nih-stroke-scale英文版NIHSS评分

NIHStrokeScaleIntroduction•TheNIHSSisa15itemneurologicexaminationthatprovidesaquantitativemeasureofstroke-relatedneurologicdeficit.(Maximumscoreof42)•Thestrokescaleisvalidforpredictinglesionsizeandcanserveasameasureofstrokeseverity.•Originallydevelopedasaresearchtooltomeasurebaselinedatainpatientsinacutestrokeclinicaltrials.Now,itisusedasaclinicalassessmenttooltoevaluatetheacuityofstrokepatients,determineappropriatetreatment,andpredictpatientoutcome.Introduction•Toensurereliabilityandreproducibilityofresults,examiner-patientinteractionsshouldbeasuniformaspossible.•Administerthestrokescaleintheexactorder.•Avoidcoachingthepatient.•Acceptthepatient’sfirsteffort.•ScoreonlywhatthepatientDOES,notwhatyouthinktheycando.•Includealldeficitsinscoring,eventhosefrompriorstrokes.1a–Levelofconsciousness•Canassessthiswhiletakingthehistoryfromthepatient•Ask2-3questionsaboutthesituation•Ifnotalert,trytogetthepatienttoattend,obey,orrespondwithnon-noxiousstimuli.(E.g.patting,tappingthepatient)•Ifnon-noxiousstimulidoesn’twork,resorttonoxiousstimuli.(E.g.Nailbedpinching,sternalrub)1a–LevelofConsciousness•0–Alert•1–Notalert,butarousablebyminorstimulationtoobey,answer,orrespond.•2–Notalert,requiresrepeatedstimulationtoattend.Or,obtundedandrequiresstrong,painful,ornoxiousstimulitomakemovements.•3–Makesonlyreflexiveposturingmovementstorepeatedpainfulstimuli.Or,theyaretotallyunresponsive.Thesepatientsareinacoma.•Inpatientsinacomawhoscorelessthan3,allitemsintheNIHSSmustbeattempted.However,mostlikelywillhavetofallbackonthepredefinedvaluesforcomapatients.1b–LOCQuestions•Askthecurrentmonthandthepatient’sage.•Becausethisisastandardizedtestandinordertoensurereproducibilityofresults,otherquestionsarenotasked.•Youcanhavepatientswhoarenotspeakingtrytowritedowntheiranswers.1b–LOCQuestions•0–Answeredbothquestionscorrectly•1–Answeredonecorrectly•Peopleunabletocommunicatebecauseofintubation,orotrachealtrauma,severedysarthriafromanycause,languagebarrier,oranyotherproblemnotsecondarytoaphasia•2–Answeredneitherquestioncorrectly•Comatosepatients•Aphasicandstuporouspatientswhodon’tcomprehendthequestions1c–LOCCommands•Askthepatienttoopen/closetheeyesandmakeafist/relaxthenon-paretichand.•Cansaythecommandverballyandpantomimethecommand.•Youcanrepeatthecommandonce,butdonotcoachorencouragethepatient.•Givecreditifarealattemptismadetofollowthecommand,butcannotbecompletedduetoweakness.•Ifdealingwithapatientwithtrauma,amputation,orotherphysicalimpediments,substituteother1stepcommands.1c–LOCCommands•0–Performedbothcorrectly•1–Performedonecorrectly•2–Performedneithercorrectly2–BestGaze•Teststhehorizontaleyemovements•DoesNOTmeasuredisordersofverticalgaze,nystagmus,orskeweddeviation•Observetheeyesatrest.Watchforanyspontaneousmovementstotherightorleft.•Next,havethepatienttrackyourfinger.•Ifhewon’ttrackyourfinger,trytohavehimtrackyourface.Establisheyecontactandmovefromonesideofthepatienttotheother.•Ifhestillwon’ttrack,performtheoculocephalicmaneuver.•Comatosepatients•Patientswithoculartrauma,bandages,pre-existingblindness,orotherdisordersofvisualacuity/fields2-BestGaze•0–Normal•Patientswithstrabismuswholeavethemidlineandtrytolookrightandleft•1–Partialgazepalsy-Conjugategazedeviationthatcanbeovercomewithvoluntaryorreflexiveactivity•Isolatedcranialnerve(IIIorVI)palsy•2-Forceddeviation–Cannotbeovercomebyoculocephalic3–Visual•Teststhevisualfieldsofbotheyes•Testeacheyeindependently.Makesurethepatientislookingdirectlyatyoureyes.•Eachquadrantistestedbyconfrontation•Cancheckfingercountingorresponsetomovementorthreat•Doublesimultaneousvisualstimulationisperformedatthispoint.ResultsareusedtoanswerItem11.•Ifpatientsareunabletorespondverbally,checkforanyresponsetostimuliinall4quadrants.•Ifthereisunilateralblindnessorenucleation,visualfieldsaretestedintheothereye.3-Visual•0–Novisualloss•Patientswithmonocularvisionlossfromintrinsiceyedisease,butintactfieldsintheothereye•1–PartialHemianopia•Patientswhoextinguishondoublesimultaneousvisualstimulation•2-CompleteHemianopia•3–BilateralHemianopia•Blindnessfromanycause4–FacialPalsy•Verballyaskandpantomimetothepatienttoshowteeth,closetheeyes,andraisetheeyebrows.•Fortheaphasic,poorlyresponsivepatient,usenoxiousstimuliandevaluateforsymmetryofthegrimace.•Inthecaseoffacialtrauma,removebandages,tape,orotherphysicalbarriersthatmightobscuretheface.•Tips:Askyourselfifthepatientisclearlynormal.Ifyes,scoreazero.Ifno,askyourselfifthepatienthasdefiniteclearcutasymmetryofthesmile.Ifyes,scorea2.4–FacialPalsy•0–Normal•1–MinorparalysissuchasflattenednasolabialfoldorMILDasymmetrywhilesmiling•PatientswhoarelessthanCLEARLYnormal•2–Partialparalysis(totalorneartotalparalysisoflowerface)–indicatesuppermotorneuronfacialweakness•3-Completeparalysisofupperandlowerface•Comatosepatients•Patientswithunilateralupperandlowerfacialweaknesshavelowermotorneuronfacialweakness5–MotorArm•Extendthearmat90degreesifpatientissitting,45degreesifpatientislyingdown.(Palmisdown.)•Scorefordriftifthearmfallsbefore10secondswhileyoucountoutloud.Also,countdownwithyourfingersinfullviewoft