1. 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

2. 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

3. 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.

4. 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

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

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

8. 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.

9. Review clip 1,6,9,12

10. 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

11. 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).  

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

13. 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

14. 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

15. 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.

16. 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

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

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

19. 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

20. 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

21. Case examples
(R)
(L)

22. Large Middle Cerebral Artery Infarct
Not alert
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)

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

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

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

26. NIHSS Training

27. FREE training via
windex.aspx?rx=nihss-english.trainingcampus.net

28. 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)

29. Examples of Apps for NIHSS
Canopy Medical
Translator
Android
translator/id ?mt=8

30. Boehringer Ingelheim App

31. Boehringer Ingelheim App

32. 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:
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:
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: 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:

33. 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:
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:
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:
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

34. 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
12. Meyer BC, Lyden PD. "The Modified National Institutes of Health Stroke Scale (mNIHSS): Its Time Has Come" Int J Stroke 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:
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:

35. Questions... Comments?