What tools are recommended for neuro exam scoring?

Recommended Tools for Neurological Examination Scoring

The NIH Stroke Scale (NIHSS) is the gold standard recommended tool for neurological examination scoring in acute stroke settings, and should be used by all healthcare providers committed to stroke care to quantify neurological deficits, facilitate communication between providers, and guide treatment decisions. 1, 2

Primary Recommended Scoring Tool

Use the NIH Stroke Scale (NIHSS) as your primary neurological assessment tool for the following reasons:

• The NIHSS is validated for use by a broad spectrum of non-neurological healthcare providers and ensures all major components of a neurological examination are performed in a timely fashion 1
• It quantifies the degree of neurological deficit, facilitates communication between healthcare professionals, identifies possible location of vessel occlusion, provides early prognosis, and helps identify patient eligibility for various interventions 1
• The scale must be performed by certified examiners trained via standardized methods to ensure reliability 2
• Serial NIHSS measurements should be obtained at defined intervals: immediately post-intervention, 24 hours, 72 hours, 7-10 days, 30 days, and 90 days 2
• Additional NIHSS scoring is required when neurological deterioration occurs, defined as a 4-point increase 2

NIHSS Components and Scoring

The NIHSS evaluates 11 key domains 1:

• Level of consciousness (alert to coma, 0-3 points)
• Orientation questions (0-2 points)
• Response to commands (0-2 points)
• Gaze (horizontal eye movements, 0-2 points)
• Visual fields (0-3 points)
• Facial movement (0-3 points)
• Motor function in arms (left and right, 0-4 points each)
• Motor function in legs (left and right, 0-4 points each)
• Limb ataxia (0-2 points)
• Sensory (0-2 points)
• Language/aphasia (0-3 points)
• Articulation/dysarthria (0-2 points)
• Extinction or inattention (0-2 points)

Important Limitations and Caveats

Be aware that the NIHSS may underestimate posterior circulation strokes because it lacks assessment of vertigo and dysphagia 2. For patients with suspected posterior circulation involvement, supplement your assessment accordingly.

Avoid using "slim" versions of the NIHSS or the Glasgow Coma Scale alone for stroke assessment, as they have false-negative rates of 5-19% and 56% respectively, particularly in patients with low NIHSS scores 3. The full NIHSS provides critical assessment data that should not be sacrificed for ease of use 3.

Additional Recommended Scoring Tools

Beyond the NIHSS, incorporate these validated instruments into your comprehensive neurological assessment:

For Functional Outcomes

• Modified Rankin Scale Score for disability outcomes 2
• Barthel Index or Pfeffer Functional Activities Questionnaire (FAQ) for activities of daily living 2

For Cognitive Screening

• Montreal Cognitive Assessment (MoCA) when mild cognitive impairment is suspected or when MMSE scores are in the "normal" range (24+ out of 30) but cognitive concerns persist 1, 4
• The MoCA is more sensitive than the MMSE for detecting mild cognitive impairment, particularly early in disease progression 4

For Behavioral Assessment

• Neuropsychiatric Inventory-Q (NPI-Q) or Mild Behavioural Impairment Checklist (MBI-C) for behavioral and psychological symptoms 1, 2

For Level of Consciousness

• Glasgow Coma Scale as part of comprehensive neurological examination for level of consciousness assessment 2

For Subarachnoid Hemorrhage

• World Federation of Neurological Surgeons (WFNS) scale, Hunt and Hess scale, or Fisher Scale for SAH severity assessment 1

Implementation Best Practices

Ensure proper certification and training for all staff administering the NIHSS to reduce interobserver variability 2. Multiple studies demonstrate that emergency physicians committed to stroke care can correctly identify and safely treat stroke patients when using standardized scales 1.

Perform serial examinations at 6,24, and 72 hours after admission in acute settings 2. This allows for detection of neurological deterioration and guides ongoing management decisions.

Combine cognitive tests with functional screens and informant reports to improve case-finding in patients with cognitive difficulties 1, 4. Using standardized tools increases diagnostic accuracy when combined with patient-related measures 1.