Stroke Impact/Outcome - Adults Date of SC Final Approval

Stroke Impact/Outcome - Adults Date of SC final approval

About the Measure
Domain: / Sickle Cell Disease – Neurology, Quality of Life, and Health Services
Measure:
/ Stroke Impact/Outcome
Definition:
/ This measure is a physical assessment to determine neurological deficits due to a stroke.
Purpose: / This measure is used to describe the consequences of a stroke and to monitor the effects of treatment and recovery.
About the Protocol
Description of Protocol:
/ The NIH Stroke Scale (NIHSS) is a physical assessment of the various symptoms associated with a stroke and consists of 11 categories. For each category, thetest administrator asks the respondent to perform an activity or respond tostimuli.Respondents receive a score for each category based upon their ability to complete the activity or respond to the action. Each score typically ranges from 0 to 3. Each category of the NIHSS is designed to determine the respondent’s level of consciousness (LOC), visual, motor, or language ability.
SelectionRationale: / The Sickle Cell Disease Neurology, Quality of Life, and Health Services Working Group selected the NIH Stroke Scale (NIHSS) because it is a valid, reliable, and widelyused comprehensive evaluation of the effects of a stroke.In addition, a pediatric version of the NIHSS (PedNIHSS; see Stroke Impact/Outcome–Pediatric) is available. By using the NIHSS and PedNIHSS, investigators can collect comparable data about stroke in both pediatric and adult populations.
Specific Instructions: / The National Institute of Neurological Disorders and Stroke (NINDS) provides a comprehensive interactive training DVD for the NIHSS. Information and purchasing details for this training are available on the NINDS website:
Protocol Text:
/ Interval:
[ ] Baseline
[ ] 2 hours post treatment
[ ] 24 hours post onset of symptoms ±20 minutes
[ ] 7-10 days
[ ] 3 months
[ ] Other______(______)
Time:______:______[ ]am [ ]pm
Person Administering Scale:______
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).
Instructions / ScaleDefinition / Score
1a.LevelofConsciousness:Theinvestigatormustchoosearesponseifafullevaluationispreventedbysuchobstaclesasanendotrachealtube,languagebarrier,orotrachealtrauma/bandages. A3 isscoredonly ifthepatientmakesnomovement(otherthanreflexiveposturing)inresponsetonoxiousstimulation. / 0= Alert;keenlyresponsive.
1= Notalert;butarousablebyminorstimulationtoobey,answer,orrespond.
2= Notalert;requiresrepeatedstimulationtoattend,orisobtundedandrequiresstrongorpainfulstimulationtomakemovements(notstereotyped).
3= Respondsonlywithreflexmotororautonomiceffectsortotallyunresponsive,flaccid,andareflexic.
1b.LOCQuestions:Thepatientisaskedthemonthandhis/herage.Theanswermustbecorrect-thereisnopartialcreditforbeingclose.Aphasicandstuporouspatientswhodonotcomprehendthequestionswillscore2.Patientsunabletospeakbecauseofendotrachealintubation,orotrachealtrauma,severedysarthriafromanycause,languagebarrier,oranyotherproblemnotsecondarytoaphasiaaregiven a 1.Itisimportantthatonly theinitialanswerbegradedandthattheexaminernot"help"thepatientwithverbalornon-verbalcues. / 0= Answersbothquestionscorrectly.
1= Answersonequestioncorrectly.
2= Answersneitherquestioncorrectly.
1c.LOCCommands:Thepatientisaskedtoopenandclosetheeyesandthentogripandreleasethenon-paretichand.Substituteanotheronestepcommandifthehandscannotbeused.Creditisgivenifanunequivocalattemptismadebutnotcompletedduetoweakness.Ifthepatientdoesnotrespondtocommand,thetaskshouldbedemonstratedtohimorher(pantomime),andtheresultscored(i.e.,followsnone,oneortwocommands). Patientswithtrauma,amputation,orotherphysicalimpedimentsshouldbegivensuitableone-stepcommands.Onlythefirstattemptisscored. / 0=Performsbothtaskscorrectly.
1=Performsonetaskcorrectly.
2=Performsneithertaskcorrectly.
2.BestGaze:Onlyhorizontaleyemovementswillbetested.Voluntaryorreflexive(oculocephalic)eyemovementswillbescored,butcalorictestingisnotdone.Ifthepatienthasaconjugatedeviationoftheeyesthatcanbeovercomebyvoluntaryorreflexiveactivity,thescorewillbe1. Ifapatienthasanisolatedperipheralnerveparesis(CNIII,IVorVI),scorea1.Gazeistestableinallaphasicpatients.Patientswithoculartrauma,bandages,pre-existingblindness,orotherdisorderofvisualacuityorfieldsshouldbetestedwithreflexivemovements,andachoicemadebytheinvestigator.Establishing eyecontactandthenmovingaboutthe patientfrom sidetosidewilloccasionallyclarifythepresenceofapartialgazepalsy. / 0=Normal.
1=Partialgazepalsy;gazeisabnormalinoneorbotheyes,butforceddeviationortotalgazeparesisisnotpresent.
2=Forceddeviation,ortotalgazeparesisnotovercomebytheoculocephalicmaneuver.
3.Visual:Visualfields(upperandlowerquadrants)aretestedbyconfrontation,usingfingercountingorvisualthreat,asappropriate.Patientsmaybe encouraged, butiftheylookatthesideofthemovingfingersappropriately,thiscanbescoredasnormal.Ifthereisunilateralblindnessorenucleation,visualfieldsintheremainingeyearescored.Score1onlyifaclear-cutasymmetry,includingquadrantanopia,isfound.Ifpatientisblindfromanycause,score3.Doublesimultaneous stimulation isperformed atthis point.If there isextinction,patientreceivesa1,andtheresultsareusedtorespondtoitem11. / 0=Novisualloss.
1=Partialhemianopia.
2=Completehemianopia.
3=Bilateralhemianopia(blindincludingcorticalblindness).
4.FacialPalsy: Ask–orusepantomimetoencourage–thepatienttoshowteethorraiseeyebrowsandcloseeyes.Scoresymmetryofgrimaceinresponsetonoxiousstimuliinthepoorlyresponsiveornon-comprehendingpatient.Iffacialtrauma/bandages,orotrachealtube,tapeorotherphysicalbarriersobscuretheface,theseshouldberemovedtotheextentpossible. / 0=Normalsymmetricalmovements.
1=Minorparalysis(flattenednasolabialfold,asymmetryonsmiling).
2=Partialparalysis(totalornear-totalparalysisoflowerface).
3=Completeparalysisofoneorbothsides(absenceoffacialmovementintheupperandlowerface).
5. Motor Arm: The limb is placed in the appropriate position; extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice. / 0=Nodrift;limbholds90(or45)degreesforfull10seconds.
1=Drift;limbholds90(or45)degrees,butdriftsdownbeforefull10seconds;doesnothitbedorothersupport.
2=Someeffortagainstgravity;limbcannotgettoormaintain(ifcued)90(or45)degrees,driftsdowntobed,buthassomeeffortagainstgravity.
3=Noeffortagainstgravity;limbfalls.
4=No movement.
UN=Amputationorjointfusion,explain:
5a.LeftArm
5b.RightArm
6.MotorLeg:Thelimbisplacedintheappropriateposition:holdthe leg at 30 degrees (alwaystested supine).Drift is scoredif the legfallsbefore5seconds.Theaphasicpatientisencouragedusingurgencyinthevoiceandpantomime,butnotnoxiousstimulation.Eachlimbistestedinturn,beginningwiththenon-pareticleg.Onlyinthecaseofamputationorjointfusionatthehip,theexaminershouldrecordthescoreasuntestable(UN),andclearlywritetheexplanationforthischoice. / 0=Nodrift;legholds30-degreepositionforfull5seconds.
1=Drift;legfallsbytheendofthe5-secondperiodbutdoesnothitbed.
2=Someeffortagainstgravity;legfallstobedby5seconds,buthassomeeffortagainstgravity.
3=Noeffortagainstgravity;legfallstobedimmediately.
4=No movement.
UN=Amputationorjointfusion,explain:
6a.LeftLeg
6b.RightLeg
7.LimbAtaxia:Thisitem isaimedat findingevidence ofa unilateralcerebellarlesion.Testwitheyesopen.Incaseofvisualdefect,ensuretestingisdoneinintactvisualfield.Thefinger-nose-fingerand heel-shintests areperformedon both sides, andataxia isscoredonlyifpresentoutofproportiontoweakness.Ataxiaisabsentinthepatientwhocannotunderstandorisparalyzed.Onlyinthecaseofamputationorjointfusion,theexaminershouldrecordthescoreasuntestable(UN),andclearlywritetheexplanationforthischoice.Incaseofblindness,testbyhavingthepatienttouchnosefromextendedarmposition. / 0=Absent.
1=Presentinonelimb.
2=Presentintwolimbs.
UN=Amputationorjointfusion,explain:
8.Sensory:Sensationorgrimacetopinprickwhentested,orwithdrawalfromnoxiousstimulusintheobtundedoraphasicpatient.Onlysensorylossattributedtostrokeisscoredasabnormalandtheexaminershouldtestasmanybodyareas(arms[nothands],legs,trunk,face)asneededtoaccuratelycheckforhemisensoryloss.Ascoreof2,“severeortotalsensoryloss,”shouldonlybegivenwhenasevereortotallossofsensationcanbeclearlydemonstrated.Stuporousandaphasicpatientswill,therefore,probablyscore1or0.Thepatientwithbrainstemstrokewhohasbilaterallossofsensationisscored2.Ifthepatientdoesnotrespondandisquadriplegic,score
2.Patientsinacoma(item1a=3)areautomaticallygivena2onthisitem. / 0=Normal;nosensoryloss.
1=Mild-to-moderatesensoryloss;patientfeelspinprickislesssharporisdullontheaffectedside;orthereisalossofsuperficialpainwithpinprick,butpatientisawareofbeingtouched.
2=Severetototalsensoryloss;patientisnotawareofbeingtouchedintheface,arm,andleg.
9.BestLanguage:Agreatdealofinformationaboutcomprehensionwillbeobtainedduringtheprecedingsectionsoftheexamination.Forthisscaleitem,thepatientisaskedtodescribewhatishappeningintheattachedpicture,tonametheitemsontheattachednamingsheetandtoreadfromtheattachedlistofsentences.Comprehensionisjudgedfromresponseshere,aswellastoallofthecommandsintheprecedinggeneralneurologicalexam.Ifvisuallossinterfereswith thetests, askthe patienttoidentifyobjectsplacedinthehand,repeat,andproducespeech.Theintubatedpatientshouldbeaskedtowrite.Thepatientinacoma(item1a=3)willautomaticallyscore3onthisitem.Theexaminermustchooseascoreforthepatientwithstupororlimitedcooperation,butascoreof3shouldbeusedonlyifthepatientismuteandfollowsnoone-stepcommands. / 0=Noaphasia;normal.
1=Mild-to-moderateaphasia;someobviouslossoffluencyorfacilityofcomprehension,withoutsignificantlimitationonideasexpressedorformofexpression.Reductionofspeechand/orcomprehension,however,makesconversationaboutprovidedmaterialsdifficultorimpossible.Forexample,inconversationaboutprovidedmaterials,examinercanidentifypictureornamingcardcontentfrompatient’sresponse.
2=Severeaphasia;allcommunicationisthroughfragmentaryexpression;greatneedforinference,questioning,andguessingbythelistener.Rangeofinformationthatcanbeexchangedislimited;listenercarriesburdenofcommunication.Examinercannotidentifymaterialsprovidedfrompatientresponse.
3=Mute,globalaphasia;nousablespeechorauditorycomprehension.
10.Dysarthria:If patientisthoughttobenormal,anadequatesampleofspeechmustbeobtainedbyaskingpatienttoreadorrepeatwordsfromtheattachedlist.Ifthepatienthassevereaphasia,theclarityofarticulationofspontaneousspeechcanberated.Onlyifthepatientisintubatedorhasotherphysicalbarriers toproducingspeech, theexaminershouldrecordthescoreasuntestable(UN),andclearlywriteanexplanationforthischoice.Donottellthepatientwhyheorsheisbeingtested. / 0=Normal.
1=Mild-to-moderatedysarthria;patientslursatleastsomewordsand,atworst,canbeunderstoodwithsomedifficulty.
2=Severedysarthria;patient'sspeechissoslurredastobeunintelligibleintheabsenceoforoutofproportiontoanydysphasia,orismute/anarthric.
UN=Intubatedorotherphysicalbarrier,
explain:
11.ExtinctionandInattention(formerlyNeglect):Sufficientinformationtoidentifyneglectmaybeobtainedduringthepriortesting.Ifthepatienthasaseverevisuallosspreventingvisualdoublesimultaneousstimulation,andthecutaneousstimuliarenormal,thescoreisnormal.Ifthepatienthasaphasiabutdoesappeartoattendtobothsides,thescoreisnormal.Thepresenceofvisualspatialneglectoranosagnosiamayalsobetakenasevidenceofabnormality.Sincetheabnormalityisscoredonlyifpresent,theitemisneveruntestable. / 0=Noabnormality.
1=Visual,tactile,auditory,spatial,orpersonalinattentionorextinctiontobilateralsimultaneousstimulationinoneofthesensorymodalities.
2=Profoundhemi-inattentionorextinctiontomorethanonemodality;doesnotrecognizeownhandororientstoonlyonesideofspace.

You know how.
Down to earth.
I got home from work.
Near the table in the dining room.
They heard him speak on the radio last night.

MAMA
TIP – TOP
FIFTY – FIFTY
THANKS
HUCKLEBERRY
BASEBALL PLAYER
Participant: / Adult, ages 18 years and older
Source:
/ Brott, T., Adams, H.P., Olinger, C.P., Marler, J.R., Barsan, W.G., Biller, J., Spilker, J., Holleran, R., Eberle, R., Hertzberg, V., Rorick, M., Moomaw, C.J.,Walker, M. (1989). Measurements of acute cerebral infarction: A clinical examination scale. Stroke,20, 864–870
National Institute of Health, National Institute of Neurological Disorders and Stroke. (2003).NIHstroke scale. Available at
Language of Source: / English
Personnel and Training Required: / Examiners must be trained to administer, score, and interpret the NIH Stroke Scale (NIHSS).The National Institute of Neurological Disorders and Stroke (NINDS) provides a comprehensive interactive training DVD for the NIHSS. Information and purchasing details for this training is available on the NINDS website:
Equipment Needs: / None
Protocol Type: / Physical examination
Requirements: / Requirements Category / Required (Yes/No):
Major equipment / No
Specialized training / No
Specialized requirements for biospecimen collection / No
Average time of greater than 15 minutes in an unaffected individual / No
Common Data Elements: / TBD by PhenX Staff
General References: / Inoa, V., Aron, A.W., Staff, I., Fortunato, G., Sansing, L.H. (2014). Lower NIH stroke scale scores are required to accurately predict a good prognosis in posterior circulation stroke.Cerebrovascular Diseases 37(4), 251–255.
Schmülling, S., Grond, M., Rudolf, J., Kiencke, P. (1998). Training as a prerequisite for reliable use of NIH Stroke Scale.Stroke 29(6), 1258–1259.
Wityk, R.J., Pessin, M.S., Kaplan, R.F., Caplan, L.R. (1994). Serial assessment of acute stroke using the NIH Stroke Scale.Stroke, 25(2), 362–365.
Additional Information About the Measure
Essential Data: / Current Age
Related PhenX Measures: / Functionality After Stroke, History of Stroke–Ischemic Infarction and Hemorrhage
Derived Variables: / None
Keywords/Related Concepts: / NIH Stroke Scale, NIHSS, Pediatric NIH Stroke Scale, PedNIHSS, Stroke outcome, Stroke, Level of consciousness, LOC, Visual ability, Motor ability, Language ability, sickle cell disease, SCD

Version 10 – 10/21/09