _____ strong or painful stimulation to make movements (not stereotyped). to noxious stimulation. 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, and areflexic. 1b. Level of consciousness questions: The 0 = Answers both questions correctly. patient is asked the month and his/her age. The answer must be correct - there is no 1 = Answers one question correctly. 2 = Answers neither question correctly. partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from _____ any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues. 1c. Level of consciousness commands: The patient is asked to open and close the eyes 0 = Performs both tasks correctly. _____ 1 = Performs one task correctly. and then to grip and release the non-paretic hand. Substitute another one step 2 = Performs neither task correctly. command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (ie, https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 34/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or 0 = Normal. 1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the total gaze paresis is not present. 2 = Forced deviation, or total gaze paresis eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a not overcome by the oculocephalic maneuver. patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI), score a 1. _____ Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre- existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy. 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, 0 = No visual loss. 1 = Partial hemianopia. using finger counting or visual threat, as appropriate. Patients may be encouraged, 2 = Complete hemianopia. but if they look at the side of the moving fingers appropriately, this can be scored as 3 = Bilateral hemianopia (blind including cortical blindness). normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut _____ asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 4. Facial palsy: Ask - or use pantomime to encourage - the patient to show teeth or 0 = Normal symmetrical movements. _____ 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling). raise eyebrows and close eyes. Score symmetry of grimace in response to noxious 2 = Partial paralysis (total or near-total stimuli in the poorly responsive or non- paralysis of lower face). comprehending patient. If facial trauma/bandages, orotracheal tube, tape or https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 35/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate other physical barriers obscure the face, these should be removed to the extent 3 = Complete paralysis of one or both sides (absence of facial movement in the upper possible. and lower face). 5. Motor arm: The limb is placed in the 0 = No drift; limb holds 90 (or 45) degrees appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient hit bed or other support. is encouraged using urgency in the voice and pantomime, but not noxious 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) stimulation. Each limb is tested in turn, degrees, drifts down to bed, but has some effort against gravity. beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the _____ shoulder, the examiner should record the score as untestable (UN), and clearly write 3 = No effort against gravity; limb falls. 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 0 = No drift; leg holds 30-degree position appropriate position: hold the leg at 30 degrees (always tested supine). Drift is for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. against gravity. _____ Only in the case of amputation or joint fusion at the hip, the examiner should 3 = No effort against gravity; leg falls to bed immediately. record the score as untestable (UN), and 4 = No movement. clearly write the explanation for this choice. UN = Amputation or joint fusion, explain:________________ 6a. Left leg 6b. Right leg 7. Limb ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. 0 = Absent. _____ 1 = Present in one limb. Test with eyes open. In case of visual defect, 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, are performed on both sides, and ataxia is scored only if present out of proportion to explain:________________ weakness. Ataxia is absent in the patient https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 36/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - 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 when tested, or withdrawal from noxious 0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is affected side; or there is a loss of superficial pain with pinprick, but patient is aware of scored as abnormal and the examiner should test as many body areas (arms [not being touched. hands], legs, trunk, face) as needed to 2 = Severe to total sensory loss; patient is accurately check for hemisensory loss. A score of 2, "severe or total sensory loss," not aware of being touched in the face, arm, and leg. should only be given when a severe or total loss of sensation can be clearly _____ 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 information about comprehension will be 0 = No aphasia; normal. _____ 1 = Mild-to-moderate aphasia; some obtained during the preceding sections of obvious loss of fluency or facility of comprehension, without significant the examination. For this scale item, the patient is asked to describe what is limitation on ideas expressed or form of expression. Reduction of speech and/or happening in the attached picture, to name the items on the attached naming sheet and comprehension, however, makes conversation about provided materials to read from the attached list of sentences. 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, examiner can identify picture or naming the preceding general neurological exam. If visual loss interferes with the tests, ask the card content from patient's response. patient to identify objects placed in the hand, repeat, and produce speech. The 2 = Severe aphasia; all communication is through fragmentary expression; great need intubated patient should be asked to write. for inference, questioning, and guessing by The patient in a coma (item 1a=3) will automatically score 3 on this item. The the listener. Range of information that can be exchanged is limited; listener carries examiner must choose a score for the patient with stupor or limited cooperation, burden of communication. Examiner cannot but a score of 3 should be used only if the https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 37/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - 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 slurs at least some words and, at worst, can be obtained by asking patient to read or repeat words from the attached list. If the be understood with some difficulty. patient has severe aphasia, the clarity of articulation of spontaneous speech can be 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence _____ rated. Only if the patient is intubated or has of or out of proportion to any dysphasia, or other physical barriers to producing speech, the examiner should record the score as is mute/anarthric. untestable (UN), and clearly write an explanation for this choice. Do not tell the UN = Intubated or other physical barrier, explain:________________ patient why he or she is being tested. 11. Extinction and inattention (formerly neglect): Sufficient information to identify 0 = No abnormality. 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous bilateral simultaneous stimulation in one of the sensory modalities. stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient 2 = Profound hemi-inattention or extinction to more than one modality; _____ has aphasia but does appear to attend to both sides, the score is normal. The does not recognize own hand or orients to only one side of space. 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/use-and-utility-of-stroke-scales-and-grading-systems/print 38/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The Modified National Institutes of Health Stroke Scale (mNIHSS) scoring sheet Patient score Item number Item name Scoring guide 1b LOC questions 0 = Answers both correctly 1 = Answers one correctly _____ 2 = Answers neither correctly 1c LOC commands 0 = Performs both tasks correctly 1 = Performs one task _____ correctly 2 = Performs neither task 2 Gaze 0 = Normal 1 = Partial gaze palsy _____ 2 = Total gaze palsy 3 Visual fields 0 = No visual loss 1 = Partial hemianopsia _____ 2 = Complete hemianopsia 3 = Bilateral hemianopsia 5a Left arm motor 0 = No drift 1 = Drift before 10 seconds 2 = Falls before 10 seconds _____ 3 = No effort against gravity 4 = No movement https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 39/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate 5b Right arm motor 0 = No drift 1 = Drift before 10 seconds 2 = Falls before 10 seconds _____ 3 = No effort against gravity 4 = No movement 6a Left leg motor 0 = No drift 1 = Drift before 5 seconds 2 = Falls before 5 seconds _____ 3 = No effort against gravity 4 = No movement 6b Right leg motor 0 = No drift 1 = Drift before 5 seconds 2 = Falls before 5 seconds _____ 3 = No effort against gravity 4 = No movement 8 Sensory 0 = Normal _____ 1 = Abnormal 9 Language 0 = Normal 1 = Mild aphasia _____ 2 = Severe aphasia 3 = Mute or global aphasia 11 Neglect 0 = Normal 1 = Mild _____ 2 = Severe Score (out of 31): _____ The item numbers correspond to the NIHSS scale. The scale is shorter, having only 11 total items (versus 15 items on the NIHSS). LOC: level of consciousness. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 40/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate From: Meyer BC, Hemmen TM, Jackson CM, Lyden PD. Modi ed National Institutes of Health Stroke Scale for use in stroke clinical trials: prospective reliability and validity. Stroke 2002; 33:1261. DOI: 10.1161/01.str.0000015625.87603.a7. Copyright 2002 American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 130998 Version 1.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 41/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Pediatric National Institutes of Health Stroke Scale (PedNIHSS) PedNIHSS INSTRUCTIONS: Administer stroke scale items in the order listed. Follow directions provided for each exam item. Scores should reflect what the patient does, not what the clinician thinks the patient can do. MODIFICATIONS FOR CHILDREN: Modi cations to testing instructions from the adult version for use in children are shown in bold italic with each item where appropriate. Items with no modi cations should be administered and scored with children in the same manner as for adults. Scale definition and Item# and instructions scoring guide 1a. Level of consciousness: The investigator must choose a response, even if a full evaluation 0 = Alert; keenly responsive. is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the 1 = Not alert, but arousable by minor stimulation to obey, answer, or respond. patient makes no movement (other than reflexive posturing) in response to noxious stimulation. 2 = Not alert, requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped). 3 = Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic. 1b. LOC questions: The patient is asked the month and his/her age. The answer must 0 = Answers both questions be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will correctly. 1 = Answers one question correctly. score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, 2 = Answers neither question language barrier or any other problem not secondary to aphasia correctly. are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non- verbal cues. Modi ed for children, age 2 years and up. A familiar Family Member must be present for this item: Ask the child "how old are you?" Or "How many years old are you?" for question number one. Give credit if the child states the correct age, or shows the correct number of ngers for his/her age. For the second question, ask the child "where is XX?", XX referring to the name of the parent or other familiar family member present. Use the name for that person which the child typically uses, eg, https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 42/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate "mommy". Give credit if the child correctly points to or gazes purposefully in the direction of the family member. 1c. LOC commands: The patient is asked to open and close the eyes and then to grip 0 = Performs both tasks and release the non-paretic hand. For children one may substitute the command to grip the hand with the command "show me your correctly. 1 = Performs one task correctly. nose" or "touch your nose". Substitute another one step command if the hands cannot be used. Credit is given if an 2 = Performs neither task unequivocal attempt is made but not completed due to weakness. correctly. If the patient does not respond to command, the task should be demonstrated to them (pantomime) and score the result (ie, follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. 2. Best gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric 0 = Normal. 1 = Partial gaze palsy. This score is given when gaze is testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the abnormal in one or both eyes, but where forced deviation or score will be 1. If a patient has an isolated peripheral nerve paresis (cranial nerves III, IV or VI) score a 1. Gaze is testable in all aphasic total gaze paresis are not present. patients. Patients with ocular trauma, bandages, pre-existing blindness or other disorder of visual acuity or fields should be tested with reflexive movements and a choice made by the 2 = Forced deviation, or total gaze paresis not overcome by investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a the oculocephalic maneuver. partial gaze palsy. 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting (for children >6 years) or 0 = No visual loss. 1 = Partial hemianopia. visual threat (for children age 2 to 6 years) as appropriate. Patient must be encouraged, but if they look at the side of the moving 2 = Complete hemianopia. fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining 3 = Bilateral hemianopia (blind including cortical blindness). eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia is found. If patient is blind from any cause score 3. Double simultaneous stimulation is performed at this point. If there is extinction patient receives a 1 and the results are used to answer question 11. 4. Facial palsy: Ask, or use pantomime to encourage the patient to show teeth or 0 = Normal symmetrical raise eyebrows and close eyes. Score symmetry of grimace in movement. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 43/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate response to noxious stimuli in the poorly responsive or non- 1 = Minor paralysis (flattened comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barrier obscures the face, these nasolabial fold, asymmetry on smiling). should be removed to the extent possible. 2 = Partial paralysis (total or near total paralysis of lower face). 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). 5 & 6. Motor arm and leg: https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 44/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The limb is placed in the appropriate position: extend the arms 5a. Left arm (palms down) 90 degrees (if sitting) or 45 degrees (if supine) and the leg 30 degrees (always tested supine). Drift is scored if the arm 5b. Right arm 0 = No drift, limb holds 90 (or 45) degrees for full 10 falls before 10 seconds or the leg before 5 seconds. For children too immature to follow precise directions or uncooperative for seconds. any reason, power in each limb should be graded by observation of spontaneous or elicited movement according to the same 1 = Drift, limb holds 90 (or 45) degrees, but drifts down grading scheme, excluding the time limits. The aphasic patient is before full 10 seconds; does encouraged using urgency in the voice and pantomime but not noxious stimulation. Each limb is tested in turn, beginning with not hit bed or other support. the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder or hip, or immobilization by an IV board, may the 2 = Some effort against gravity, limb cannot get to or score be "9" and the examiner must clearly write the explanation maintain (if cued) 90 (or 45) degrees, drifts down to bed, for scoring as a "9". Score each limb separately. but has some effort against gravity. 3 = No effort against gravity, limb falls. 4 = No movement. 9 = Amputation, joint fusion explain. 6a. Left leg 6b. Right leg 0 = No drift, leg holds 30 degrees position for full 5 seconds. 1 = Drift, leg falls by the end of the 5 second period but does not hit bed. 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. 4 = No movement. 9 = Amputation, joint fusion explain. 7. Limb ataxia: https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 45/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate This item is aimed at finding evidence of a unilateral cerebellar 0 = Absent. lesion. Test with eyes open. In case of visual defect, insure testing 1 = Present in one limb. is done in intact visual field. The finger-nose-finger and heel-shin 2 = Present in two limbs. tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. In children, substitute this task with reaching for a toy for the upper extremity, and kicking a toy or the examiner's hand, in children too young (<5 years) or otherwise uncooperative for the standard exam item. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion may the item be scored "9", and the examiner must clearly write the explanation for not scoring. In case of blindness test by touching nose from extended arm position. 8. Sensory: Sensation or grimace to pin prick when tested, or withdrawal from 0 = Normal; no sensory loss. noxious stimulus in the obtunded or aphasic patient. For children 1 = Mild to moderate sensory too young or otherwise uncooperative for reporting gradations of loss; patient feels pinprick is sensory loss, observe for any behavioral response to pin prick, less sharp or is dull on the affected side; or there is a loss and score it according to the same scoring scheme as a "normal" response, "mildly diminished" or "severely diminished" response. of superficial pain with Only sensory loss attributed to stroke is scored as abnormal and pinprick but patient is aware the examiner should test as many body areas [arms (not hands), he/she is being touched. legs, trunk, face] as needed to accurately check for hemisensory 2 = Severe to total sensory loss. A score of 2, "severe or total," should only be given when a severe or total loss of sensation can be clearly demonstrated. loss; patient is not aware of being touched in the face, Stuporous and aphasic patients will therefore probably score 1 or arm, and leg. 0. 9. Best language: A great deal of information about comprehension will be obtained 0 = No aphasia, normal. during the preceding sections of the examination. For children age 6 years and up with normal language development before 1 = Mild to moderate aphasia; some obvious loss of fluency onset of stroke: The patient is asked to describe what is or facility of comprehension, happening in the attached picture, to name the items on the without significant limitation on ideas expressed or form of attached naming sheet, to repeat words from the attached list, and to read from the attached list of sentences (see Table expression. Reduction of S1 "Language testing items" below, and see separate gures speech and/or for Cookie theft picture, Picture naming for PedNIHSS, and comprehension, however, Reading for PedNIHSS). Comprehension is judged from responses makes conversation about provided material difficult or here as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the impossible. For example in patient to identify objects placed in the hand, repeat, and produce conversation about provided speech. The intubated patient should be asked to write. The materials examiner can patient in coma (question 1a = 3) will arbitrarily score 3 on this identify picture or naming card from patient's response. item. The examiner must choose a score in the patient with stupor https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 46/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate 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, 12:03 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, 12:03 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, 12:03 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, 12:03 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, 12:03 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, 12:03 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, 12:03 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)