7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Official reprint from UpToDate www.uptodate.com 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved. Use and utility of stroke scales and grading systems : Larry B Goldstein, MD, FAAN, FANA, FAHA : Scott E Kasner, MD : John F Dashe, MD, PhD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jun 2023. This topic last updated: Mar 09, 2023. INTRODUCTION This topic will review stroke scales and grading systems that are used for ischemic and hemorrhagic stroke. Grading systems used to classify patients with subarachnoid hemorrhage are reviewed separately. (See "Subarachnoid hemorrhage grading scales".) Categorization systems used in the classification and etiology of stroke are also discussed elsewhere. (See "Stroke: Etiology, classification, and epidemiology", section on 'TOAST classification' and "Stroke: Etiology, classification, and epidemiology", section on 'SSS-TOAST and CCS classification'.) ROLE OF SCALES IN STROKE ASSESSMENT In addition to their importance for assessing the impact of therapeutic interventions in clinical trials, stroke scales are useful in the routine clinical setting as aids to improve diagnostic accuracy, help determine the appropriateness of specific treatments, monitor a patient's neurologic deficits through the continuum of care, and predict and gauge outcomes. Not only are different types of scales needed for these different purposes, but no single scale is suitable for capturing all of the effects of stroke. A plethora of stroke scales have been developed for each of these purposes as discussed in the sections that follow. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 1/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Dimensions of disease The International Classification of Functioning, Disability and Health, developed by the World Health Organization, categorizes the impact of disease into three dimensions [1]: Body Dimension, referring to the structure and function of body systems Activities Dimension, referring to the complete range of activities performed by an individual Participation Dimension, classifying areas of life in which an individual is involved, has access, has societal opportunities or barriers These three general dimensions correspond to what clinicians might describe as neurologic impairments (ie, deficits such as a hemianopsia, aphasia, limb paresis, gait imbalance, or sensory loss), disabilities (ie, loss of the ability to perform daily tasks, such as eating, dressing, and bathing, resulting from physiological deficits), and handicaps (ie, the impact of deficits and disabilities on social participation such as employment) [2]. Additionally, it is becoming increasingly important to assess the effects of disease and treatment on quality of life. Measuring the impact of stroke Although the impact of stroke as reflected by these different dimensions (body, activity, participation) is generally consistent, it is important to measure each dimension, as focusing on any one alone could be misleading. As an example, consider a patient with a paralyzed hand. This deficit would be measured in the Body Dimension as a motor impairment. With compensatory strategies such as the use of the unimpaired hand or prosthetics, that same patient might have no disability (ie, able to eat, dress, bathe). If the patient was a truck driver, they might be able to return to work by driving a modified vehicle (no handicap), whereas if they were a watchmaker, they might be unable to return to their previous employment (ie, a social handicap). Thus, the impact of a neurologic impairment on quality of life can be quite different depending on individual circumstances. In addition, a stroke considered to be mild based upon a measure of one dimension may be severe when measured on a different dimension [3]. A homonymous inferior quadrantanopia might represent a minimal impairment and result in no disability, but could be an important handicap and have a large impact on quality of life because driving a motor vehicle is precluded. Therefore, when choosing a stroke scale, one must first consider why it is being used and what it is measuring. STROKE DIAGNOSIS https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 2/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Because of poor recognition and the nonspecific nature of many stroke symptoms, stroke scales and grading systems have been developed both to aid the general public, emergency responders, and emergency physicians in the identification of persons with acute stroke, and to hasten transport of stroke victims to appropriate medical facilities. These tools must be simple and rapidly applicable. Selected diagnostic scales The best-studied scales for general stroke recognition and diagnosis are the Face Arm Speech Test (FAST), the Cincinnati Prehospital Stroke Scale (CPSS), the Los Angeles Prehospital Stroke Screen (LAPSS), and the Recognition of Stroke in the Emergency Room (ROSIER). FAST and CPSS are simple and easy to use, which makes them most appropriate for the general public and nonmedical first responders [4]. Each evaluates the presence or absence of facial weakness, arm weakness, and speech difficulty. The main difference between the two is that FAST incorporates assessment of language function during normal conversation, whereas CPSS tests language by asking the patient to repeat a short sentence. Both the American Stroke Association and the United States Centers for Disease Control and Prevention promote FAST as a tool to increase public awareness of stroke signs and symptoms [5,6]. LAPSS and ROSIER are more complex and may be more appropriate for use by trained emergency responders and emergency physicians [4]. The LAPSS and ROSIER scales incorporate additional items to help exclude stroke mimics and to increase specificity with a potential disadvantage of reduced sensitivity [7]. FAST The Face Arm Speech Test (FAST; the "T" is a reminder of the importance of time and the need to reach a hospital immediately) evaluates patients with suspected stroke by assessing them for the presence of facial weakness, arm weakness, and speech impairment ( figure 1) [8]. FAST is considered positive if at least one item is abnormal. A prospective study found good agreement for the detection of the acute stroke signs between emergency medical responders using the FAST system and stroke physicians [9]. The scale is insensitive to isolated stroke-related visual or sensory impairments, vertigo, and gait disturbances. BE-FAST The BE-FAST test is a modification of FAST that accounts for imbalance or leg weakness (B for balance) and visual symptoms (E for eyes), as these potentially debilitating symptoms are not otherwise captured by either screening tool [10]. The BE-FAST test may reduce the likelihood of a stroke diagnosis missed using the FAST test but requires field validation in a prospective study. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 3/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate CPSS The CPSS focuses on the assessment facial paresis, arm drift, and abnormal speech ( table 1) [11]. In a prospective report evaluating the CPSS, the diagnostic accuracy for emergency department physicians compared with non-physician emergency medical personnel was similar with high correlation for total score between these groups [12]. The presence of an abnormality on any one of the three stroke scale items was associated with a marked increase in the likelihood of stroke [13]. It has the same limitations as FAST for certain stroke-related deficits that can occur in isolation. LAPSS The LAPSS assesses for unilateral arm drift, handgrip weakness, and facial paresis ( form 1) [14]. The criteria for an "in-the-field" stroke diagnosis are met when the patient age is >45 years, seizure/epilepsy history is absent, symptom duration is <24 hours, the patient is not a full-time wheelchair user or bedridden at baseline, the blood glucose is between 60 and 400 mg/dL, and a unilateral deficit is present in one of the three items (arm, handgrip, or face). The LAPSS was evaluated in an observer-blind prospective study of all non-comatose, non-trauma patients with neurologic complaints compatible with stroke who were transported by emergency medical technicians to a single hospital [14]. Compared with the final diagnosis, a prehospital stroke diagnosis made by paramedics with LAPSS had a sensitivity of 91 percent (95% CI 76-98 percent) and specificity of 97 percent (95% CI 93-99 percent). ROSIER The ROSIER scale was developed to facilitate rapid stroke patient identification and triage by emergency department clinicians [15]. The ROSIER scale incorporates the Glasgow Coma Scale ( table 2) and measurement of blood pressure and blood glucose along with assessment of a seven-item stroke-recognition scale. The first two items inquire about clinical history to exclude stroke mimics [15]: Loss of consciousness or syncope (yes = -1; no = 0) Seizure activity (yes = -1; no = 0) The next five items inquire about specific neurologic deficits of new acute onset (or present since awakening from sleep): Asymmetric facial weakness (yes = +1; no = 0) Asymmetric arm weakness (yes = +1; no = 0) Asymmetric leg weakness (yes = +1; no = 0) Speech disturbance (yes = +1; no = 0) Visual field defect (yes = +1; no = 0) https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 4/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The total score range is -2 to +5. Stroke is unlikely, but not completely excluded, if total score is 0 [15]. When prospectively validated at a cut-off score of >0 in the original publication, the scale had a sensitivity of 93 percent (95% CI 89-97 percent) and specificity of 83 percent (95% CI 77-89 percent) [15]. A 2020 systematic review and meta-analysis identified 15 datasets that evaluated the ROSIER scale and found that the combined sensitivity and specificity were 88 and 66 percent, respectively [16]. Utility of stroke diagnostic scales In a 2019 systematic review of studies evaluating the accuracy of stroke recognition scales used in the prehospital setting or emergency department, the CPSS had the highest sensitivity in prehospital settings, while the ROSIER had the highest sensitivity in emergency department settings [4]. LARGE VESSEL OCCLUSION TRIAGE Selected triage scales The advent of proven therapies for the treatment of patients with large-vessel distribution ischemic stroke requires the triage of patients to centers capable of rapid endovascular clot retrieval [17]. Scales that have been evaluated as stroke triage aids to detect patients with large vessel occlusion include the Rapid Arterial oCclusion Evaluation (RACE) scale ( table 3), the Los Angeles Motor Scale (LAMS) ( table 4), the Cincinnati Stroke Triage Assessment Tool (C-STAT) ( table 5), and the Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale ( table 6). As reviewed below, none of the available scales predict stroke due to large vessel occlusion with both high sensitivity and specificity. With this limitation in mind, our EMS providers generally use RACE. (See 'Utility of stroke triage scales' below.) RACE The RACE scale is based on the items of National Institutes of Health Stroke Scale (NIHSS) that had the highest predictive value for large artery occlusion, as determined in a retrospective study of 654 patients with acute ischemic stroke of the anterior circulation [18]. The RACE scale assesses facial palsy, limb motor function, head and gaze deviation, and aphasia or agnosia, as shown in the table ( table 3). The RACE score ranges from a normal of 0 to a maximum of 9 points. For detecting large vessel occlusion, a RACE scale score 5 had sensitivity and specificity of 85 and 68 percent, respectively [18]. LAMS The LAMS ( table 4) employs a three-item motor score derived from the LAPSS and assesses facial droop, arm drift, and grip strength, with the total score ranging from 0 to 5 points [19]. In a retrospective study of 119 patients with anterior circulation ischemic stroke evaluated within 12 hours of time last known well, a LAMS score of 4 predicted a large vessel occlusion with a sensitivity and specificity of 81 and 89 percent, respectively [20]. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 5/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate C-STAT The C-STAT ( table 5) is a three-item score that assigns two points for conjugate gaze deviation, one point if the patient answers incorrectly on one of two level of consciousness questions and does not follow one of two commands from the NIHSS, and one point for arm weakness; the total score ranges from 0 to 4 points [21,22]. In a prospective study of prehospital evaluation with complete data for 58 patients who had a positive FAST score among 158 screened for suspicion for stroke or TIA, a C-STAT score 2 had a sensitivity of 71 percent (95% CI 29-96) and specificity of 70 percent (95% CI 55-83) for the diagnosis of large vessel stroke [22]. FAST-ED The FAST-ED scale ( table 6) assigns points for facial palsy, arm weakness, speech changes, eye deviation, and denial or neglect; the total score ranges from 0 to 9 [23]. In a retrospective study of 727 patients suspected of having acute stroke within 24 hours of symptom onset, large vessel occlusion was detected in 240. For prediction of large vessel occlusion, a FAST-ED score 4 had a sensitivity of 61 percent and a specificity of 89 percent [23]. Utility of stroke triage scales Although detection of ischemic stroke caused by a large artery occlusion is important to help identify patients who may benefit from mechanical thrombectomy, none of the available scales predicts this type of stroke with optimal accuracy. Triage decisions based on the use of these scales will miss some patients with large vessel occlusion who have milder stroke impairments [24]. This limitation needs to be understood if these scales are used to help triage patients for mechanical thrombectomy. (See "Approach to reperfusion therapy for acute ischemic stroke" and "Mechanical thrombectomy for acute ischemic stroke".) In a 2018 systematic review of prediction scales for large vessel occlusion, the sensitivities of these scales ranged from 47 to 73 percent, and the specificities ranged from 78 to 90 percent; no single scale could predict a large vessel occlusion with high sensitivity and specificity [24]. A prospective cohort study of 2007 patients conducted in the Netherlands comparing seven stroke prediction scales found that sensitivities for large vessel occlusion ranged from 38 to 62 percent and specificities ranged from 80 to 93 percent, with LAMS and RACE having the highest accuracy [25]. Another prospective cohort study from the Netherlands of over 1000 patients with suspected stroke found that the RACE was the best performing scale for detecting large vessel occlusion [26]. Another cohort study found similar calibrations for RACE, LAMS C-STAT, and FAST- ED [27]. None had an AUC (area under the receiver operating curve) >0.8, a threshold generally considered for clinical usefulness. STROKE IMPAIRMENT AND SEVERITY https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 6/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate The main stroke impairment scales are the National Institutes of Health Stroke Scale (NIHSS), the Pediatric National Institutes of Health Stroke Scale (pedNIHSS), the European Stroke Scale, and the Canadian Neurologic Scale (CNS). The Scandinavian Stroke Scale has also been used in clinical trials. Although these scales are useful to assess the severity of neurologic impairment due to stroke, they are not useful for making the diagnosis of stroke. Stroke severity and prognosis Stroke severity is assessed with an impairment-level scale, such as the NIHSS. Stroke prognosis is largely determined by the severity of the patient's initial impairments. The association of neurologic impairment, stroke severity, and outcome after ischemic stroke is reviewed separately. (See "Overview of ischemic stroke prognosis in adults", section on 'Neurologic severity'.) NIHSS The NIHSS is both reliable and valid, and has become a standard stroke impairment scale for use in both clinical trials and as part of clinical care in the United States in many other countries [28-32]. As examples, the NIHSS score is part of the assessment that helps determine whether a patient is a candidate for reperfusion therapy with intravenous thrombolysis and/or mechanical thrombectomy (see "Intravenous thrombolytic therapy for acute ischemic stroke: Therapeutic use" and "Mechanical thrombectomy for acute ischemic stroke"). In addition, the baseline NIHSS score is predictive of long-term outcome after acute stroke, as noted above. The NIHSS can also be assessed remotely and may be useful in telemedicine programs [33]. The NIHSS measures neurologic impairment using a 15 item scale ( table 7) [28]. A printable version of the NIHSS is available online at https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf. An NIHSS calculator (calculator 1) is best used by a certified NIHSS examiner in conjunction with a copy of the full NIHSS. Both physician and nurse stroke providers can be trained to use the scale with similar levels of accuracy [34]. Reliability can be further improved through the use of standardized video training [35,36]. However, the value of routine retraining is uncertain [37]. The NIHSS has been validated for retrospective use based upon information available in the patient's medical record over a range of severities [38-41]. An important limitation of the NIHSS is that it does not capture all stroke-related impairments, particularly with infarction involving the vertebrobasilar circulation [42,43]. This is also true for modified, shortened versions of the scale [44,45]. Modified NIHSS The modified NIHSS (mNIHSS) is a shortened version of the NIHSS that omits level of consciousness (item 1a), facial weakness (item 4), limb ataxia (item 7), and dysarthria (item 10) from the original NIHSS and condenses the sensory test (item 8) choices from three to two responses ( table 8) [46]. In the original derivation study and subsequent prospective https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 7/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate validation, the validity and reliability of the mNIHSS was nearly identical to the original NIHSS [44,46]. The use of the "Cookie Theft" picture for language assessment as part of the NIHSS may be culturally biased [47]. An alternative has not yet been adopted. Pediatric NIHSS The Pediatric National Institutes of Health Stroke Scale (PedNIHSS) was developed by modifying the adult NIHSS so that examination items and testing materials are age-appropriate ( table 9 and figure 2 and figure 3 and figure 4) [48]. In a multicenter, prospective cohort study of children with acute arterial ischemic stroke, the PedNIHSS showed good interrater reliability when employed by trained pediatric neurologists. Other impairment scales European Stroke Scale The European Stroke Scale was designed to evaluate patients with stroke involving the territory of the middle cerebral artery. It is similar to the NIHSS and is also reliable and partially validated [49]. Canadian Neurological Scale The Canadian Neurological Scale (CNS) is simpler and more rapidly performed than the NIHSS, but does not capture many stroke-related impairments ( table 10) [50,51]. Like the NIHSS, the CNS has been validated for use retrospectively based on information available in the patient's medical record over a range of severities [40,52]. Scandinavian Stroke Scale The Scandinavian Stroke Scale assesses consciousness, gaze palsy, arm and leg weakness, dysphasia, orientation, facial palsy, and gait [53]. The scale has good to excellent reliability. It can be reliably scored based on data routinely recorded in the medical record and has been validated for retrospective use [54]. Specific neurologic deficits Scales to measure specific types of deficits have been developed and validated in patients with stroke: Motor impairments (eg, Fugl-Meyer Assessment [55,56], Motor Assessment Scale [57], and Motricity Index [58,59]) Balance (eg, Berg Balance Scale [60]) Arm/hand function (eg, Research Action Arm Test [61-64]) Mobility (eg, Rivermead Mobility Index [65]) Aphasia (eg, Frenchay Aphasia Screening Test [66,67] and Porch Index of Communicative Ability [68]) Cognition (eg, Montreal Cognitive Assessment [MoCA] [69,70]) https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 8/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate These scales are most useful for research studies targeting specific types of deficits. One exception is the MoCA, which is a widely used clinical screening test for cognitive impairment. The MoCA includes assessments of executive functions that are commonly affected by stroke. (See "Mental status scales to evaluate cognition", section on 'Montreal Cognitive Assessment (MoCA)'.) In addition, depression commonly complicates the recovery of stroke patients, and several instruments are available to aid in its diagnosis and measurement, including the following: Beck Depression Inventory (BDI) [71] Center for Epidemiological Studies of Depression (CES-D) [72] Hamilton Depression Scale [73] Personal Health Questionnaire (PHQ-9) [74] Of these, aphasic patients and older adults may have difficulty with the BDI, CES-D, and the PHQ- 9. The Hamilton Depression Scale is observer- rather than patient-rated, but its inter-observer reliability may be limited. These depression rating scales have been used primarily in research settings. The PHQ-9 has been validated for use as a depression screening tool in general practice settings. A simple two-question screen for depression has been used in primary care settings, but its use in stroke populations has not been assessed [75]. DISABILITY The two most frequently used stroke disability scales are the Barthel Index (BI) and the Functional Independence Measure (FIM). Both were similarly responsive to change in disability in one study [76], whereas another report found that the FIM was more sensitive to change [77]. Instrumental activities of daily living (IADL) scales attempt to bridge the gap between disability and handicap. Combining basic scales such as the BI or FIM with IADL assessments may provide more comprehensive information than can be gleaned from either type of scale alone and can be a useful strategy for both clinical and research applications in stroke patients [78]. Barthel Index The BI measures 10 basic aspects of self-care and physical dependency ( table 11) [79-81]. A normal score is 100, and lower scores indicate increasing disability; a BI >60 corresponds to assisted independence, and a BI <40 corresponds to severe dependency [80]. A systematic review and meta-analysis concluded that the interrater reliability of the BI is excellent [82]. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 9/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Although not specifically designed as a stroke scale, the BI correlates moderately well with radiologic infarct size [83-86]. In addition, the BI is frequently used as an outcome measure for stroke trials [81], and limited evidence suggests that the BI can predict outcome after stroke [83,87,88]. However, the predictive capacity of the BI for outcome is reduced in the setting of acute stroke, particularly within the first 72 hours [42,89]. In addition, the BI has significant limitations related to floor and ceiling effects, meaning that the BI is relatively insensitive to change in function at the extreme ends of the scale [3,77,81]. FIM The FIM is a proprietary instrument that assesses patient disability in 13 aspects of motor function and five aspects of cognitive function [90-92]. The FIM is widely used for monitoring functional improvement through the course of rehabilitation therapy [93,94]. It can be assessed by telephone as well as in person [95]. A systematic review concluded that the FIM may have some utility for predicting outcome after stroke, though high-quality evidence was limited [91]. IADL As noted above, IADL scales attempt to bridge the gap between disability and handicap [96]. They are intended to capture the patient's ability to live independently in the home and assess a variety of activities (cooking, home management, recreation, etc). Several IADL scales are available, but the Frenchay Activities Index was specifically developed for use with stroke patients and is reliable [97-99]. HANDICAP The main stroke handicap scales are the Rankin Scale and its derivatives, the modified Rankin Scale (mRS), the Rankin Focused Assessment, and the Oxford Handicap Scale [100-104]. Of these, the mRS is the most widely used. The Craig Handicap Assessment and Reporting Technique (CHART) was specifically designed to assess handicap [105,106], but has not been used as extensively as the mRS in the assessment of patients with stroke. Modified Rankin Scale The mRS measures functional independence on a seven grade scale ( table 12) [100,101]. The mRS has been used as a measure of stroke-related handicap in many interventional trials and is frequently used as a global measure of the functional impact of stroke [31,107,108]. In addition, the mRS score at 90 days after intravenous thrombolysis or endovascular interventions for acute ischemic stroke is a proposed "core metric" of comprehensive stroke centers in the United States [31]. A systematic review published in 2007 concluded that interrater reliability of the mRS was moderate and was improved with structured interview [109], although a subsequent study found no significant difference between standard and structured mRS [110]. A systematic review https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 10/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate published in 2009 found that the overall interrater reliability of the mRS was moderate but varied widely among included studies; the effect of structured interview was inconsistent [111]. The mRS score shows moderate correlation with the volume of cerebral infarction [85,86,112]. The mRS ( table 12) places particular emphasis on the patient's ability to walk. Because it is weighted towards physical function [107], the results of the mRS correlate closely with scores on the Barthel Index [113-115] and therefore do not fully reflect the impact of stroke on social participation. There has been some debate regarding cutoffs and the analysis of mRS data in the setting of clinical trials. Different trials have used dichotomous cutoff scores of 1, 2, or 3 to identify those with favorable compared with unfavorable outcomes. Another approach is using a so- called "shift" analysis, in which the entire range of possible scores is considered rather than dichotomous outcomes [116]. Some trials that were negative using prespecified dichotomous cutoffs might have been positive if a shift analysis had been used [117]. QUALITY OF LIFE Health-related quality of life (HRQOL) reflects the physical, emotional, and social aspects of life that can be affected by acute or chronic disease [118]. These types of assessments are generally used for research and not clinical purposes. Generic scales Several generic scales have been used for the assessment of HRQOL in patients with stroke, including the following: Sickness Impact Profile [119,120] Short Form 36 [121] Health Utilities Index [122-125] EuroQol [126-128] The use of these HRQOL scales in patients with stroke is particularly challenging because the scales are generally lengthy, and because the disease itself can affect the patient's ability to respond, often necessitating obtaining responses from proxies [129]. The physical subscore of the Sickness Impact Profile correlates with stroke-related impairments as measured with the National Institutes of Health Stroke Scale (NIHSS) and Canadian Neurologic Scale (CNS) [114]. Disability scores measured with the Barthel Index and handicap scores measured with the Rankin Scale explain only 33 percent of the variance in Sickness Impact Profile scores [130]. https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 11/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Stroke-specific scales One response to the difficulty of assessing quality of life in stroke patients with generic scales has been the development of stroke-specific HRQOL instruments, such as the following: Stroke Impact Scale (SIS) [131] Stroke-Specific Quality of Life Scale [132,133] Stroke-adapted version of the Sickness Impact Profile [134] The SIS was designed to measure changes in hand function, activities of daily living, mobility, emotion, communication, memory, thinking, and participation after stroke [131]. The SIS is reliable, valid, and sensitive to change [131,135]. A briefer version focused on physical functioning has also been developed [136]. In addition, the SIS has been evaluated for postal administration [137]. As with other HRQOL scales, a major limitation of the SIS is that assessment is made by self-report of the patient, posing an obstacle to its use in patients with aphasia or other cognitive impairments [42]. This limitation can be partially addressed by use of a proxy [138]. ADDITIONAL STROKE SCALES A number of stroke scales specific to transient ischemic attack (TIA), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage are discussed in separate topic reviews. These include: 2 TIA The ABCD score ( table 13) is intended to estimate the risk of ischemic stroke in the first days after a TIA. Intracerebral hemorrhage The ICH score is intended to predict mortality after intracerebral hemorrhage. Subarachnoid hemorrhage Grading systems used to classify patients with subarachnoid hemorrhage include the Glasgow Coma Scale, the Hunt and Hess grading system, the World Federation of Neurological Surgeons scale, the Fisher scale, the modified Fisher scale, and the Ogilvy and Carter grading system. (See "Subarachnoid hemorrhage grading scales".) SUMMARY AND RECOMMENDATIONS Stroke scales are useful for clinical and research purposes as aids to improve diagnostic accuracy, determine the suitability of specific treatments, monitor change in neurologic https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 12/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate 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. Stroke 1997; 28:740. 4. Zhelev Z, Walker G, Henschke N, et al. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev 2019; 4:CD011427. 5. American Stroke Association. Stroke symptoms. Available at: https://www.stroke.org/en/abo ut-stroke/stroke-symptoms (Accessed on March 05, 2021). https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 13/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate 6. Centers for Disease Control and Prevention. Stroke signs and symptoms. Available at: http s://www.cdc.gov/stroke/signs_symptoms.htm (Accessed on March 05, 2021). 7. Rudd M, Buck D, Ford GA, Price CI. A systematic review of stroke recognition instruments in hospital and prehospital settings. Emerg Med J 2016; 33:818. 8. Harbison J, Hossain O, Jenkinson D, et al. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke 2003; 34:71. 9. Nor AM, McAllister C, Louw SJ, et al. Agreement between ambulance paramedic- and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke 2004; 35:1355. 10. Aroor S, Singh R, Goldstein LB. BE-FAST (Balance, Eyes, Face, Arm, Speech, Time): Reducing the Proportion of Strokes Missed Using the FAST Mnemonic. Stroke 2017; 48:479. 11. Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4:986. 12. Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999; 33:373. 13. Goldstein LB, Simel DL. Is this patient having a stroke? JAMA 2005; 293:2391. 14. Kidwell CS, Starkman S, Eckstein M, et al. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000; 31:71. 15. Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol 2005; 4:727. 16. Han F, Zuo C, Zheng G. A systematic review and meta-analysis to evaluate the diagnostic accuracy of recognition of stroke in the emergency department (ROSIER) scale. BMC Neurol 2020; 20:304. 17. Schlemm L, Ebinger M, Nolte CH, Endres M. Impact of Prehospital Triage Scales to Detect Large Vessel Occlusion on Resource Utilization and Time to Treatment. Stroke 2018; 49:439. 18. 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. 19. Llanes JN, Kidwell CS, Starkman S, et al. The Los Angeles Motor Scale (LAMS): a new measure to characterize stroke severity in the field. Prehosp Emerg Care 2004; 8:46. 20. Nazliel B, Starkman S, Liebeskind DS, et al. A brief prehospital stroke severity scale identifies ischemic stroke patients harboring persisting large arterial occlusions. Stroke 2008; https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 14/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate 39:2264. 21. 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. 22. McMullan JT, Katz B, Broderick J, et al. Prospective Prehospital Evaluation of the Cincinnati Stroke Triage Assessment Tool. Prehosp Emerg Care 2017; 21:481. 23. 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. 24. Smith EE, Kent DM, Bulsara KR, et al. Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke 2018; 49:e111. 25. Nguyen TTM, van den Wijngaard IR, Bosch J, et al. Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting. JAMA Neurol 2021; 78:157. 26. Duvekot MHC, Venema E, Rozeman AD, et al. Comparison of eight prehospital stroke scales to detect intracranial large-vessel occlusion in suspected stroke (PRESTO): a prospective observational study. Lancet Neurol 2021; 20:213. 27. Grewal P, Lahoti S, Aroor S, et al. Effect of Known Atrial Fibrillation and Anticoagulation Status on the Prehospital Identification of Large Vessel Occlusion. J Stroke Cerebrovasc Dis 2019; 28:104404. 28. Brott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20:864. 29. Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol 1989; 46:660. 30. Wityk RJ, Pessin MS, Kaplan RF, Caplan LR. Serial assessment of acute stroke using the NIH Stroke Scale. Stroke 1994; 25:362. 31. Leifer D, Bravata DM, Connors JJ 3rd, et al. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:849. 32. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early https://www.uptodate.com/contents/use-and-utility-of-stroke-scales-and-grading-systems/print 15/59 7/5/23, 12:03 PM Use and utility of stroke scales and grading systems - UpToDate Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344.