Stroke Scales

Contents

APECTS. 1

Posterior circulation ASPECTS (pc-ASPECTS) 1

NIHSS. 1

NIHSS Tips. 1

Modified Rankin Scale (mRS) 1

APECTS

Alberta Stroke Programme Early CT Score

10 point scale – subtract 1 point for each region involved on CT imaging - (LOWER SCORE is worse)

1. caudate

2. putamen

3. internal capsule

4. insular cortex

5. M1: "anterior MCA cortex," corresponding to the frontal operculum

6. M2: "MCA cortex lateral to insular ribbon" corresponding to the anterior temporal lobe

7. M3: "posterior MCA cortex" corresponding to the posterior temporal lobe

8. M4: "anterior MCA territory immediately superior to M1"

9. M5: "lateral MCA territory immediately superior to M2"

10. M6: "posterior MCA territory immediately superior to M3"

pc-ASPECTS (Posterior Circulation)

10 point scale – subtract points for each region affected:

1. thalami (1 point each side)

2. occipital lobes (1 point each side)

3. midbrain (2 points if either side affected)

4. pons (2 points if either side affected)

5. cerebellar hemispheres (1 point each side)

NIHSS

1a. Level of consciousness: MUST SCORE A "3" is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.	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 ortotally unresponsive, flaccid, and areflexic. MUST SCORE
1b. LOC Questions: The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.	0 = Answers both questions correctly. 1 = Answers one question correctly. 2 = Answers neither question correctly. MUST SCORE
2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.	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 MUST SCORE
3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. Unconscious patients are tested using threat and scores 3 if no response	0 = No visual loss. 1 = Partial hemianopia. 2 = Complete hemianopia. 3 = Bilateral hemianopia (blind including cortical blindness). MUST SCORE
4. Facial Palsy: Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient.	0 = Normal symmetrical 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). MUST SCORE
5. Motor Arm: Extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Each limb is tested in turn, beginning with the non-paretic arm. 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. Any movement (even a shrug or slight leg movt.) Scores a 3.	0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; 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. MUST SCORE UNLESS: UN = Amputation or joint fusion
6. Motor Leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Each limb is tested in turn, beginning with the non-paretic leg. Drift is scored if the leg falls before 5 seconds. Any movement (even a shrug or slight leg movt. Scores a 3.	0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. 3 = No effort against gravity; leg falls to bed immediately. 4 = No movement. UN = Amputation or joint fusion, explain: MUST SCORE UNLESS: UN = Amputation or joint fusion
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, Ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. In case of blindness, test by having the patient touch nose from extended arm position.	0 = Absent. 1 = Present in one limb. 2 = Present in two limbs. ONLY SCORE IF PRESENT UN = Amputation or joint fusion, explain: ________________
8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item.	0 = Normal; no sensory loss. 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched. 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg.
9. Best Language: The patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands.	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 the listener. 3 = Mute, global aphasia; no usable speech or auditory comprehension. Coma = score 3.
10. Dysarthria: An adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for this choice. 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 worst, can be understood with some difficulty. 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric. UN = Intubated or other physical barrier, explain:_____________________________
11. Extinction and Inattention (formerly Neglect): The presence of visual or spatial neglect or anosagnosia may also be taken as evidence of abnormality. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. Since the abnormality is scored only if present, the item is never untestable.	0 = No abnormality. 1 = Extinction/inattention in one of the sensory modalities. (Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation). 2 = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.

Score	Stroke
0	No symptoms
1-4	Minor stroke
5-15	Moderate stroke
16-20	Moderate to severe
21-24	Severe

NIHSS Tips

Best Gaze

· Use oculocephalic reflex, only score a 2 if gaze palsy cannot be overcome by reflex

· Use of reflex can be done in unconscious patient and so should be scorable in everyone.

Visual

· Use blink to threat if patient aphasic

Facial palsy

· If patient aphasic consider noxious stimulus to make patient grimace and then assess

· Minor paralysis = minor facial asymmetry

· Partial paralysis = standard UMN weakness

· Complete paralysis = score for patient with LMN type weakness (usually suggestive of brainstem stroke) or patient in coma

Motor

· Always scored unless joint fused or amputation etc.

· Any movement – such as shoulder shrug or hip flexion, results in a score of 3.

Ataxia

· If there is significant weakness or inability to perform test then score 0. Only score if present.

· Must be considered out of proportion to weakness

Sensory

· Use noxious stimulus if patient aphasic or obtunded

· Never marked untestable.

· If the patient is totally unconscious the patient automatically scores a 2.

Language

· Score 3 for unconscious or mute patient

·

Modified Rankin Scale (mRS)

Score	Official Wording	Additional pointers
0	No symptoms at all
1	No significant disability despite symptoms; able to carry out all usual duties and activities.	Can do usual activities (i.e. activities that would usually be done on own, at least monthly). May not do as much activity or as fast as before.
2	Slight disability Unable to carry out all previous activities, but able to look after own affairs without assistance	Could be left at home for one week May have chosen to give up some previous activities i.e working or driving
3	Moderate disability Requiring some help, but able to walk without assistance	Able to walk from one room to another without assistance Need supervision at least once/week (may be just advisory assistance) – but could not be left alone for one week. Need help with more complex tasks – cooking, cleaning. i.e. not able to complete all basic ADLs
4	Moderately severe disability Unable to walk without assistance and unable to attend to own bodily needs without assistance	Still able to sit up in bed without assistance
5	Severe disability Bedridden, incontinent and requiring constant nursing care and attention
6	Dead