NIH Stroke Scale

National Institute of

Neurological Disorders

and Stroke

Instructions

• 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).

www.stroke.nih.gov

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1a: Level of Consciousness

Instructions – Level of Consciousness (LOC): 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

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.

Score

2

1c: Level of Consciousness

Instructions – LOC Commands: The patient is asked to open and close the eyes and then to grip and release the nonparetic 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

0 Performs both tasks correctly.

1 Performs one task correctly.

2 Performs neither task correctly.

Score

1b: Level of Consciousness

Instructions – 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

0 Answers both questions correctly.

1 Answers one question correctly.

2 Answers neither question correctly.

Score
3

2: Best Gaze

Instructions: 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

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.

Score

3: Visual

Instructions: 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

0 No visual loss.

1 Partial hemianopia.

2 Complete hemianopia.

3 Bilateral hemianopia (blind including cortical blindness).

Score

4: Facial Palsy

Instructions: 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

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).

Score
4

5: Motor Arm

Instructions: 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.

Scale Definition

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.

UN Amputation or joint fusion, explain:

Score 5a: Left Arm 5b: Right Arm

6: Motor Leg

Instructions: 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.

Scale Definition

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.

UN Amputation or joint fusion, explain:

Score 6a: Left Leg 6b: Right Leg
5

7: Limb Ataxia

Instructions: 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 finger-nose-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

0 Absent.

1 Present in one limb.

2 Present in two limbs.

UN Amputation or joint fusion, explain:

Score

8: Sensory

Instructions: 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

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.

Score
6

9: Best Language

Instructions: 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 (p. 9), to 

name items on the naming sheet (p. 10), and to read from the list of sentences (p. 11). 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.

Scale Definition

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.

Score

10: Dysarthria

Instructions: 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 (p. 12). 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 or she is being tested.

Scale Definition

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.

UN

Intubated or other physical barrier, explain:

Score
7

11: Extinction and Inattention

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

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.

Score
Total Score of Patient

ITEM SCORE

1a

1b

1c

2

3

4

5

6

7

8

9

10

11

TOTAL SCORE

8
9

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10
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.

11
12

MAMA

TIP – TOP

FIFTY – FIFTY

THANKS

HUCKLEBERRY

BASEBALL PLAYER

CATERPILLAR