Neurological stroke scores. Annex G4. NIHSS scale (National Institutes of Health Stroke Scale) - National Institutes of Health Stroke Scale. Dysfunction of the facial nerve

Cardiologist

Higher education:

Cardiologist

Kabardino-Balkarian State University named after A.I. HM. Berbekova, Faculty of Medicine (KBGU)

Level of education - Specialist

Additional education:

"Cardiology"

State Educational Institution "Institute for the Improvement of Doctors" of the Ministry of Health and Social Development of Chuvashia

Every neurologist should know what the nihss stroke severity rating scale is. The data obtained with its help are important for making a decision on the advisability of prescribing thrombolytic therapy, its expected effectiveness, and the prognosis of the disease itself. Its principle is that the more points the patient gains, the more difficult his state of health.

If, as a result of evaluation, the patient has more than 3 points, this is an indication for the appointment of thrombolytic therapy, and if more than 25 points are scored, such treatment is strongly not recommended.

nihss scale

The patient can be assessed using the nihss or the National Institutes of Health Stroke Scale. It includes 15 tasks that must be completed and scored. At the same time, the assessment takes place in a strict order, it is impossible to swap subsections or return to unfulfilled ones. Unless required by the conditions of the task, it is also forbidden to prepare the patient for the passage of a particular task.

Vigor level

If it is not possible to make an accurate assessment for a number of reasons, then the overall result of the answers is examined, as well as the reaction to them. The maximum score is given if the patient is in a coma or the reaction and reflexes are completely absent.

0 - clear;

1 - stunning (slight lethargy or drowsiness, but a complete reaction to even the slightest stimulus);

2 - stupor (repetition or stronger stimulation is necessary for the manifestation of the reaction);

3 - coma (complete absence of speech contact).

Answers on questions

A person is asked two questions: his age, and what month it is. Answers must be complete and clear, even the slightest error in the numbers must be taken into account. In this case, only the first response received is taken into account.

0 - answers to all two questions;

1 - the correct answer to only one of the questions;

2 - incorrect answers to all two questions.

Command execution

A person must first close and then open their eyes. Next, you will need to clench and unclench the fist of the hand that is not paralyzed. If for some reason the second action is not possible, you can ask to execute another similar command. If there is no reaction to speech, you can show by your own example what is required of the victim. Evaluation occurs on the first attempt:

0 - correct execution of both tasks;

1 - execution of one task;

2 - complete or incorrect failure to complete the tasks.

Eyeball movement

0 - norm;

1 - partial paralysis;

2 - complete paralysis of the eyeball.

line of sight

The study is carried out by confrontation and counting the number of fingers, starting from the periphery and ending with the center of the eye.

0 - no violations, the pupils move in the direction of the fingers;

1 - the presence of asymmetry or partial hemianopsia;

2 - blindness or complete hemianopia.

Identification of disorders of the facial nerve

0 - no violations detected;

1 - slight asymmetry of the face;

2 - moderate paralysis of the facial muscles;

3 - complete paralysis of the face.

Strength of the muscles of the left arm

The arm from the extended state is made at an angle of 90 ° (sitting) or 45 ° (lying down). In this case, it is necessary that the palms are turned down. In this position, the patient needs to hold out for 10 seconds, after which the nihss scale is filled.

2 - Strength cannot be tested due to missing limb or broken joint.

Right hand muscle strength

The same actions are performed as with the left hand and points are calculated based on the result.

0 - if the hand is held in this position for the required amount of time;

1 - if the hand is first held at the desired angle, and then begins to fall;

2 - it is impossible to examine the strength due to the absence of a limb or a fracture of the joint;

3 - the hand falls almost immediately after lifting, there is no way to fight against gravity;

4 - complete absence of movement.

Muscular strength of the left leg

The study is performed in the supine position. The specialist asks to raise the patient's leg at an angle of 30 ° and hold out in this position for 5 seconds. Points are awarded based on the result.

Strength of the muscles of the right leg

This task, derived by the Institute of Health, is identical to the previous one (for the left leg). The scoring is the same.

0 - The leg is in the right position for the required time;

1 - at first the limb is in the desired position, but then it falls;

2 - the limb immediately descends, holding in the desired position for an extremely short time;

3 - the fall of the leg occurs immediately, the person cannot cope with gravity;

4 - the limb does not rise.

Limb ataxia

This task allows you to determine if there is a violation of the cerebellum of one of the parties. In the presence of violations of the visual fields, the study is carried out in the one that is not affected, the victim's eyes are open. A knee-heel test is performed, as well as a toe-nose-heel test.

0 - no ataxia;

1 - ataxia in the upper or lower extremities;

2 - ataxia of all limbs.

Degree of sensitivity

The study is carried out by light pricks with a pin or needle, as well as by touch.

0 - sensitivity is normal;

1 - there is a slight decrease in sensitivity;

2 - the patient is in a coma or his sensitivity is significantly reduced.

Speech

The stroke scale involves determining the state of speech. To do this, the victim is offered a description of the picture or a reading of some text. If such requests are not possible due to lack of vision, the patient can be asked to name objects that will fit in his palm.

0 - the entire task was completed;

1 - partial ignoring or violation of speech;

2 - coma, as well as complete failure to complete the task.

The area of ​​study is not voiced to the person at this stage. Dialogue is expected.

0 - correct articulation with intelligible pronunciation;

1 - dysarthria of mild or moderate form, in which the patient can slur some words;

2 - coma or incomprehensible pronunciation of all words.

Neglect

At this stage, the perception of half of the body (in most cases, the left) is assessed. Usually, the data obtained from the previous paragraphs is sufficient.

0 - the perception of stimuli is not impaired;

1 - slight deviations;

2 - gross deviations from the norm;

3 - total absence of reflexes and reactions to external stimuli.

The nihss study or stroke severity scale is a fairly simple, and most importantly, effective way to determine the patient's condition after a stroke. The probability of a lethal outcome of the patient increases to the limit if the number of points is at least 31.

Every neurologist is familiar with the National Institutes of Health Stroke Scale (NIHSS). After all, it is her data that is used to decide on the advisability of thrombolytic therapy, evaluate its effectiveness, and also to determine the prognosis of the disease. The principle is this: the more points on the NIHSS scale, the more severe the condition.

In the case of a neurological deficit of more than 3 points on the NIHSS scale, this is regarded as an indication for thrombolytic therapy. If the patient's condition corresponds to more than 25 points on this scale, this is a relative contraindication to thrombolysis. There is evidence that with a score of less than 10 points, the probability of a favorable outcome after 1 year = 60-70%, and with a score of more than 20 points = 4-16%.

Evgeny Chernyshkov contributed to the fact that the popular scale appeared in the smartphones of medical workers. So, back in 2012, the NIHSS application for Android devices appeared, which works safely on both smartphones and tablets.

Compatible with Android devices only.

Language: Russian, English.

National Institutes of Health Stroke Scale (NIHSS)

1. Level of consciousness:

• 0 - conscious, actively reacting;
• 1 - doubt, but wake up with minimal irritation, follow commands, answer questions;
• 2 - stupor, requires repeated stimulation to maintain activity or lethargy, and requires strong and painful stimulation to produce non-stereotypical movements;
• 3 - coma, reacts only with reflex actions or completely does not respond to stimuli

2. Level of consciousness - questions:

Ask the patient what month it is and his age. Write down the first answer.

If aphasia and stupor - score 2.

If endotracheal tube, trauma, severe dysarthria, language barrier score 1.

• 0 - the correct answer to both questions;
• 1 - the correct answer to one question;
• 2 - none of the questions were answered correctly

3. Level of consciousness - execution of commands:

The patient is asked to open and close their eyes, then to squeeze and unclench their non-paralyzed hand. Only the first attempt counts:

• 0 - both commands are executed correctly;
• 1 — one command was executed correctly;
• 2 - no command executed correctly

4. Movement of the eyeballs:

Only horizontal eye movements are taken into account:

• 0 - norm;
• 1 - partial paralysis of the gaze;
• 2 - tonic abduction of the eyes or complete paralysis of the gaze, not overcome by the induction of oculocephalic reflexes

5. Examination of visual fields:

• 0 - norm;
• 1 - partial hemianopsia;
• 2- complete hemianopsia

6. Paresis of the facial muscles:

• 0 - norm;
• 1 - minimal paralysis (asymmetry);
• 2 - partial paralysis - complete or almost complete paralysis of the lower muscle group;
• 3 - complete paralysis (lack of movement in the upper and lower muscle groups)

7. Movements in the upper limbs:

The arms are raised for 10 seconds at an angle of 45 degrees if the patient is lying down, and 90 degrees if the patient is sitting. If the patient does not understand, then the doctor must place the hands in position himself. Scores are recorded separately for the right and left limbs:

On right:
• 4 - no active movements;

Left:
• 0 - no lowering for 10 seconds;
• 1 - lowers after a short hold (before 10 seconds);
• 2 - limbs cannot rise or maintain an elevated position, but produce some resistance to gravity;
• 3 - limbs fall without resistance to gravity;
• 4 - no active movements;
• 9 - impossible to check (limb mutated, artificial joint)

8. Movements in the lower limbs:

If the patient is lying, raise the paretic leg for 5 seconds at an angle of 30º.

Scores are recorded separately for the right and left limbs.

On right:
• 3 - limbs fall without resistance to gravity;
• 4 - no active movements;
• 9 - impossible to check (limb amputated, artificial joint)

Left:
• 0 - no lowering for 5 seconds;
• 1 - lowers after a short hold (before 5 seconds);
• 2 - the limbs cannot rise or maintain an elevated position, but offer some resistance to gravity;
• 3 - limbs fall without resistance to gravity;
• 4 - no active movements;
• 9 - impossible to check (limb amputated, artificial joint)

9. Ataxia of limbs:

Finger-nose and heel-to-knee tests are carried out on both sides. Ataxia is counted if it is not due to weakness:

• 0 - absent;
• 1 - in one limb;
• 2 - in two limbs

10. Sensitivity:

Only hemitetype disorder is taken into account:

• 0 - norm;
• 1 - mild or moderate violations;
• 2 - significant or complete violation of sensitivity.

11. Aphasia:

Ask the patient to describe the picture, name the object, read the sentence:

• 0 - no aphasia;
• 1 - mild aphasia;
• 2 - severe aphasia;
• 3 - complete aphasia

12. Dysarthria:

• 0 - normal articulation;
• 1 - soft or medium. May not pronounce some words;
• 2 - severe dysarthria
• 9 - intubated or other physical barrier

13. Agnosia (ignorance):

• 0 - no agnosia;
• 1 - ignoring to bilateral sequential stimulation of one sensory modality;
• 2 - severe hemiagnosia or hemiagnosia in more than one modality.

Total score:

Interview with Nathan Bornstein

Interview with Nathan Bornstein

Nathan M. Bornstein (IL), MD

Neurological Department, Medical Center. Sorasky, Tel Aviv

Nathan M. Bornstein is Professor and Head of the Department of Neurology at the Medical Center. Elias Soraski, Faculty of Medicine. Sackler, Tel Aviv University, Israel.

Dr. Bornstein's research interests include: lateralized epileptiform discharges (PLEDs) that developed after a stroke and are associated with metabolic disorders, non-valvular atrial fibrillation, menopause and ischemic stroke, the role of hormone replacement therapy, antiplatelet agents in the treatment of strokes, infection as a trigger for ischemic stroke, transcranial Doppler sonography, dynamics and treatment of asymptomatic carotid stenosis and clinical significance of hemorrhages in carotid plaques.

Dr. Bornstein is a lead researcher for the Tel Aviv Stroke Registry and the Mediterranean Stroke Society, and a member of the European Stroke Registry. Author and co-author of more than 90 scientific articles on cerebrovascular diseases published in such journals as Stroke, Neurology, Adverse Neurology, Cardiology, Acta Diabetologiсa, Cerebrovascular Diseases, Lancet, Archives of Neurology, Headache, The Journal of Neurological Sciences, The European Journal of Neurology.

— Professor Bornstein, you recently visited Seoul and took part in the work of the International Stroke Congress. What are the most significant scientific and clinical studies you would highlight?

— This year was not marked by such cutting-edge research as ECASS III in 2008 conducted in Vienna. However, the congress presented the results of several important studies, namely the SENTIS study on the use of the NeuroFlo catheter to increase cerebral circulation in acute ischemic stroke, and CASTA on the use of Cerebrolysin in the treatment of acute ischemic stroke. Dr. Cohen and Dr. Dirnagl's brilliantly delivered lectures on the impressive results of preclinical scientific studies in stroke models also attracted attention.

- Professor Bornstein, you personally participated in the CASTA study. How would you comment on the main results of the study?

- Yes, that's right. I served on the Steering Committee and therefore have some responsibility for the design of this study. More than 1060 patients were included, of which more than 900 completed the study. The final results of the study regarding primary performance indicators were neutral. However, we think that this was probably due to the fact that a large proportion of the study patients experienced mild strokes, with a median NIHSS stroke score of 9, as too many mild cases were included in the study. , then the “ceiling effect” could be strongly manifested.

— Professor Geiss, an ardent supporter of evidence-based medicine, presented the results of the CASTA study from an optimistic and positive perspective. What are these conclusions about?

— I think that at the time of presentation of the data, the possible existence of a “ceiling effect” was correctly pointed out, which may explain the neutral results of the study. However, Cerebrolysin showed significant beneficial effects in a subset of patients with baseline NIHSS > 12 or even higher (NIHSS > 17). These effects should be taken into account by clinicians as this is the first time in stroke clinical trials that a neuroprotective agent has demonstrated such a strong clinical efficacy.

Could you tell us a little more about these beneficial effects?

— In a subgroup of 246 people enrolled in the CASTA study with NIHSS scores > 12, the study drug group experienced an improvement of approximately 5 points on the NIHSS after 90 days, compared with the control group, where the decrease was less than 2 points . This difference of 3 points indicates the development of a very pronounced clinical improvement in the treatment of patients with Cerebrolysin. It is also important to note that positive effects were observed already on the 10th day of treatment - the point in time when clinicians can decide to intensify neurorehabilitation if the patient's biological state is stable. For many patients, this decline means that if they start rehabilitation early, instead of a long-term course of the disease, their condition will improve continuously.

- Were the results obtained in patients with strokes in the right or left hemispheres different?

- As far as I know, no. This indicates that improvement occurs in any case, regardless of the side of the damage. However, we must wait for the final report of the results of the study, which will appear sometime at the end of December, in order to more accurately answer the question of which subgroups of patients benefited most from Cerebrolysin therapy.

- Please explain if any positive effect can be expected in patients with mild stroke, since CASTA does not give a clear answer to this question.

- A positive effect can also be determined in patients suffering from mild forms of stroke and having, accordingly, low values ​​on the NIHSS scale. However, to do this, many more patients must be included in the study. Imagine, for example, two patients with mild stroke, one in the placebo group and one in the Cerebrolysin group, with an NIHSS score of 8. As you are well aware, mild stroke usually improves within 90 days to the point where the neurological impairment is very small and the patients' cognitive/motor function can be restored. As a result, it is difficult to identify a significant therapeutic effect in this group.

Previous studies have shown that Cerebrolysin helps such patients recover faster, which improves the quality of life of patients and their caregivers. We can also assume that patients who recover faster do not develop post-stroke depression, which often occurs with a long course of disorders.

“Another important aspect of stroke research is data on the safety of treatment. What were they like in the CASTA study?

“One of the most important benefits of Cerebrolysin has always been the safe profile of its use, and this was again confirmed in the CASTA study, for the first time in more than 1000 patients. In particular, there was a trend towards a decrease in mortality in the Cerebrolysin group by 1.3%. I think that this figure will be even higher in the subgroup of patients with more severe lesions in the final report. But for now, all of this is just speculation.

- Do you believe that, in the end, convincing data can be obtained on the possibility of a significant neuroprotective effect in ischemic stroke?

- Yes, I believe. However, we must understand that for many years, neuroscientists around the world have had high hopes that neuroprotective effects could become a proven therapy in acute stroke in addition to r-tPA. But, the results of several studies fell short of these expectations.

What kind of research do you mean?

“Recent studies include the SAINT study on NXY-059 and the EAST study on a free radical scavenger called Edaravone. In both cases, negative results were obtained. We can also recall the great review by James Grotta in 2004, which looked at drugs tested as neuroprotective agents, with negative results in almost all cases.

Do you believe in the future of Cerebrolysin?

“From my point of view, more research needs to be done on the use of Cerebrolysin in acute ischemic stroke. However, the pronounced positive trends in the subgroups of the CASTA study should impress both the pharmaceutical company and the medical community. As is known, for only a small number of drugs, certainty in relation to evidence has been achieved in one step. However, the first step is always the hardest, and the first step taken in this Cerebrolysin study was very impressive for both the pharmaceutical company and us stroke specialists.

— Cerebrolysin is a biological drug with a complex multimodal action. Don't you think that this complexity is part of the answer to why Cerebrolysin is a good candidate for hard evidence?

You raised a very interesting question. In parallel with clinical research, we must also study the mechanisms of action of Cerebrolysin in acute stroke. Preclinical data indicate that Cerebrolysin is a multimodal drug that is useful for both neuroprotection in acute stroke and long-term neurorehabilitation. In addition, due to its ability to influence the ischemic cascade at various levels (pleiotropic effect), it is the most suitable candidate for neuroprotection in the acute period of stroke.

If you remember Stephen Davis' lecture at the International Stroke Congress in Seoul, he noted that there is already proof of concept related to Cerebrolysin, the only thing missing is randomized controlled trials (RCTs). We already know that the mechanism of action of Cerebrolysin is pleiotropic and multimodal. In this regard, it is appropriate to recall that back in 2006, Marc Fisher expressed the opinion that the best candidates for identifying efficacy in large RCTs are agents with multimodal effects, including neurotrophic factors.

Cerebrolysin may even be a better candidate than neurotrophic factors alone due to its more pronounced multimodal properties. This is due to the fact that it mimics the influence of neurotrophic factors, and the active peptides contained in the preparation are small enough to pass through the blood-brain barrier, which enhances the effect.

- Well, let's finish this interview, look into the future. What do you think will happen next in Cerebrolysin research?

— Over the past few weeks, I have been discussing with my colleagues the CASTA study and its results. The signal I received is clear enough that everyone hopes that the sponsor will soon initiate a new study, the design of which will be adjusted to focus only on patients with moderate to severe strokes, which may require higher doses. drug or increase the duration of treatment.

We have important lessons to learn from the CASTA study. And if the subgroup analysis proves to be justified, then the next study is likely to find positive significant results, which will be an excellent achievement in the treatment of strokes.

— Professor Bornstein, we would like to thank you for sharing with us information about this important congress held in Seoul, and in particular about the CASTA study.

Thank you for your questions. Was happy to help.

When assessed by NIHSS scale it is necessary to strictly follow the sections of the scale, registering points in each of the subsections in turn. You can not go back and change the previously set ratings. Follow the instructions for each of the subsections. The score should reflect what the patient is actually doing, not what the investigator thinks the patient can do. Record the answers and assessments of the test subject during the study, work quickly. Unless indicated in the instructions for the appropriate subsection, the patient should not be coached and/or made to perform better on the command.

wakefulness level

If a full examination is not possible (for example, due to an endotracheal tube, a language barrier, or damage to the orotracheal area), the overall level of responses and reactions is assessed.
Grade 3 is given only in cases where the patient is in a coma and does not respond to pain stimuli or his reactions are reflex in nature (extension of the limbs).

Clear mind, responsive

Stunning and/or somnolence; responses and instructions can be achieved with minimal stimulation.

Deep stupor or stupor, reacts only to strong and painful stimuli, but the movements are not stereotyped.

Atony, areflexia and unresponsiveness or responses to stimuli consist of reflex non-purposeful movements and/or autonomic reactions.

Level of wakefulness: answers to questions

The patient is asked to name the current month and their age. Answers must be exact, you can not count the answer, which is close to the correct one. If the patient does not perceive the question (aphasia, a significant decrease in the level of wakefulness), a score of 2 is given. If the patient is unable to speak due to mechanical obstructions (endotracheal tube, damage to the maxillofacial region), severe dysarthria, or other problems not related to aphasia, a score of 1 is given. It is important that only the first response is scored and that the investigator does not assist the patient in any way.

Correct answers to both questions.

Correct answer to one question.

Didn't answer both questions.

Wakefulness level: executing commands

The patient is asked to open and then close the eyes, clench and unclench the fist of the non-paralyzed hand. If there are obstacles (for example, it is impossible to use the hand), replace this command with another command that provides a one-step action. If an explicit attempt is made, but the action is not completed due to weakness, the result is read. If the patient does not respond to the utterance of the command, he should demonstrate what is required of him, and then evaluate the result (repeated both, one or none). Only the first attempt is scored.

Run both commands.

Run one command.

Didn't follow any of the commands.

Eyeball movements

Norm.

Partial paresis of the gaze; the movements of one or both eyes are disturbed, but there is no tonic deviation of the eyeballs and complete paralysis of the gaze.

Tonic deviation of the eyeballs or complete paralysis of the gaze, which persists when checking oculocephalic reflexes.

Fields of view

Visual fields (upper and lower quadrants) are examined by confrontation, by counting the number of fingers or frightening sudden movements from the periphery to the center of the eye. It is possible to give appropriate prompts to patients, but if they look in the direction of moving fingers, this can be regarded as the norm. If one eye does not see or is missing, the second is examined. A score of 1 is given only if there is a clear asymmetry (including quadrantanopsia). If the patient is blind (for any reason), a 3 is given. Simultaneous stimulation on both sides is also examined here, and if there is hemiignorance, a 1 is put and the result is used in the "Hemiignorance (neglect)" section.

Fields of vision are not broken.

Partial hemianopia.

Complete hemianopia.

Blindness (including cortical).

Dysfunction of the facial nerve

Normal symmetrical movements of facial muscles.

Slight paresis of mimic muscles (smoothed nasolabial fold, asymmetrical smile).

Moderate prosoparesis (complete or pronounced paresis of the lower group of facial muscles).

Paralysis of one or both halves of the face (lack of movement in the upper and lower parts of the face).

Strength of the muscles of the left arm

There are no movements in the hand.

impossible to explore.

Right hand muscle strength

The extended arm is set at an angle of 90° (if the patient is sitting) or 45° (if the patient is lying) to the body with palms down and the patient is asked to hold it in this position for 10 s. First evaluate the non-paralyzed hand, then the other. With aphasia, you can help to take the starting position and use pantomime, but not painful stimuli. If it is impossible to examine the strength (the limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

The arm does not go down for 10 s.

The arm begins to descend before the 10s elapse, but does not touch the bed or other surface.

The hand is held for some time, but within 10 seconds it touches a horizontal surface.

The hand immediately falls, but there are movements in it.

There are no movements in the hand.

impossible to explore.

Strength of the muscles of the left leg

There is no movement in the leg.

impossible to explore.

Strength of the muscles of the right leg

Always examined in the supine position. The patient is asked to raise the leg at an angle of 30° to the horizontal surface and hold in this position for 5 seconds. With aphasia, you can help to take the starting position and use pantomime, but not painful stimuli. The non-paralyzed leg is evaluated first, then the other. If it is impossible to examine the strength (the limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

The leg is not lowered for 5 s.

The leg begins to descend before 5 s elapses, but does not touch the bed.

The leg is held for some time, but within 5 seconds it touches the bed.

The leg immediately falls, but there are movements in it.

There is no movement in the leg.

impossible to explore.

Ataxia in the limbs

This section provides for the identification of signs of damage to the cerebellum on the one hand. The study is carried out with open eyes. If there is a limitation of the visual fields, the study is carried out in the area where there are no violations. Finger-nose-finger and knee-heel tests are performed on both sides. Points are awarded only when the severity of ataxia exceeds the severity of paresis. If the patient is not available for contact or is paralyzed, there is no ataxia. If the patient cannot see, a finger-nose test is performed. If it is impossible to examine the strength (the limb is missing, ankylosis in the shoulder joint, fracture), an appropriate mark is made.

There is no ataxia.

Ataxia in one limb.

Ataxia in two limbs.

impossible to explore.

Sensitivity

It is examined with the help of pricks with a pin (toothpick) and touches. In case of impaired consciousness or aphasia, grimaces, withdrawal of a limb are evaluated. Only hypoesthesia caused by a stroke (by hemitype) is evaluated, therefore, for verification, it is necessary to compare the reaction to injections in different parts of the body (forearms and shoulders, hips, torso, face). A score of 2 is given only in cases where a gross decrease in sensation in one half of the body is not in doubt, so patients with aphasia or impaired consciousness at the level of stupor will receive a 0 or 1. With bilateral hemihypesthesia caused by a stem stroke, a 2 is given. Patients in a coma automatically get 2.

Norm.

Mild or moderate hemihypesthesia; on the affected side, the patient feels the injections as less sharp or as touches.

Severe hemihypesthesia or hemianesthesia; the patient does not feel any injections or touches.

Speech

Information regarding the understanding of addressed speech has already been obtained in the course of the study of the previous sections. To study speech production, the patient is asked to describe the events in the picture, name objects and read a passage of text (see Appendix). If the study of speech is hindered by vision problems, ask the patient to name the objects placed in his hand, repeat the phrase and tell about some event from his life. If an endotracheal tube is placed, the patient should be asked to complete the tasks in writing. Patients in a coma automatically receive 3. In case of impaired consciousness, the assessment is determined by the researcher, but 3 is set only for mutism and complete disregard for simple commands.

Norm.

mild or moderate aphasia; speech is distorted or comprehension is disturbed, but the patient can express his thought and understand the researcher.

severe aphasia; only fragmentary communication is possible, understanding the patient's speech is very difficult, according to the patient, the researcher cannot understand what is shown in the pictures.

Mutism, total aphasia; the patient does not utter any sounds and does not understand the addressed speech at all.

dysarthria

You do not need to tell the patient what exactly you are going to evaluate. With normal articulation, the patient speaks clearly, he does not have difficulty pronouncing complex combinations of sounds, tongue twisters. In severe aphasia, the pronunciation of individual sounds and fragments of words is evaluated, with mutism, 2 is put. If it is impossible to examine the force (intubation, facial trauma), an appropriate mark is made.

Norm.

mild or moderate dysarthria; some sounds are "blurred", the understanding of words causes some difficulties.

Rough dysarthria; the words are so distorted that they are very difficult to understand (the reason is not aphasia), or anartria / mutism is noted.

research impossible

Hemiignorance (neglekt)

Sensory hemiignorance is understood as a violation of perception on one half of the body (usually the left) when stimuli are applied simultaneously on both sides in the absence of hemihypesthesia. Visual hemiignorance is understood as a violation of the perception of objects in the left half of the visual field in the absence of left-sided hemianopia. As a rule, the data from the previous sections is sufficient. If it is not possible to examine visual hemiignorance due to visual impairment, and the perception of pain stimuli is not impaired, the score is 0. Anosognosia indicates hemiignorance. The assessment in this section is given only in the presence of hemishoring, so the conclusion "it is impossible to investigate" does not apply to it.

Norm.

Signs of hemiignorance of one type of stimuli (visual, sensory, auditory) were revealed.

Signs of hemiignorance of more than one type of stimuli were revealed; does not recognize his hand or perceives only half of the space.

In contact with

National Institutes of Health Stroke Scale / NIH Stroke Scale

Developed by the American National Institutes of Health (National Institutes of Health Stroke Scale - NIH Stroke Scale) T. Brott et al, 1989, J. Biller et al, 1990.

It is used to objectify the state of a patient with ischemic stroke at admission, in the dynamics of the process and the outcome of a stroke by the 21st day of hospitalization.

The scale contains 15 points that characterize the main functions that are most often impaired due to cerebral stroke. Functions are evaluated in points. The scale is notable for its obvious simplicity, filling it requires no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive study of the neurological status, and allows you to record the dynamics of the patient's condition in the acute period of the disease. The internal consistency and retest reliability of the scale has been confirmed by a number of studies (Goldstein J.C. et al 1989). The absence of changes in the neurological status is provided as 0 points, the death of the patient is 31 points.

To assess the severity of neurological symptoms during an acute ischemic period, the NIHSS scale is used. Thanks to the test, doctors are able to adequately assess the condition of an admitted person, which is necessary to provide competent first aid and determine the course of treatment.

What is this scale?

The international NIHSS scale was presented by the American National Institutes of Health (National Institutes of Health Stroke Scale). It is used to objectively assess the condition of a patient admitted to a hospital with an ischemic stroke. The test is carried out in the dynamics of the process and after 21 days of hospitalization.

The scale consists of 15 consecutive tests, each of which is scored from 0 to 4. Each study allows you to assess the state of the main functions that most often suffer from cerebral stroke. The test is simple, so it will take no more than 5-10 minutes to complete it.

The test results help the doctor assess the patient's neurological status and determine the dynamics of his general condition in the acute phase of the disease.

Scale tests

As mentioned earlier, there are only 15 of them. We will consider each study further.

wakefulness level

The more cheerfully a person reacts, the lower the score is given to him. The maximum score is possible only in the case of coma or the complete absence of reactions and reflexes. So, the score depends on the reaction of the person:

• 0 - is awake and shows an active reaction;
• 1 - reacts slightly inhibited or feels drowsy, but fully responds to even minor stimuli;
• 2 - is in an unconscious state or a more aggressive impact is required for him to show a reaction;
• 3 - completely ignores external stimuli (may be associated with coma).

Ability to answer questions

The doctor asks the patient to clarify his age and the current month of the year. The score depends on the completeness and clarity of the answers:

• 0 - gave correct answers to 2 questions;
• 1 - answered correctly once;
• 2 - did not answer both questions.

It should be borne in mind that the patient must give accurate answers in numbers. The doctor records only the first uttered answer.

Command execution

The doctor invites the patient to perform a series of actions - close and open his eyes, put his fingers into a fist and unclench. If the patient cannot execute any command for one reason or another, for example, due to disability, another command must be given. If the patient does not respond to speech, you can show by example what is required of him. The first attempt to run the command is evaluated:

• 0 - both actions were completed successfully;
• 1 - only 1 action was performed;
• 2 - both actions are partially completed or not performed at all.

Eyeball response

You need to ask the patient to follow the movements of the finger with their eyes:

• 0 - normal reaction;
• 1 - partial paralysis of the eyeballs, but their fixed deviation is absent;
• 2 - complete paralysis with a fixed deviation of the eyeballs.

line of sight

The test is carried out using confrontation and counting the number of fingers, both from the periphery and from the center of the eyes:

• 0 - no violations recorded;
• 1 - there is asymmetry or partial 2-sided blindness in half of the field of view;
• 2 - complete.

facial muscles

It is determined how the facial nerve "works":

• 0 - no violations were recorded;
• 1 - there is a slight facial asymmetry;
• 2 - facial muscles are moderately paralyzed;
• 3 - facial muscles are completely paralyzed.

hand strength

It is important to note that this test is carried out for each hand separately, so two marks are given. As part of this task, the doctor asks the patient to open his arm, and then bend it at an angle of 90 (sitting) or 45 (lying) degrees. In this case, the palm must be turned down. The patient must withstand in this position for 10 seconds, after which a score is given:

• 0 - managed to keep the bent arm for all 10 seconds;
• 1 - the hand is initially held at a given angle, but gradually lowers;
• 2 - it is impossible to conduct a study, because the limb is missing or there is a fracture of the joint;
• 3 - the arm falls immediately, as it was bent, and it is not possible to overcome gravity;
• 4 - it is not possible to bend the arm at the right degree at all.

leg strength

Similar to the previous test, this study is carried out for each leg separately. The patient must be in a supine position. The doctor asked him to raise his leg at an angle of 30 degrees and fix the position for 5 seconds. Then the score is given:

• 0 - the leg was at the right angle for all 5 seconds;
• 1 - gradually descended;
• 2 - descended faster, lingering at a given angle for an extremely short time;
• 3 - fell immediately, because the patient is not able to overcome gravity;
• 4 - did not manage to take the desired position at all.

Limb ataxia

This test is done to determine if there is a motor coordination disorder on one side. If the visual field is disturbed, the study is carried out on the side where there is no lesion. The doctor also conducts a knee-calcaneal and finger-nose-heel test. One of the following ratings is given:

• 0 - no violations were detected;
• 1 - there is ataxia in either the upper or lower extremities;
• 2 - ataxia of all limbs is observed.

Sensitivity level

To determine the level of sensitivity of the patient, the doctor uses touch and light piercing with a needle or pin. The score depends on the patient's response:

• 0 - feels all touches and piercings;
• 1 - weakly feels all the manipulations of the doctor;
• 2 - sensitivity is extremely low.

Speech

The specialist conducts a study to evaluate the patient. To do this, he is invited to describe the picture or read some text. If this is not possible, for example, due to vision problems, you can offer him to describe the object, having previously felt it with his hands.

The following ratings can be given:

• 0 - the task was completed correctly, that is, speech is normal;
• 1 - there is a partial violation of the speech apparatus;
• 3 - complete failure to complete the task or even the patient's coma.

dysarthria

The doctor determines whether the patient's pronunciation is impaired as a result of a violation of the innervation of the speech apparatus due to damage to the nervous system (dysarthria). During this test, the doctor does not voice the area of ​​study, but simply conducts a dialogue with the patient. The following scores are given:

• 0 - the patient shows articulation within the norm and clearly answers questions;
• 1 - mild or moderate dysarthria is noted, that is, the patient slurs some words;
• 3 - complete dysarthria is noted, when the patient incomprehensibly pronounces all the words or is completely in a coma.

Neglect (ignore)

Right-hemispheric brain damage is often accompanied by neglekt - ignoring the person of the body, the affected limb or space. So, the test involves assessing the perception of half of the body (usually the left side). For this, touching, piercing with a needle or pin, etc. are also used. The following assessments are possible:

• 0 - the body responds adequately to stimuli, without showing signs of neglect;
• 1 - partial visual, auditory or tactful ignoring is noted;
• 2 - gross deviations from the norm are recorded;
• 3 - there is a complete lack of response to stimuli.

The patient cannot be pre-prepared for a specific task unless the test itself requires it.

Research results

The prognosis of a stroke is determined depending on the total score on the scale:

• 0 - there are no disorders in the neurological status;
• up to 10 - a good prognosis for recovery is given (observed in 60-70% of cases);
• more than 20 - a poor prognosis is given, since successful recovery is observed only in 4-16% of cases;
• 31 - the maximum increase in the risk of death.

According to the final assessment, the course of treatment is also adjusted. So, if there is a slight neurological deficit (overall score - above 3-5), then it is prescribed to prevent the development of the patient's disability. If there is a severe neurological deficit (overall score - 25), then thrombolysis is not prescribed, since it is no longer able to significantly affect the outcome of the disease and stop the development.

So, the scale under consideration consists of 15 tasks. For each of them, the doctor sets certain points, and testing is carried out sequentially, that is, you cannot change the established order of tasks or return to unfulfilled tests. After all the studies, the results are summed up, and the specialist gives a prognosis for the disease.