EM Neuro 3 (NIHSS)

Question 1

What is NIHSS?

Answer 1

National Institutes of Health Stroke Scale

Question 2

Remarks on NIHSS

Answer 2

An important caveat is that the NIHSS is weighted toward the detection of anterior circulation strokes as opposed to posterior circulation strokes

NIHSS has a bias toward detection of left hemisphere strokes

Question 3

important scoring rules for the proper use of NIHSS

Answer 3

Score what you see, not what you think

Score the first response, not the best response, except item 9 (best language)

do not coach

Question 4

Components of NIHSS

Answer 4

1a LOC
1b LOC questions
1c LOC commands

2. Best gaze
3. Visual
4. Facial palsy
5. Motor arm
6. Motor leg
7. Limb ataxia
8. Sensory
9. Best language
10. Dysarthria
11. Extinction and inattention

Question 5

score of nihss used commonly for criteria for thrombolytic admisnistration

Answer 5

5-21

“between 4 and 22”

Question 6

stroke severity as per NIHSS score

Answer 6

0: no stroke symptoms
1-4: minor stroke
5-15: moderate stroke
16-21: moderate-to-severe stroke
22-42: severe stroke

Question 7

1a

Answer 7

Level of consciousness (LOC)
0 = alert; keenly responsive
1 = not alert, but arousable by minor stimulation to obey, answer, or respond

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 is totally unresponsive, flaccid, and areflexic

Question 8

1b

Answer 8

LOC questions: month and age
0 = answers both question correctly
1 = answers one questions correctly; unable to speak due to problems not due to aphasia (e.g. ET, orotracheal trauma, severe dysarthria)
2 = answers neither question correctly; aphasic or stuporous

Question 9

1c

Answer 9

1c. LOC commands
open and close eyes, grip and release
0 = performs both tasks correctly
1 = performs one task ccorrectly
2 = performs neither task correctly

Question 10

2

Answer 10

2 - “Best gaze”
only horizontal gaze is tested

0 = normal
1 = partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is NOT present

2 = forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver

Question 11

3.

Answer 11

3 - “visual”
0 = no vision loss
1 = partial hemianopia; clear-cut asymmetry; extinction

2 = complete hemianopia
3 = bilateral hemianopia; blind of any cause

Question 12

4.

Answer 12

4 - “FACIAL PALSY”
show teeth, raise eyebrows, and close eyes

0 = normal symmetric movements
1 = 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 (absence of facial movement in the upper and lower face)

Question 13

5

Answer 13

5 - “Motor arm”
(5a left arm, 5b right arm)

0 = no drift for full 10 seconds
1 = drifts down before full 10 seconds; does not hit bed or other support

2 = limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity

3 = no effort against gravity; limb falls

4 = NO MOVEMENT

Question 14

6

Answer 14

6 - “motor leg”
hold leg 30 degrees
the patient is always tested supine
5 seconds

0 =. no drift for full 5 seconds
1 = drift, but does not hit bed

2 = some effort against gravity; leg falls to bed by 5 s

3 = no effort against gravity; leg falls to bed immediately

4 = no movement

Question 15

7

Answer 15

7. LIMB ATAXIA
   (a) aimed at finding evidence of unilateral cerebellar lesion
   (b) finger-nose and heel-shin tests are performed on both sides
   (c) ataxia is absent in the patient who cannot understand or is paralyzed

0 = absent
1 = present in one limb
2 = present in two limbs

Question 16

8

Answer 16

8 - “Sensory”
0 = normal; no sensory loss

1 = mild-to-moderate sensory loss;
stuporous and aphasic

2
= severe to total sensory loss;
=patient is not aware of being touched on face, arm, and leg
= bilateral sensory loss, indicative of brainstem stroke
= patient does not respond and is quadriplegic
= coma (itema 1a is 3)

Question 17

9

Answer 17

9 - “best language”
0 = no aphasia; normal

1 = mild-to-moderate aphasia
= some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression

2 = severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by listener
= listener carries burden of communication

3 = mute, global aphasia;
= no usable speech or auditory comprehension
= does NOT follow one-step commands
= coma

Question 18

10

Answer 18

10 - “dysarthria”
do not tell the patient why he or she is being tested
0 = normal

1 = mild-to-moderate dysarthria; patient slurs at least some words and, at worse, can be understood with some difficulty

2 = severe dysarthria; patient’s speech is so sluured as to be unintelligible, in the absence of or out of proportion to any dysphasia, or is mute/anarthric

Question 19

11

Answer 19

11 - “extinction and inattention”
0 = no abnormality
1 = visual, tactile auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities

2 = profound hemi-inattention or extinction in more than 1 modality;
patient does NOT recognize own hand or orients to only one side of space