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

0

20

40

60

80

100

Thrombolysis Control

Alive andindependent

Alive butdependent

Dead

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

Outcome measures/Stroke scales

• Pathology

• Impairment - abnormality of structure/function

• Disability - functional consequence of impairment

• Handicap - social consequence of impairment

• QOL

• Survival

Outcome measures/Stroke scales• Valid

• Reliable

• Reproducible

• Relevant

• Practical

• Sensitive

• Communicable

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. 1957. 2: 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. 1994. 4: 314–24)

3 simple questions (Lindley et al. 1994)

Is the patient alive?

Does the patient require help from anybody for everyday activities?

Has the stroke left the patient with any problems?

Dead

Poor

Indifferent

Good

No

No

No

Yes

Yes

Yes

6

5

4

3

1

2

0

Modified Rankin Scale0 - 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.

mRS 0-3 mRS 4-6

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

• 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

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

National Institutes of Health Stroke Scale (NIHSS)

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

1a Level of consciousness

1b Level of consciousness questions

What is the month?

How old are you?

1c Level of consciousness commands

Open and close

the eyes.

Grip and release the non-paretic hand.

2 Best gaze

3 Visual fields

4 Facial palsy

5 Motor - Arm

6 Motor - Leg

7 Limb ataxia

8 Sensory

9 Language

10 Dysarthria

11 Extinction and inattention

NIHSS

i NIHSS

i NIHSS

NIHSSNIHSS Category Pre-thrombolysis Time… after thrombolysis

LOC Ia 0 0

LOC Ib 2 0

LOC Ic 2 0

Gaze 0 0

Visual fields 2 0

Facial palsy 2 0

Motor – right arm 3 0

Motor – left arm 0 0

Motor – right leg 3 0

Motor – left leg 0 0

Ataxia 0 0

Sensory 2 0

Language 3 0

Dysarthria 0 0

Extinction 2 0