How to Remember the NIHSS Easily
Use the mnemonic "LEVEL OF CONSCIOUSNESS" to remember the 11 core components of the NIHSS, which assesses consciousness (3 items), visual fields, gaze, facial palsy, motor arms (2 items), motor legs (2 items), limb ataxia, sensory, language, dysarthria, and extinction/inattention. 1
Structured Approach to NIHSS Components
The NIHSS is an 11-item standardized assessment tool with scores ranging from 0 to 42, where higher scores indicate more severe strokes, and can be completed in 5-8 minutes. 1, 2
Memory Framework: Group by Body Region (Top to Bottom)
Brain/Consciousness (Items 1a-1c):
- Level of consciousness - observe alertness and response to stimulation 1
- LOC questions - test orientation (month, age) 1
- LOC commands - test ability to follow commands (open/close eyes, grip/release hand) 1
Eyes and Face (Items 2-4):
- Best gaze - assess horizontal eye movements 1
- Visual fields - test all four quadrants 1
- Facial palsy - ask patient to show teeth or raise eyebrows (note: this item has lower inter-rater reliability) 1
Arms and Legs (Items 5-6):
- Motor arm (both sides) - extend arms palm down at 90° for 10 seconds, scoring 0-4 based on drift or fall 3
- 0 = No drift
- 1 = Drift before 10 seconds
- 2 = Some effort against gravity
- 3 = No effort against gravity
- 4 = No movement at all 3
- Motor leg (both sides) - similar assessment at 30° for 5 seconds 1
Coordination and Sensation (Items 7-8):
- Limb ataxia - finger-nose-finger and heel-shin tests (note: this has lower reliability, especially via telemedicine) 1
- Sensory - test pinprick sensation 1
Language and Speech (Items 9-11):
- Best language - describe picture, name objects, read sentences 1
- 0 = Normal
- 1 = Mild-moderate aphasia
- 2 = Severe aphasia
- 3 = Mute/global aphasia 4
- Dysarthria - assess speech clarity (distinct from language function) 4
- Extinction/inattention - test for neglect 1
Critical Pitfalls to Avoid
Do not confuse aphasia with dysarthria - aphasia is a language problem (item 9), while dysarthria is a speech clarity problem (item 10). 4
Do not confuse decreased consciousness with aphasia - if the patient cannot speak due to altered mental status rather than language dysfunction, score consciousness items appropriately, not language. 4
Distinguish between motor scores 3 and 4 - score 3 means no effort against gravity but some movement is present, while score 4 means absolutely no movement at all. 3
Important Clinical Context
The NIHSS underestimates posterior circulation strokes because symptoms like vertigo, dysphagia, and balance disorders are not adequately captured, requiring lower cutoff scores (NIHSS ≥2-4) to predict poor outcomes in PC strokes versus AC strokes (NIHSS ≥4-8). 1, 5
Items with highest reliability include level of consciousness and motor-related questions, while facial palsy, ataxia, and dysarthria consistently show lower inter-rater reliability. 6, 1
Training and certification in NIHSS administration through watching training videos and passing an examination is recommended by the American Academy of Neurology to ensure accurate assessment. 1