NIHSS TRAINING

1A. Level of 0 = Alert

Consciousness 1 = not alert, minor verbal stimulation
o Ask Q 2 = not alert, painful/strong/repeated
stimulation Max = 3
3 = comatose/not arousable

1B. LOC Questions 0 = Both questions

o Age 1 = one question correct (or
o Month/year intubated, tracheal trauma, language
barrier, severe dysarthria, most other
*If first answer wrong problems not due to aphasia)
then corrects = score 2 = none correct (or if coma on 1A)
as incorrect Max = 2

*If give birth date

instead of age =
incorrect

1C. LOC 0 = both correct

commands/tasks 1 = one correct
o Close eyes, 2 = none correct
now open
o Make a fist with
your hand – tell
them what hand
to use (and
mime actions Max = 2
aka show them
a fist)

*Repeat only once if

needed
*if does not speak
English, let fam/friend
translate
*if real attempt is made
but limited by
weakness, can give
them credit
2. Best Gaze 0 = Normal (or if attempts to look
(Horizontal eye both ways over midline, but has
movements) strabismus or something)
o Follow finger 1 = partial gaze palsy (or if not
following directions but can overcome Max = 2
*If not following by moving the head)
commands, move my 2 = forced gaze deviation (not
face while keeping eye overcome by occulocephalics/gaze
contact to see if deviation is not overcome by moving
tracking or do the head)
occulocephalic
*If comatose so cannot
follow finger but can be **basically, if normal give 0 but
overcome by moving otherwise, consider 1-2. If eyes
the head = score of 1 deviated such that they cannot be
moved at all give 2
3. Visual (one of these) 0 = normal upper + lower VF
o Visual threat 1 = Partial
o Finger hemianopia/quadrantanopia OR
movement on extinction (regardless of VF testing)
one or both 2 = Complete hemianopia (both eyes
sides – cover when covered, do not see entire half
each eye of VF)
separately and 3 = Bilateral hemianopia (blind Max = 3
ask to point to including cortical blindness)
side that’s
wiggling
o Finger counting
in all 4 quads -
cover each eye
separately &
ask pt to look at
you

*if cannot respond, let

pt show # of fingers
seen or let them look
to the side of the
moving finger
*if coma (1A score was
3), test by doing
bilateral threat
*if pt w/ monocular
vision loss, but other
eye is totally normal,
score 0
4. Facial palsy 0 = normal
o Ask patient to 1 = minor paralysis/mild asymmetry
smile/show (just nasolabial flattening)
teeth OR raise 2 = partial paralysis of lower face
eyebrows and (clear cut palsy aka UMN lesion)
close eyes 3 = complete paralysis of upper &
o If coma/not lower face (LMN lesion) Max = 3
responsive, use
noxious
stimulus and
score grimace

*if facial trauma,

remove bandaids or
whatever that is
covering face

5A. Motor Arm (Left) 0 = no drift

o Palms down 1 = jerks or drifts down before 10 sec
o Sitting = 90 (but can still kinda hold it up &
degrees doesn’t hit bed)
o Lying down = 2 = some effort against gravity, but Max = 4
45 degrees cannot get to or maintain position 
o If has an initial drifts down to support in 5/10
dip when you seconds
release the 3 = no effort against gravity, drops
limb, its ok  but can do small proximal movement
does not count (shrug or hip flexion) while its resting
as drift; drift is if on bed/body
it goes down 4 = no movement, just drops
after this dip
o Drift = fall
before 10 sec
o Count out loud
& with fingers in
front of pt
o Start w/ normal
limb
o Do only 1 limb
at a time

*If limited by RA or
something non-stroke
related, STILL NEED
TO GIVE SCORE!
*don’t need to score
amputated limb **just
note it

*if on 1A, scored a 3

(comatose), should
give them a 4 on this

5B. Motor Arm (Right) 0 = no drift

1 = jerks or drifts down before 10 sec
(but can still kinda hold it up &
doesn’t hit bed) Max = 4
2 = some effort against gravity, but
cannot get to or maintain position 
drifts down to support
3 = no effort against gravity, drops
but can do small proximal movement
(shrug or hip flexion) while its resting
on bed/body
4 = no movement, just drops

6A. Motor Leg (Left) 0 = no drift

o Drift = before 5 1 = jerks or drifts down before 10 sec
sec (but can still kinda hold it up & Max = 4
doesn’t hit bed)
2 = some effort against gravity, but
cannot get to or maintain position 
drifts down to support
3 = no effort against gravity, falls to
support immediately but can do small
proximal movement (shrug or hip
flexion) while its resting on bed/body
4 = no movement, just drops
6B. Motor leg (Right) 0 = no drift
1 = jerks or drifts down before 10 sec
(but can still kinda hold it up &
doesn’t hit bed)
2 = some effort against gravity, but Max = 4
cannot get to or maintain position 
drifts down to support
3 = no effort against gravity, drops
but can do small proximal movement
(shrug or hip flexion) while its resting
on bed/body
4 = no movement, just drops
7. Limb Ataxia 0 = normal (or if significant weakness
o FNF + HS or paralysis)
1 = in 1 limb
*if weakness or 2 = in 2 limbs (both legs, both arms
paralysis, GIVEN 0 BC or leg + arm on same side)
IT DOES NOT COUNT MAX = 2
AS ATAXIA

*if amputation, don’t

need to score it, just
make note

8. Sensory 0 = normal
o Pin prick w/
safety pin 1 = feels it but its decreased
o Ask which is
sharper or if 2 = does not feel it at all/unaware MAX = 2
same
o All 4
PROXIMAL
limbs &
compare two
sides
o Face, trunk, leg
& arm (No feet
or hands)
o Don’t need to
close eyes
o OR noxious
stimulus (look
for grimace)

*DO NOT test hands

or feet (may be
confounded by
peripheral neuropathy)

**ONLY scored if due

to stroke  do not
score neuropathies

*If 1A score was 3 aka

coma, automatically
gets 2 here
9. Best Language (all 0 = no aphasia
3)
o Describe picture 1 = mild-moderate  obvious loss of
o Read sentences fluency or comprehension or reduced
o Name items speech which makes conversation MAX = 3
difficult  but NO significant
limitation of ideas expressed or form
**if pt in stupor, must of expressing (you can still figure out
give them a 3 what theyre naming/identifying in pic,
they cant pronounce everything
*if intubated, ask to correctly)
write answers
2= severe  all communication is
*if blind, ask to identify fragmented  you cant figure out
objects in hand what theyre talking about when
naming card content
*if 1A was score of 3
aka coma, give them a 3 = intubated or mute (for whatever
3 here reason), global aphasia, or if
stuporous

10. Dysarthria 0 = normal

(articulation & clarity of
speech) 1 = mild-mod slurring  some words MAX = 2
o Repeat (or sound weird/slurred but can
read) words on understand them
card
o MAMA, Tip top, 2 = severe slurring or mute or if coma
50-50, thanks,
huckleberry,
baseball player

*don’t test if intubated

or other barriers to
make speech, just
document it

*if unable to read or

aphasic, have pt
repeat the words

*if difficult to
understand due to
non-neuro issues (like
dental), still give a 1
11. Neglect (Extinction 0 = normal
& Inattention) MAX = 2
o May already 1 = neglect of ONE stimulus (visual,
know this auditory, tactile, spatial, personal); or
already if pt does not show extinction but
o Otherwise, obvious neglect is seen, give 1
simultaneous
stimulation 2 = neglect of multiple stimuli OR if
o Close eyes, neglect of one side to both visual and
touch one side tactile stimuli (profound hemi-
then other side, inattention)
then both
o If neglect, will
only identify one
side even when
touching both
(cortical issue)
o Cutaneous
stimuli (Face,
arms, legs) &
visual stimuli
(wiggling
fingers)

*if pt is blind & other

stimuli are normal, give
them 0

*if 1A score was 3,

given an automatic 2
here
1A. Level of consciousness (3)

1B. LOC Questions (2)

1C. LOC Commands (2)

2. Best Gaze (2)

3. Visual (3)

4. Facial palsy (3)

5A. Motor Arm – left (4)

5B. Motor Arm – right (4)

6A. Motor Leg – left (4)

6B. Motor Leg – right (4)

7. Limb Ataxia (2)

8. Sensory (2)

9. Best language (3)

10. Dysarthria (2)

11. Extinction (2)