Yes, the NIHSS Should Be Re-Scored When Clinical Status Changes
You should absolutely re-score the NIHSS in this patient—serial NIHSS assessments are not only appropriate but strongly recommended when neurological status changes, as they guide critical treatment decisions and help identify stroke progression or complications. 1
Why Serial NIHSS Scoring Is Essential
The NIHSS is designed to be administered at multiple time points throughout acute stroke care. Guidelines explicitly recommend:
- Initial assessment at presentation/hospital admission (within first 24 hours) 1
- Reassessment at acute care discharge 1
- Additional scoring when clinical status changes 1
The rationale is clear: a second assessment may be more accurate because the patient will have been stabilized and may be better able to cooperate with the examiner 1. However, in your case, the opposite has occurred—the patient has deteriorated—making reassessment even more critical.
How to Score This Patient's Current State
Your patient's evolution from NIHSS 6 to a state where she opens eyes spontaneously but cannot answer questions or follow commands represents significant neurological deterioration that must be captured:
Level of Consciousness Items (1A-1C):
- 1A (Alertness): Score 1 (arousable to minor stimulation) since she opens eyes spontaneously and holds gaze 2, 3
- 1B (Orientation): Score 2 (answers neither correctly) since she cannot answer questions 2, 3
- 1C (Commands): Score 2 (performs neither) since she cannot follow any directions 2, 3
This alone adds 5 points to her consciousness assessment, compared to what was likely 0-1 initially.
Language Assessment (Item 9):
Her inability to answer questions or follow commands suggests severe aphasia or global aphasia, potentially scoring 2-3 on the language item 2, 3. This represents worsening from her initial "mild/moderate aphasia."
Clinical Implications of This Deterioration
This change in NIHSS score has profound implications for prognosis and management:
- Initial NIHSS <10 predicts 60-70% favorable outcome at 1 year 2
- NIHSS >16 forecasts high probability of death or severe disability 1
- Your patient's score has likely increased significantly (potentially to 10-15 or higher depending on motor findings)
What This Deterioration Suggests:
- Stroke progression/extension of the embolic infarct
- Hemorrhagic transformation (though you mention extensive CT scans)
- Cerebral edema developing around the infarct
- New embolic event to a different vascular territory
- Seizure activity with post-ictal state
Immediate Actions Required
Document the new NIHSS score immediately and consider:
Repeat neuroimaging urgently (CT or MRI) to assess for:
- Infarct expansion
- Hemorrhagic transformation
- New ischemic territory
- Mass effect/edema
Reassess treatment eligibility if within appropriate time windows
Adjust monitoring intensity given higher risk profile
Communicate prognosis to family based on updated severity
Common Pitfalls to Avoid
Do not assume the initial NIHSS remains valid when clinical examination changes. The NIHSS is explicitly designed to track neurological status over time 2. The scale "can be administered at any stage by any trained clinician" 1 and should be used to identify patients at greatest risk for complications 2.
Do not delay reassessment waiting for "stability." While guidelines note that reassessment may be more accurate when patients are stabilized 1, this refers to routine follow-up scoring—not to situations where deterioration signals potential complications requiring urgent intervention.
The NIHSS has high inter-rater reliability (ICC >0.80) 4, 5, 6 and can even be estimated retrospectively from medical records with excellent validity 4, 5, so real-time bedside reassessment is certainly feasible and appropriate.
Your patient's worsening neurological status demands immediate NIHSS re-scoring, urgent repeat imaging, and escalation of care.