impairments, and measure outcome. No single stroke scale is available or appropriate for all purposes, and each available scale has its own inherent limitations. (See 'Role of scales in stroke assessment' above.) The Cincinnati Prehospital Stroke Scale (CPSS) or the Face Arm Speech Test (FAST) have been suggested for use by prehospital personnel because they are easy to learn and rapidly administered. BE-FAST offers the advantage of also capturing vertebrobasilar symptoms and is being used more widely, but it has not been fully validated in the prehospital setting. (See 'Stroke diagnosis' above.) Scales to detect ischemic stroke caused by large artery occlusion, such as the Rapid Arterial oCclusion Evaluation (RACE) scale, have limited utility; none of the available scales has both high sensitivity and specificity. (See 'Large vessel occlusion triage' above.) The National Institutes of Health Stroke Scale (NIHSS) is a measure of general stroke impairment and is useful for both clinical and research purposes. (See 'NIHSS' above.) Despite their shortcomings, the Barthel Index and Rankin Scales are the most widely used measures of stroke-related disability and handicap, respectively. (See 'Barthel Index' above and 'Modified Rankin Scale' above.) Health-Related Quality of Life (HRQOL) in patients with stroke may be best measured with a stroke-specific instrument such as the Stroke Impact Scale (SIS). Use of UpToDate is subject to the Terms of Use. REFERENCES 1. World Health Organization. International Classification of Functioning, Disability and Health (ICF). http://www.who.int/classifications/icf/en/ (Accessed on April 21, 2011). 2. Orgogozo JM. The concepts of impairment, disability, and handicap. Cerebrovasc Dis 1994; 4 (Suppl 2):2. 3. Duncan PW, Samsa GP, Weinberger M, et al. Health status of individuals with mild stroke. 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Stroke 2002; 33:2593. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 22/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Topic 14084 Version 16.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 23/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate GRAPHICS Face Arm Speech Test Reproduced with permission from: Harbison J, Hossain O, Jenkinson D, et al. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance sta using the face arm speech test. Stroke 2003; 34:71. Copyright 2003 Lippincott Williams & Wilkins. Graphic 54134 Version 7.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 24/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Cincinnati Prehospital Stroke Scale (CPSS) The CPSS evaluates for facial palsy, arm weakness, and speech abnormalities. Items are scored as either normal or abnormal. Facial droop The patient shows teeth or smiles Normal: Both sides of face move equally. Abnormal: One side of face does not move as well as the other. Arm drift The patient closes their eyes and extends both arms straight out for 10 seconds Normal: Both arms move the same, or both arms do not move at all. Abnormal: One arm either does not move, or one arm drifts down compared to the other. Speech The patient repeats "The sky is blue in Cincinnati" Normal: The patient says correct words with no slurring of words. Abnormal: The patient slurs words, says the wrong words, or is unable to speak. Reproduced from: Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999; 33:373. Illustration used with the permission of Elsevier Inc. All rights reserved. Graphic 62856 Version 3.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 25/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Los Angeles Prehospital Stroke Screen Reproduced with permission from: Kidwell CS, Starkman S, Eckstein M, et al. Identifying stroke in the eld. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000; 31:71. Copyright 2000 Lippincott Williams & Wilkins. Graphic 78128 Version 10.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 26/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 27/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Rapid Arterial oCclusion Evaluation (RACE) scale RACE NIHSS score Item score equivalence Facial palsy Absent 0 0 Mild 1 1 Moderate to severe 2 2 to 3 Arm motor function Normal to mild 0 0 to 1 Moderate 1 2 Severe 2 3 to 4 Leg motor function Normal to mild 0 0 to 1 Moderate 1 2 Severe 2 3 to 4 Head and gaze deviation Absent 0 0 Present 1 1 to 2 Aphasia* (if right hemiparesis) Performs both tasks correctly 0 0 Performs 1 task correctly 1 1 Performs neither tasks 2 2 Agnosia (if left hemiparesis) Patient recognizes their arm and the impairment 0 0 Does not recognize their arm or the impairment 1 1 Does not recognize their arm nor the impairment 2 2 Score total 0 to 9 Aphasia: Ask the patient to (1) "close your eyes"; (2) "make a fist" and evaluate if the patient obeys. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 28/59 7/5/23, 12:14 PM Use and utility of stroke scales and grading systems - UpToDate Agnosia: Ask the patient: (1) while showing their the paretic arm: "Whose arm is this" and evaluate if the patient recognizes their own arm. (2) "Can you lift both arms and clap" and evaluate if the patient recognizes their functional impairment. From: P rez de la Ossa N, Carrera D, Gorchs M, et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 2014; 45:87. DOI: 10.1161/STROKEAHA.113.003071. Copyright American Heart Association. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited. Graphic 130953 Version 2.0 https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 29/59 7/5/23, 12:14 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, 12:14 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, 12:14 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, 12:14 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, 12:14 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, 12:14 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