Scandinavian Stroke Scale. Appendix G4. NIHSS (National Institutes of Health Stroke Scale) - National Institutes of Health Stroke Scale. What scale is this

(NIHSS, NATIONAL INSTITUTES OF HEALTH STROKE SCALE BROTT T., ADAMS H.P., 1989)

It is carried out to determine the level of neurological deficit after a stroke. A high score corresponds to a more severe stroke, even if it is not detected on early neuroimaging. This scale is used in most clinical studies and is also necessary for assessing the condition of patients after thrombolysis or anticoagulant therapy. This scale should be assessed for all patients with stroke. Follow-up assessment will help assess changes in the patient's condition.

Level of consciousness Grade

Conscious, answers questions clearly

Drowsy, but reacts even to the minimum stimulus - a command, question

Reaction only in the form of motor or autonomic reflexes or complete areflexia

Level of consciousness: answers to questions.

The patient is asked to name the month of the year and his age
0
1
2

Level of consciousness: execution of commands. the patient is asked to close his eyes and clench his fist

Correct answers to both questions or there is a language barrier

 0

Correct answer to one question

 1

Answers both questions incorrectly or cannot answer

 2

Eyeball movements

Full range of motion

 0

Partial gaze paralysis or isolated paralysis

 1

Fixed deviation of the eyeballs or complete paralysis of gaze, insurmountable with the help of the “doll’s eyes” technique.

 2

Visual fields: examined in each field using finger movements, which the researcher performs simultaneously on both sides.

Normal or long-standing blindness

 0

Asymmetry or partial hemianopsia

 1

Complete hemianopsia

 2

Bilateral hemianopsia or coma

 3

Facial paralysis

None or sedation

 0

Minimal (only smoothness of the nasolabial fold)

 1

Partial (lower half of face)

 2

Complete (entire half of face involved) or coma

 3

D movement in the left arm: the patient holds the outstretched arm at an angle of 90°

0
1
2
3

No movement

 4

D movement in the right hand: the patient holds the outstretched arm at an angle of 90°

Patient holds arm at 90° for 10 seconds, swelling or amputation

 0

The patient first holds the hand in a given position, the hand begins to lower before 10 seconds have elapsed

 1

The patient does not hold the arm in position for 10 seconds, but still holds it somewhat against gravity

 2

The arm falls immediately, the patient cannot overcome gravity

 3

No movement

 4

Movements in the left leg: the patient raises the leg 30° for 5 seconds
0
1
2
3

No movement

 4

Movements in the right leg: the patient raises the leg 30° for 5 seconds

Patient holds leg in position for 5 seconds, swelling or amputation

 0

The leg drops to an intermediate position at the end of 5 seconds

 1

The leg falls within 5 seconds, but the patient still holds it somewhat against gravity

 2

The leg falls immediately, the patient cannot overcome gravity

 3

No movement

 4

RESULT:

Speech: assessed when naming standard pictures.

Normal

 0

Mild to moderate errors in naming, word selection, or paraphasia

 1

Severe: complete Broca's (motor) or Wernicke's (sensory) aphasia

 2

Mutism, or total aphasia, or coma

 3

Dysarthria
0

Mild to moderate slurred speech, patient can be understood

 1

Severe dysarthria (speech is slurred, unintelligible)

 2

A Taxi in the extremities: finger-to-nose and heel-knee tests

No (no movement in the limbs), cannot be assessed

 0

Ataxia is present in one limb

 1

Ataxia in two limbs

 2

Sensitivity: tested using a pin. if the level of consciousness is reduced, assessed only if there is a grimace or asymmetric withdrawal

Normal, sedation or amputation

 0

Light and moderate. The patient feels the injection less acutely, but is aware of the touch

 1

Significant or complete loss of sensation, unaware of touch

 2

Syndrome of "denial" (ignoring)

None or sedation

 0

Visual, tactile or auditory ignoring of half the space

 1

Profound neglect of half the space in two or more modalities

 2

RESULT:

Cardiologist

Higher education:

Cardiologist

Kabardino-Balkarian State University named after. HM. Berbekova, Faculty of Medicine (KBSU)

Level of education – Specialist

Additional education:

"Cardiology"

State educational institution "Institute for Advanced Medical Studies" of the Ministry of Health and Social Development of Chuvashia


Every neurologist should know what the NIHSS Stroke Severity Scale is. The data obtained with its help are important for deciding on the advisability of prescribing thrombolytic therapy, its expected effectiveness and the prognosis of the disease itself. Its principle is that the more points the patient scores, the more severe his health condition.

If, as a result of the assessment, the patient has more than 3 points, this is an indicator for prescribing thrombolytic therapy, and if the patient scores more than 25 points, it is strictly not recommended to prescribe such treatment.

nihss scale

The patient can be assessed using the NIHSS or the National Institute of Health Stroke Scale. It includes 15 tasks that must be completed and scored. In this case, the assessment takes place in a strict order; subsections cannot be swapped or returned to uncompleted ones. Unless required by the conditions of the task, it is also prohibited to prepare the patient for a particular task.

Vigor level

If it is not possible to make an accurate assessment for a number of reasons, then the overall result of the answers, as well as the reaction to them, is examined. The maximum score is given if the patient is in a coma or has no reaction or reflexes.

0 – clear;

1 – stupor (slight lethargy or drowsiness, but full reaction to even the slightest stimulus);

2 – stupor (repetition or stronger stimulation is necessary for a reaction to occur);

3 – coma (complete absence of speech contact).

Answers on questions

A person is asked two questions: his age, and what month it is. The answers must be complete and clear, even the slightest error in the numbers must be taken into account. In this case, only the first received response is taken into account.

0 – answers to all two questions asked;

1 – correct answer to only one of the questions;

2 – incorrect answers to all two questions.

Executing commands

A person must first close and then open his eyes. Next, you will need to clench and unclench the fist of the hand that is not paralyzed. If for some reason the second action is not possible, you can ask to execute another similar command. If there is no reaction to speech, you can show by your own example what is required of the victim. Evaluation occurs on the first attempt:

0 – correct completion of both tasks;

1 – execution of one task;

2 – complete or incorrect failure to complete assigned tasks.

Eyeball movement

0 – normal;

1 – partial paralysis;

2 – complete paralysis of the eyeball.

line of sight

The examination is carried out by confronting and counting the number of fingers, starting from the periphery and ending with the center of the eye.

0 – no violations, pupils move in the direction of the fingers;

1 – presence of asymmetry or partial hemianopsia;

2 – blindness or complete hemianopsia.

Detection of facial nerve disorders

0 – no violations detected;

1 – slight facial asymmetry;

2 – moderate paralysis of the facial muscles;

3 – complete facial paralysis.

Left arm muscle strength

From an extended position, the arm is made at an angle of 90° (sitting) or 45° (lying). In this case, it is necessary that the palms are turned down. The patient needs to hold in this position for 10 seconds, after which the nihss scale is filled.

2 – strength cannot be tested due to a missing limb or a fractured joint.

Right arm muscle strength

The same actions are performed as with the left hand and points are calculated based on the result.

0 – if the hand is held in this position for the required amount of time;

1 – if the hand is first held at the desired angle, and then begins to fall;

2 – strength cannot be tested due to the absence of a limb or a fractured joint;

3 – the hand falls almost immediately after being raised, there is no way to fight against gravity;

4 – complete absence of movement.

Muscle strength of the left leg

The study is performed in a supine position. The specialist asks to raise the patient’s leg at an angle of 30° and hold in this position for 5 seconds. Points are assigned based on the results.

Right leg muscle strength

This task, developed by the Institute of Health, is identical to the previous one (for the left leg). The calculation of points is the same.

0 - The leg is in the desired position for the required time;

1 – at first the limb is in the desired position, but then falls;

2 – the limb immediately lowers, remaining in the desired position for an extremely short time;

3 – the leg falls immediately, the person cannot cope with gravity;

4 – the limb does not rise.

Limb ataxia

This task allows you to determine whether there is a cerebellar disorder on one side. If there are disturbances in the visual fields, the study is carried out in the one that is not affected, the victim’s eyes are open. A knee-heel test is performed, as well as a toe-nose-heel test.

0 – absence of ataxia;

1 – ataxia in the upper or lower extremities;

2 – ataxia of all limbs.

Sensitivity degree

The examination is carried out by light pricks with a pin or needle, as well as by touch.

0 – sensitivity is normal;

1 – there is a slight decrease in sensitivity;

2 – the patient is in a coma or his sensitivity is significantly reduced.

Speech

The stroke scale involves determining the state of speech. To do this, the victim is asked to describe a picture or read some text. If such requests are not possible due to lack of vision, you can ask the patient to name objects that will be placed in his palm.

0 – the entire task was completely completed;

1 – partial ignorance or speech impairment;

2 – coma, as well as complete failure to complete the task.

The area of ​​study is not announced to the person at this stage. Dialogue is expected.

0 – correct articulation with clear pronunciation;

1 – mild or moderate dysarthria, in which the patient can slurred some words;

2 – coma or incomprehensible pronunciation of all words.

Neglect

At this stage, the perception of half the body (in most cases, the left) is assessed. Usually, the data obtained from the previous paragraphs is sufficient.

0 – perception of stimuli is not impaired;

1 – slight deviations;

2 – gross deviations from the norm;

3 – total absence of reflexes and reactions to external stimuli.

The NIHSS study or the Stroke Severity Scale is a fairly simple, and most importantly, effective way to determine the patient’s condition after a stroke. The probability of a patient's death increases to the limit if the number of points is at least 31.

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 the 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 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.

line of sight

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.

“SCALES FOR ASSESSING THE SEVERITY OF ISCHEMIC STROKE IN THE ACUTE PERIOD NIHSS scale Severity of neurological symptoms in the acute period of ischemic stroke...”

SCALES IN GENERAL

NEUROLOGY

SCALES FOR ASSESSING THE DEGREE OF SEVERITY

ISCHEMIC STROKE IN ACUTE PERIOD

NIHSS scale

Severity of neurological symptoms in the acute period

It is advisable to evaluate ischemic stroke over time using specially developed scales. Widespread

of Health Stroke Scale). The NIHSS score is also important for planning thrombolytic therapy (TLT) and monitoring its effectiveness. The indication for thrombolytic therapy is the presence of a neurological deficit (from 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.

National Institutes of Health Stroke Scale (NIHSS)

1. Level of consciousness (scored in points):

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 inhibited - requires strong and painful stimulation to produce non-stereotypical movements;



3 - coma, reacts only with reflex actions or does not respond to stimuli.

2. Level of consciousness - answers to questions.

Ask the patient what month it is and his age. Write down the first answer. If aphasia or stupor - score 2.

If endotracheal tube, severe dysarthria, language barrier - 1.

0 - correct answer to both questions;

1 - correct answer to one question;

2 - no correct answers were given.

3. Level of consciousness - execution of commands.

The patient is asked to open and close his eyes, 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 - not a single command was executed correctly.

4. Movements of the eyeballs.

Only horizontal eye movements are taken into account.

1 - partial gaze paralysis;

2 - tonic abduction of the eyes or complete gaze paralysis, which cannot be overcome by inducing oculocephalic reflexes.

5. Visual field examination:

1 - partial hemianopsia;

2 - complete hemianopia.

6. Paresis of facial muscles:

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 at an angle of 45° in a lying position, at an angle of 90° in a sitting position. If the patient does not understand the task, the doctor must place his hands in the required position himself. Scores are recorded separately for the right and left limbs.

0 - limbs are held for 10 s;

1 - limbs are held for less than 10 s;

13 2 - limbs do not rise or do not maintain a given position, but produce some resistance to gravity;

4 - no active movements;

8. Movements in the lower extremities.

In a supine position, raise the paretic limb for 5 seconds at an angle of 30°. Scores are recorded separately for the right and left limbs.

0 - limbs are held for 5 s;

1 - limbs are held for less than 5 s;

2 - limbs do not rise or do not 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).

9. Limb ataxia.

Finger and heel-knee tests are carried out on both sides; ataxia is counted if it is not caused by paresis.

0 - absent;

1 - in one limb;

2 - in two limbs.

10. Sensitivity.

Only hemitype disorder is taken into account.

1 - mild or moderate impairment;

2 - significant or complete loss of sensitivity.

11. Aphasia.

The patient is asked to describe a picture, name an object, and read a sentence.

0 - no aphasia;

1 - mild aphasia;

2 - severe aphasia;

3 - complete aphasia.

12. Dysarthria:

0 - normal articulation;

15 1 - mild or moderate dysarthria. Can't pronounce some words;

2 - severe dysarthria;

3 - 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.

The data obtained correspond to the following severity of neurological deficit:

0 - satisfactory condition;

3–8 - mild neurological disorders;

9–12 - moderate neurological disorders;

13–15 - severe neurological disorders;

16–34 - neurological disorders of extreme severity;

The use of the NIHSS scale will allow us to objectively approach the condition of a patient with a stroke and assess the neurological status during the patient’s hospital stay. The total score determines the severity and prognosis of the disease. 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%. This assessment is also important for planning thrombolytic therapy and monitoring its effectiveness. Thus, the indication for thrombolytic therapy is the presence of a neurological deficit (no more than 3–5 points). Severe neurological deficit (more than 25 points on this scale) is a contraindication to thrombolysis, since this manipulation may not have a significant effect on the outcome of the disease.

Systemic thrombolytic therapy is used today in many cities of Ukraine. The NIHSS scale, introduced into practical neurology, has shown its effectiveness.

On the first day after thrombolytic therapy, patients are assessed for changes in the dynamics of neurological status using the NIHSS scale.

Clinical example. Patient K., 50 years old, was admitted to the neurological department of the thrombolytic therapy center of City Hospital No. 5.

Mariupol with complaints of weakness and numbness of the left limbs.

When examining the neurological status - left-sided prosoparesis, severe left-sided hemiparesis, left-sided hemihypesthesia (NIHSS scale - 10 points). A CT scan, ECG, duplex scanning of the great vessels, and express blood and urine tests were performed.

Thrombolytic therapy was started:

Bolus administration - the patient retains moderate left-sided prosoparesis, left-sided hemiparesis: pronounced in the arm, moderately expressed in the leg; left-sided hemihypesthesia (NIHSS - 6 points);

At the end of TLT, the patient still has mild left-sided prosoparesis, left-sided moderately severe hemiparesis, left-sided hemihypesthesia (NIHSS - 4 points);

After 24 hours, the patient still has mild left-sided prosoparesis and mild paresis of the left arm (NIHSS - 2 points).

Scandinavian Stroke Scale For a combined assessment of the severity of patients in the acute period of ischemic stroke and the effectiveness of treatment, the European Stroke Initiative also recommends using the Scandinavian Stroke Scale, according to which significant improvement is noted if regression of neurological symptoms is observed on this scale (10 points or more) and at the same time, there is a positive trend in laboratory and functional research methods. Moderate improvement can be judged if the regression of the neurological deficit is less than 10 points. At the same time, it is possible to improve some indicators of paraclinical research methods. Minor improvement - with minimal regression of neurological symptoms (1–2 points) and the absence of positive dynamics in laboratory and functional research methods.

19 Table 1. Scandinavian Stroke Scale (SSS; Scandinavian Stroke Study Group, 1985)

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When assessed by NIHSS scale It is necessary to strictly follow the sections of the scale, recording points in each of the subsections in turn. You cannot go back and change previously assigned grades. Follow the instructions for each of the subsections. The assessment should reflect what the patient actually does, not what the researcher thinks the patient can do. Register the test subject's answers and assessments during the research process, work quickly. If this is not indicated in the instructions for the relevant subsection, you should not train the patient and/or get him to better perform the command.

Level of wakefulness

If a full examination is not possible (for example, due to an endotracheal tube, a language barrier, or damage to the orotracheal area), the overall level of responses and reactions is assessed.
A score of 3 is given only in cases where the patient is in a coma and does not respond to painful stimuli or his reactions are reflexive in nature (extension of the limbs).

Clear consciousness, responsive

Stunning and/or somnolence; responses and compliance with instructions can be achieved with minimal stimulation.

Deep stupor or stupor, reacts only to strong and painful stimuli, but movements are not stereotyped.

Atonia, areflexia and arereactivity or responses to stimuli consist of reflexive non-purposeful movements and/or autonomic reactions.

Level of wakefulness: answers to questions

The patient is asked to state the current month and his age. Answers must be accurate; an answer that is close to the correct one cannot be counted. If the patient does not respond to the question (aphasia, significant reduction in wakefulness), a score of 2 is given. If the patient is unable to speak due to mechanical obstructions (endotracheal tube, maxillofacial injury), severe dysarthria, or other problems not related to aphasia, a score of 1 is given. It is important that only the first response is scored and that the researcher does not help the patient in any way.

Correct answers to both questions.

Correct answer to one question.

Didn't answer both questions.

Level of wakefulness: execution of commands

The patient is asked to open and then close his eyes, clench and unclench the fist of his non-paralyzed hand. If there are obstacles (for example, the arm cannot be used), replace this command with another one-step command. If a clear attempt is made but the action is not completed due to weakness, the result is counted. If the patient does not respond to the command, he should demonstrate what is required of him and then evaluate the result (repeated both, one or neither). Only the first attempt is scored.

Executed both commands.

Executed one command.

Didn't execute any of the commands.

Eyeball movements

Norm.

Partial gaze paresis; the movements of one or both eyes are impaired, but there is no tonic deviation of the eyeballs and complete gaze paralysis.

Tonic deviation of the eyeballs or complete gaze paralysis, which persists when testing oculocephalic reflexes.

Fields of view

The visual fields (upper and lower quadrants) are examined using the confrontation method, by counting the number of fingers or frightening sharp movements from the periphery to the center of the eye. You can give patients appropriate cues, but if they look in the direction of the moving fingers, this can be regarded as normal. If one eye does not see or is missing, the second is examined. A score of 1 is given only if clear asymmetry is detected (including quadrantanopsia). If the patient is blind (for any reason), a 3 is given. Here, simultaneous stimulation on both sides is examined, and if there is hemiignoring, a 1 is given and the result is used in the section “Hemiignoring (neglect).”

The visual fields are not impaired.

Partial hemianopsia.

Complete hemianopsia.

Blindness (including cortical).

Facial nerve dysfunction

Normal symmetrical movements of facial muscles.

Mild paresis of facial muscles (smoothed nasolabial fold, asymmetrical smile).

Moderate prosoparesis (complete or severe paresis of the lower group of facial muscles).

Paralysis of one or both halves of the face (lack of movement in the upper and lower parts of the face).

Left arm muscle strength

There is no movement in the hand.

impossible to explore.

Right arm muscle strength

The extended arm is placed at an angle of 90° (if the patient is sitting) or 45° (if the patient is lying) to the body with the palms downwards and the patient is asked to hold it in this position for 10 s. The non-paralyzed arm is assessed first, then the other. With aphasia, you can help to take the starting position and use pantomime, but not painful stimuli. If it is impossible to study the strength (a limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

The hand does not lower for 10 s.

The hand begins to fall before 10 s, but does not touch the bed or other surface.

The hand is held for some time, but within 10 s it touches a horizontal surface.

The hand immediately falls, but there is movement in it.

There is no movement in the hand.

impossible to explore.

Left leg muscle strength

There is no movement in the leg.

impossible to explore.

Right leg muscle strength

Always examined in the supine position. The patient is asked to raise his leg at an angle of 30° to the horizontal surface and hold it in this position for 5 seconds. With aphasia, you can help to take the starting position and use pantomime, but not painful stimuli. The non-paralyzed leg is assessed first, then the other. If it is impossible to study the strength (a limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

The leg does not lower for 5 seconds.

The leg begins to fall before 5 s, but does not touch the bed.

The leg is held for some time, but within 5 s it touches the bed.

The leg immediately falls, but there is movement in it.

There is no movement in the leg.

impossible to explore.

Ataxia in the limbs

This section involves identifying signs of damage to the cerebellum on one side. The study is carried out with open eyes. If there is a limitation of visual fields, the study is carried out in the area where there are no violations. The finger-nose-toe and knee-heel tests are performed on both sides. Points are awarded only when the severity of ataxia exceeds the severity of paresis. If the patient is inaccessible or paralyzed, there is no ataxia. If the patient does not see, a finger-nose test is performed. If it is impossible to study the strength (a limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

There is no ataxia.

Ataxia in one limb.

Ataxia in two limbs.

impossible to explore.

Sensitivity

It is examined using pin pricks (toothpick) and touching. In case of impaired consciousness or aphasia, grimaces and withdrawal of limbs are assessed. Only hypoesthesia caused by a stroke (by hemitype) is assessed, so for verification it is necessary to compare the reaction to injections in different parts of the body (forearms and shoulders, hips, torso, face). A score of 2 is given only in cases where a gross decrease in sensitivity in one half of the body is beyond doubt, so patients with aphasia or impaired consciousness at the level of stupor will receive a 0 or 1. In case of bilateral hemihypesthesia caused by a brainstem stroke, a score of 2 will be given. Patients in a coma are automatically given get 2.

Norm.

Mild or moderate hemihypesthesia; on the affected side, the patient feels the injections as less sharp or as touches.

Severe hemihypesthesia or hemianesthesia; the patient does not feel any injections or touches.

Speech

Information regarding the understanding of addressed speech has already been obtained during the study of the previous sections. To study speech production, the patient is asked to describe the events in the picture, name objects and read a passage of text (see Appendix). If speech testing is hampered by vision problems, ask the patient to name objects placed in his hand, repeat a phrase, and talk about an event in his life. If an endotracheal tube is inserted, the patient should be asked to complete written assignments. Patients in a coma automatically receive a 3. If consciousness is impaired, the score is determined by the researcher, but 3 is given only for mutism and complete disregard for simple commands.

Norm.

Mild or moderate aphasia; speech is distorted or understanding is impaired, but the patient can express his thoughts and understand the researcher.

Severe aphasia; Only fragmentary communication is possible; understanding the patient’s speech is very difficult; according to the patient, the researcher cannot understand what is shown in the pictures.

Mutism, total aphasia; the patient does not make any sounds and does not understand the addressed speech at all.

Dysarthria

There is no need to tell the patient exactly what you are going to assess. With normal articulation, the patient speaks clearly; he has no difficulty pronouncing complex combinations of sounds and tongue twisters. In case of severe aphasia, the pronunciation of individual sounds and fragments of words is assessed; in case of mutism, a 2 is given. If it is impossible to study the strength (intubation, facial trauma), an appropriate mark is made.

Norm.

Mild to moderate dysarthria; Some sounds are “blurred”; understanding words causes some difficulties.

Severe dysarthria; words are so distorted that they are very difficult to understand (the cause is not aphasia), or anarthria/mutism is noted.

impossible to research

Hemiignoring (neglect)

Sensory hemi-ignorance is understood as a violation of perception on half of the body (usually the left) when stimuli are applied simultaneously on both sides in the absence of hemihypesthesia. Visual hemiignoring is understood as a violation of the perception of objects in the left half of the visual field in the absence of left-sided hemianopsia. As a rule, the data from the previous sections is sufficient. If it is impossible to study visual hemiignoring due to visual disturbances, and the perception of painful stimuli is not impaired, the score is 0. Anosognosia indicates hemiignoring. The assessment in this section is given only in the presence of hemishoring, therefore the conclusion “impossible to study” is not applicable to it.

Norm.

Signs of hemi-ignoring one type of stimuli (visual, sensory, auditory) were revealed.

Signs of hemiignoring more than one type of stimulus were revealed; does not recognize his hand or perceives only half of the space.

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