What is the National Institutes of Health (NIH) stroke scale score for a patient with severe aphasia who is unable to articulate their best language?

NIH Stroke Scale Score for Patients with Severe Aphasia

For a patient with severe aphasia who is unable to articulate, the appropriate NIH Stroke Scale (NIHSS) score for the "Best Language" item (item 9) would be 3, indicating "mute, global aphasia, or coma." 1

Understanding the NIHSS Language Assessment

The NIHSS is an 11-part standardized stroke severity assessment tool with scores ranging from 0 to 42, where higher scores indicate more severe strokes:

• Item 9 (Best Language) specifically evaluates language function using the following scoring criteria 1:

  • 0 = Normal language
  • 1 = Mild to moderate aphasia (partly comprehensible)
  • 2 = Severe aphasia (almost no information exchanged)
  • 3 = Mute, global aphasia, or coma

• When a patient is unable to articulate at all due to severe aphasia, the appropriate score is 3 1

Clinical Assessment Technique

When evaluating a patient with severe aphasia:

• Ask the patient to describe a standardized picture (e.g., cookie jar picture), name objects, and read sentences 1
• If the patient cannot produce any meaningful language or is completely unable to articulate, score as 3 1
• This assessment should be distinguished from dysarthria (item 10), which evaluates speech clarity rather than language function 1

Clinical Significance and Implications

• The presence of severe aphasia (score of 3) contributes significantly to the overall NIHSS score 1
• Higher NIHSS scores correlate with poorer outcomes - scores >20 indicate large strokes with only 4-16% chance of favorable outcomes at one year 1
• Aphasia at baseline and persistent aphasia at three months are both associated with poorer functional outcomes as measured by the modified Rankin Scale 2
• Approximately 45% of acute stroke patients present with some degree of aphasia, with 23.7% having persistent aphasia at three months 2

Common Pitfalls in Assessment

• The NIHSS has a sensitivity of only 72% for detecting aphasia when compared to comprehensive language assessments, potentially missing milder cases 3
• Do not confuse inability to speak due to decreased consciousness (item 1A) with aphasia 1
• Distinguish between aphasia (language disorder) and dysarthria (speech articulation disorder) 1
• Isolated aphasia without other neurological deficits is uncommon in acute stroke and may suggest a stroke mimic 4

Management Implications

• Patients with severe aphasia should be referred to a Speech-Language Pathologist for comprehensive assessment and therapy 1
• Early access to intensive language and communication therapy improves outcomes 1
• Treatment approaches may include language therapy, conversational treatment, constraint-induced language therapy, and use of assistive technology 1
• The prognosis for language recovery is generally good, with 86% showing improvement and 74% achieving complete resolution by 6 months 5

Remember that accurate scoring of aphasia severity is crucial for proper stroke assessment, prognosis determination, and treatment planning.