What it’s for: NIHSS is a structured neurological exam that standardises stroke severity description and helps track change over time. It works best when you follow the script, do items in order, and score what you see on the first attempt.

Ground rules (do these every time)

Do items in the official order and score immediately. Don’t go back and change scores.
Score what you observe on the first attempt (don’t coach, don’t “practice run”).
Document both: total NIHSS and the headline deficits (e.g., “NIHSS 9: gaze 2, aphasia 2, arm 3, neglect 2”).
UN / Untestable only when there is a true barrier (e.g., amputation/joint fusion for limb items; intubation for dysarthria) and state the reason.

NIHSS

Item	How you do it (script + technique)	Scoring anchors
1a. LOC	Observe alertness. If reduced: voice → light touch → painful stimulus (e.g., trapezius pinch).	0 alert • 1 drowsy/arousable • 2 needs repeated/painful • 3 coma/unresponsive
1b. LOC questions	Ask: “What month is it?” and “How old are you?” (no cues/options).	0 both correct • 1 one correct • 2 neither correct
1c. LOC commands	Give two commands: “Open and close your eyes.” then “Grip and release my hand.” Use the non-paretic (normal) hand for the grip/release command.	0 both correct • 1 one correct • 2 neither correct
2. Best gaze	Test horizontal eye movements: “Follow my finger” left/right. Score forced deviation if gaze is fixed and cannot be overcome. Note: oculocephalic manoeuvre is only for selected cases if appropriate/safe.	0 normal • 1 partial palsy • 2 forced deviation/total (not overcome)
3. Visual fields	Confrontation (finger counting/movement). If abnormal, repeat each eye individually where possible; in reduced LOC/aphasia, visual threat may help.	0 none (or coma) • 1 partial • 2 complete hemianopia • 3 bilateral/cortical blindness
4. Facial palsy	“Show me your teeth/smile.” “Raise your eyebrows.” “Close your eyes tight.” If cannot follow commands, score at rest + grimace.	0 normal • 1 minor • 2 partial (lower face) • 3 complete
5a/5b. Motor arm	Test each arm separately for 10 seconds. Sitting: 90°. Supine: 45°. Palm down. Start with the non-paretic limb.	0 no drift • 1 drift • 2 some effort vs gravity • 3 no effort vs gravity • 4 no movement • UN (explain)
6a/6b. Motor leg	Supine: lift leg to 30° for 5 seconds (each side). Score drift/fall.	0 no drift • 1 drift • 2 some effort vs gravity • 3 no effort vs gravity • 4 no movement • UN (explain)
7. Limb ataxia	Finger–nose–finger and heel–shin. Only score if ataxia is out of proportion to weakness. If cannot test due to severe weakness/amputation → UN.	0 absent (or coma) • 1 one limb • 2 two+ limbs • UN (explain)
8. Sensory	Pinprick/sharp-dull to face/arm/leg comparing sides. In obtunded/aphasic patients use grimace/withdrawal to noxious stimulus.	0 normal • 1 mild/moderate (“not as sharp”) • 2 severe/total: not aware of being touched (or coma)
9. Best language (aphasia)	Use the standard materials: picture description, naming, and sentence reading. Score overall aphasia severity (fluency + comprehension + naming).	0 none • 1 mild/moderate • 2 severe • 3 mute/global (or coma)
10. Dysarthria	Ask patient to read/repeat the standard word list. If aphasic, judge articulation from spontaneous speech if needed. If intubated/physical barrier → UN.	0 normal • 1 mild/moderate • 2 unintelligible or mute/anarthric or coma • UN intubated/physical barrier (explain)
11. Extinction & inattention (neglect)	Double simultaneous stimulation (visual/tactile/auditory) + behavioural evidence during earlier items (fields/conversation). Test left, right, then both.	0 none (or coma) • 1 extinction/one modality • 2 profound multi-modality neglect

Common NIHSS pitfalls (the “issues” that matter clinically)

Posterior circulation under-scored: severe disability risk can coexist with a low NIHSS (e.g., truncal ataxia, dysphagia, diplopia). Don’t let a low score falsely reassure you.
NIHSS 0 ≠ no stroke: small cortical/posterior infarcts can score 0; NIHSS is a deficit quantifier, not a diagnostic rule-out test.
Subjective items drift most: ataxia, sensory and neglect are where rater variability bites-use strict scripting and document what you saw.
Totals hide anatomy: the pattern (gaze, aphasia, neglect, hemianopia) is often more informative than the final number-always document key components.

Reference materials (images) to embed on this page

NIHSS score sheet / proforma (PDF download)
Item 9 language cards: (a) picture description stimulus, (b) naming sheet, (c) sentence reading list
Item 10 dysarthria: standard word list

Key references (NIHSS-specific)

NIHSS “one-page” scoring anchors (sensory, dysarthria, neglect, language). PDF
NHS Scotland NIHSS proforma (clear coma handling, UK-friendly). PDF
MUSC NIHSS cheat sheet (quick bedside technique reminders + language card workflow). PDF
NINDS: NIH Stroke Scale updated with new visual stimuli (2024). NINDS page
Stockbridge MD, et al. New picture stimuli for NIHSS: validation study (details of updated language stimuli). Stroke (AHA)

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National Institutes of Health Stroke Scale (NIHSS)

Ground rules (do these every time)

NIHSS

Common NIHSS pitfalls (the “issues” that matter clinically)

Reference materials (images) to embed on this page

Key references (NIHSS-specific)

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