Nihss 1 point. Appendix G4
Every neurologist is familiar with the NIHSS (National Institutes of Health Stroke Scale). After all, it is its data that is used to decide on the advisability of thrombolytic therapy, assess its effectiveness, and also to determine the prognosis of the disease. The principle is this: the higher the NIHSS score, the more severe the condition.
In the case of a neurological deficit of more than 3 points on the NIHSS scale, this is regarded as an indication for thrombolytic therapy. If the patient's condition corresponds to more than 25 points on this scale, this is a relative contraindication to thrombolysis. There is evidence that with a score of less than 10 points, the probability of a favorable outcome after 1 year = 60-70%, and with a score of more than 20 points = 4-16%.
Evgeny Chernyshkov helped ensure that the popular scale appeared in the smartphones of medical workers. So, back in 2012, the NIHSS application appeared for Android devices, working safely on both smartphones and tablets.
Compatible with Android devices only.
Language: Russian, English.
National Institutes of Health Stroke Scale (NIHSS)
1. Level of consciousness:
- 0- conscious, actively reacting;
- 1 - somnolence, but can be awakened with minimal irritation, follows commands, answers questions;
- 2 - stupor, requires repeated stimulation to maintain activity or lethargy, and requires strong and painful stimulation to produce non-stereotypical movements;
- 3 - coma, reacts only with reflex actions or does not respond completely to stimuli
2. Level of consciousness – questions:
Ask the patient what month it is and his age. Write down the first answer.
If aphasia and stupor - score 2.
If endotracheal tube, trauma, severe dysarthria, language barrier - score 1.
- 0 - correct answer to both questions;
- 1 - correct answer to one question;
- 2 - no correct answer was given to any question
3. Level of consciousness – execution of commands:
The patient is asked to open and close his eyes, then clench and unclench his non-paralyzed hand. Only the first attempt counts:
- 0 - both commands were executed correctly;
- 1 - one command was executed correctly;
- 2 - no command executed correctly
4. Eyeball movements:
Only horizontal eye movements are taken into account:
- 0 - normal;
- 1 - partial gaze paralysis;
- 2 - tonic abduction of the eyes or complete gaze paralysis, not overcome by inducing oculocephalic reflexes
5. Visual field examination:
- 0 - normal;
- 1 - partial hemianopsia;
- 2- complete hemianopsia
6. Paresis of facial muscles:
- 0 - normal;
- 1 - minimal paralysis (asymmetry);
- 2 - partial paralysis - complete or almost complete paralysis of the lower muscle group;
- 3 - complete paralysis (lack of movement in the upper and lower muscle groups)
7. Movements in the upper limbs:
The arms are raised for 10 seconds at an angle of 45 degrees if the patient is lying down, and 90 degrees if the patient is sitting. If the patient does not understand, then the doctor must place the arms in the position himself. Scores are recorded separately for the right and left limbs:
- Right:
- 4 - no active movements;
- Left:
- 0 - no lowering for 10 seconds;
- 1 - lowers after a short hold (before 10 seconds);
- 2 - limbs cannot rise or maintain an elevated position, but produce some resistance to gravity;
- 3 - limbs fall without resistance to gravity;
- 4 - no active movements;
- 9 - impossible to check (limb amputated, artificial joint)
8. Movements in the lower extremities:
If the patient is lying down, raise the paretic leg for 5 seconds at an angle of 30º.
Scores are recorded separately for the right and left limbs.
- Right:
- 3 - limbs fall without resistance to gravity;
- 4 - no active movements;
- 9 - impossible to check (limb amputated, artificial joint)
- Left:
- 0 - no lowering for 5 seconds;
- 1 — lowers after a short hold (before 5 seconds);
- 2 - limbs cannot rise or maintain an elevated position, but produce some resistance to gravity;
- 3 - limbs fall without resistance to gravity;
- 4 - no active movements;
- 9 - impossible to check (limb amputated, artificial joint)
9. Limb ataxia:
Finger-toe and heel-knee tests are carried out on both sides. Ataxia is counted if it is not due to weakness:
- 0—absent;
- 1 - in one limb;
- 2 - in two limbs
10. Sensitivity:
Only hemitype disorder is taken into account:
- 0 - normal;
- 1 - mild or moderate impairment;
- 2 - significant or complete loss of sensitivity.
11. Aphasia:
Ask the patient to describe the picture, name the object, read the sentence:
- 0 - no aphasia;
- 1 - mild aphasia;
- 2 - severe aphasia;
- 3 - complete aphasia
12. Dysarthria:
- 0 - normal articulation;
- 1 - soft or medium. May not pronounce some words;
- 2 - severe dysarthria
- 9 - intubated or other physical barrier
13. Agnosia (ignoring):
- 0 - no agnosia;
- 1 — ignoring bilateral sequential stimulation of one sensory modality;
- 2 - severe hemiagnosia or hemiagnosia in more than one modality.
Total score:
Interview with Nathan Bornstein
Interview with Nathan Bornstein
Nathan M. Bornstein (IL), MD
Neurological Department, Medical Center named after. Soraski, Tel Aviv
Nathan M. Bornstein is Professor and Chief of the Department of Neurology at Johns Hopkins Medical Center. Elias Soraski, Faculty of Medicine. Sackler, Tel Aviv University, Israel.
Dr. Bornstein's scientific interests include the following areas: lateralized epileptiform discharges (PLEDs) developed after stroke and associated with metabolic disorders, non-valvular atrial fibrillation, menopause and ischemic stroke, the role of hormone replacement therapy, antiplatelet drugs in the treatment of strokes, infections as a trigger factor for ischemic stroke, transcranial Doppler sonography, dynamics and treatment of asymptomatic carotid stenosis and the clinical significance of hemorrhages in carotid plaques.
Dr. Bornstein is a principal investigator for the Tel Aviv Stroke Registry and the Mediterranean Stroke Society, and a member of the European Stroke Registry. Author and co-author of more than 90 scientific articles on the problems of cerebrovascular diseases, published in journals such as Stroke, Neurology, Adverse Neurology, Cardiology, Acta Diabetologica, Cerebrovascular Diseases, Lancet, Archives of Neurology, Headache, The Journal of Neurological Sciences, The European Journal of Neurology.
— Professor Bornstein, you recently visited Seoul and took part in the International Congress on Stroke. What would you highlight as the most significant scientific and clinical studies?
— This year was not marked by such advanced research as ECASS III in 2008, conducted in Vienna. However, the congress presented the results of several important studies, namely the SENTIS study on the use of the NeuroFlo catheter to increase cerebral circulation in acute ischemic stroke, and the CASTA study on the use of the drug Cerebrolysin for the treatment of acute ischemic stroke. Also noteworthy were the excellent lectures by Dr. Cohen and Dr. Dirnagl on the impressive results of preclinical research in stroke models.
— Professor Bornstein, you personally participated in the CASTA study. How would you comment on the main findings of the study?
- Yes, that's right. I served on the Steering Committee and am therefore partially responsible for the design of this study. More than 1,060 patients were enrolled, of whom more than 900 completed the study. The final results of the study regarding the primary effectiveness indicators were neutral. However, we think this was likely due to the fact that a large proportion of the study patients experienced mild strokes, with a median NIHSS score of 9, because too many mild cases were included in the study , then the “ceiling effect” could be strongly manifested.
— Professor Geiss, an ardent supporter of evidence-based medicine, presented the results of the CASTA study from an optimistic and positive point of view. What are the reasons for these conclusions?
“I think that during the presentation of the data, it was correct to point out the possible existence of a ceiling effect, which may explain the neutral results of the study.” However, Cerebrolysin showed significant beneficial effects in the subgroup of patients with baseline NIHSS scores > 12 or even higher (NIHSS > 17). These effects should be taken into account by clinicians as this is the first time in a stroke clinical trial that a neuroprotective agent has demonstrated such robust clinical efficacy.
— Could you tell us a little more about these beneficial effects?
— In a subgroup of 246 people enrolled in the CASTA study with NIHSS scores > 12, the study drug group experienced an improvement of approximately 5 points on the NIHSS after 90 days, compared with the control group, which had a decrease of less than 2 points . This difference of 3 points indicates the development of a very pronounced clinical improvement when patients were treated with Cerebrolysin. It is also important to note that positive effects were observed as early as day 10 of treatment, a point in time when clinicians may decide to intensify neurorehabilitation if the patient's biological condition is stable. For many patients, this reduction means that if rehabilitation is started early, instead of a prolonged course of the disease, their condition will continuously improve.
— Were the results obtained in patients with strokes in the right or left hemispheres different?
- As far as I know, no. This indicates that improvement occurs in any case, regardless of the side of the damage. However, we must wait until the final report of the study results, due sometime in late December, to more definitively answer the question of which subgroups of patients benefited most from Cerebrolysin therapy.
— Please explain whether any positive effect can be expected in patients with mild stroke, since CASTA does not provide a clear answer to this question.
— A positive effect can also be determined in patients suffering from mild forms of stroke and having, accordingly, low values on the NIHSS scale. However, for this to happen, the study must include many more patients. Imagine, for example, two mild stroke patients, one in the placebo group and one in the Cerebrolysin group, with an NIHSS score of 8. As you are well aware, mild strokes usually improve within 90 days to the point where there is very little neurological impairment and the patient's cognitive/motor function can be restored. As a result, it is difficult to detect a significant treatment effect in this group
Previous studies have demonstrated that Cerebrolysin helps these patients recover faster, which improves the quality of life of patients and their caregivers. We can also assume that patients who recover more quickly do not develop post-stroke depression, which often occurs with long-term disorders.
“Another important aspect of stroke research is data on the safety of treatment. What were they like in the CASTA study?
“One of the most important benefits of Cerebrolysin has always been its safety profile, and this was again confirmed in the CASTA study, for the first time in more than 1000 patients. In particular, there was a trend towards a decrease in mortality in the Cerebrolysin group by 1.3%. I think that in the final report, in the subgroup of patients with more severe lesions, this figure will be even higher. But for now all this is just speculation.
— Do you believe that, in the end, convincing data can be obtained about the possibility of achieving a significant neuroprotective effect in ischemic stroke?
- Yes, I believe it. However, we must understand that for many years, neurologists around the world had high hopes that neuroprotection could become an established therapy for acute stroke in addition to r-tPA. But the results of several studies did not live up to these expectations.
— What research do you mean?
— Among the latest studies, we can mention the SAINT study, devoted to the study of the substance NXY-059, and the EAST study, devoted to the study of the free radical scavenger called Edaravone. In both cases negative results were obtained. We can also recall a large review by James Grotta in 2004, which examined drugs tested as neuroprotective agents, with negative results in almost all cases.
— Do you believe in the future of Cerebrolysin?
— From my point of view, it is necessary to carry out more scientific research on the use of Cerebrolysin in acute ischemic stroke. However, the pronounced positive trends in the subgroups of the CASTA study should impress both the pharmaceutical company and the medical community. As is known, only a small number of drugs have achieved certainty in terms of evidence in one step. However, the first step is always the hardest, and the first step taken in this Cerebrolysin study was very exciting for both the pharmaceutical company and for us stroke specialists.
— Cerebrolysin is a biological drug with complex multimodal action. Do you think this complexity is part of the answer to why Cerebrolysin is a good candidate to look for compelling evidence?
— You raised a very interesting question. In parallel with conducting clinical trials, we must also study the mechanisms of action of Cerebrolysin in acute stroke. Preclinical data indicate that Cerebrolysin is a multimodal drug that is useful for both neuroprotection in acute stroke and long-term neurorehabilitation. In addition, due to its ability to influence the ischemic cascade at various levels (pleiotropic effect), it is the most suitable candidate for neuroprotection in the acute period of stroke.
If you remember Stephen Davis's lecture at the International Stroke Congress in Seoul, he noted that the proof of concepts associated with Cerebrolysin has already been established, the only thing missing is data from randomized controlled trials (RCTs). We already know that the mechanism of action of Cerebrolysin is pleiotropic and multimodal in nature. In this regard, it is worth recalling that back in 2006, Marc Fisher expressed the opinion that the best candidates for detecting effectiveness in large RCTs are drugs with multimodal action, including neurotrophic factors.
Cerebrolysin may be an even better candidate than neurotrophic factors themselves due to its greater multimodal properties. This is due to the fact that it mimics the effects of neurotrophic factors, and the active peptides contained in the drug are small enough to pass through the blood-brain barrier, which enhances the effect.
- Well, let's end this interview with a look into the future. What new things do you think will happen in Cerebrolysin research in the near future?
“Over the past few weeks, I have been discussing the CASTA study and its results with my colleagues. The message I received is quite clear: the hope is that the sponsor will soon initiate a new trial whose design will be adjusted to focus only on patients with moderate to severe strokes, which may require higher doses. drug or increasing the duration of treatment.
We must learn important lessons from the CASTA study. And if the subgroup analysis is justified, then the next study has a high probability of finding positive, reliable results, which would be an excellent advance in the treatment of strokes.
“Professor Bornstein, we would like to thank you for sharing with us information about this important congress in Seoul, and in particular about the CASTA study.
Thank you for your questions. I was glad to help.
It is used to assess the neurological status, localization of stroke (in the carotid or vertebrobasilar region), differential diagnosis and treatment results. It is based on a number of parameters reflecting the levels of impairment of the underlying disorders due to acute cerebrovascular disease. The NIHSS score is important for planning thrombolytic therapy and monitoring its effectiveness. Thus, the indication for thrombolytic therapy is the presence of a neurological deficit (more than 3 points on the NIHSS scale), suggesting the development of disability. Severe neurological deficit (more than 25 points on this scale) is a relative contraindication to thrombolysis and does not have a significant effect on the outcome of the disease. Also, the results of assessing the condition on the NIHSS scale allow you to roughly determine the prognosis of the disease. So, with a score of less than 10 points, the probability of a favorable outcome after 1 year is 60 - 70%, and with a score of more than 20 points, 4 - 16%.
Patient Assessment Criteria | Number of points on the NIHSS scale |
Study of the level of consciousness - the level of wakefulness (if the study is impossible due to intubation or language barrier, the level of reactions is assessed) | 0 - conscious, actively reacting. 1 - somnolence, but can be awakened with minimal irritation, follows commands, answers questions. 2 - stupor, requires repeated stimulation to maintain activity or is inhibited and requires strong and painful stimulation to produce non-stereotypical movements. 3 - coma, reacts only with reflex actions or does not respond to stimuli. |
Study of the level of wakefulness - answers to questions The patient is asked to answer the questions: “What month is it now?”, “How old are you?” (if the study is impossible due to intubation, etc. - 1 point is given) | 0 - Correct answers to both questions. 1 - Correct answer to one question. 2 - Didn't answer both questions. |
Studying the level of wakefulness - executing commands The patient is asked to perform two actions - close and open the eyelids, squeeze the non-paralyzed hand, or move the foot | 0 - both commands were executed correctly. 1 - one command was executed correctly. 2 - not a single command was executed correctly. |
Eyeball movements The patient is asked to follow the horizontal movement of the hammer. | 0 is normal. 1 - partial gaze paralysis. 2 - tonic abduction of the eyes or complete gaze paralysis, which cannot be overcome by inducing oculocephalic reflexes. |
Visual field examination We ask the patient to say how many fingers he sees, while the patient must follow the movement of the fingers | 0 is normal. 1 - partial hemianopsia. 2 - complete hemianopia. |
Determination of the functional state of the facial nerve We ask the patient to show his teeth, move his eyebrows, close his eyes | 0 is normal. 1 - minimal paralysis (asymmetry). 2 - partial paralysis - complete or almost complete paralysis of the lower muscle group. 3 - complete paralysis (lack of movement in the upper and lower muscle groups). |
Assessment of motor function of the upper limbs The patient is asked to raise and lower his arms 45 degrees in a supine position or 90 degrees in a sitting position. If the patient does not understand the commands, the doctor independently places the hand in the desired position. This test determines muscle strength. Points are recorded for each hand separately | 0 - limbs are held for 10 seconds. 1 - limbs are held for less than 10 seconds. 2 - limbs do not rise or do not maintain a given position, but produce some resistance to gravity. 4 - no active movements. 5 - impossible to check (limb amputated, artificial joint) |
Assessment of motor function of the lower extremities Raise the parathecal leg in a supine position by 30 degrees for 5 seconds. Points are recorded for each leg separately | 0 - legs are held for 5 seconds. 1 - limbs are held for less than 5 seconds. 2 - limbs do not rise or maintain an elevated position, but produce some resistance to gravity. 3 - limbs fall without resistance to gravity. 4 - no active movements. 5 - impossible to check (limb amputated, artificial joint). |
Motor coordination assessment This test detects ataxia by assessing cerebellar function. A finger-nose test and a heel-knee test are performed. Assessment of coordination impairment is carried out from both sides. | 0 - No ataxia. 1 - Ataxia in one limbs. 2 - Ataxia in two limbs. UN - impossible to research (reason indicated) |
Sensitivity test examine the patient using a needle or roller to test sensitivity | 0 is normal. 1 - mild or moderate sensory impairment. 2 - significant or complete loss of sensitivity |
Identifying a speech disorder | 0 - Normal. 1 - Light or moderate dysarthria; some sounds are blurry, understanding words causes difficulties. 2 - Severe dysarthria; The patient’s speech is difficult, or mutism is detected. UN - it is impossible to investigate (specify the reason). |
Identification of perception disorders - hemiignoring or neglet | 0 - Normal. 1 - Signs of hemi-ignoring one type of stimuli (visual, sensory, auditory) were revealed. 2 - Signs of hemiignoring more than one type of stimulus were revealed; does not recognize his hand or perceives only half of the space. |
1. Eye opening:
2. Motor reaction 12
:
^
3. Verbal response
13
The sum of points in three sections and its correspondence to the level of consciousness
^
Motor Deficiency Rating Scale (Zacharia)
| Range of motion | Number of points |
| Absence of all movements | 0 |
| Contraction of a part of the muscle without motor effect in the corresponding joint | 1 |
| Muscle contraction with a motor effect in the joint without the ability to lift the limb | 2 |
| Muscle contraction with lifting of the limb without the ability to overcome the additional load applied by the examining hand | 3 |
| Active movement of the limb with the ability to overcome additional load applied by the examining hand | 4 |
| Normal strength. The examiner cannot overcome the resistance of the examinee when extending the arm | 5 |
^
Glasgow Emergency Outcome Scale
| 1 point | Death in the first 24 hours. |
| 2 points | Death in more than 24 hours. |
| 3 points | Persistent vegetative state: vital functions are stable; neuromuscular and communication functions are deeply impaired; the phases of sleep and wakefulness are preserved; the patient may be in the special care of the intensive care unit. |
| 4 points | Neuromuscular failure: mental status is within normal limits, but profound motor deficits (tetraplegia) and bulbar disorders force the patient to remain in a specialized intensive care unit. |
| 5 points | Severe disability: severe physical, cognitive and/or emotional impairment that precludes self-care. The patient can sit and eat independently. Immobile and needs nursing care. |
| 6 points | Moderate lack of independence: mental status is within normal limits. Can perform some daily functions himself. Communication problems. Can move with assistance or special devices. Needs outpatient monitoring. |
| 7 points | Mild lack of independence: mental status is within normal limits. The patient cares for himself and can walk alone or with outside support. Needs special employment. |
| 8 points | Good recovery: the patient returns to his previous pattern of life, although not everything is working out yet. Complete independence, although residual neurological impairment is possible. Walks independently without assistance. |
| 9 points | Complete recovery: complete recovery to premorbid levels without residual effects in the somatic and neurological status. |
^
National Institutes of Health Stroke Scale
Developed by the American National Institutes of Health
(National Institutes of Health Stroke Scale - NIH Stroke Scale)
T.Brott et al, 1989, J.Biller et al, 1990.
It is used to objectify the condition of a patient with ischemic stroke upon admission, in the dynamics of the process and outcome of the stroke by the 21st day of hospital stay.
The scale contains 15 items that characterize the basic functions most often impaired due to cerebral stroke. Functions are assessed in points. The scale is distinguished by its obvious simplicity, filling it out requires no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive examination of the neurological status, and allows recording the dynamics of the patient’s condition in the acute period of the disease. The internal consistency and test-retest reliability of the scale has been confirmed by a number of studies (Goldstein J.C. et al 1989). The absence of changes in the neurological status is provided as 0 points, the death of the patient - 31 points.
| Sign | Point | Description |
| Consciousness: level of wakefulness | 0 | Clear Stupefaction (inhibited, drowsy, but reacts even to a minor stimulus - a command, a question) Stupor (requires repeated, strong or painful stimulation to move or become temporarily available for contact) Coma (inaccessible to speech contact, responds to stimulation only with reflex motor or autonomic reactions) |
| Consciousness: answers to questions. Ask the patient to name the month of the year and his age | 0 | Correct answers to both questions Correct answer to one question Wrong answers to both questions |
| Consciousness: following instructions Ask the patient to open and close his eyes, clench his fingers into a fist and unclench them | 0 | Executes both commands correctly Executes one command correctly Both commands run incorrectly |
| Eyeball movements | 0 | Norm Partial gaze paralysis (but no fixed gaze deviation) Fixed deviation of the eyeballs |
| Fields of view (examined using finger movements, which the researcher performs simultaneously on both sides) | 0 | No violations Partial hemianopsia Complete hemianopsia Bilateral hemianopsia |
| Facial paralysis | 0 | No Moderately expressed Full |
| Movements in the hand on the side of paresis The hand is asked to be held for 10 seconds in a position of 90° flexion at the shoulder joint if the patient is sitting; and in a 45° flexion position if the patient is lying down | 0 | The hand doesn't go down No active movements |
| Movements in the opposite hand (trunk stroke) | 0 | The hand doesn't go down The patient first holds his hand in a given position, then the hand begins to lower The hand begins to fall immediately, but the patient still holds it somewhat against gravity The hand immediately falls, the patient is completely unable to overcome gravity No active movements |
| Movements in the leg on the paresis side The patient, lying on his back, is asked to hold his leg raised (bent at the hip joint) at an angle of 30° for 5 seconds. | 0 | No active movements |
| Movements in the opposite leg (trunk stroke) | 0 | The leg does not lower for 5 seconds The patient first holds the leg in a given position, then the leg begins to lower The leg begins to fall immediately, but the patient still holds it somewhat against gravity The leg immediately falls, the patient is completely unable to overcome gravity No active movements |
| Ataxia in the limbs Finger-nose and heel-knee tests (ataxia is scored in cases where it is disproportionate to the degree of paresis; in case of complete paralysis, it is coded with the letter “H”) 14 | 0 | No Present in either the upper or lower limb Available in both upper and lower limbs |
| Sensitivity Examined using a pin, only hemitype disorders are taken into account | 0 | Norm Slight decrease Significantly reduced |
| Denial syndrome | 0 | No Partial Full |
| Dysarthria | 0 | Normal articulation Mild to moderate dysarthria Slurred speech |
| Aphasia Evaluated by the patient’s verbal responses during the examination process | 0 | No Mild to moderate aphasia Severe aphasia Mutism |
Classification of the severity of the condition in subarachnoid hemorrhage according to Hunt-Hess
(Henry J.M.Barnett, Stroke: Pathophysiology, Diagnosis and Management, 1986)
This scale is additionally used to assess the severity of the patient’s condition in case of intracranial hemorrhage or cerebellar infarction (degree 0-V); patients whose condition corresponds to grade 0-III have no contraindications on this scale for hospitalization in the neurosurgical department.
| Degree | Characteristic |
| 0 | Unruptured aneurysm |
| I | Asymptomatic or minimal headache and mild neck stiffness |
| I.A. | Absence of meningeal or cerebral symptoms, but presence of persistent neurological deficit |
| II | Moderate to severe headache, stiff neck; no neurological deficit other than cranial nerve palsy |
| III | Stunning-stupor, confusion (disorientation in time and space), or mild local deficits |
| IV | Stupor, moderate to profound hemiparesis, possible early decerebrate rigidity and autonomic disturbances |
| V | Deep coma, decerebrate rigidity and signs of agony |
^
Barthel ADL index
(F. Mahoney, D. Barthel, 1965; C. Granger et al, 1979; D. Wade, 1992)
Instructions
The index should reflect the patient’s actual actions, and not supposed ones (not how the patient could perform certain functions).
The main purpose of testing is to establish the degree of independence from any assistance, physical or verbal, no matter how insignificant this assistance may be and for whatever reasons.
The need for supervision means that the patient does not belong to the category of those who do not need help (the patient is not independent).
The level of functioning should be determined in the best possible way for a particular situation: most often by questioning the patient, his friends/relatives or caring staff, but direct observation and common sense are also important. No direct testing is required.
Typically, the patient's functioning is assessed over the previous 24-48 hours, but sometimes a longer assessment period is warranted.
Average categories mean that the patient makes more than 50% of the efforts required to perform a particular function.
The “independent” category allows the use of auxiliary aids.
0 – incontinence (or requires an enema administered by a caregiver);
5 – random incidents (no more than once a week) or assistance is required when using an enema or suppository;
10 – complete control of bowel movements, can use an enema or suppositories if necessary, does not need assistance;
^ Controlling urination
0 – incontinence or a catheter is used, which the patient cannot control independently;
5 – random incidents (maximum once in 24 hours);
10 – complete control of urination (including those cases of bladder catheterization when the patient independently controls the catheter).
^ Personal hygiene (brushing teeth, manipulating dentures, combing hair, shaving, washing face)
0 – needs assistance with personal hygiene procedures;
5 – independent when washing your face, combing your hair, brushing your teeth, shaving (tools for this are provided)
^ Visiting the toilet (moving in the toilet, undressing, cleansing the skin, dressing, leaving the toilet)
5 – needs some help, but some of the actions, incl. hygiene procedures, can perform independently;
10 – does not need assistance (when moving, taking off and putting on clothes, performing hygiene procedures);
^Eating
0 – completely dependent on the help of others (feeding with assistance is required);
5 – partially needs help, for example, when cutting food, spreading butter on bread, etc., while eating independently;
10 – does not need help (able to eat any normal food, not just soft food; independently uses all necessary cutlery; food is prepared and served by others, but is not cut);
^ Moving (from bed to chair and back)
0 – movement is impossible, unable to sit (maintain balance), assistance from two people is required to get out of bed;
5 – requires significant physical assistance (one strong/trained person or two ordinary people) when getting out of bed, can sit up in bed independently;
10 – when getting out of bed, little assistance is required (physical, from one person), or supervision or verbal assistance is required;
15 – does not need help.
^ Mobility (movement within the home/ward and outside the home; assistive devices may be used)
0 – unable to move;
5 – can move around using a wheelchair, incl. go around corners and use doors;
10 – can walk with the help of one person (physical support or supervision and moral support);
15 – does not need assistance (but can use aids, such as a cane).
Dressing
0 – completely dependent on the help of others;
5 – partially needs help (for example, when fastening buttons, buttons, etc.), but performs more than half of the actions independently, can put on some types of clothing completely independently, spending a reasonable amount of time on it;
10 – does not need help, incl. when fastening buttons, snaps, tying shoelaces, etc., can choose and put on any clothes.
^ Climbing stairs
0 – unable to climb stairs, even with support;
5 – needs supervision or physical support;
10 – does not need help (can use aids).
^ Taking a bath
0 – takes a bath (gets in and out of it, washes itself) without assistance or supervision or washes in the shower without requiring supervision or assistance;
5 – needs help.
National Institutes of Health Stroke Scale/NIH Stroke Scale
Developed by the American National Institutes of Health (National Institutes of Health Stroke Scale - NIH Stroke Scale) T.Brott et al, 1989, J.Biller et al, 1990.
It is used to objectify the condition of a patient with ischemic stroke upon admission, in the dynamics of the process and outcome of the stroke by the 21st day of hospital stay.
The scale contains 15 items that characterize the basic functions most often impaired due to cerebral stroke. Functions are assessed in points. The scale is distinguished by its obvious simplicity, filling it out requires no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive examination of the neurological status, and allows recording the dynamics of the patient’s condition in the acute period of the disease. The internal consistency and test-retest reliability of the scale has been confirmed by a number of studies (Goldstein J.C. et al 1989). The absence of changes in the neurological status is provided as 0 points, the death of the patient - 31 points.
|
Determining scale point values |
|
|
Consciousness: level |
0 - Clear |
|
Consciousness: answers to |
0 - Correct answers to both questions |
|
Consciousness: execution |
0 - Executes both commands correctly |
|
Eyeball movements |
0 - Normal |
|
Visual fields (examined with |
0 - No violations |
|
facial |
0 - No |
|
Movements in the hand |
0 - Hand does not lower |
|
Movements in the leg |
0 - Leg does not lower for 5 seconds |
|
Ataxia in the limbs of the PNP |
0 - No |
|
Sensitivity |
0 - Normal |
|
Ignoring (neglect, |
0 - Does not ignore |
|
Dysarthria |
0 - Normal articulation |
|
0 - No |
To assess the severity of neurological symptoms during acute ischemic disease, the NIHSS scale is used. Thanks to the test, doctors are able to adequately assess the condition of an admitted person, which is necessary to provide competent first aid and determine the course of treatment.
What scale is this?
The international NIHSS scale was presented by the American National Institutes of Health Stroke Scale. It is used to objectively assess the condition of a patient who was admitted to the hospital with an ischemic stroke. The test is carried out in the dynamics of the process and after 21 days in the hospital.
The scale consists of sequential 15 tests, each of which is scored from 0 to 4. Each test allows you to assess the state of the basic functions that most often suffer from cerebral stroke. The test is simple, so it will take no more than 5-10 minutes to complete.
The test results help the doctor assess the patient’s neurological status and determine the dynamics of his general condition in the acute phase of the disease.
Scale tests
As mentioned earlier, there are only 15 of them. We will consider each study further.
Level of wakefulness
The more cheerfully a person reacts, the lower the score he is given. The maximum assessment is possible only in the case of coma or complete absence of reactions and reflexes. So, the score depends on the person’s reaction:
- 0 – awake and showing an active reaction;
- 1 – reacts slightly inhibited or feels drowsy, but fully responds even to minor stimuli;
- 2 – is unconscious or requires more aggressive influence in order for him to show a reaction;
- 3 – completely ignores external stimuli (may be associated with coma).
Ability to answer questions
The doctor asks the patient to clarify his age and the current month of the year. The score depends on the completeness and clarity of the answers:
- 0 – gave correct answers to 2 questions;
- 1 – answered correctly once;
- 2 – did not answer both questions.
It must be taken into account that the patient must give precise answers in numbers. The doctor records only the first spoken answer.
Executing commands
The doctor asks the patient to perform a series of actions - close and open his eyes, form a fist and unclench his fingers. If the patient cannot carry out any command for one reason or another, for example, due to disability, another command must be given. If the patient does not respond to speech, you can show by example what is required of him. The first attempt to execute the command is evaluated:
- 0 – both actions were completed successfully;
- 1 – only 1 action was performed;
- 2 – both actions are partially completed or not completed at all.
Reaction of the eyeballs
You need to ask the patient to follow the movements of the finger with his eyes:
- 0 – normal reaction;
- 1 – partial paralysis of the eyeballs, but there is no fixed deviation;
- 2 – complete paralysis with fixed deviation of the eyeballs.
Field of view
The test is carried out using confrontation and counting the number of fingers, both from the periphery and from the center of the eyes:
- 0 – no violations recorded;
- 1 – there is asymmetry or partial 2-sided blindness in half the visual field;
- 2 – full.
Facial muscles
How the facial nerve “works” is determined:
- 0 – no violations were recorded;
- 1 – there is slight facial asymmetry;
- 2 – facial muscles are moderately paralyzed;
- 3 – facial muscles are completely paralyzed.
Arm strength
It is important to note that this test is carried out separately for each hand, so two scores are given. As part of this task, the doctor asks the patient to open his arm, and then bend it at an angle of 90 (sitting) or 45 (lying) degrees. In this case, the palm must be turned down. The patient must remain in this position for 10 seconds, after which a score is assigned:
- 0 – managed to hold the bent arm for all 10 seconds;
- 1 – the hand is initially held at a given angle, but gradually lowers;
- 2 – the study cannot be carried out because the limb is missing or there is a fracture of the joint;
- 3 – the arm drops immediately as it was bent, and it is not possible to overcome the force of gravity;
- 4 – it is not possible to bend the arm at all to the desired degree.
Leg strength
Similar to the previous test, this study is carried out for each leg separately. The patient should be in a supine position. The doctor asked him to raise his leg at an angle of 30 degrees and hold the position for 5 seconds. Then the score is given:
- 0 – the leg was at the desired angle for all 5 seconds;
- 1 – gradually dropped;
- 2 – descended faster, staying at a given angle for an extremely short time;
- 3 – fell immediately because the patient is unable to overcome gravity;
- 4 – it was not possible to take the desired position at all.
Limb ataxia
This test is performed to determine whether there is a coordination disorder on one side. If the field of vision is impaired, the examination is carried out on the side where there is no lesion. The doctor also performs a knee-heel and toe-nose-heel test. One of the following ratings is assigned:
- 0 – no violations were detected;
- 1 – there is ataxia in either the upper or lower extremities;
- 2 – ataxia of all limbs is observed.
Sensitivity level
To determine the patient's sensitivity level, the doctor uses touch and light pricking with a needle or pin. The assessment depends on the patient's reaction:
- 0 – feels all touches and punctures;
- 1 – weakly feels all the doctor’s manipulations;
- 2 – sensitivity is extremely low.
Speech
The specialist conducts a study to evaluate the patient. To do this, he is asked to describe the picture or read some text. If this is not possible, for example, due to vision problems, you can invite him to describe the object after feeling it with his hands.
The following ratings can be given:
- 0 – the task was completed correctly, that is, speech is normal;
- 1 – there is a partial violation of the speech apparatus;
- 3 – complete failure to complete the task or the patient is completely in a coma.
Dysarthria
The doctor determines whether the patient’s pronunciation is impaired as a result of impaired innervation of the speech apparatus due to damage to the nervous system (dysarthria). During this test, the doctor does not voice the area of study, but simply conducts a dialogue with the patient. The following points are awarded:
- 0 – the patient exhibits articulation within the normal range and clearly answers questions;
- 1 – mild or moderate dysarthria is noted, that is, the patient slurs some words;
- 3 – complete dysarthria is noted, when the patient pronounces all words incomprehensibly or is completely in a coma.
Neglect (ignoring)
Right hemisphere brain damage is often accompanied by neglect - a person’s ignoring of the body, affected limb or space. Thus, the test involves assessing the perception of half the body (usually the left side). This is also done by touching, piercing with a needle or pin, etc. The following assessments are possible:
- 0 – the body responds adequately to stimuli without showing signs of neglect;
- 1 – partial visual, auditory or tactful ignoring is noted;
- 2 – gross deviations from the norm are recorded;
- 3 – there is a complete lack of response to stimuli.
The patient cannot be prepared in advance for a specific task unless required by the test itself.
Research results
The prognosis of stroke is determined depending on the total score on the scale:
- 0 – there are no disturbances in the neurological status;
- up to 10 – a good prognosis for recovery is given (observed in 60-70% of cases);
- more than 20 – a poor prognosis is given, since successful recovery is observed only in 4-16% of cases;
- 31 – maximum increase in risk of death.
Based on the final assessment, the course of treatment is also adjusted. So, if there is a slight neurological deficit (overall score above 3-5), then it is prescribed to prevent the development of the patient’s disability. If there is a severe neurological deficit (total score - 25), then thrombolysis is not prescribed, since it is no longer able to significantly affect the outcome of the disease and stop the development.
So, the scale under consideration consists of 15 tasks. For each of them, the doctor assigns certain points, and testing is carried out sequentially, that is, you cannot change the established order of tasks or return to uncompleted tests. After all the studies, the results are summed up, and the specialist gives a prognosis for the disease.
