Acute Stroke Assessment (ROSIER&NIHSS)

Related Subjects: | Acute Stroke Assessment (ROSIER&NIHSS) | Atrial Fibrillation | Atrial Myxoma | Causes of Stroke | Ischaemic Stroke | Cancer and Stroke | Cardioembolic stroke | CT Basics for Stroke | Endocarditis and Stroke | Haemorrhagic Stroke | Stroke Thrombolysis | Hyperacute Stroke Care

Calculate ROSIER SCORE

National Institute for Health Stroke Scale/Score (NIHSS)

1A: Level of Consciousness: (If intubated/difficult to assess, make best guess, but only choose 3 if posturing/unresponsive)

• Alert; keenly responsive 0
• Not Alert, but rousable by minor stimulation 1
• Not Alert, requires repeated stimulation to arouse 2
• Not Alert/Obtunded, Makes Movements to Pain 2
• Postures or Unresponsive to Pain 3

1B: Ask Month and Age

• Both Questions Right 0
• Answers 1 Question Right 1
• Answers 0 Questions Right 2
• Dysarthric, Intubated, Trauma, Language Barrier 1
• Aphasic 2

1C: Tell Patient To Open and Close Eyes, then Hand Grip Squeeze (Substitute/Pantomime Commands if Language Barrier/Confusion)

• Performs Both Tasks Correctly 0
• Performs One Task Correctly 1
• Performs 0 Tasks Correctly 2

2: Test Horizontal Extraocular Movements

• Normal Extraocular Movements 0
• Partial Gaze Palsy: Can Be Overcome 1
• Partial Gaze Palsy: Corrects with Oculocephalic Reflex 1
• Forced Gaze Palsy: Cannot Be Overcome 2

3: Test Visual Fields

• No Visual Loss 0
• Partial Hemianopia 1
• Complete Hemianopia 2
• Patient is Bilaterally Blind 3
• Bilateral Hemianopia 3

4: Test Facial Palsy (Use Grimace if Obtunded)

• Normal symmetrical movements 0
• Minor paralysis (flat nasolabial fold, smile asymmetry) 1
• Partial paralysis (total/near-total lower face paralysis) 2
• Unilateral Complete paralysis (no facial movement upper/lower face) 3
• Bilateral Complete paralysis (no facial movement upper/lower face) 3

5A: Test Left Arm Motor Drift

• No Drift for 10 Seconds 0
• Drift, but does not hit bed/support 1
• Drift, but hits bed/support 2
• Some Anti-Gravity Effort 2
• No Effort Against Gravity 3
• No Movement 4
• Amputation/Joint Fusion Unable

5B: Test Right Arm Motor Drift

• No Drift for 10 Seconds 0
• Drift, but does not hit bed/support 1
• Drift, but hits bed/support 2
• Some Anti-Gravity Effort 2
• No Effort Against Gravity 3
• No Movement 4
• (Amputation/Joint Fusion Unable to score)

6A: Test Left Leg Motor Drift

• No Drift for 5 Seconds 0
• Drift, but does not hit bed 1
• Drift, but hits bed/support 2
• Some Anti-Gravity Effort 2
• No Effort Against Gravity 3
• No Movement 4
• (Amputation/Joint Fusion Unable to score)

6B: Test Right Leg Motor Drift

• No Drift for 5 Seconds 0
• Drift, but does not hit bed 1
• Drift, but hits bed/support 2
• Some Anti-Gravity Effort 2
• No Effort Against Gravity 3
• No Movement 4
• (Amputation/Joint Fusion Unable to score)

7: Test Limb Ataxia (FNF/Heel-Shin)

• No Ataxia 0
• Ataxia in 1 Limb 1
• Ataxia in 2 Limbs 2
• Does Not Understand 0
• Paralyzed 0
• (Amputation/Joint Fusion Unable to score)

8: Test Sensation

• Normal; No sensory loss 0
• Mild-Moderate Loss: Less Sharp/More Dull 1
• Mild-Moderate Loss: Can Sense Being Touched 1
• Complete Loss: Cannot Sense Being Touched At All 2
• No Response and Quadriplegic 2
• Coma/Unresponsive 2

9: Test Language/Aphasia: Describe the scene; name the words; read the sentences.

• Normal; No aphasia 0
• Mild-Moderate Aphasia: Some Obvious Changes, Without Significant Limitation 1
• Severe Aphasia: Fragmentary Expression, Inference Needed, Cannot Identify Materials 2
• Mute/Global Aphasia: No Usable Speech/Auditory Comprehension 3
• Coma/Unresponsive 3

10: Test Dysarthria (Read the words.)

• Normal 0
• Mild-Moderate Dysarthria: Slurring but can be understood 1
• Severe Dysarthria: Unintelligible Slurring or Out of Proportion to Dysphasia 2
• Mute/Anarthric 2
• Intubated/Unable to Test UN

11: Test Extinction/Inattention

• No abnormality 0
• Visual/tactile/auditory/spatial/personal inattention 1
• Extinction to bilateral simultaneous stimulation 1
• Profound hemi-inattention (ex: does not recognize own hand) 2
• Extinction to >1 modality 2