use of the nih stroke scale (nihss) in emergency department patients with acute stroke edward sloan,...

7/25/2019 Use of the NIH Stroke Scale (NIHSS) in Emergency Department Patients with Acute Stroke Edward Sloan, MD, MPH Associate

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Edward Sloan, MD, MPH

Use of the NIH Stroke Scale (NIHSS)Use of the NIH Stroke Scale (NIHSS)

in Emergency Deartment Patients witin Emergency Deartment Patients wit

!c"te Stroke!c"te StrokeEdward Sloan, MD, MPHEdward Sloan, MD, MPH

!ssociate Professor!ssociate Professor

Deartment of Emergency MedicineDeartment of Emergency MedicineUni#ersity of Illinois $ollege of MedicineUni#ersity of Illinois $ollege of Medicine

$hicago, I%$hicago, I%
http://www.ferne.org/


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&lo'al 'ecti#es&lo'al 'ecti#es

Imro#e t o"tcome in stroke

*now how to "se the NIHSS to g"ide +

Pro#ide rationale ED "se of tP! Maimi-e o"tcome

Minimi-e mor'idity associated with tP!


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Session 'ecti#esSession 'ecti#es

Eamine the NIHSS

Simlify its calc"lation

!sk clinically rele#ant ."estions !ddress imortant iss"es in literat"re

$onsider ractical "se in the ED


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/hy Do 0his Eercise1/hy Do 0his Eercise1

0he NIHSS is the ind"stry standard

It is not "st a research tool

It allows "s to ."antify o"r clinical eam It ro#ides for standardi-ation

It manages risk effecti#ely


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Ne"rologic Eam2 NIH Stroke ScaleNe"rologic Eam2 NIH Stroke Scale

34 item scoring system, 5 min"te eam

Integrates ne"rologic eam comonents

$N (#is"al), motor, sensory, cere'ellar,

inattention, lang"age, %$ Maim"m score is 67, signifying se#ere stroke

Minim"m score is 8, a normal eam

Scores greater than 39:78 are more se#ere


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NIH Stroke Scale2 Imortant ;"estionsNIH Stroke Scale2 Imortant ;"estions

/hich elements are consistently collected1

/hich correlate with o"tcome1

/hich imro#e with tP!1 /hich s"ggest a comlicated tP! co"rse1

/hich arts o#erla with one another1

Does the side of the stroke matter1


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NIH Stroke Scale2 Practical S"ggestionNIH Stroke Scale2 Practical S"ggestion

*now the general categories of the NIHSS

%et these 5 areas g"ide yo"r eam

*now how to score an aroimate NIHSS

&o to the we' to score yo"r eam f"lly


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NIH Stroke Scale2 Internet $alc"latorNIH Stroke Scale2 Internet $alc"lator

!llows calc"lation on:line

/ill add #al"es, ro#ide total

htt2


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0he NIHSS is theind"stry standard

It is not "st a researchtool

It allows "s to ."antify

o"r clinical eam It ro#ides for

standardi-ation

It manages riskeffecti#ely


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0he NIHSS is theind"stry standard

It is not "st a researchtool

It allows "s to ."antify

o"r clinical eam It ro#ides for

standardi-ation

It manages riskeffecti#ely


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NIHSS Elements2 %$NIHSS Elements2 %$

%$ o#erall 8:4 ts

%$ ."estions8:7 ts

%$ commands 8:7 ts

%$2 5

oints total


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NIHSS Elements2 %$NIHSS Elements2 %$

%$ o#erall 8:4 ts

%$ ."estions 8:7 ts

%$ commands 8:7 ts

%$2 5 oints total


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NIHSS Elements2 $ranial Ner#esNIHSS Elements2 $ranial Ner#es

&a-e alsy 8:7 ts

>is"al field deficit 8:4 ts

?acial motor 8:4 ts

$ranial ner#es2 @ oints total


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NIHSS Elements2 MotorNIHSS Elements2 Motor

Each arm 8:6 ts

Each leg 8:6 ts

Motor2 3A oints total

@ oints right @ oints left


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NIHSS Elements2 $ere'ellarNIHSS Elements2 $ere'ellar

%im' ataia 8:7 ts

$ere'ellar2 7 oints total


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NIHSS Elements2 SensoryNIHSS Elements2 Sensory

Pain, noio"s stim"li 8:7 ts

Sensory2 7 oints total


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NIHSS Elements2 %ang"ageNIHSS Elements2 %ang"age

!hasia 8:4 ts

Dysarthria 8:7 ts

%ang"age2 9 oints total


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NIHSS Elements2 InattentionNIHSS Elements2 Inattention

Inattention 8:7 ts

Inattention2 7 oints total


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NIHSS Elements2 $omositeNIHSS Elements2 $omosite

$N (#is"al)2 @

Unilateral motor2 @

%$2 5 %ang"age2 9

!taia2 7

Sensory2 7 Inattention2 7


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NIHSS2 *ey ElementsNIHSS2 *ey Elements

$N (#is"al)2 ?acial alsy, ga-ealsy, #is"al fielddeficit

Unilateral motor2 Hemiaresis %$2 Deressed %$, oor

resonsi#eness

%ang"age2 !hasia, dysarthria 7@ total oints


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NIHSS $r"de EstimateNIHSS $r"de Estimate

$N (#is"al)2 @

Unilateral motor2 @

%$2 @ %ang"age2 @

Mild 7, Moderate 6, Se#ere, @ Incororates other elements


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NIHSS $r"de Estimate2 EamleNIHSS $r"de Estimate2 Eamle

$N (#is"al)2 some alsy 6

Unilateral motor2 hemiaresis @

%$2 mild decreased %$ 7

%ang"age2 some seech 6

3@ oints total

More se#ere decrease in %$2 ca"tionB


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NIHSS ;"estion2 PredictionNIHSS ;"estion2 Prediction

Does the 'aseline NIHSS redicto"tcome1

Ces=

Adams HP Neurology 1999;53:126131

aseline NIH Stroke Scale score stronglyredicts o"tcome after stroke (0!S0)
http://www.ferne.org/http://www.ferne.org/


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NIHSS $r"de EstimateNIHSS $r"de Estimate $N (#is"al)2 @

Unilateral motor2 @

%$2 @

%ang"age2 @

Mild 7, Moderate 6, Se#ere, @

Incororates other elements


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$N (#is"al)2 @ Unilateral motor2 @ %$2

@ %ang"age2

@

Mild 7, Moderate 6,Se#ere, @

Incororates other

elements


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$N (#is"al)2 @ Unilateral motor2 @ %$2

@ %ang"age2

@

Mild 7, Moderate 6,Se#ere, @

Incororates other

elements


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NIHSS and "tcome PredictionNIHSS and "tcome Prediction

NIHSS 'elow 37:36 will ha#e an @8 good orecellent o"tcome=

NIHSS a'o#e 78:7A will ha#e less than a 78

good or ecellent o"tcome= %ac"nar infarct atients had the 'est

o"tcomes=

Adams HP Neurology 1999;53:126131 aseline NIH Stroke Scale score strongly redicts o"tcome after stroke

(0!S0)


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NIHSS ;"estion2 NINDS 0rial DataNIHSS ;"estion2 NINDS 0rial Data

Did the NINDS trial show 'enefit across all'aseline NIHSS strata1 ased on strokes"'tye1

No and yes=

N!NDS r"PA S"ro#e S"udy $rou%,

NE&M1995;333:15'1() 0iss"e lasminogen !cti#ator for !c"te

Ischemic Stroke


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NIHSS and 0he NINDS 0rialNIHSS and 0he NINDS 0rial

+egardless of stroke s"'tye (small:#esseloccl"si#e, large:#essel occl"si#e orcardioem'olic), there was 'enefit with tP!=

0here was no data that showed how 'enefitwas related to 'aseline NIHSS=

nly median NIHSS data was ro#ided, and noother s"'gro" analysis was erformed=

N!NDS r"PA S"ro#e S"udy $rou%, NE&M1995;333:15'1() 0iss"e lasminogen !cti#ator for !c"te Ischemic Stroke


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NIHSS ;"estion2 NINDS Place'o Pts1NIHSS ;"estion2 NINDS Place'o Pts1

Did factors redict oor o"tcome of the

lace'o ts in the NINDS clinical trial1

Sho"ld these ts still 'e treated with tP!1

Ces and ro'a'ly=

*ran#el M+, Neurology 2;55:952959)

Predicting rognosis after stroke2 Place'o gro" in the NINDS Stroke 0ria


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"tcome of the NINDS Place'o Pts"tcome of the NINDS Place'o Pts

FA PP>2 ts with an NIHSS G 35 and afi'

will ha#e a oor o"tcome=

Same oor o"tcome with NIHSS G 35 and

imaired conscio"sness=

0here was imro#ement with tP! "se=

*ran#el M+, Neurology 2;55:952959)

Predicting rognosis after stroke2 Place'o gro" in the NINDS Stroke 0ria


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NIHSS ;"estion2 ther Stroke ScalesNIHSS ;"estion2 ther Stroke Scales

Do other stroke scales eist that areeasier to "se1 !re they #alid1 $an they'e "sed1

Ces, yes, and no=

-o"e +, Neurology19'9;39:63'6.3) 0he $anadian Ne"rologic Scale

%yden PD, Stroke 7883473438:3435=

! Modified NIHSS for Use in Stroke $linical 0rials


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NIHSS and ther Stroke ScalesNIHSS and ther Stroke Scales

ther scales do eist that may makecalc"lating stroke se#erity easier=

0hese other scales ha#e 'een #alidated= 0he NINDS and other stroke trials ha#e not

indicated what the stroke se#erity was "singthese other scoring systems, s"ch that wecannot infer this info and incororate it intoclinical ractice=

-o"e +, Neurology19'9;39:63'6.3) 0he $anadian Ne"rologic Scale /yden PD, S"ro#e 21;32;131131()


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NIHSS ;"estion2 +etrosecti#e Use1NIHSS ;"estion2 +etrosecti#e Use1

$an these scales 'e determined

retrosecti#ely1

Ces=

$olds"e0n /, S"ro#e 199(;2':11'111'.)

+etrosecti#e !ssessment with the $anadian Ne"rologic Scale 0ll0ams /S, S"ro#e 2;31:'5''62

+etrosecti#e !ssessment with the NIHSS


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+etrosecti#e Se#erity Scale Use+etrosecti#e Se#erity Scale Use

0hese scales can 'e determined inretrosect if ade."ate doc"mentation ofthe ne"rologic eam is in the ED record=

Imlications for $;I and indi#id"al casesin which tP! "se is considered=

$olds"e0n /, S"ro#e 199(;2':11'111'.)

+etrosecti#e !ssessment with the $anadian Ne"rologic Scale

0ll0ams /S, S"ro#e 2;31:'5''62

+etrosecti#e !ssessment with the NIHSS


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NIHSS2 Does $>! Side Imact +1NIHSS2 Does $>! Side Imact +1

Does it matter whether or not the stroke

findings are on the right side or left side

of the 'ody1

Ces=

oo D, S"ro#e1999;3:23552359)

Does the NIHSS ?a#or %eft Hemisheric Strokes1


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$>! Symtom Side and +$>! Symtom Side and +

+ sided stroke, % sided symtoms

+ sided stroke, non:dominant

+ sided stroke, inattention, 7 oints

% sided stroke, + sided symtoms

% sided stroke, dominant % sided stroke, lang"age, 9 oints


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$>! Symtom Side and +$>! Symtom Side and +

! + sided stroke has a stroke the same si-e as a %sided stroke with an NIHSS that is 9 oints higher=

Perhas we sho"ld treat + sided strokes (% sided

aralysis) that ha#e lower NIHSS=

Perhas we sho"ld treat higher % sided strokes (+sided aralysis) that ha#e a higher NIHSS=

In 'oth cases, the motor score is often the same=

oo D, S"ro#e1999;3:23552359)

Does the NIHSS ?a#or %eft Hemisheric Strokes1


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NIHSS2 !nt #s= Post $irc"lation1NIHSS2 !nt #s= Post $irc"lation1

Sho"ld tP! 'e administered regardless of

the tye of stroke noted1

Ces=

Personal comm"nication, %ewandowski, 7883=


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tP! in Posterior $irc"lation StrokestP! in Posterior $irc"lation Strokes

U to 38:39 of ts in the NINDS stroke

trial were osterior circ"lation strokes=

0hese ts were randomi-ed to recei#e

tP! as were other stroke ts= 0here is no reason not to gi#e tP! to

these ts er the clinical trial rotocol=

Personal comm"nication, %ewandowski, 7883=


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Use of the NIHSS2 $oncl"sionsUse of the NIHSS2 $oncl"sions

0he NIHSS m"st 'e aroimated

Scores a'o#e 35:78 imart greater risk

tP! still m"st 'e considered, since 'enefi Stroke side, lang"age m"st 'e considered

! ro"gh scale m"st 'e "sed, since no

a''re#iated scale #alidated


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Use of the NIHSS2 +ecommendationsUse of the NIHSS2 +ecommendations

+isk


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timal tP! Pt Using NIHSStimal tP! Pt Using NIHSS

%imited alteration in mental stat"s

Moderate to se#ere #is"al


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;"estions;"estions1111

Edward Sloan, MD, MPHEdward Sloan, MD, MPH

edsloanK"ic=ed"

437 634 56F8437 634 56F8

use of the nih stroke scale (nihss) in emergency department patients with acute stroke edward sloan,...

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