NIH Stroke Scale
Administer stroke scale items in the 

order listed. Record performance in 

each category after each subscale exam. 

Do not go back and change scores. 

Follow directions provided for each 

exam technique. Scores should reflect

what the patient does, not what the 

clinician thinks the patient can do. 

The clinician should record answers while

administering the exam and work quickly.

Except where indicated, the patient 

should not be coached (i.e., repeated

requests to patient to make a 

special effort).

Instructions

Level of Consciousness: 

The investigator must choose a response 

if a full evaluation is prevented by such 

obstacles as an endotracheal tube, language

barrier, orotracheal trauma/bandages. A 3 is

scored only if the patient makes no movement

(other than reflexive posturing) in response to

noxious stimulation.

Scale Definition 

Level of Consciousness

0 Alert; keenly responsive.

1 Not alert; but arousable by minor 

stimulation to obey, answer, 

or respond.

2

Not alert; requires repeated 

stimulation to attend, or is 

obtunded and requires strong 

or painful stimulation to make 

movements (not stereotyped).

3 Responds only with reflex motor 

or autonomic effects, or totally 

unresponsive, flaccid, and areflexic.

1a

Instructions

Score
LOC Questions: 

The patient is asked the month and his/her

age. The answer must be correct — there is

no partial credit for being close. Aphasic and

stuporous patients who do not comprehend 

the questions will score 2. Patients unable 

to speak because of endotracheal intubation, 

orotracheal trauma, severe dysarthria from any

cause, language barrier, or any other problem

not secondary to aphasia are given a 1. It 

is important that only the initial answer be

graded and that the examiner not “help” the

patient with verbal or non-verbal cues.

Scale Definition 

Level of Consciousness

0 Answers both questions correctly.

1 Answers one question correctly.

2 Answers neither question correctly.

1b

Instructions

LOC Commands: 

The patient is asked to open and close 

the eyes and then to grip and release 

the non-paretic hand. Substitute 

another one-step command if the hands 

cannot be used. Credit is given if an 

unequivocal attempt is made but not 

completed due to weakness. If the 

patient does not respond to command, 

the task should be demonstrated to 

him or her (pantomime), and the result scored

(i.e., follows none, one, or two commands).

Patients with trauma, amputation, or 

other physical impediments should be 

given suitable one-step commands. 

Only the first attempt is scored.

Scale Definition 

Level of Consciousness

0 Performs both tasks correctly.

1 Performs one task correctly.

2 Performs neither task correctly.

1c

Instructions

Score Score
Best Gaze: 

Only horizontal eye movements will be tested.

Voluntary or reflexive (oculocephalic) eye

movements will be scored, but caloric testing 

is not done. If the patient has a conjugate

deviation of the eyes that can be overcome 

by voluntary or reflexive activity, the score 

will be 1. If a patient has an isolated 

peripheral nerve paresis (CN III, IV, or VI),

score a 1. Gaze is testable in all aphasic

patients. Patients with ocular trauma, 

bandages, pre-existing blindness, or other 

disorder of visual acuity or fields should be

tested with reflexive movements, and a choice

made by the investigator. Establishing eye

contact and then moving about the patient

from side to side will occasionally clarify the

presence of a partial gaze palsy.

Scale Definition 

Best Gaze

0 Normal.

1 Partial gaze palsy; gaze is abnormal 

in one or both eyes, but forced 

deviation or total gaze paresis is 

not present.

2 Forced deviation, or total 

gaze paresis is not overcome by the 

oculocephalic maneuver.

2

Instructions

Visual: 

Visual fields (upper and lower quadrants) are

tested by confrontation, using finger counting

or visual threat, as appropriate. Patients may

be encouraged, but if they look at the side of

the moving fingers appropriately, this can 

be scored as normal. If there is unilateral

blindness or enucleation, visual fields in the

remaining eye are scored. Score 1 only if a

clear-cut asymmetry, including quadrantanopia,

is found. If patient is blind from any cause,

score 3. Double simultaneous stimulation is

performed at this point. If there is extinction,

patient receives a 1, and the results 

are used to respond to item 11.

Scale Definition 

Visual

0 No visual loss.

1 Partial hemianopia.

2 Complete hemianopia.

3 Bilateral hemianopia (blind including

cortical blindness).

3

Instructions

Score Score
Facial Palsy:

Ask — or use pantomime to encourage — the

patient to show teeth or raise eyebrows and

close eyes. Score symmetry of grimace in

response to noxious stimuli in the poorly

responsive or non-comprehending patient. 

If facial trauma/bandages, orotracheal tube,

tape, or other physical barriers obscure 

the face, these should be removed to the

extent possible.

Scale Definition 

Facial Palsy

0 Normal symmetrical movements.

1 Minor paralysis (flattened nasolabial 

fold, asymmetry on smiling).

2 Partial paralysis (total or near-total 

paralysis of lower face).

3 Complete paralysis of one or both 

sides (absence of facial movement in 

the upper and lower face).

4

Instructions

Motor Arm:

The limb is placed in the appropriate position:

extend the arms (palms down) 90 degrees 

(if sitting) or 45 degrees (if supine). Drift is

scored if the arm falls before 10 seconds. The

aphasic patient is encouraged using urgency 

in the voice and pantomime, but not noxious

stimulation. Each limb is tested in turn,

beginning with the non-paretic arm. Only 

in the case of amputation or joint fusion at

the shoulder, the examiner should record the

score as untestable (UN) and clearly write the

explanation for this choice.

Motor Arm 5

Instructions Scale Definition 

Score

5a

5b Score

Score Left Arm

Right Arm

0 No drift; limb holds 90 (or 45) degrees 

for full 10 seconds.

1 Drift; limb holds 90 (or 45) degrees, 

but drifts down before full 10 seconds; 

does not hit bed or other support.

2

Some effort against gravity; limb 

cannot get to or maintain (if cued) 90 

(or 45) degrees, drifts down to bed, 

but has some effort against gravity.

3 No effort against gravity; limb falls.

4 No movement.

Amputation or joint fusion, explain: UN
Motor Leg:

The limb is placed in the appropriate position:

hold the leg at 30 degrees (always tested

supine). Drift is scored if the leg falls before

5 seconds. The aphasic patient is encouraged

using urgency in the voice and pantomime but

not noxious stimulation. Each limb is tested

in turn, beginning with the non-paretic leg.

Only in the case of amputation or joint fusion

at the hip, the examiner should record the

score as untestable (UN) and clearly write the

explanation for this choice.

Motor Leg 6

Instructions

Limb Ataxia: 

This item is aimed at finding evidence of a

unilateral cerebellar lesion. Test with eyes

open. In case of visual defect, ensure testing

is done in intact visual field. The fingernose-finger and heel-shin tests are performed

on both sides, and ataxia is scored only if 

present out of proportion to weakness. Ataxia

is absent in the patient who cannot understand or is paralyzed. Only in the case of

amputation or joint fusion, the examiner

should record the score as untestable (UN) 

and clearly write the explanation for this

choice. In case of blindness, test by having

the patient touch nose from extended arm

position. 

Scale Definition 

Limb Ataxia

0 Absent.

1 Present in one limb.

2 Present in two limbs.

Amputation or joint fusion, explain: 

7

Scale Definition Instructions

Score

6a

6b Score

Score Left Leg

Right Leg

0 No drift; leg holds 30-degree position 

for full 5 seconds.

1 Drift; leg falls by the end of the 5-

second period but does not hit the bed.

2 Some effort against gravity; leg falls 

to bed by 5 seconds but has some 

effort against gravity.

3 No effort against gravity; leg falls to 

bed immediately.

4 No movement.

Amputation or joint fusion, explain: UN UN
Sensory: 

Sensation or grimace to pinprick when tested,

or withdrawal from noxious stimulus in the

obtunded or aphasic patient. Only sensory

loss attributed to stroke is scored as abnormal

and the examiner should test as many body 

areas [arms (not hands), legs, trunk, face] 

as needed to accurately check for hemisensory

loss. A score of 2, “severe or total sensory

loss,” should only be given when a severe 

or total loss of sensation can be clearly 

demonstrated. Stuporous and aphasic patients

will, therefore, probably score 1 or 0. The

patient with brainstem stroke who has bilateral

loss of sensation is scored 2. If the patient

does not respond and is quadriplegic, score 2.

Patients in a coma (item 1a=3) are automatically given a 2 on this item. 

Scale Definition 

Sensory

0 Normal; no sensory loss.

1

Mild-to-moderate sensory loss; 

patient feels pinprick is less sharp 

or is dull on the affected side; or 

there is a loss of superficial pain 

with pinprick, but patient is aware 

of being touched.

2 Severe or total sensory loss; patient 

is not aware of being touched in the 

face, arm, and leg.

8

Instructions

Best Language: 

A great deal of information about 

comprehension will be obtained during the

preceding sections of the examination. For

this scale item, the patient is asked to

describe what is happening in the attached

picture, to name the items on the attached

naming sheet, and to read from the attached

list of sentences. Comprehension is judged

from responses here, as well as to all of the

commands in the preceding general neurological

exam. If visual loss interferes with the tests,

ask the patient to identify objects placed in

the hand, repeat, and produce speech. The

intubated patient should be asked to write.

The patient in a coma (item 1a=3) will 

automatically score 3 on this item. The examiner

must choose a score for the patient with stupor

or limited cooperation, but a score of 3 should

be used only if the patient is mute and follows

no one-step commands.

Best Language 9

Instructions Scale Definition 

Score Score

0 No aphasia; normal.

1

Mild-to-moderate aphasia; some obvious 

loss of fluency or facility of comprehension, 

without significant limitation on ideas 

expressed or form of expression. Reduction 

of speech and/or comprehension, however, 

makes conversation about provided materials

difficult or impossible. For example, in 

conversation about provided materials, 

examiner can identify picture or naming card

content from patient’s response.

2

Severe aphasia; all communication is 

through fragmentary expression; great need 

for inference, questioning, and guessing by 

the listener. Range of information that can 

be exchanged is limited; listener carries 

burden of communication. Examiner cannot 

identify materials provided from patient 

response.

3 Mute, global aphasia; no usable speech 

or auditory comprehension.
Dysarthria: 

If patient is thought to be normal, an 

adequate sample of speech must be obtained

by asking patient to read or repeat words from

the attached list. If the patient has severe 

aphasia, the clarity of articulation of 

spontaneous speech can be rated. Only if the

patient is intubated or has other physical 

barriers to producing speech, the examiner

should record the score as untestable (UN) and

clearly write the explanation for this choice.

Do not tell the patient why he/she is being

tested.

Scale Definition 

Dysarthria

0 Normal.

1 Mild-to-moderate dysarthria; 

patient slurs at least some words 

and, at worst, can be understood 

with some difficulty.

2

Severe dysarthria; patient’s speech 

is so slurred as to be unintelligible 

in the absence of or out of 

proportion to any dysphasia, or is

mute/anarthric.

Intubated or other physical barrier,

explain:

10

Instructions

Extinction and Inattention (formerly Neglect):

Sufficient information to identify neglect may

be obtained during the prior testing. If the

patient has a severe visual loss preventing

visual double simultaneous stimulation, and

the cutaneous stimuli are normal, the score is

normal. If the patient has aphasia but does

appear to attend to both sides, the score is

normal. The presence of visual spatial neglect

or anosagnosia may also be taken as evidence

of abnormality. Since the abnormality is

scored only if present, the item is never

untestable.

Scale Definition 

Extinction and Inattention

0 No abnormality.

1

Visual, tactile, auditory, spatial, or 

personal inattention, or extinction to 

bilateral simultaneous stimulation in 

one of the sensory modalities.

2

Profound hemi-inattention or extinction 

to more than one modality; does not 

recognize own hand or orients to only one 

side of space.

11

Instructions

Score Score

UN

You know how.

Down to earth.

I got home from work.

Near the table in the dining room.

They heard him speak on the

radio last night.

MAMA

TIP – TOP

FIFTY – FIFTY

THANKS

HUCKLEBERRY

BASEBALL PLAYER
www.ninds.nih.gov

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