One article to understand the 5 main points of the "NIHSS score" in the book of neurophysical examinations!

Whether it is white department or professor level Daniel, as long as the neurologist, everyone for the US National Institutes of Health Brain Stroke Scale (NIHSS) must not unfamiliar, the score has been widely used in clinical and prognostic evaluation of patients with stroke In each study
.

The stroke score has been widely used in clinical prognostic evaluation of stroke patients and in various studies
.

 

 

However, in clinical evaluation, there are always ambiguities in the scoring situation, and there are obvious differences in the uniform patient scores between different physicians, and it is even difficult to distinguish whether the patient's answer is correct or not
.

Today, let us review the details of the NIHSS score, hoping to bring some help to you who are busy clinically

Obvious differences are even difficult to distinguish whether the patient's answer is correct or not

 

N IHSS past and present

N IHSS Past and Present N IHSS Past and Present

 

 

In 1989, Thmos et al.
designed the NIHSS scale for 15 items
.

The scale adopts a hierarchical evaluation method to comprehensively evaluate the overall situation of the patient's nervous system dimensions such as consciousness, eye movement, visual field, limb movement and sensation, limb mutual aid, language, cognition and attention

Over the years, NIHSS has gradually developed into a well-known scale for evaluating the degree of neurological impairment in patients with acute stroke

Now the NIHSS score has received extensive attention, especially on the basis of the rise of endovascular treatment techniques in recent years
.

Among them, the "U.

Vascular management of large blood vessel diseases: neurological deficit score NIHSS ≥ 7 points [1, 2]

Reliability and validity of NIHSS

NIHSS reliability and validity NIHSS reliability and validity

 

 

Generally, evaluating the reliability of a scale is often considered in terms of validity and sensitivity
.

In general, the data shows that when the scorer undergoes formal NIHSS training for consistency evaluation, the initial score and re-scoring after 3 months by the same rater show that the inter-group correlation coefficient (ICC) is 0.

 

In terms of effectiveness , the NIHSS score was compared with CT or MRI imaging infarct volume, and the correlation coefficient was found to be 0.
4-0.
8, suggesting that the NIHSS scale score is closely related to the infarct volume of stroke patients [4]
.

At the same time, for patients with acute stroke, the baseline NIHSS score can more accurately predict the prognosis at 7 days and 3 months [5]

In terms of effectiveness

 

 

In terms of sensitivity , whether it is compared with the traditional Glasgow Coma Scale (GCS) and pupil examination, or compared with other professional scales (such as mRS and BI), the NIHSS score is used to assess changes in the condition of patients with brain diseases Both are more sensitive, which is more powerful for judging the efficacy of different treatment methods
.

At the same time, because the NIHSS scoring is simple and easy to operate, it is helpful for medical staff to conduct assessments multiple times a day to timely judge changes in the condition

In terms of sensitivity

 

 

Five basic principles of NIHSS scoring

The five basic principles of NIHSS scoring The five basic principles of NIHSS scoring

 

1.
Scoring item by item according to the score sheet, according to the patient's first response score, once you have scored, do not go back and change it ;

Don't go back and make changes once you have scored

 

2.
In any item, the scoring will be carried out according to the instructions, if there is no explanation, do not counsel ;

If there is no explanation, do not counsel

 

3.
Some items can only be scored if they absolutely exist ;

Absolutely exist

 

4.
Even if there is a contradiction, the score should be recorded by the patient , not what the evaluator thinks the patient can do;

What the patient actually did

 

5.
The scoring needs to be fast.
The patient's score should be recorded immediately after the examination.
The evaluation event should generally not exceed 10 minutes
.

The evaluation event generally does not exceed 10 minutes

 

 

NIHSS scoring items and results

NIHSS scoring items and results NIHSS scoring items and results

 

 

 

 

1.
Detection time point during thrombolysis: before thrombolysis; 2 hours after thrombolysis; 24 hours after thrombolysis; 7 days after thrombolysis; 90 days after thrombolysis;

1.
Detection time point during thrombolysis: before thrombolysis; 2 hours after thrombolysis; 24 hours after thrombolysis; 7 days after thrombolysis; 90 days after thrombolysis;

 

2.
Baseline assessment can assess the severity of stroke, and the effect of treatment can be regularly assessed after treatment;

2.
Baseline assessment can assess the severity of stroke, and the effect of treatment can be regularly assessed after treatment;

 

3.
Patients with a baseline assessment score of >16 may die, while a score of <6 is likely to recover well.
For each additional point, the probability of a good prognosis is reduced by 17%;

3.
Patients with a baseline assessment score of >16 may die, while a score of <6 is likely to recover well.
For each additional point, the probability of a good prognosis is reduced by 17%;

 

4.
The score range is 0-42 points.
The higher the score, the more severe the nerve damage.
The classification is as follows:

4.
The score range is 0-42 points.
The higher the score, the more severe the nerve damage.
The classification is as follows:

0-1 points: normal or almost normal;

0-1 points: normal or almost normal;

 

1-4 points: mild stroke/minor stroke;

1-4 points: mild stroke/minor stroke;

 

5-15 points: moderate stroke;

5-15 points: moderate stroke;

 

15-20 points: moderate to severe stroke;

15-20 points: moderate to severe stroke;

 

21-42 points: severe stroke
.

21-42 points: severe stroke
.

 

The scoring formula of NIHSS scoring

The scoring formula of NIHSS scoring The scoring formula of NIHSS scoring

 

 

Due to the large number of NIHSS scoring items, many doctors who are new to contact always suffer from memory
.
To this end, Mr.
Du Wanliang from Beijing Tiantan Hospital affiliated to Capital Medical University invented the Seven Wonders of the Stroke Scale , which has benefited a lot of "neurology novices ".
It is hereby quoted for your reference:

Teacher Du Wanliang from Beijing Tiantan Hospital Affiliated to Capital Medical University invented the Seven Wonders of the Stroke Scale

 

The wake-up question order is late (3 items, 3+2+2 = 7 points)

Wake-up question command late Wake-up question command late

 

Staring at the field of vision and knowing the face (3 items, 2+3+3 = 8 points)

Staring at the field of vision

 

Coordinated movement up and down (5 items, 4+4+4+4+2 = 18 points)

Up and down, left and right coordinated movements

 

Feel that the voice is not ignored (4 items, 2+3+2+2 = 9 points)

Feeling the voice not ignoring Feeling the voice not ignoring

 

In addition, the "FLEAS" formula is more popular internationally.
For students with better English, you can also try:

"FLEAS" formula

 

F: Face  facial paralysis 3;

F: Face  facial paralysis 3; F: Face

 

L: L OC  wake up 3, question 2, ignore 2, command 2;

L: L OC  wake up 3, question 2, ignore 2, command 2; L: L OC

 

E: Eyes  Gaze 2, Vision 3;

E: Eyes  Gaze 2, Vision 3; E: Eyes

 

A: Arms/ Legs  exercise 16, sensation 2, mutual aid 2;

A: Arms/ Legs  movement 16, sensation 2, mutual aid 2; A: Arms/ Legs

 

S: Speech  language 3, articulation 2
.

S: Speech  language 3, articulation 2
.
S: Speech

 

Limitations of NIHSS scoring

Limitations of NIHSS Score Limitations of NIHSS Score

 

 

Many advantages of NIHSS scoring are mentioned above, and the problems existing in NIHSS scoring are summarized as follows:

Problems with NIHSS scoring

 

1.
NIHSS is not sensitive to cerebral infarction of the posterior circulation, especially those patients with headache, dizziness, nausea and trunk ataxia usually cannot be accurately detected by NIHSS ;

Patients with headache, dizziness, nausea, and trunk ataxia are usually not accurately detected by NIHSS

 

2.
Some items of NIHSS (such as facial nerve palsy, ataxia, level of consciousness, dysarthria, and gaze items) have poor reliability , and differences in understanding among different assessors affect consistency;

Poor reliability

 

3.
For the same infarct volume, the NIHSS score of left hemisphere infarction will be greater than that of right hemisphere, that is, NIHSS will underestimate the severity of right hemisphere stroke;

The NIHSS score of left hemisphere infarction will be greater than that of right hemisphere, that is, NIHSS will underestimate the severity of right hemisphere stroke;

 

4.
NIHSS lacks items to evaluate cognitive decline and abnormal gait, so it is not suitable for cerebral small vessel disease
.

Not suitable for cerebral small vessel disease
.

 

In summary , NIHSS is a scale that has been used by neurologists around the world for more than 20 years.
Its validity and sensitivity are trustworthy, but there are still some shortcomings.
Neurologists should make choices when using them to better serve the clinic.

.

NIHSS is a scale that has been used by neurologists around the world for more than 20 years.
Its validity and sensitivity are trustworthy, but there are still some shortcomings.
Neurologists should make choices when using it in order to better serve the clinic
.

 

 

references:

references:

 

[1] Powers WJ, Rabinstein AA, Ackerson T, et al.
2018 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.
2018 Mar;49( 3):e46-e110.

[2] Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Chinese Acute Ischemic Stroke Diagnosis and Treatment Guide 2018.
Chinese Journal of Neurology, 2018, 51 (9): 666-682.

[3] Goldstein LB, Samsa GP.
Reliability of the National Institutes of Health stroke scale: extension to non-neurologists in the context of a clinical trial.
Stroke 1997; 28: 307–10.

[4] Brott TG, Adams HP Jr, Olinger CP, et al.
Measurements of acute cerebral infarction: a clinical examination scale.
Stroke 1989; 20: 864–70.

[5] Adams HP Jr, Davis PH, Leira EC, et al.
Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke T reatment (TOAST).
Neurology 1999; 53: 126 –31.

 

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