Rapid Focused Neurological Assessment for Stable Patients
For stable patients presenting with suspected acute neurological emergencies, perform an immediate standardized neurological examination using the National Institutes of Health Stroke Scale (NIHSS) for awake or drowsy patients, or the Glasgow Coma Scale (GCS) for obtunded or comatose patients. 1
Core Assessment Components
Level of Consciousness
- Assess alertness using a three-tiered approach: alert and responsive, arousable to minor stimulation, or arousable only to painful stimulation 1
- Test orientation by asking the patient's age and current month; answers must be exact 1
- Evaluate command-following by asking the patient to open/close eyes and grip/release the non-paretic hand 1
Cranial Nerve Examination
- Visual fields: Test using confrontation or visual threat if necessary; document any hemianopia, quadrantanopia, or extinction 1
- Eye movements: Assess horizontal gaze only (voluntary or reflexive); note any partial gaze palsy or forced deviation 1
- Facial movement: Observe for symmetry at rest and with smile; check for flat nasolabial fold, asymmetric smile, or complete paralysis 1
Motor Function Assessment
- Upper extremities: Have patient hold arms outstretched at 90 degrees (sitting) or 45 degrees (supine) for 10 seconds; score any drift, antigravity effort, or absence of movement 1
- Lower extremities: Raise leg to 30 degrees and hold for 5 seconds; test both sides and document drift or weakness 1
- Pronator drift: Specifically assess for rapid arm movement abnormalities 2
Coordination and Sensory Testing
- Limb ataxia: Perform finger-to-nose and heel-to-shin testing; score only if ataxia is out of proportion to weakness 1
- Sensory examination: Use pinprick to check for stroke-related unilateral or bilateral sensory loss 1
Language and Speech
- Language function: Have patient describe a standard picture (e.g., cookie jar), name objects, and read sentences; grade severity of aphasia from mild to global 1
- Articulation: Assess dysarthria by having patient read a list of words; determine if speech is slurred but intelligible versus unintelligible 1
Neglect and Extinction
- Simultaneously touch patient on both hands and show fingers in both visual fields 1
- Ask if patient recognizes their own left hand 1
- Document any neglect or extinction to double simultaneous stimulation in visual, auditory, or sensory modalities 1
Gait Assessment
- Observe gait pattern if patient is ambulatory and stable enough to walk safely 2
Timing and Documentation
The entire NIHSS examination can be performed rapidly in 5–10 minutes and should be completed before imaging decisions are finalized. 1 The scale ranges from 0 to 42, where scores less than 5 indicate small stroke and greater than 20 indicate large stroke 1. This standardized assessment quantifies baseline severity, facilitates team communication, identifies vessel occlusion location, provides early prognosis, helps select patients for interventions, and identifies potential for complications 1.
Critical Monitoring Parameters
Beyond the neurological examination, simultaneously assess:
- Heart rate and rhythm 1
- Blood pressure 1
- Temperature 1
- Oxygen saturation 1
- Hydration status 1
- Presence of seizure activity 1
Common Pitfalls
- Do not delay stroke code activation if initial history and brief examination suggest stroke; the standardized assessment can be completed during the acute workup 1
- Do not substitute informal assessment for a validated scale; standardized tools ensure uniform evaluation and improve communication across the care team 1, 3
- For patients with suspected cervical spinal cord injury rather than stroke, foot motor and sensory function plus handgrip strength can rapidly indicate injury severity and level 4
- The general physical examination (auscultation for carotid bruits, cardiac murmurs, skin examination for embolic lesions) should occur concurrently but must not delay the focused neurological assessment 1