Do traumatic brain injuries require National Institutes of Health Stroke Scale (NIHSS) documentation?

NIHSS Documentation for Traumatic Brain Injuries

Traumatic brain injuries do not require NIHSS documentation as this scale was specifically designed for stroke assessment, not TBI evaluation. While the NIHSS is mandatory for stroke patients, TBI severity is assessed using different clinical and radiological criteria.

Assessment Tools for TBI

Recommended Assessment Approach for TBI

• Glasgow Coma Scale (GCS): The primary clinical tool for assessing TBI severity 1

  • Severe TBI: GCS ≤ 8
  • Moderate TBI: GCS 9-13
  • Mild TBI: GCS 14-15

• CT Scan: Recommended for all severe and moderate TBI cases, and for mild TBI with specific indicators 1

  • Should be performed systematically and without delay
  • Mild TBI patients need CT if they have: signs of basal skull fracture, displaced skull fracture, post-traumatic epilepsy, focal neurological deficit, or coagulation disorders

• Transcranial Doppler: Suggested as an additional tool to assess TBI severity 1

  • Can estimate cerebral perfusion pressure through Pulsatility Index (PI)
  • Low mean blood flow velocity (<28 cm/s) associated with higher mortality

NIHSS vs. TBI Assessment

The NIHSS is specifically designed and validated for stroke assessment, not TBI 1, 2:

• NIHSS Purpose: Standardized tool for quantifying neurological deficits after stroke

  • Designed so virtually any stroke will register abnormality on the scale
  • Administration time: 5-10 minutes
  • Based solely on examination without historical information

• NIHSS Application: Used to guide decisions concerning acute stroke therapy 1, 2

  • Initial scores stratify stroke patients by severity and likely outcome
  • Score >16 forecasts high probability of death or severe disability
  • Score <6 forecasts good recovery
  • Used to determine eligibility for thrombolytic therapy

TBI-Specific Assessment Tools

For TBI assessment, specialized tools have been developed:

• Neurological Outcome Scale for TBI (NOS-TBI): An adaptation of the NIHSS specifically for TBI patients 3, 4
  • Includes additional items specific to TBI
  • Adjusted scoring algorithm to quantify deficits in comatose/vegetative or agitated patients
  • Reassigns problematic items (like limb ataxia) as supplemental items
  • Designed to serve a similar role for TBI as NIHSS does for stroke

Clinical Implications

Documentation Requirements

• For stroke patients: NIHSS documentation is strongly recommended at presentation/admission, within 24 hours, and at discharge 1, 2
• For TBI patients: Documentation should focus on 1:
  • GCS score
  • CT scan findings
  • Other neurological assessments specific to trauma

Pitfalls to Avoid

• Don't use NIHSS for TBI assessment: The NIHSS was not designed or validated for TBI and may miss important TBI-specific deficits
• Don't delay appropriate imaging: CT scans should be performed without delay in suspected TBI cases
• Don't overlook specialized TBI assessment tools: Consider using TBI-specific tools like the NOS-TBI when available

Summary of Approach to TBI Assessment

1. Assess GCS score to determine TBI severity (severe ≤8, moderate 9-13, mild 14-15)
2. Perform CT scan for all severe and moderate TBI, and for mild TBI with specific indicators
3. Consider supplementary assessment with transcranial Doppler
4. Document findings using TBI-appropriate scales rather than NIHSS
5. Consider specialized TBI assessment tools like NOS-TBI when available

By using the appropriate assessment tools for TBI rather than the stroke-specific NIHSS, clinicians can more accurately evaluate severity and guide treatment decisions to improve morbidity, mortality, and quality of life outcomes.