Assessment and Diagnosis of Stroke
There are certain assessment scales which are used for quick identification and diagnosis of Stroke in clinical practice. There are also scales which are used to predict the functional out in stroke and are therefore important while doing the physiotherapy and predicting the functional out come in physiotherapy or rehabilitation setting at any stage during the over all management of stroke population of patients. How do you find these scales affective in your own clinical practice while managing and predicting the functional out come in stroke patient. The detail of these scales is:
CINCINNATI PREHOSPITAL STROKE SCALE
Facial Droop
Normal: Both sides of face move equally
Abnormal: One side of face does not move at all
Arm Drift
Normal: Both arms move equally or not at all
Abnormal: One arm drifts compared to the other
Speech
Normal: Patient uses correct words with no slurring
Abnormal: Slurred or inappropriate words or mute
LOS ANGELES PREHOSPITAL STROKE SCREEN (LAPSS)
Screening Criteria Yes No
4. Age over 45 years ____ ____
5. No prior history of seizure disorder ____ ____
6. New onset of neurologic symptoms in last 24 hours ____ ____
7. Patient was ambulatory at baseline (prior to event) ____ ____
8. Blood glucose between 60 and 400 ____ ____
Normal Right Left
Facial smile/grimace Droop Droop
Grip Weak Grip Weak Grip
No Grip No Grip
Arm weakness Drifts Down Drifts Down
Falls Rapidly Falls Rapidly
Based on exam, patient has only unilateral (and not bilateral) weakness: Yes No
10. If Yes (or unknown) to all items above LAPSS screening criteria met: Yes No
11. If LAPSS criteria for stroke met, call receiving hospital with “CODE STROKE”, if not then return to the appropriate treatment protocol. (Note: the patient may still be experiencing a stroke if even if LAPSS criteria are not met.
There are scales for functional assessment of stroke among which the The National Institutes of Health Stroke Scale (NIHSS) is the most reliable clinically used tool for assessment of fuctional outcome in stroke.
NIH(National Intitutes of Health) Stroke Scale
Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ________________________________(___ ___)
Time: ___ ___:___ ___ [ ] am [ ] pm
Person Administering Scale _____________________________________
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).
Instructions
1a. Level of Consciousness: 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 flexic.
Score: _______
Instructions
1b. 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: _____
Instructions
1c. LOC Commands: The patient is asked to open and close the eyes and then to grip and release the non-paretic 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: ________
Instructions
2. Best Gaze: 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 not overcome by the oculocephalic maneuver.
Score: _______
Instructions
3. Visual: 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: ****______
Instructions
4. Facial Palsy: 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: ______
Instructions
5. Motor Arm: 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: _____________________
5a. Left Arm
5b. Right Arm
Score: _______
Instructions
6. Motor Leg: 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 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: ________________
6a. Left Leg
6b. Right Leg
Score: ________
Instructions
7. Limb Ataxia: 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: _______
Instructions
8. Sensory: 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 to total sensory loss; patient is not aware of being touched in the face, arm, and leg.
Score: ________
Instructions
9. Best Language: 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, to name the items on the attached naming sheet and to read from the attached list of sentences. 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: ________
Instructions
10. Dysarthria: 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. 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 an 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: ____________
Instructions
11. 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: _______
The NIHSS score strongly predicts the likelihood of a patient’s recovery after stroke. A score of greater than 16 forecasts a high probability of death or severe disability, whereas a score of less than 6 forecasts a good recovery.28Patients with a severe neurological deficit after stroke, as measured by the NIHSS, have a poor prognosis. During the first week after acute ischemic stroke, it is possible to identify a subset of patients who are highly likely to have a poor outcome.
The National Institutes of Health Stroke Scale (NIHSS) is a standardized, validated instrument that assesses severity of neurological impairment after stroke. It is designed so that virtually any stroke will register some abnormality on the scale. The scale has an administration time of 5 to 10 minutes. The NIHSS score is based solely on examination and requires no historical information or contributions from surrogates. It can be administered at any stage by any trained clinician. The original 11 items of the NIHSS do not test distal upper extremity weakness, which is more common in stroke patients than proximal arm weakness. An additional item examining finger extension is often added to the NIHSS. Although not contributing to the total NIHSS score, this item should be recorded as part of the NIHSS assessment.
Recommendations
1. Strongly recommend that the patient be assessed for stroke severity using the NIHSS at the time of presentation/ hospital admission, or at least within the first 24 hours after presentation.
2. Strongly recommend that all professionals involved in any aspect of the stroke care be trained and certified to assess stroke severity using the NIHSS.
3. Recommend that patients be reassessed using the NIHSS at the time of acute care discharge.
4. Recommend that if the patient is transferred to rehabilitation or physiotherapy and there are no NIHSS scores in the record, the rehabilitation team should complete an NIHSS assessment.
The NIHSS is used to guide decisions concerning acute stroke therapy. Initial scores have been used to stratify patients according to severity and likely outcome. A second assessment serves as a recheck of the initial measurement and may be more accurate, because the patient will have been stabilized and may be better able to cooperate with the examiner, thus improving the accuracy of scoring. Because the severity of stroke as assessed using the NIHSS may influence decisions concerning the acute treatment of stroke patients (such as the use of thrombolytic therapy), application of this scale in clinical settings is becoming more common.
The NIHSS score strongly predicts the likelihood of the patient’s recovery after stroke. A score of greater than 16 forecasts a high probability of death or severe disability, whereas a score of less than 6 forecasts a good recovery. Patients with a severe neurological deficit after stroke, as measured using the NIHSS, have a poor prognosis. During the first week after acute ischemic stroke, it is possible to identify a subset of patients who are highly likely to have a poor outcome. Potential examiners become certified.
