1. Using stroke scales to assess the patient – Rankin and NIHSS
Dr Jonathan Birns
Consultant in Stroke Medicine, Geriatrics and General Medicine
Guy’s & St Thomas’ NHS Foundation Trust

2. Differences/1000: 141 extra alive and independent (P<0.01) 80
Alive but
dependent 60
Dead 40 20
Thrombolysis
Control
Differences/1000: 141 extra alive and independent (P<0.01)
130 fewer dependent survivors (P<0.01)
To save 1 patient from disablement NNT is 7

3. Outcome measures/Stroke scales
Pathology
Impairment - abnormality of structure/function
Disability - functional consequence of impairment
Handicap - social consequence of impairment
QOL
Survival

4. Outcome measures/Stroke scales
Valid
Reliable
Reproducible
Relevant
Practical
Sensitive
Communicable

8. Modified Rankin Scale
measures the degree of disability or dependence in the daily activities of people who have suffered a stroke.
originally introduced in 1957 by Rankin
(Rankin J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J : 200–15)
modified by Lindley et al in 1994
(Lindley RI, Waddell F, Livingstone M et al. Can simple questions assess outcomes after stroke?. Cerebrovasc Dis : 314–24)

9. 3 simple questions (Lindley et al. 1994)No
Is the patient alive? 6
Dead
Yes 5
Yes
Does the patient require help from anybody for everyday activities? 4
Poor 3 No 2
Yes
Indifferent
Has the stroke left the patient with any problems? 1 No
Good

10. Modified Rankin Scale 0 - No symptoms. 1 - No significant disability.
Able to carry out all usual activities, despite some symptoms.
2 - Slight disability.
Able to look after own affairs without assistance, but unable to carry out all previous activities.
3 - Moderate disability.
Requires some help, but able to walk unassisted.
4 - Moderately severe disability.
Unable to attend to own bodily needs without assistance, and unable tto walk unassisted.
5 - Severe disability.
Requires constant nursing care and attention, bedridden, incontinent.
6 - Dead.

14. mRS 0-3
mRS 4-6

16. National Institutes of Health Stroke Scale (NIHSS)
15-item neurologic examination stroke scale
Used to evaluate the effect of acute cerebral infarction on:
level of consciousness
extraocular movement
visual-field loss
motor strength
ataxia
sensory loss
language
dysarthria
neglect

17. National Institutes of Health Stroke Scale (NIHSS)
Provides a quantitative measure of stroke-related neurologic deficit
Originally designed as a research tool
Now widely used as a clinical assessment tool
May serve as a measure of stroke severity
Valid for predicting lesion size, short and long term outcome
Provides a common language for information exchanges among healthcare providers

18. National Institutes of Health Stroke Scale (NIHSS)
Designed to be:
Simple
Valid
Reliable
Administered at the bedside consistently by:
Physicians
Nurses
Therapists
Should take <10 minutes to complete

19. NIHSS Instructions Administer NIHSS items in order
Record performance in each category after assessment
Do not go back and change scores
Do not repeat assessments within NIHSS
Range: 0-42

20. 1a Level of consciousness

21. 1b Level of consciousness questions
What is the month?
How old are you?

22. 1c Level of consciousness commands
Open and close
the eyes.
Grip and release the non-paretic hand.

23. 2 Best gaze

24. 3 Visual fields

25. 4 Facial palsy

26. 5 Motor - Arm

27. 6 Motor - Leg

28. 7 Limb ataxia

29. 8 Sensory

30. 9 Language

31. 10 Dysarthria

32. 11 Extinction and inattention

33. NIHSS

35. i NIHSS

36. i NIHSS

38. NIHSS NIHSS Category Pre-thrombolysis Time… after thrombolysis LOC Ia
LOC Ib 2
LOC Ic
Gaze
Visual fields
Facial palsy
Motor – right arm 3
Motor – left arm
Motor – right leg
Motor – left leg
Ataxia
Sensory
Language
Dysarthria
Extinction