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Clinical References

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Clinical Pearls

Neurology4 results

NIH Stroke Scale (NIHSS)

NeurologyThomas Brott
Open

The NIH Stroke Scale (NIHSS) was developed by the National Institute of Neurological Disorders and Stroke to provide a standardised, reproducible assessment of neurological deficit severity in acute stroke patients. Originally published in 1989, it has become the global standard for stroke severity quantification, used in clinical trials, treatment eligibility determinations (particularly for IV thrombolysis and mechanical thrombectomy), and outcome prediction. The scale consists of 15 items assessing consciousness, gaze, visual fields, facial palsy, limb motor function, ataxia, sensation, language, dysarthria, and extinction.

12 criteria6 pearls3 refsValidated

The NIH Stroke Scale (NIHSS) was developed by the National Institute of Neurological Disorders and Stroke to provide a standardised, reproducible assessment of neurological deficit severity in acute stroke patients. Originally published in 1989, it has become the global standard for stroke severity quantification, used in clinical trials, treatment eligibility determinations (particularly for IV thrombolysis and mechanical thrombectomy), and outcome prediction. The scale consists of 15 items assessing consciousness, gaze, visual fields, facial palsy, limb motor function, ataxia, sensation, language, dysarthria, and extinction.

Validated In

Validated in multiple large stroke trials including NINDS tPA trial, ECASS, SITS-MOST

Thomas Brott, Harold P. Adams Jr., and colleagues at the University of Cincinnati

1

1a. Level of Consciousness

0=Alert, 1=Drowsy, 2=Obtunded, 3=Unresponsive

2

1b. LOC Questions (month/age)

0=Both correct, 1=One correct, 2=Neither correct

3

1c. LOC Commands (open/close eyes, fist)

0=Both obeyed, 1=One obeyed, 2=Neither obeyed

4

2. Best Gaze

0=Normal, 1=Partial palsy, 2=Forced deviation

5

3. Visual Fields

0=No loss, 1=Partial hemianopia, 2=Complete, 3=Bilateral

6

4. Facial Palsy

0=Normal, 1=Minor, 2=Partial, 3=Complete

7

5-6. Motor Arm/Leg (each side)

0=No drift to 4=No movement (0-4 per limb)

8

7. Limb Ataxia

0=Absent, 1=One limb, 2=Two limbs

9

8. Sensory

0=Normal, 1=Mild/moderate loss, 2=Severe/total loss

10

9. Best Language

0=No aphasia, 1=Mild/moderate, 2=Severe, 3=Mute/global

11

10. Dysarthria

0=Normal, 1=Mild/moderate, 2=Severe/unintelligible

12

11. Extinction/Inattention

0=Normal, 1=Inattention one modality, 2=Profound

NIHSS ≤5 correlates with minor stroke — these patients have excellent prognosis and may be candidates for dual antiplatelet therapy instead of IV tPA (POINT/CHANCE trials).

NIHSS ≥6 with confirmed large vessel occlusion (LVO) on CTA: mechanical thrombectomy reduces disability even up to 24 hours post-onset if perfusion imaging demonstrates salvageable tissue (DAWN/DEFUSE-3 criteria).

A "wake-up stroke" or unknown onset time does not preclude treatment — use MRI DWI/FLAIR mismatch or CT perfusion to identify the therapeutic window.

The score is poorly sensitive for posterior circulation strokes (brainstem/cerebellum) which may have severe deficits with low NIHSS scores.

Serial NIHSS monitoring: a decrease of ≥4 points = clinically meaningful improvement; increase of ≥4 = neurological deterioration requiring urgent re-evaluation.

tPA eligibility requires NIHSS ≥3 (lower scores may still be treated if disabling deficit) within 4.5 hours of last known well.

[1]

Brott T, et al. Measurements of Acute Cerebral Infarction: A Clinical Examination Scale. Stroke. 1989;20(7):864-870.

[2]

Adams HP Jr, et al. Baseline NIH Stroke Scale Score Strongly Predicts Outcome After Stroke. Neurology. 1999;53(1):126-131.

[3]

Powers WJ, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 AHA/ASA Guidelines. Stroke. 2019;50(12):e344-e418.

Montreal Cognitive Assessment (MoCA)

NeurologyDr. Ziad Nasreddine
Open

The Montreal Cognitive Assessment (MoCA) was developed by Dr. Ziad Nasreddine and colleagues in 1996 as a brief, sensitive screening tool specifically designed to detect mild cognitive impairment (MCI) — a stage often missed by the less sensitive MMSE. The MoCA takes approximately 10 minutes to administer and evaluates eight cognitive domains. It has been translated into over 100 languages and is now the most widely used brief cognitive screening instrument globally, endorsed by major neurology, geriatrics, and dementia societies. It was memorably referenced in public discourse when U.S. President Trump cited his "perfect score" on the test in 2020.

9 criteria6 pearls3 refsValidated

Mini-Mental State Examination (MMSE)

NeurologyMarshal F. Folstein
Open

The Mini-Mental State Examination (MMSE) was developed by Folstein, Folstein, and McHugh in 1975 and became the most widely administered cognitive screening instrument in the world, used in over 300 million assessments. It assesses orientation, registration, attention/calculation, recall, and language/visuospatial function. Despite being largely superseded by the MoCA for MCI detection, the MMSE remains in widespread clinical use for tracking dementia severity, monitoring treatment response, and determining decision-making capacity. The MMSE is copyrighted by Psychological Assessment Resources (PAR) and technically requires a license for clinical use.

11 criteria6 pearls3 refsValidated

Glasgow Coma Scale (GCS)

NeurologyGraham Teasdale and Bryan Jennett
Open

The Glasgow Coma Scale (GCS) was developed by Graham Teasdale and Bryan Jennett at the University of Glasgow in 1974 to provide an objective, standardised method of measuring consciousness in patients with traumatic brain injury. It quickly became the universal standard for neurological observation and is used in trauma, neurosurgery, neurology, and intensive care. The scale assesses three components: eye opening, verbal response, and motor response, with a total score ranging from 3 (deep coma or death) to 15 (fully awake). The Paediatric GCS (pGCS) modifies the verbal and motor components to account for age-appropriate responses in infants and young children.

7 criteria7 pearls3 refsValidated

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