Liz Mackey, Stroke Nurse Practitioner, Western Health Melbourne Lizzie Dodd, Clinical Practice Consultant, Acute Stroke Unit Coordinator, The Queen Elizabeth Hospital SA Health Application of the National Institutes of Health Stroke Scale and common pitfalls

Aims Introduction to the National Institutes of Health Stroke Scale Common pitfalls of the NIHSS Discuss how the NIHSS can be incorporated into practice Patient assessment Communication Decision making Stroke trial recruitment Reporting outcomes Case examples Training options

National Institutes of Health Stroke Scale 15-item neurologic examination stroke scale Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. Range 0 – 42 Mild 0-7 Moderate 8-16 Severe > 16 The single patient assessment requires less than 10 minutes to complete.

National Institutes of Health Stroke Scale A trained observer rates the patient’s ability to answer questions and perform activities. The evaluation of stroke severity depends upon the ability of the observer to accurately and consistently assess the patient

National Institutes of Health Stroke Scale Evaluates the effect of stroke on: Level of consciousness Extraocular movement

http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

Pitfalls of the NIHSS Three main pitfalls in using the NIHSS: Items with poor reliability Dominant-hemisphere strokes Lessened weighting for posterior circulation strokes

Pitfalls: Items with poor reliability The NIHSS contains FOUR items which are widely acknowledged to have poor reliability 1a Loss of Consciousness 4 Facial Palsy 7 Ataxia 10 Dysarthria Potential issues if not scored accurately include: Communication difficulties between practitioners Decision making errors (eg in thrombolysis or trial recruitment) Difficulties assessing patient outcomes Ref 12.

Review clip 1,6,9,12 https://www.youtube.com/watch?v=awscZzCVaqE&list=PLfvzF_UhY1eZhoSn_uox8Fi3wtdku3x7K&index=13

Pitfalls: dominant hemisphere strokes Communication / language impairments in dominant hemisphere strokes Higher scores for more deficits related to language / communication impairments Tendency for dominant hemisphere strokes to receive a higher rating, approximately 4-points more for the same size stroke, compared with non-dominant hemisphere strokes. Items affected particularly: 1b LOC Questions, 1c LOC Commands, 9 Best language, 10 Dysarthria Ref 13, 14

Pitfalls: Posterior circulation Lessened weighting for vertebro-basilar (posterior circulation) strokes Items include: 1a LOC 3 Visual fields 4 Facial palsy 5&6 Motor 7 Ataxia 8 Sensory 10 Dysarthria Other elements that provide more information about the posterior circulation receive no score e.g. diplopia dysphagia gait instability hearing nystagmus Ref 12  Another downside is the lessened weighting for posterior circulation strokes, a problem for nearly all neurological deficit scales. Though some items related to the verterbo-basilar system can be scored (e.g. LOC, visual fields, facial palsy, sensory, motor, dysarthria and ataxia), other elements receive no score (e.g. diplopia, dysphagia, gait instability, hearing, and nystagmus).  

Why should we bother doing NIHSS? Whose job is it to do this?

Why should we bother doing NIHSS? Well-validated, reliable Time efficient & standardised brief neurological examination Assesses degree of neurological deficit Predictor of mortality & functional outcomes (short- and long-term) Clinical Guidelines for Stroke Management 2010 (NSF p.55) “Stroke severity should be assessed & recorded on admission by a trained clinician using a validated tool (e.g. NIHSS or SSS)” Facilitates: Communication (clinicians, patients, care givers) Identification of location of infarct Early understanding of prognosis Selection for interventions / trials Identification of potential for complications Ref 1-9

NIHSS use in everyday clinical practice Emergency Department Who? Why? Rapid assessment & decision making: Location of stroke Thrombolysis Patient management & prognosis Facilitate coordination of care Adds to the picture of the stroke subtype TACI, PACI, LACI, POCI, haemorrhage Trial recruitment Communication when referring to other teams eg. neurointervention, neurosurgery Facilitates communication to patients and families / care givers

NIHSS use in everyday clinical practice Thrombolysis decision making: Baseline differences in NIHSS scores can affect the response of stroke patients to intravenous tissue plasminogen activator Risk of haemorrhage is considerable among patients with high NIHSS scores: US FDA labelling: use intravenous tissue-type plasminogen activator in patients with NIHSS scores >22 with caution. Ref 2,10 Thrombolysis decision making: The NIHSS is widely used in current clinical practice. 29 These baseline differences in NIHSS scores can affect the response of stroke patients to intravenous tissue plasminogen activator, which is the only FDA-approved medical therapy to reduce disability after acute ischemic stroke. Moreover, federal drug labeling for intravenous tissue-type plasminogen activator incorporates the NIHSS. Because the risk of hemorrhage is considerable among patients with high NIHSS scores, FDA labeling indicates the decision to treat with intravenous tissue-type plasminogen activator in patients with NIHSS scores >22 should be made with caution. Therefore, the AHA/ASA advocates that efforts continue to focus on how to collect and incorporate the NIHSS into a revised version of the 30-day measures.

NIHSS use in everyday clinical practice Acute Stroke Care Unit Who? Why? Facilitate coordination of care Communication of changes Recruitment to trials When? At intervals during acute stay: Thrombolysis: NIHSS at 2-hours, 24-hours, discharge

NIHSS use in everyday clinical practice Follow-up in Outpatient Clinic Communication of changes Audit of outcomes for thrombolysis

NIHSS use in everyday clinical practice Stroke trial recruitment Most stroke trials require NIHSS to be > 4 or < 26

NIHSS use in reviewing hospital morbidity & mortality performance Growing interest in ensuring stroke severity is accurately quantified By scoring stroke costs to health services are potentially more accurately identified i.e. adjustment for stroke severity Fonarow et al (2014): “Stroke severity has been documented to be a key mortality risk determinant in acute ischemic stroke. Prior analyses demonstrated that stroke severity, as quantified by the NIHSS, was the strongest predictive variable for in-hospital and 30-day mortality and substantially improved the performance of a model based on clinical variables without stroke severity” Ref 2

NIHSS use in reviewing hospital morbidity & mortality performance Fonarow et al (2012): Among hospitals ranked in the top 20% or bottom 20% of performers by the claims model without NIHSS scores, 26.3% were ranked differently by the model with NIHSS scores. Of hospitals initially classified as having “worse than expected” mortality, 57.7% were reclassified to “as expected” by the model with NIHSS scores. Ref 11

Case examples (R) (L)

Large Middle Cerebral Artery Infarct Not alert 2 x age, x month 2 Does not follow commands 2 Eyes deviated to left 2 Homonymous hemianopia 2 R) facial droop 2 UL - R) UL no mvmt & L) drift 5 LL - R) sev weak L) some effort 5 Absent ataxia 0 R) Hemiparesis (face,arm) 2 Non-verbal 3 Dysarthria = mute 2 ? Inattention 0 Total = 29 L) MCA infarct (TACI) (R) (L)

Large Middle Cerebral Artery Infarct Discussion: Mild / moderate/ severe? Prognosis? Treatment options? L) MCA infarct (TACI) (R) (L)

Lacunar Infarct R) internal capsule infarct (LACI) Alert 0 Age, Month 0 Follows commands 0 Normal gaze 0 No visual loss 0 L) minor facial droop 1 UL - L) UL some effort 2 LL - L) some effort 2 No ataxia 0 L) mild sensory loss face,arm,leg 1 No aphasia 0 Mild dysarthria 1 No Inattention 0 Total = 7 R) internal capsule infarct (LACI) (R) (L) Image: Stroke July 2012 vol. 43 no. 7 1837-1842

Lacunar Infarct R) internal capsule infarct (LACI) Discussion: Mild / moderate/ severe? Prognosis? Treatment options? (R) (L) Image: Stroke July 2012 vol. 43 no. 7 1837-1842

NIHSS Training

FREE training via https://secure.trainingcampus.net/uas/modules/trees/ windex.aspx?rx=nihss-english.trainingcampus.net

Boehringer Ingelheim training offer In hospital group training and accreditation for NIHSS (can be a 2 hour session or 2 x 1 hour sessions = 1 hour to train + 1 hour for exam) BI sponsor paper exams ($25 each), everyone gets booklet ($3 each), a DVD for the department ($50 worth) The DVD does the teaching Get sent to the National Stroke Association in Colorado for official processing and accreditation, certificates will be provided Benefits are that a group of doctors/nurses can do training in one in-house session, (no need to do it at home)

Examples of Apps for NIHSS Canopy Medical Translator Android https://itunes.apple.com/us/app/canopy-medical- translator/id792808936?mt=8

Boehringer Ingelheim App

Boehringer Ingelheim App

References Clinical Guidelines for Stroke Management 2010 (NSF) Fonarow GC, Alberts MJ, Broderick JP, Jauch EC, Kleindorfer DO, Saver JL, Solis P, Suter R, Schwamm LH. Stroke Outcomes Measures Must Be Appropriately Risk Adjusted To Ensure Quality Care of Patients: A Presidential Advisory From the American Heart Association/American Stroke Association Stroke. published online February 12, 2014 Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N, RemondaL, Schroth G, Arnold M, Mattle HP. Predictors of early mortality after acute ischaemic stroke. Swiss Med Wkly. 2010;140:254-259. Chang KC, Tseng MC, Tan TY, Liou CW. Predicting 3-month mortality among patients hospitalized for first-ever acute ischemic stroke. J Formos Med Assoc. 2006;105:310-317. Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED, Fonarow GC, Schwamm LH. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With The Guidelines–Stroke Program. Circulation. 2010;122:1496-1504.24. Johnston KC, Connors AF Jr, Wagner DP, Knaus WA, Wang X, Haley EC Jr. A predictive risk model for outcomes of ischemic stroke. Stroke. 2000;31:448-455.

6. Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, Duhamel A, Pruvo JP. Early predictors of death and disability after acute cerebralischemic event. Stroke 1995;26:392-398. 7. Weimar C, Konig IR, Kraywinkel K, Ziegler A, Diener HC. Age and National Institutes of Health Stroke Scale score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models. Stroke 2004;35:158-162. 8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947. 9. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, PhD; Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-e143

10. Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH; on behalf of the GWTG-Stroke Steering Committee & Investigators. Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care. J Am Heart Assoc 11. Fonarow GC, Pan W, Saver J et al “Comparison of 30-Day Mortality Models for Profiling Hospital Performance in Acute Ischemic Stroke With vs Without Adjustment for Stroke Severity” JAMA, July 18, 2012—Vol 308, No. 3 257-264 12. Meyer BC, Lyden PD. "The Modified National Institutes of Health Stroke Scale (mNIHSS): Its Time Has Come" Int J Stroke. 2009 August ; 4(4): 267–273 13. Lyden P, Claesson L, Havstad S, AshwoodT, Lu M. Factor analysis of the national institutes of health stroke scale in patients with large strokes. Arch Neurol. 2004;61:1677-1680. 14.Woo D, Broderick J, Kothari R, et al.,Group Nr-PSS. Does the national institutes of health stroke scale favor left hemisphere strokes. Stroke. 1999;30:2355-2359.

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