Stroke Scales Flashcards
GCS
Best score is 15 Coma scale Best eye response Best verbal response Best motor response
In GCS, a person with spontaneous eye opening would get a score of
4
In GCS, a person who opens eyes in response to verbal command, speech, or shout would score
3
In GCS a person who open eyes to pain would score
2
In GCS a person who has absent eye opening scores
0
Best verbal response in GCS, a person that is orientated would score
5
Best verbal response in GCS with confused conversation but able to answer questions would score
4
Best verbal response in GCS inappropriate responses but understandable responses would score
3
Best verbal response in GCS incomprehensible speech would score
2
Best verbal response in GCS with no speech would score
0
Best motor response in GCS and can obey commands for movement would score
6
Best motor response in GCS with purposeful movement to painful stimuli would score
5
Best motor response GCS for pain withdrawal
4
Best motor response GCS abnormal spastic flexion- decorticate posturing would score
3
Best motor response in GCS for extension posturing - decerebrate would score
2
Best motor response in GCS with no movement would score
1
FOUR coma scale includes what?
Respirations and brainstem
What’s the max NIHSS
42
NIHSS of <3 usually correlates with
A good outcome
Pts can usually be dc Home with a NIHSS
<5
Discharge dispo for pts with a NIHSS 7-13
Usually rehab
Dispo for pts with NIHSS >14
SNF
What is considered a significant neurologic change on the NIHSS
2-4 points
What are the NIHSS categories?
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
What is the ICH scale used for?
Intracerebral hemorrhages Predicts 30 day mortality and 12 month functional outcome
Which scale is scored 1-6 and predicts 30 day mortality?
ICH scale
What is assessed in a ICH scale
GCS ICH volume IVH Location Age
What is the Hunt & Hess scale?
For subarachnoid hemorrhage Helps to make the decision of when to go to OR Used Roman numerals Score I - V Score is based on clinical findings
In the hunt and Hess scale, scores of I - III
Have a better outcome but need OR quickly
In the hunt Hess scale scores of IV - V
Have a worse outcome and must be stabilized before going to the OR
A hunt Hess score of I would exhibit
Asymptomatic or mild HA
A hunt Hess score of II would exhibit signs of
Moderate to sever HA with oculomotor palsy
A hunt Hess score of III would exhibit
Confusion, drowsiness, or mild focal signs
A hunt Hess score of IV would exhibit
Stupor bit can localize to pain
A hunt Hess score of V would exhibit
Coma- posturing or no motor response
What is the Fisher-Miller scale used for?
Measures volume of SAH BLOOD ON CT
Predicts cerebral vasospasm
Scoring is 1-4
What is the ABCD2 score
- Score for TIA to predict the 90 day AIS risk
- Used to determine hospitalization need vs d/c and f/u
On the ABCD a score of 1-3
1% 2 day risk
D/C
On the ABCD risk a 4-5
4.1% 2 day risk
8-12% 90 day risk
Admit
A ABCD a score of 6-7 is
8.1% 2 day risk
17-22% 90 day risk
Admit
What’s the max score on a ABCD TIA risk score?
9
What is the modified rankin used for?
Measures functional outcome
What is the scale in modified rankin
0-6
What is the Barthel Index
Stroke outcome scale Measures self care and mobility Correlates with infarcts volume Normal = 100 The lower the score the higher the disability
What is measured in the Barthel Index
Bowel Bladder Grooming Toileting Feeding Transferring Mobility Dressing Stairs Bathing
What is the FIM
Functional outcome scale Measures 18 ADLS Used in rehab Scored 1-7 1= total assist 7= independent
