If patient under 2, Age of patient in months
1a. Level of Consciousness: For children age 2 yrs and up, the investigator must choose a response, even if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation. For infants age 4 months up to age 2 years, multiply the score for this item by three, and omit scoring items 1b and 1c. 0 = Alert; keenly responsive.
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. Modified for children, age 2 years and up. A familiar Family Member must be present for this item: Ask the child “how old are you?” Or “How many years old are you?” for question number one. Give credit if the child states the correct age, or shows the correct number of fingers for his/her age. For the second question, ask the child “where is XX?”, XX referring to the name of the parent or other familiar family member present. Use the name for that person which the child typically uses, e.g. “mommy”. Give credit if the child correctly points to or gazes purposefully in the direction of the family member. Omit this item for infants age 4 months up to age 2 years. See comment under item 1a.
1c. LOC Commands: The patient is asked to open and close the eyes (For children > age 2 years, this command to open and close the eyes is suitable and can be scored as for adults.) and then to grip and release the non-paretic hand. For children > age 2 years, substitute the command to grip the hand with the command “show me your nose” or “touch your nose”. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to them (pantomime) and score the result (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored. Omit this item for infants age 4 months up to age 2 years. See comment under item 1a.
2. Best Gaze: Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric testing is not done. 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.
3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting (for children > 6 years) or visual threat (for children age 4 months to 6 years) as appropriate. Patient must be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. 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 answer question 11.
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. If facial trauma/bandages, orotracheal tube, tape or other physical barrier obscures the face, these should be removed to the extent possible.
5 & 6. Motor Arm and Leg: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine) and the leg 30 degrees (always tested supine). Drift is scored if the arm falls before 10 seconds or the leg before 5 seconds. For children too immature to follow precise directions or uncooperative for any reason, power in each limb should be graded by observation of spontaneous or elicited movement according to the same grading scheme, excluding the time limits. 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 or hip, or immobilization by an IV board, may the score be "9" and the examiner must clearly write the explanation for scoring as a "9".
5a. Left Arm
5b. Right Arm
6a. Left Leg
6b. Right Leg
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, insure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. In children, substitute this task with reaching for a toy for the upper extremity, and kicking a toy or the examiner’s hand, in children too young (< 5 years) or otherwise uncooperative for the standard exam item. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion may the item be scored "9", and the examiner must clearly write the explanation for not scoring. In case of blindness test by touching nose from extended arm position.
8. Sensory: Sensation or grimace to pin prick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. For children too young or otherwise uncooperative for reporting gradations of sensory loss, observe for any behavioral response to pin prick, and score it according to the same scoring scheme as a “normal” response, “mildly diminished” or “severely diminished” response. 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. A score of 2, "severe or total," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brain stem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic score 2. Patients in coma (item 1a=3) are arbitrarily given a 2 on this item.
9. Best Language: A great deal of information about comprehension will be obtained during the preceding sections of the examination. For children age 6 years and up with normal language development before onset of stroke: The patient is asked to describe what is happening in the attached, to name the items on the attached naming sheet (see pictures used in the STOP study, attached), and to read from the attached list of sentences (see the list of words/phrases from the STOP study; or who premorbid were known to be unable to read). Comprehension is judged from responses here as well as to all of the commands in the preceding general neurological exam. 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 coma (question 1a=3) will arbitrarily score 3 on this item. The examiner must choose a score in 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. For children age 2 yrs to 6 yrs (or older children with premorbid language disability), score this item based on observations of language comprehension and speech during the preceding examination. For infants age 4 months to 2 years, score for auditory alerting and orienting responses.
For Children age 2 years and up:
For Infants age 4 months to 2 years:
Pediatric NIH Stroke Scale: Testing material for Item 9 “Best Language” At the bottom of the page
10. Dysarthria: If patient is thought to be normal 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 barrier to producing speech, may the item be scored "9", and the examiner must clearly write an explanation for not scoring. Do not tell the patient why he/she is being tested.
11. Extinction and Inattention (formerly Neglect): For children age 2 years and up: Sufficient information to identify neglect may be obtained during the prior testing. 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. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable. For children age 4 months to 2 years, score as “1” if there is either a sensory or motor deficit, score as a “2” if there are both sensory and motor deficits on the general neurological examination.
Total Score
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