JNS-13921; No of Pages 5

Journal of the Neurological Sciences xxx (2015) xxxxxx

Contents lists available at ScienceDirect

Journal of the Neurological Sciences

journal homepage: www.elsevier.com/locate/jns

Arabic cross cultural adaptation and validation of the National Institutes

of Health Stroke Scale
Haitham M. Hussein a,, Amr Abdel Moneim b, Tamer Emara b, Yousry A. Abd-elhamid b, Haitham H. Salem b,
Foad Abd-Allah c, Mohammad A. Farrag c, M. Amir Tork b, Ali S. Shalash b, Khaled H. Ezz el dein b,
Gamaleldin Osman b, Shady S. Georgy b, Peter G. Ghali b, Patrick D. Lyden d, Ramez R. Moustafa b
a

HealthPartners Clinics and Services Department of Neurosciences, St Paul, MN, United States
Ain Shams University Department of Neurology, Cairo, Egypt
c
Cairo University, Kasralainy School of Medicine, Neurology Department, Cairo, Egypt
d
Cedars-Sinai Department of Neurology, Los Angeles, CA, United States
b

a r t i c l e

i n f o

Article history:
Received 5 March 2015
Received in revised form 20 June 2015
Accepted 10 July 2015
Available online xxxx
Keywords:
NIHSS
Cross-cultural
Translation
Arabic
Ischemic stroke
Neurological examination
Stroke scale
Stroke severity

a b s t r a c t
Introduction: The National Institutes of Health Stroke Scale (NIHSS), the most commonly used tool to quantify
neurological decit in acute stroke, was initially developed in English. We present our experience in developing
and validating an Arabic version of the NIHSS (arNIHSS).
Methods:
A) Scale development phase: 6 bilingual neurologists translated the scale to Arabic. Items 9 and 10 were
modied to suit the Arabic language and culture. A panel of 11 Arab neurologists reviewed the nal product
and an Arabic language expert did nal editing.
B) Scale validation phase: 10 examiners (four neurology residents and six nurses), who had no experience
with the NIHSS, were trained to use the arNIHSS. Patients with acute stroke were recruited at two academic
institutions in Egypt. Each patient was examined on admission by 3 examiners using the arNIHSS and at
24 hours by one of the three examiners. The agreement between the rst three examinations was used to
calculate the interrater agreement. The agreement between the admission and the 24-hour arNIHSS performed by the same examiner was used to calculate the intrarater agreement. Construct validity was
evaluated by correlating the arNIHSS on admission with the infarct volume on initial the diffusion weighted
imaging (DWI) using the Alberta Stroke Program Early CT score (DWI-ASPECTS) and the functional outcome
at 3 months assessed by the modied Rankin Scale (mRS).
Results: In 6 months, 137 patients were recruited (mean age standard deviation 62 12 years; 48 women). For
interrater agreement, weighted kappa value ranged from 0.36 to 0.66 and intraclass correlation coefcient (ICC)
for the whole scale was excellent at 0.95 (95% condence interval [CI] 0.940.97). For intrarater agreement,
weighted kappa ranged from 0.52 to 1.0 and the ICC was 0.94 (95% CI 0.870.98). The construct validity of
the arNIHSS is demonstrated by its correlation with the DWI-ASPECT and the 3 months mRS score (Spearman
correlation 0.46 and 0.58 respectively; P b 0.001 for both).
Conclusion: We developed and validated a culturally adapted Arabic version of the NIHSS. Further validation in
other Arab countries is recommended.
2015 Elsevier B.V. All rights reserved.

1. Introduction
The original NIH Stroke Scale (NIHSS) was developed at the University of Cincinnati [1,2] and subsequently modied for the NINDS rtPA
Funding source: None.
Corresponding author at: HealthPartners Clinics and Services, 401 Phalen Blvd.,
St. Paul, MN 55130, United States.
E-mail address: Haitham.M.Hussein@healthpartners.com (H.M. Hussein).

trial [3]. The current version was rst published in 1994 [4]. It has
since become an integral part of stroke clinical trials and practice [57].
Utilization of the NIHSS in non-English-speaking countries is challenging. The difference in language may impair the examiner's ability
to understand the instructions. The objects used to test aphasia in
item 9 may not be familiar in other cultures and the syllables used in
item 10 maybe foreign or inadequate to test for dysarthria in languages
other than English. Several cross-cultural adaptations of the NIHSS have
addressed these issues in their respective cultures [814].

http://dx.doi.org/10.1016/j.jns.2015.07.022
0022-510X/ 2015 Elsevier B.V. All rights reserved.

Please cite this article as: H.M. Hussein, et al., Arabic cross cultural adaptation and validation of the National Institutes of Health Stroke Scale, J
Neurol Sci (2015), http://dx.doi.org/10.1016/j.jns.2015.07.022

H.M. Hussein et al. / Journal of the Neurological Sciences xxx (2015) xxxxxx

The aim of this study was to develop an Arabic version of the NIHSS
(arNIHSS). A culturally adapted Arabic version of the NIHSS is needed
to serve more than 200 million Arabic native speakers; most of them
do not speak any other languages [15]. It will be particularly useful
in standardizing acute stroke care (initial assessment and monitoring
of clinical progression) performed by neurologists as well as nonneurologists (other specialty physicians and non-physician providers).
The non-neurologists group is important given the rarity of neurologists
in the Arab world, which has one neurologist per 100,000500,000
population (much less than Europe and USA which have approximately
4 per 100,000 population) [16].
2. Methods
The study was performed in 2 phases. Phase 1 was to develop the
arNIHSS according to standard methods of cross-cultural adaptation
[17,18], and phase 2 was to validate it in an Arabic speaking clinical
setting.
2.1. Phase 1: arNIHSS scale development
Four bilingual neurologists translated the NIHSS to Arabic, creating
the rst draft of the arNIHSS by consensus. A fth bilingual neurologist
independently back-translated the draft to English. Another investigator compared the NIHSS with the back translation and made corrections
to the Arabic draft to reconcile discrepancies. The following changes
were made to items 9, aphasia, and 10, dysarthria (see online Supplementary material):
Cookie jar card: the word cookie on the jar was replaced by its
Arabic equivalent
Object naming card: the original card was replaced by the one developed for the Spanish version of the NIHSS [10] because it has objects
that are more familiar to natives of the Arabic world.
Sentence reading card: except for minor modication in the order of
words to fulll the proper Arabic grammar, the original sentences
were translated word for word to maintain the meaning and the
incremental complexity of the original version.
Word reading card: we chose 6 words that would: a) test labial,
lingual and glottal sounds, b) include the phonemes that are unique
to the Arabic language, and c) be devoid of any cultural, social, or
religious insinuations.
To ensure that the scale was comprehensible and acceptable in the
various Arab-speaking countries, the draft scale was sent to a panel of
eleven bilingual Arab neurologists from eight different Arab countries.
Each neurologist independently reviewed and edited the draft. These
changes were incorporated into one draft. Finally, an Arabic language expert proofread the draft for spelling and grammar mistakes, producing
the nal version of the arNIHSS (online supplementary material 1 and 2).
2.2. Phase 2: scale validation:
The goal of this phase was to assess a) the feasibility of training
Arabic speaking examiners to use the arNIHSS and b) the psychometric
characteristics of the scale.

examination techniques and scoring rules. Phase 2 focused on practicing the arNIHSS in groups and individually on actors with real time
feedback and discussion. Phase 3 allowed examiners to independently
practice arNIHSS on actual stroke patients. Scores were reviewed and
corrected by the trainers. Examiners were admitted to the study when
at least 75% of their score was correct.
2.2.2. Study subjects
Patients 18 years or older who were admitted with ischemic stroke
to the stroke units of two academic institutions in Cairo, Egypt (Ain
Shams University Hospital and Cairo University Hospital) were identied. We excluded patients with hemorrhagic strokes, thrombolytic
treatment, and onset N48 hours from presentation.
2.2.3. Study protocol
Each patient was examined on admission three separate times using
the arNIHSS by three different examiners. Each examiner was blinded to
the scores given by the other examiners. A fourth examination was performed 24 hours later by one of those three examiners.
For patients with anterior circulation stroke, recruited at Ain Shams
University Hospital, the diffusion weighted imaging (DWI) sequence
of the admission brain magnetic resonance imaging (MRI) was used to
calculate the infarct volume using the modication of the Alberta Stroke
Program Early CT score (DWI-ASPECTS) [19,20]. Modied Rankin Scale
(mRS) was assessed through telephone interview at 3 months [21,22]
by study investigators unaware of initial assessment. The procedures
followed in this study were in accordance of institutional guidelines
and the research authority at both academic institutions and hospitals
approved the study. All patients (or their caregivers) consented to participate in the study.
2.2.4. Statistical analysis
Baseline population characteristics were reported using frequency
for categorical variables, mean standard deviation (SD) for continuous variables, and median (interquartile range IQR) for nonparametric variables. The initial three examinations were used to calculate
the interrater agreement. Weighted Kappa statistic was calculated
for individual arNIHSS items, and was categorized as follows: poor if
b0.40, moderate if 0.40.75, and excellent if N0.75. If the kappa of
NIHSS item is included within the 95% CI of its corresponding item on
the arNIHSS, then the two kappas were considered to be not statistically
different. The two examinations done by the same examiner 24 hours
apart were used to calculate the intrarater agreement. The intraclass
correlation coefcient (ICC) was also calculated but for the total scores.
To assess the construct validity of the arNIHSS, Spearman's correlation was calculated between arNIHSS (total and individual items) and
DWI-ASPECTS, and between arNIHSS (total and individual items) and
mRS. For the construct validity correlations, we calculated the average
of the initial three arNIHSS scores instead of choosing the scores given
by one examiner, since none of the initial scores represent the reference
or the gold standard.
All analytical procedures were conducted using SPSS statistical packages version 18 (SPSS Inc.) and SAS (PC SAS 9.2, SAS Institute Inc., Cary,
North Carolina).
3. Results
3.1. Subjects' characteristics

2.2.1. Training of examiners

Neurology residents and nurses were approached to participate
in the study. Those who had previous experience with the NIHSS were
excluded. Both study sites were allowed to design their own training
program provided that they follow these guidelines: a) the training
would be provided by in Arabic by senior neurologists with extensive experience in NIHSS, and b) the training would consist of three
phases. Phase 1 involved explaining the purpose and use of the NIHSS,

A total of 137 patients were recruited into the study (mean age
62 12 years; 48 women). Ain Shams University Hospital contributed
117 patients and Cairo University Hospital contributed 20 patients
(Table e-1). The median (IQR) arNIHSS score at admission and at
24 hours was the same 5 (8). Median (IQR) DWI-ASPECTS (n = 68)
was 7 (410). The median (IQR) mRS at 3 months (n = 117) was
2 (05).

Please cite this article as: H.M. Hussein, et al., Arabic cross cultural adaptation and validation of the National Institutes of Health Stroke Scale, J
Neurol Sci (2015), http://dx.doi.org/10.1016/j.jns.2015.07.022

H.M. Hussein et al. / Journal of the Neurological Sciences xxx (2015) xxxxxx
Table 1
Distribution of responses for arNIHSS components by the initial three examinations.

Table 3
Intrarater agreement of the arNIHSS.

Components

Total responses
(max = 411)

Component

Kappa
(median)

Interquartile
range

Agreement
beyond chance

LOC (1a)
LOC questions (1b)
LOC Command (1c)
Gaze (2)
Visual Fields (3)
Facial Weakness (4)
Motor left arm (5a)
Motor right arm (5b)
Motor left leg (6a)
Motor right leg (6b)
Ataxia (7)
Sensory (8)
Aphasia (9)
Dysarthria (10)
Extinction (11)

411
411
411
411
411
411
411
411
411
411
411
411
408a
411
411

87.4
68.1
90.3
91.2
78.8
34.1
67.2
75.9
61.1
65.5
68.9
52.6
80.6
51.8
91.2

9.3
14.4
4.9
5.6
10.7
45.3
10.2
11.7
11
13.6
23.6
44
6.4
38.9
6.1

3.4
17.5
4.9
3.2
9.5
18.2
5.4
3.7
11.7
10.7
7.5
3.4
7.8
9.3
2.7

1
1.5
8.5
3.4
11
7.1

5.2

8.8
5.4
5.4
3.2

LOC (1a)
LOC questions (1b)
LOC command (1c)
Gaze (2)
Visual Fields (3)
Facial Weakness (4)
Motor left arm (5a)
Motor right arm (5b)
Motor left leg (6a)
Motor right leg (6b)
Ataxia (7)
Sensory (8)
Aphasia (9)
Dysarthria (10)
Extinction (11)

0.52
0.81
1.00
1.00
0.63
0.68
0.79
0.65
0.76
0.90
0.77
0.56
1.00
0.72
0.81

0.030.93
0.711.00
0.731.00
1.001.00
0.420.95
0.471.00
0.620.85
0.450.95
0.550.97
0.631.00
0.511.00
0.140.68
0.681.00
0.621.00
0.451.00

Moderate
Excellent
Excellent
Excellent
Moderate
Moderate
Excellent
Moderate
Excellent
Excellent
Excellent
Moderate
Excellent
Moderate
Excellent

Total score

ICC, Median
0.94

Interquartile range
0.921.00

Excellent

arNIHSS: Arabic version of the National Institutes of Health Stroke Scale; LOC: level of
consciousness.
a
Item was untestable in 3 patients.

Six nurses and four neurology residents were recruited to the study
(Table e-2). There were 411 responses recorded for each of the scale
items on admission (137 patients 3 examiners) except for item
9 (aphasia) for which only 408 responses were recorded because of
intubation of one patient. Responses distributed throughout all possible
levels for all items except level 3 for item 1a (see Table 1). At 24 hours,
110 responses were available for each item.

3.2. Interrater agreement

The three independent examinations performed on the rst day
of admission, had kappa value for interrater agreement ranging from
0.36 to 0.66. One item was categorized as poor agreement (facial weakness), and the rest of the fourteen items were categorized as moderate
agreement (Table 2). In comparison with the NIHSS, which had a
broader distribution of agreement (2 excellent, 2 poor, and 11 moderate
agreement) the 95% CI of the kappa of all but three items of the arNIHSS
overlapped with the Kappa of the NIHSS: level of consciousness
commands (item 1c) and visual eld (item 3) better interrater agreement in favor of NIHSS [23], and ataxia (item 7) in favor of arNIHSS.
The ICC for the whole scale was excellent at 0.95 (95% CI 0.940.97),
which is similar to the NIHSS ICC of 0.94 (95% CI 0.841.00) [23].

arNIHSS: Arabic version of the NIH Stroke Scale; LOC: level of consciousness.

3.3. Intrarater agreement

One hundred and ten patients were examined a second time by the
same examiner, 24 hours after the initial examination. Kappa for
intrarater agreement ranged from 0.52 to 1.0. The agreement was excellent for nine items and moderate for six items. The ICC of the overall
score was 0.94 (95% CI 0.870.98; Table 3) with no difference between
nurses 0.94 (95% CI 0.861.0) and physicians 0.91 (95% CI 0.810.99).
We performed a comparison of individual items and total score by specialty (physician versus nurses) and even compared individual examiners; however, we did not nd statistically signicant differences.

3.4. Construct validity

The construct validity of the arNIHSS is demonstrated by the
correlation between the average of the three initial arNIHSS assessments with the infarct volume on MRI using the DWI-ASPECTS (Spearman correlation 0.46; P b 0.001; Fig. 1) and with the functional
outcome at 3 months as measured by mRS (Spearman correlation 0.58;
P b 0.001; Fig. 2).

Table 2
Interrater agreement of the arNIHSS compared with NIHSS.
Kappa (95%CI)
Components

arNIHSS (95% CI)

Agreement category

NIHSS (95% CI) [23]

Agreement category

LOC (1a)
LOC questions (1b)
LOC Command (1c)
Gaze (2)
Visual Fields (3)
Facial Weakness (4)
Motor left arm (5a)
Motor right arm (5b)
Motor left leg (6a)
Motor right leg (6b)
Ataxia (7)
Sensory (8)
Aphasia (9)
Dysarthria (10)
Extinction (11)

0.61 (0.53, 0.69)

0.64 (0.56, 0.72)
0.58 (0.50, 0.66)
0.42 (0.34, 0.49)
0.44 (0.36, 0.52)
0.36 (0.28, 0.44)
0.57 (0.51, 0.63)
0.66 (0.60, 0.72)
0.61 (0.55, 0.67)
0.56 (0.50, 0.62)
0.41 (0.33, 0.49)
0.51 (0.43, 0.59)
0.64 (0.58, 0.70)
0.53 (0.45, 0.61)
0.55 (0.47, 0.63)

Moderate
Moderate
Moderate
Moderate
Moderate
Poor
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate
Moderate

0.46 (0.39, 0.53)

0.77 (0.64, 0.90)
0.92 (0.75, 1.0)
0.70 (0.39, 1.0)
0.72 (0.57, 0.87)
0.38 (0.27, 0.49)
0.65 (0.51, 0.79)
0.72 (0.54, 0.79)
0.64 (0.53, 0.72)
0.64 (0.53, 0.72)
0.21 (0.12, 0.30)
0.73 (0.53, 0.93)
0.64 (0.53, 0.75)
0.56 (0.39, 0.73)
0.57 (0.40, 0.74)

Moderate
Excellent
Excellent
Moderate
Moderate
Poor
Moderate
Moderate
Moderate
Moderate
Poor
Moderate
Moderate
Moderate
Moderate

ICC (95%)
Total scores

0.95 (0.94, 0.97)

Excellent

0.94 (0.84, 1.00)

Excellent

arNIHSS: Arabic version of the NIH Stroke Scale; CI: condence interval; LOC: level of consciousness.

Please cite this article as: H.M. Hussein, et al., Arabic cross cultural adaptation and validation of the National Institutes of Health Stroke Scale, J
Neurol Sci (2015), http://dx.doi.org/10.1016/j.jns.2015.07.022

H.M. Hussein et al. / Journal of the Neurological Sciences xxx (2015) xxxxxx

Fig. 1. arNIHSS according to DWI-ASPECTS. The construct validity of the arNIHSS is demonstrated by the incremental increase in the median of the average of the three baseline
assessments, indicating more severe neurologic decit, as the DWI-ASPECTS score
decreases, indicating larger infarct volume. arNIHSS: Arabic version of the National
Institutes of Health Stroke Scale; DWI: diffusion weighted imaging; ASPECTS: Alberta
Stroke Program Early CT score.

4. Discussion
Our study design is similar to the Thai version of the NIHSS [11]
in which the examiners were practicing nurses and physicians (not
neurologists with long clinical experience as in the Spanish version
[10]) and the patients were actual patients of those examiners (versus
videotaped cases as in the NIHSS [23] and the Italian version [13]).
This design makes our study more representative of real life training
and patient care encounters rather than ideal educational conditions.
The difference in methods probably accounts for some of the differences in results when our study is compared to previous studies. While
the NIHSS items analysis used unweighted kappa, we did use weighted
kappa since it is the more suitable to compare ordinal variables. All the
items in which interrater agreement was categorized as moderate by
the NIHSS were similarly categorized as moderate by the arNIHSS. The
difference between the two scales is in three items that were categorized as moderate by the arNIHSS, while categorized as excellent
(items 1b and 1c) or poor (item 7) by the NIHSS. The random patient
selection and the variable mixes of examiners (every patient was examined by any 3 out of the 10 examiners, but not all examiners examined
each patient) may have brought the agreement to a realistic middle
rather than extreme values. Another contributing factor is the acuity
of the cases, as the patients had suffered an acute stroke 48 hours
prior to study participation. In this acute stage, patients' neurological
state, particularly the level of consciousness, may uctuate for a variety
of medical reasons. This is in contrast to the NIHSS in which 26 patients
were selected from stroke clinics and were sent to a professional TV studio to optimize videotaping quality and then the interrater agreement is

derived from all examiners who reviewed the same video clip of the
item examined [23]. In developing the Spanish version NIHSS, only
two examiners examined the patients and the statistical analysis was
based on the score values obtained by them.
Comparing the current study to other NIHSS-validation studies,
this study used dual indicators for construct validity while other studies
used only functional outcome scales. The construct validity of the
arNIHSS has a signicant correlation for both DWI-ASPECTS and functional outcome at 3 months as measured by mRS. Its correlation with
both radiological and clinical marker indicates that arNIHSS version
functioned as it was hypothesized.
The NIHSS itself has well recognized limitations, which led to the
development of the modied NIHSS (mNHISS) trying to eliminate the
items with low reliability: level of consciousness, facial palsy, limb
ataxia, and dysarthria [24]. The arNIHSS shares the same limitations
for facial palsy and limb ataxia, and dysarthria, performs better than
NIHSS in level of consciousness, and worse in visual eld and gaze
items. An exploration into a modied arNIHSS is warranted to assess
whether it will increase the reliability. The intrarater reliability in this
study was undertaken by comparing individual rater's arNIHSS examination of the same patient on admission and at 24 hours. The assumption was that the change in neurological state would not cause a
signicant change in the arNIHSS score over this time period for the
vast majority of patients. To minimize the chance of a signicant change
in the arNIHSS, we excluded patients who were treated with thrombolysis and we limited the time period between the rst and the second
examination to 24 hours. This method was used in the validation of
the Spanish version of the NIHSS [10].
In the Arab world, NIHSS has always been taught in English and left
to the individual to create his/her own Arabic version for their practice.
We are aware of several attempts by individuals and institutions to
create an Arabic version of the NIHSS, yet these versions were not validated and remained local. The arNIHSS is an opportunity to standardize
the utilization of the NIHSS among Arabic-speaking populations. The
inclusion of a panel of neurologists from all over the Arab world in the
development of the scale aimed at this pan-Arab goal. However, the
validation phase was implemented only in Egypt on Egyptian patients.
Future validation in other Arabic-speaking countries is needed to ensure
that the current arNIHSS version is universally pertinent. Another
potential limitation is the lack of a unied training program, which
can potentially improve the interrater agreement. Creating a certication process will ensure the standardization of instructions and the
rigor of training. Further work should be directed at new training strategies using in-print and online materials to increase the utilization of
arNIHSS.
5. Conclusion
A culturally adapted Arabic version of the NIHSS has been developed.
The proposed version has been found to be valid and reliable using a
cohort in Egypt. Validation in other Arab countries is recommended.
Acknowledgment

Fig. 2. arNIHSS according to mRS. The construct validity of the arNIHSS is demonstrated by
the incremental increase in the median of the average of the three baseline assessments,
indicating more severe neurologic decit, as the 3-months mRS score increases, indicating
more severe disability. arNIHSS: Arabic version of the National Institutes of Health Stroke
Scale; mRS: modied Rankin Scale.

Panel of bilingual Arab Neurologists by country of origin:

Tunisia: Senda Ajroud-Driss MD (Chicago, IL), Nizar Souayah MD
(Newark, NJ)
Sudan: Khalafallah Bushara, MD (Minneapolis, MN)
Lebanon: Mustapha Ezzeddine MD (Minneapolis, MN), Gamil Fteeh
MD (Houston, TX)
Syria: Yousef Hennawi MD (Houston, TX), Amrou Serajj MD
(Houston, TX)
Palestine: Akram Shehadeh MD (Milwaukee, WI)
Saudi Arabia: Amer Zahrallayalli MD (Houston, TX)
Jordan: Osama Zaidat MD (Milwaukee, WI)
Iraq: Saef Ahmed MD (Boston, MA)

Please cite this article as: H.M. Hussein, et al., Arabic cross cultural adaptation and validation of the National Institutes of Health Stroke Scale, J
Neurol Sci (2015), http://dx.doi.org/10.1016/j.jns.2015.07.022

H.M. Hussein et al. / Journal of the Neurological Sciences xxx (2015) xxxxxx

Professional ArabicEnglish Translator

Mr Suhaib Alrawi (Houston, TX)
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.jns.2015.07.022.
References
[1] T. Brott, H.P. Adams Jr., C.P. Olinger, et al., Measurements of acute cerebral infarction:
a clinical examination scale, Stroke 20 (1989) 864870.
[2] P.D. Lyden, G.T. Lau, A critical appraisal of stroke evaluation and rating scales, Stroke
22 (1991) 13451352.
[3] Tissue plasminogen activator for acute ischemic stroke. The National Institute of
Neurological Disorders and Stroke rt-PA Stroke Study Group, N. Engl. J. Med. 333
(1995) 15811587.
[4] P. Lyden, T. Brott, B. Tilley, et al., Improved reliability of the NIH Stroke Scale using
video training. NINDS TPA Stroke Study Group, Stroke 25 (1994) 22202226.
[5] M.J. Alberts, G. Hademenos, R.E. Latchaw, et al., Recommendations for the establishment of primary stroke centers. Brain Attack Coalition, JAMA 283 (2000)
31023109.
[6] J.S. McKinney, Y. Deng, S.E. Kasner, J.B. Kostis, Myocardial Infarction Data Acquisition
System Study G, Comprehensive stroke centers overcome the weekend versus
weekday gap in stroke treatment and mortality, Stroke 42 (2011) 24032409.
[7] E.C. Jauch, J.L. Saver, H.P. Adams Jr., et al., Guidelines for the early management of
patients with acute ischemic stroke: a guideline for healthcare professionals from
the American Heart Association/American Stroke Association, Stroke 44 (2013)
870947.
[8] R.T. Cheung, P.D. Lyden, T.H. Tsoi, et al., Production and validation of Putonghua
and CantoneseChinese language National Institutes of Health Stroke Scale training
and certication videos, Int. J. Stroke 5 (2010) 7479.
[9] C. Cincura, O.M. Pontes-Neto, I.S. Neville, et al., Validation of the National Institutes
of Health Stroke Scale, modied Rankin Scale and Barthel Index in Brazil: the role
of cultural adaptation and structured interviewing, Cerebrovasc. Dis. 27 (2009)
119122.

[10] R. Dominguez, J.F. Vila, F. Augustovski, et al., Spanish cross-cultural adaptation and
validation of the National Institutes of Health Stroke Scale, Mayo Clin. Proc. 81
(2006) 476480.
[11] Y. Nilanont, S. Phattharayuttawat, P. Chiewit, et al., Establishment of the Thai version
of National Institute of Health Stroke Scale (NIHSS) and a validation study, J. Med.
Assoc. Thai. 93 (Suppl. 1) (2010) S171S178.
[12] M.S. Oh, K.H. Yu, J.H. Lee, et al., Validity and reliability of a Korean version of the
National Institutes of Health Stroke Scale, J. Clin. Neurol. 8 (2012) 177183.
[13] F.R. Pezzella, O. Picconi, A. De Luca, P.D. Lyden, M. Fiorelli, Development of the Italian
version of the National Institutes of Health Stroke Scale: It-NIHSS, Stroke 40 (2009)
25572559.
[14] K. Prasad, D. Dash, A. Kumar, Validation of the Hindi version of National Institute of
Health Stroke Scale, Neurol. India 60 (2012) 4044.
[15] SIL Ethnologue, 17th, 2015. http://www.ethnologue.com/statistics/size. Accessed
November 2014 [online].
[16] H.T. Benamer, R.A. Shakir, The neurology map of the Arab world, J. Neurol. Sci. 285
(2009) 1012.
[17] M. Bullinger, J. Alonso, G. Apolone, et al., Translating health status questionnaires
and evaluating their quality: the IQOLA Project approach. International Quality of
Life Assessment, J. Clin. Epidemiol. 51 (1998) 913923.
[18] B. Gandek, J.E. Ware Jr., Methods for validating and norming translations of health
status questionnaires: the IQOLA Project approach. International Quality of Life
Assessment, J. Clin. Epidemiol. 51 (1998) 953959.
[19] P.A. Barber, M.D. Hill, M. Eliasziw, et al., Imaging of the brain in acute ischaemic
stroke: comparison of computed tomography and magnetic resonance diffusionweighted imaging, J. Neurol. Neurosurg. Psychiatry 76 (2005) 15281533.
[20] C. de Margerie-Mellon, G. Turc, M. Tisserand, et al., Can DWI-ASPECTS substitute for
lesion volume in acute stroke? Stroke 44 (2013) 35653567.
[21] R. Bonita, R. Beaglehole, Recovery of motor function after stroke, Stroke 19 (1988)
14971500.
[22] P.M. Janssen, N.A. Visser, S.M. Dorhout Mees, C.J. Klijn, A. Algra, G.J. Rinkel, Comparison of telephone and face-to-face assessment of the modied Rankin Scale,
Cerebrovasc. Dis. 29 (2010) 137139.
[23] P. Lyden, R. Raman, L. Liu, et al., NIHSS training and certication using a new digital
video disk is reliable, Stroke 36 (2005) 24462449.
[24] B.C. Meyer, P.D. Lyden, The modied National Institutes of Health Stroke Scale: its
time has come, Int. J. Stroke 4 (2009) 267273.

Please cite this article as: H.M. Hussein, et al., Arabic cross cultural adaptation and validation of the National Institutes of Health Stroke Scale, J
Neurol Sci (2015), http://dx.doi.org/10.1016/j.jns.2015.07.022