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7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
Use of the NIH Stroke Scale (NIHSS)Use of the NIH Stroke Scale (NIHSS)
in Emergency Deartment Patients witin Emergency Deartment Patients wit
!c"te Stroke!c"te StrokeEdward Sloan, MD, MPHEdward Sloan, MD, MPH
!ssociate Professor!ssociate Professor
Deartment of Emergency MedicineDeartment of Emergency MedicineUni#ersity of Illinois $ollege of MedicineUni#ersity of Illinois $ollege of Medicine
$hicago, I%$hicago, I%
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
&lo'al 'ecti#es&lo'al 'ecti#es
Imro#e t o"tcome in stroke
*now how to "se the NIHSS to g"ide +
Pro#ide rationale ED "se of tP! Maimi-e o"tcome
Minimi-e mor'idity associated with tP!
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
Session 'ecti#esSession 'ecti#es
Eamine the NIHSS
Simlify its calc"lation
!sk clinically rele#ant ."estions !ddress imortant iss"es in literat"re
$onsider ractical "se in the ED
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Edward Sloan, MD, MPH
/hy Do 0his Eercise1/hy Do 0his Eercise1
0he NIHSS is the ind"stry standard
It is not "st a research tool
It allows "s to ."antify o"r clinical eam It ro#ides for standardi-ation
It manages risk effecti#ely
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
Ne"rologic Eam2 NIH Stroke ScaleNe"rologic Eam2 NIH Stroke Scale
34 item scoring system, 5 min"te eam
Integrates ne"rologic eam comonents
$N (#is"al), motor, sensory, cere'ellar,
inattention, lang"age, %$ Maim"m score is 67, signifying se#ere stroke
Minim"m score is 8, a normal eam
Scores greater than 39:78 are more se#ere
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIH Stroke Scale2 Imortant ;"estionsNIH Stroke Scale2 Imortant ;"estions
/hich elements are consistently collected1
/hich correlate with o"tcome1
/hich imro#e with tP!1 /hich s"ggest a comlicated tP! co"rse1
/hich arts o#erla with one another1
Does the side of the stroke matter1
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIH Stroke Scale2 Practical S"ggestionNIH Stroke Scale2 Practical S"ggestion
*now the general categories of the NIHSS
%et these 5 areas g"ide yo"r eam
*now how to score an aroimate NIHSS
&o to the we' to score yo"r eam f"lly
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Edward Sloan, MD, MPH
NIH Stroke Scale2 Internet $alc"latorNIH Stroke Scale2 Internet $alc"lator
!llows calc"lation on:line
/ill add #al"es, ro#ide total
htt2
7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
/hy Do 0his Eercise1/hy Do 0his Eercise1
0he NIHSS is theind"stry standard
It is not "st a researchtool
It allows "s to ."antify
o"r clinical eam It ro#ides for
standardi-ation
It manages riskeffecti#ely
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
/hy Do 0his Eercise1/hy Do 0his Eercise1
0he NIHSS is theind"stry standard
It is not "st a researchtool
It allows "s to ."antify
o"r clinical eam It ro#ides for
standardi-ation
It manages riskeffecti#ely
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS Elements2 %$NIHSS Elements2 %$
%$ o#erall 8:4 ts
%$ ."estions8:7 ts
%$ commands 8:7 ts
%$2 5
oints total
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Edward Sloan, MD, MPH
NIHSS Elements2 %$NIHSS Elements2 %$
%$ o#erall 8:4 ts
%$ ."estions 8:7 ts
%$ commands 8:7 ts
%$2 5 oints total
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS Elements2 $ranial Ner#esNIHSS Elements2 $ranial Ner#es
&a-e alsy 8:7 ts
>is"al field deficit 8:4 ts
?acial motor 8:4 ts
$ranial ner#es2 @ oints total
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS Elements2 MotorNIHSS Elements2 Motor
Each arm 8:6 ts
Each leg 8:6 ts
Motor2 3A oints total
@ oints right @ oints left
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Edward Sloan, MD, MPH
NIHSS Elements2 $ere'ellarNIHSS Elements2 $ere'ellar
%im' ataia 8:7 ts
$ere'ellar2 7 oints total
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS Elements2 SensoryNIHSS Elements2 Sensory
Pain, noio"s stim"li 8:7 ts
Sensory2 7 oints total
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Edward Sloan, MD, MPH
NIHSS Elements2 %ang"ageNIHSS Elements2 %ang"age
!hasia 8:4 ts
Dysarthria 8:7 ts
%ang"age2 9 oints total
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Edward Sloan, MD, MPH
NIHSS Elements2 InattentionNIHSS Elements2 Inattention
Inattention 8:7 ts
Inattention2 7 oints total
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Edward Sloan, MD, MPH
NIHSS Elements2 $omositeNIHSS Elements2 $omosite
$N (#is"al)2 @
Unilateral motor2 @
%$2 5 %ang"age2 9
!taia2 7
Sensory2 7 Inattention2 7
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Edward Sloan, MD, MPH
NIHSS2 *ey ElementsNIHSS2 *ey Elements
$N (#is"al)2 ?acial alsy, ga-ealsy, #is"al fielddeficit
Unilateral motor2 Hemiaresis %$2 Deressed %$, oor
resonsi#eness
%ang"age2 !hasia, dysarthria 7@ total oints
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS $r"de EstimateNIHSS $r"de Estimate
$N (#is"al)2 @
Unilateral motor2 @
%$2 @ %ang"age2 @
Mild 7, Moderate 6, Se#ere, @ Incororates other elements
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS $r"de Estimate2 EamleNIHSS $r"de Estimate2 Eamle
$N (#is"al)2 some alsy 6
Unilateral motor2 hemiaresis @
%$2 mild decreased %$ 7
%ang"age2 some seech 6
3@ oints total
More se#ere decrease in %$2 ca"tionB
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Edward Sloan, MD, MPH
NIHSS ;"estion2 PredictionNIHSS ;"estion2 Prediction
Does the 'aseline NIHSS redicto"tcome1
Ces=
Adams HP Neurology 1999;53:126131
aseline NIH Stroke Scale score stronglyredicts o"tcome after stroke (0!S0)
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Edward Sloan, MD, MPH
NIHSS $r"de EstimateNIHSS $r"de Estimate $N (#is"al)2 @
Unilateral motor2 @
%$2 @
%ang"age2 @
Mild 7, Moderate 6, Se#ere, @
Incororates other elements
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS $r"de EstimateNIHSS $r"de Estimate
$N (#is"al)2 @ Unilateral motor2 @ %$2
@ %ang"age2
@
Mild 7, Moderate 6,Se#ere, @
Incororates other
elements
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Edward Sloan, MD, MPH
NIHSS $r"de EstimateNIHSS $r"de Estimate
$N (#is"al)2 @ Unilateral motor2 @ %$2
@ %ang"age2
@
Mild 7, Moderate 6,Se#ere, @
Incororates other
elements
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Edward Sloan, MD, MPH
NIHSS and "tcome PredictionNIHSS and "tcome Prediction
NIHSS 'elow 37:36 will ha#e an @8 good orecellent o"tcome=
NIHSS a'o#e 78:7A will ha#e less than a 78
good or ecellent o"tcome= %ac"nar infarct atients had the 'est
o"tcomes=
Adams HP Neurology 1999;53:126131 aseline NIH Stroke Scale score strongly redicts o"tcome after stroke
(0!S0)
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Edward Sloan, MD, MPH
NIHSS ;"estion2 NINDS 0rial DataNIHSS ;"estion2 NINDS 0rial Data
Did the NINDS trial show 'enefit across all'aseline NIHSS strata1 ased on strokes"'tye1
No and yes=
N!NDS r"PA S"ro#e S"udy $rou%,
NE&M1995;333:15'1() 0iss"e lasminogen !cti#ator for !c"te
Ischemic Stroke
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Edward Sloan, MD, MPH
NIHSS and 0he NINDS 0rialNIHSS and 0he NINDS 0rial
+egardless of stroke s"'tye (small:#esseloccl"si#e, large:#essel occl"si#e orcardioem'olic), there was 'enefit with tP!=
0here was no data that showed how 'enefitwas related to 'aseline NIHSS=
nly median NIHSS data was ro#ided, and noother s"'gro" analysis was erformed=
N!NDS r"PA S"ro#e S"udy $rou%, NE&M1995;333:15'1() 0iss"e lasminogen !cti#ator for !c"te Ischemic Stroke
http://www.ferne.org/7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
NIHSS ;"estion2 NINDS Place'o Pts1NIHSS ;"estion2 NINDS Place'o Pts1
Did factors redict oor o"tcome of the
lace'o ts in the NINDS clinical trial1
Sho"ld these ts still 'e treated with tP!1
Ces and ro'a'ly=
*ran#el M+, Neurology 2;55:952959)
Predicting rognosis after stroke2 Place'o gro" in the NINDS Stroke 0ria
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Edward Sloan, MD, MPH
"tcome of the NINDS Place'o Pts"tcome of the NINDS Place'o Pts
FA PP>2 ts with an NIHSS G 35 and afi'
will ha#e a oor o"tcome=
Same oor o"tcome with NIHSS G 35 and
imaired conscio"sness=
0here was imro#ement with tP! "se=
*ran#el M+, Neurology 2;55:952959)
Predicting rognosis after stroke2 Place'o gro" in the NINDS Stroke 0ria
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Edward Sloan, MD, MPH
NIHSS ;"estion2 ther Stroke ScalesNIHSS ;"estion2 ther Stroke Scales
Do other stroke scales eist that areeasier to "se1 !re they #alid1 $an they'e "sed1
Ces, yes, and no=
-o"e +, Neurology19'9;39:63'6.3) 0he $anadian Ne"rologic Scale
%yden PD, Stroke 7883473438:3435=
! Modified NIHSS for Use in Stroke $linical 0rials
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Edward Sloan, MD, MPH
NIHSS and ther Stroke ScalesNIHSS and ther Stroke Scales
ther scales do eist that may makecalc"lating stroke se#erity easier=
0hese other scales ha#e 'een #alidated= 0he NINDS and other stroke trials ha#e not
indicated what the stroke se#erity was "singthese other scoring systems, s"ch that wecannot infer this info and incororate it intoclinical ractice=
-o"e +, Neurology19'9;39:63'6.3) 0he $anadian Ne"rologic Scale /yden PD, S"ro#e 21;32;131131()
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Edward Sloan, MD, MPH
NIHSS ;"estion2 +etrosecti#e Use1NIHSS ;"estion2 +etrosecti#e Use1
$an these scales 'e determined
retrosecti#ely1
Ces=
$olds"e0n /, S"ro#e 199(;2':11'111'.)
+etrosecti#e !ssessment with the $anadian Ne"rologic Scale 0ll0ams /S, S"ro#e 2;31:'5''62
+etrosecti#e !ssessment with the NIHSS
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Edward Sloan, MD, MPH
+etrosecti#e Se#erity Scale Use+etrosecti#e Se#erity Scale Use
0hese scales can 'e determined inretrosect if ade."ate doc"mentation ofthe ne"rologic eam is in the ED record=
Imlications for $;I and indi#id"al casesin which tP! "se is considered=
$olds"e0n /, S"ro#e 199(;2':11'111'.)
+etrosecti#e !ssessment with the $anadian Ne"rologic Scale
0ll0ams /S, S"ro#e 2;31:'5''62
+etrosecti#e !ssessment with the NIHSS
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Edward Sloan, MD, MPH
NIHSS2 Does $>! Side Imact +1NIHSS2 Does $>! Side Imact +1
Does it matter whether or not the stroke
findings are on the right side or left side
of the 'ody1
Ces=
oo D, S"ro#e1999;3:23552359)
Does the NIHSS ?a#or %eft Hemisheric Strokes1
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Edward Sloan, MD, MPH
$>! Symtom Side and +$>! Symtom Side and +
+ sided stroke, % sided symtoms
+ sided stroke, non:dominant
+ sided stroke, inattention, 7 oints
% sided stroke, + sided symtoms
% sided stroke, dominant % sided stroke, lang"age, 9 oints
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Edward Sloan, MD, MPH
$>! Symtom Side and +$>! Symtom Side and +
! + sided stroke has a stroke the same si-e as a %sided stroke with an NIHSS that is 9 oints higher=
Perhas we sho"ld treat + sided strokes (% sided
aralysis) that ha#e lower NIHSS=
Perhas we sho"ld treat higher % sided strokes (+sided aralysis) that ha#e a higher NIHSS=
In 'oth cases, the motor score is often the same=
oo D, S"ro#e1999;3:23552359)
Does the NIHSS ?a#or %eft Hemisheric Strokes1
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Edward Sloan, MD, MPH
NIHSS2 !nt #s= Post $irc"lation1NIHSS2 !nt #s= Post $irc"lation1
Sho"ld tP! 'e administered regardless of
the tye of stroke noted1
Ces=
Personal comm"nication, %ewandowski, 7883=
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Edward Sloan, MD, MPH
tP! in Posterior $irc"lation StrokestP! in Posterior $irc"lation Strokes
U to 38:39 of ts in the NINDS stroke
trial were osterior circ"lation strokes=
0hese ts were randomi-ed to recei#e
tP! as were other stroke ts= 0here is no reason not to gi#e tP! to
these ts er the clinical trial rotocol=
Personal comm"nication, %ewandowski, 7883=
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Edward Sloan, MD, MPH
Use of the NIHSS2 $oncl"sionsUse of the NIHSS2 $oncl"sions
0he NIHSS m"st 'e aroimated
Scores a'o#e 35:78 imart greater risk
tP! still m"st 'e considered, since 'enefi Stroke side, lang"age m"st 'e considered
! ro"gh scale m"st 'e "sed, since no
a''re#iated scale #alidated
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Edward Sloan, MD, MPH
Use of the NIHSS2 +ecommendationsUse of the NIHSS2 +ecommendations
+isk
7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
timal tP! Pt Using NIHSStimal tP! Pt Using NIHSS
%imited alteration in mental stat"s
Moderate to se#ere #is"al
7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate
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Edward Sloan, MD, MPH
;"estions;"estions1111
Edward Sloan, MD, MPHEdward Sloan, MD, MPH
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http://www.ferne.org/