NIHSS Scoring for the comatose patient (there are defaults for the comatose patient)

Category Scale Definition Comatose patient Intubated patient

1a. Level of Consciousness: 0=Alert The stuporous patient requires strong Assess and score normally
(Alert, Drowsy, etc.) 1=Drowsy stimulation.
2=Stuporous 3=Comatose, posturing or totally
3=Coma unresponsive.
1b. LOC Questions: 0=Answers both There is no partial credit. 1 is patient with Offer choices: Is your name
(month, age) correctly ET tube, difficulty speaking, not Bill? Were you born in
1=answers one comprehending. If 3 on 1a, use 2 on 1b. 1930?
correctly Ask pt. to nod head to
2=both incorrect correct name and date.
1c. LOC Commands: 0=obeys both 2 is also for comprehensive deficits and assess and score normally
(Open & close eyes, correctly performing incorrectly.
make a fist and let go) 1=obeys one If 3 on 1a, use 2 on 1c
correctly
2=both incorrect
2. Best Gaze: 0=normal If 3 on 1a they can be 1 or 2. 1= gaze is Score normally. Use Doll’s
(eyes follow examiners 1=partial gaze palsy abnormal in one or both eyes, but forced eyes maneuver if they can’t
finger/face horizontally) 2=both incorrect deviation or total gaze paresis is not follow finger or look
present. 2=Forced deviation, or total gaze left/right when asked
paresis not overcome by the
oculocephalic maneuver.(Doll’s eyes—
use if no cervical spine injury suspected).
3. Visual: 0=No visual loss If 3 on 1a, test by using bilateral threat Score normally. You may
(Test visual fields upper 1+Cannot see in 1 need to cover their eye for
and lower quad. On quadrant them. Ask the patient to
both sides) 2=cannot see in 2 nod or blink or point if they
quadrant can
3=cannot see in any see your fingers wiggle.
quadrant Use visual threat if they
cannot participate.
4. Facial Palsy: 0=Normal For the comatose patient: Use noxious The endotracheal tube is
(Show teeth, raise 1=Minor paralysis stimuli on each side of the face to trigger taped/secured to the face
eyebrows, and squeeze 2=Partial paralysis a grimace to evaluate for symmetry. and may affect this score.
eyes shut) 3=Complete paralysis Assessment during a cough
may show facial
movement. If you are
unable to Determine give a
“0” for the score and make
a comment.

5. Motor Arm & Leg: Arms 0=No drift for elapsed Score 4 each Score normally. If the
—extend the arms with time patient has mittens on, you
palms down 90 degrees 1=Drift but does not may need to remove the
if sitting, 45 degrees if hit the bed mittens to best assess the
supine. Drift is scored if 2=Can’t resist gravity patient, then reapply the
arms fall before 10 (drifts to bed) mittens
seconds. 3=No effort against
gravity(falls to bed
6. Begin with non-paretic quickly but can lift
Limb limb)
4=No movement
With legs in supine U=Untestable
position extend legs 30 5a=left arm
degrees. Drift is scored 5b=right arm
if leg falls before 5 6a=left leg
seconds. 6b=right leg
7. Limb Ataxia: 0=Absent If 3 in 1a the patient is 0. Attempt to score normally.
NIHSS Scoring for the comatose patient (there are defaults for the comatose patient)
(Perform finger-nose- 1=Present in one limb At least the arms with
finger and heal to shin 2=Present in 2 limbs finger/nose.
on both sides)
8. Sensory: 0=Normal. No Never mark this as untestable. 2 for the Score normally. Ask them
(Pin-prick to face, arm, sensory loss comatose patient. to point to where they feel
leg, trunk. Compare 1=Mild to moderate you touching them. In the
side to side) loss dual stimulus for extinction,
2=Severe to total loss they need to point to both
sides.
9. Best Language: 0=Normal; No Mark 3 for the comatose patient Test recognition of objects
(Name items; describe aphasia and visual interpretation.
a picture, read 1=Mild to moderate Stick to objects. Hold up
sentences. Test ability aphasia glasses, pens, keys,
to express ideas) 2=Severe Aphasia watches. Give the patient
3=No usable speech; two choices: “Is this a
Mute cup?” “Is this a watch?” ask
the patient to nod when you
offer the correct option.
This is not actual speech so
the NIHSS rules would
have you
score this patient as “UN”.
10 Dysarthria: 0=Normal 2 if mute or cannot understand in any Not testable. Score as 0
(Evaluate speech clarity Articulation way. and write “not testable” in
by having pt. repeat a 1=Mild to Moderate comment.
list of words.) Dysarthria
2=Near to
unintelligible
UN=intubated or
other physical barrier
11. Extinction or 0=No neglect 2 for the comatose patient. you MIGHT be able to test
Inattention: 1=extinction or tactile by touching the right
(Using touch & visual inattention in one and left side simultaneously
stimuli, evaluate for sensory modality and asking them to point to
extinction or (partial neglect) the sides being touched.
inattention). 2=Complete Neglect Attempt visual. Comment
if untestable.
Note: Although the patient is unable to speak, they still may be testable. It takes time and patience. Despite being intubated the
standard of care for stroke assessment; NIHSS and VS MUST be met on all patients. An assessment that is not performed, or
performed poorly has the potential to miss a life-threatening event.  

Also please note: for all stroke patients who receive tPA, if a clinician tells you to discontinue any of the post tPA monitoring you
need to explain to them why these requirements are necessary. The post tPA monitoring requirements cannot be discontinued for
ANY reason.

A patient suspected to be in coma should be stimulated by rubbing on the chest or by using a painful stimulus. A 3 on 1A LOC should
only be score if the patient makes no movement, or postures, in response to the noxious stimuli. If the patient localized or withdraws,
they score better than 3 and must be tested on all NIHSS items.

Remember, for patients who aren’t in stroke coma, if you cannot test an item, you cannot prove the deficit exits and you
should not assume it does. Therefore you would score that item as zero.

EXAMPLE: A patient scores 2 on 1A. LOC but cannot participate in the visual or sensory exam and you cannot confirm that they
only feel or see on side when both are stimulated…… Score Extinction as 0. You can’t prove they are extinguishing one stimulus
when given dual. We don’t score a patient with 1 – 2 in extinction just because they are only looking in one direction. Looking in one
direction means visual field cut but which is score in Vision. Extinction is when a patient can see something on the left and right
individually but, when asked to see them both, sees only one. Extinction contributes to the action of neglect.
NIHSS Scoring for the comatose patient (there are defaults for the comatose patient)
For patients who do get a 3 on item 1A. LOC, items 2, 3 & 4 are to be TESTED/OBSERVED. They should NOT be scored as
the worst.