Neurology / Emergency

CVA / NIH Stroke Scale Assessment

Clinical scoring aid · Total score 0–42 · Not a substitute for stroke-team activation or treatment protocols.

Emergency: Possible acute stroke is an emergency. Activate EMS/stroke protocol immediately. Do not delay emergency evaluation, imaging, or stroke-team consultation to complete this form. A low NIHSS does not exclude a disabling stroke.

Patient & Exam

Patient nameDate of birthHeart rateDate/time of examLast known wellExaminerAssessment intervalBlood glucoseBlood pressureSpO₂RespirationsLeft pupil (mm)Right pupil (mm)

NIHSS Items

1a. Level of Consciousness

Choose a response even if a full evaluation is prevented (endotracheal tube, language barrier, orotracheal trauma/bandages). A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.

0 — Alert; keenly responsive1 — Not alert but arousable by minor stimulation2 — Not alert; requires repeated/strong stimulation to attend3 — Unresponsive or reflex motor/autonomic responses only

1b. LOC Questions

Ask the current month and the patient's age. Only the initial answer is graded. Aphasic and stuporous patients who do not comprehend receive a 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria, language barrier, or any other problem not secondary to aphasia are given a 1.

0 — Answers both correctly1 — Answers one correctly2 — Answers neither correctly

1c. LOC Commands

Ask the patient to open/close eyes, then to grip and release the non-paretic hand. Substitute another one-step command if the hands cannot be used. Credit given if an unequivocal attempt is made but not completed due to weakness.

0 — Performs both tasks correctly1 — Performs one task correctly2 — Performs neither task correctly

2. Best Gaze

Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements are scored; caloric testing is not done. Isolated peripheral nerve paresis (CN III, IV, VI) is scored 1.

0 — Normal1 — Partial gaze palsy (abnormal gaze in one or both eyes, no forced deviation)2 — Forced deviation or total gaze paresis not overcome by oculocephalic maneuver

3. Visual Fields

Test visual fields (upper and lower quadrants) by confrontation using finger counting or visual threat. If patient is blind from any cause, score 3.

0 — No visual loss1 — Partial hemianopia2 — Complete hemianopia3 — Bilateral hemianopia (blind including cortical blindness)

4. Facial Palsy

Ask, or use pantomime, to encourage the patient to show teeth, raise eyebrows, and close eyes. Score symmetry of grimace in response to noxious stimuli in poorly responsive/non-comprehending patient.

0 — Normal symmetrical movements1 — Minor paralysis (flattened nasolabial fold, asymmetry on smiling)2 — Partial paralysis (total or near-total paralysis of lower face)3 — Complete paralysis of one or both sides (upper and lower face)

5a. Motor Arm — Left

Extend the left arm (palms down) 90° (if sitting) or 45° (if supine). Drift is scored if the arm falls before 10 seconds. Score 9/UN only if amputation or joint fusion at shoulder — do NOT add to total.

0 — No drift; limb holds 90° (or 45°) for full 10 seconds1 — Drift; limb drifts down before 10 seconds but doesn't hit bed2 — Some effort against gravity; limb cannot get to or maintain position3 — No effort against gravity; limb falls4 — No movement

5b. Motor Arm — Right

Same technique as 5a on the right arm.

6a. Motor Leg — Left

With patient supine, hold the left leg at 30°. Drift is scored if the leg falls before 5 seconds. Score 9/UN only if amputation or joint fusion at hip.

0 — No drift; leg holds 30° for full 5 seconds1 — Drift; leg falls by end of 5 seconds but doesn't hit bed2 — Some effort against gravity; leg falls to bed within 5 seconds3 — No effort against gravity; leg falls to bed immediately4 — No movement

6b. Motor Leg — Right

Same technique as 6a on the right leg.

7. Limb Ataxia

Aimed at finding evidence of unilateral cerebellar lesion. Test with eyes open. Finger-nose-finger and heel-shin tests are performed on both sides. Ataxia is scored only if out of proportion to weakness.

0 — Absent1 — Present in one limb2 — Present in two or more limbs

8. Sensory

Test with pin. When consciousness/comprehension is impaired, score by observed grimace or withdrawal from noxious stimulus. Only stroke-related sensory loss is scored; score 2 only for severe/total loss.

0 — Normal; no sensory loss1 — Mild-to-moderate loss (patient feels pinprick as less sharp/dull)2 — Severe or total sensory loss (unaware of being touched)

9. Best Language

Ask patient to describe the standard picture, name items on the naming sheet, and read the sentences. Comprehension is judged from responses here and to all commands in the exam.

0 — No aphasia; normal1 — Mild-to-moderate aphasia (some obvious loss of fluency/comprehension without significant limitation)2 — Severe aphasia (highly fragmented communication; listener carries burden of communication)3 — Mute, global aphasia; no usable speech or auditory comprehension

10. Dysarthria

Have patient read or repeat words from the standard list. Score 9/UN only if intubated or other physical barrier — do NOT add to total.

0 — Normal1 — Mild-to-moderate dysarthria; slurs some words, can be understood with some difficulty2 — Severe dysarthria; speech so slurred as to be unintelligible or is mute/anarthric

11. Extinction and Inattention (formerly Neglect)

Sufficient information to identify neglect may be obtained during prior testing. If the patient has severe visual loss preventing double-simultaneous visual stimulation but responds to cutaneous stimuli, score is normal.

0 — No abnormality1 — Inattention or extinction to bilateral simultaneous stimulation in one modality2 — Profound hemi-inattention or extinction to more than one modality

NIHSS Total

No measurable deficit on NIHSS

Common descriptive bands: 0 no measurable deficit; 1–4 minor; 5–15 moderate; 16–20 moderate-to-severe; 21–42 severe. These bands do not determine treatment eligibility.

Clinical notes / stroke findings

Generated summary

NIHSS Assessment Summary
----------------------------

NIHSS Total: 0 / 42 — No measurable deficit on NIHSS

Item scores:
  1a. Level of Consciousness: —
  1b. LOC Questions: —
  1c. LOC Commands: —
  2. Best Gaze: —
  3. Visual Fields: —
  4. Facial Palsy: —
  5a. Motor Arm — Left: —
  5b. Motor Arm — Right: —
  6a. Motor Leg — Left: —
  6b. Motor Leg — Right: —
  7. Limb Ataxia: —
  8. Sensory: —
  9. Best Language: —
  10. Dysarthria: —
  11. Extinction and Inattention (formerly Neglect): —

Authoritative resources

Educational use only. Not a substitute for stroke-team activation, imaging, or clinical judgment. Follow your institution's acute stroke protocol.