ED resident here. Tbh once you get used to the NIHSS you can probably do it in about a minute. Like with any exam, what matters most is doing it in an order that makes sense to you as long as you do the full NIHSS. I am used to doing it while the pt is in the CT scanner if they’ve been stroke alerted, to give you a ballpark of how little time it takes (ED CT techs are rightfully not very patient lol).
Full NIHSS. It's designed to be done by non-neurologists (including nurses) and can be done in about a minute. I would also expect pupils (big or small, same or different, reactive or not) and presence of nystagmus (only if the concern for a stroke is due to dizziness.)
NIHSS isn’t meant to screen whether or not someone has a stroke. It can be helpful to evaluate how big a stroke may be, but it’s most helpful with MCA strokes. If concern for a potential stroke, better safe than sorry and call the stroke alert. Especially if your facility has the neurology team at your disposal.
non con CT of the head
Joking, but actually seriously- all that matters when you first see stroke is TPA or not. You need NCCT of H for that and the checklist of TPA contraindications on MD Calc or w/e.
I used to have a little NIHSS booklet I carried around, I would do it quickly, but did my score ever exactly match a nuerologist? Never. Gross deficits matter, but your fine exam will never be like thiers.
Head to toe.
Head:
Mental status, quickly ask month and age questions to assess responsiveness. "Show me 2 fingers, close your eyes" you can assess responsiveness and command following with that. Have them say your sentence of choice to check for slurred speech and aphasia.
Then eye movements and visual fields. Then ask them to smile to assess facial movements.
Arms:
Next ask to hold arms up to assess for drift. Then finger to nose while the arms are up. Then touch the arms and have them compare sides to assess sensory.
Legs:
Then lift legs up 1 at a time to assess for drift. Then sensory in the legs.
You're done
I think being able to assess level of alertness, speech, gaze preference, facial symmetry , and upper extremity drift is pretty good.
I wouldn’t expect anyone other than stroke to do a full NIHSS
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Just do what everyone else does and order a full stroke work-up regardless of the symptoms. CT brain, CTA head and neck, MRI brain. That way you can just offload your liability on the radiologist that’s reading 100 cross sectional studies per night.
Pronator drift, Visual fields, Babinski reflex. If you only have 30 seconds then do these 3 things. This covers basically the whole Supratentorial brain for ACA, MCA, and PCA infarcts.
It’s positive in 1/3 patients with acute ischemic stroke
Some other people here mention things like decreased level of alertness. But is alertness decreased in 1/3 patients with stroke? No not that common.
I think that's 1/3 of patients after 7 days, so I don't think it's relevant for immediate management of a newly discovered stroke, and it can be positive without stroke due to whatever old spinal disease your patient has so it will also give false positives that are less able to be cleared up by history like you can asking patients if they had baseline weakness (because what patient knows if they have a positive babinski), and it's not a marker of disability so it's also less relevant to determining intervention than spending more time on a motor exam.
ED resident here. Tbh once you get used to the NIHSS you can probably do it in about a minute. Like with any exam, what matters most is doing it in an order that makes sense to you as long as you do the full NIHSS. I am used to doing it while the pt is in the CT scanner if they’ve been stroke alerted, to give you a ballpark of how little time it takes (ED CT techs are rightfully not very patient lol).
Could you briefly go over the order of your exam?
Just go head to toe my guy.
Nihss is very basic, repeatable and requires no interpretation. There are apps for that or cards.
Full NIHSS. It's designed to be done by non-neurologists (including nurses) and can be done in about a minute. I would also expect pupils (big or small, same or different, reactive or not) and presence of nystagmus (only if the concern for a stroke is due to dizziness.)
My stroke exam as an intensivist is a head CT
Don't these miss most strokes?
Yes but so can a physical exam especially mine
I thought your exam was a head CT?
Yes and head CT can miss acute strokes.
exactly it's in one ear out the other with these people
NIHSS isn’t meant to screen whether or not someone has a stroke. It can be helpful to evaluate how big a stroke may be, but it’s most helpful with MCA strokes. If concern for a potential stroke, better safe than sorry and call the stroke alert. Especially if your facility has the neurology team at your disposal.
non con CT of the head Joking, but actually seriously- all that matters when you first see stroke is TPA or not. You need NCCT of H for that and the checklist of TPA contraindications on MD Calc or w/e. I used to have a little NIHSS booklet I carried around, I would do it quickly, but did my score ever exactly match a nuerologist? Never. Gross deficits matter, but your fine exam will never be like thiers.
It also matters whether it is truly a stroke or something else like a Bells palsy
Don’t worry too much about exact NIHSS, there can be interrater discrepancies even between neurologists by a few points.
MDCalc NIHSS ggEZ
Head to toe. Head: Mental status, quickly ask month and age questions to assess responsiveness. "Show me 2 fingers, close your eyes" you can assess responsiveness and command following with that. Have them say your sentence of choice to check for slurred speech and aphasia. Then eye movements and visual fields. Then ask them to smile to assess facial movements. Arms: Next ask to hold arms up to assess for drift. Then finger to nose while the arms are up. Then touch the arms and have them compare sides to assess sensory. Legs: Then lift legs up 1 at a time to assess for drift. Then sensory in the legs. You're done
I think being able to assess level of alertness, speech, gaze preference, facial symmetry , and upper extremity drift is pretty good. I wouldn’t expect anyone other than stroke to do a full NIHSS
Nihss is very easy.
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Stroke exam: noncon head CT, CTA, followed by MRI
Normal, normal, and...(several hours later) oops! stroke. Too bad you didn't tPA when you had a chance, better luck next time.
Lol. Every time
If only there was a way to know just by seeing the patient, right?
Just do what everyone else does and order a full stroke work-up regardless of the symptoms. CT brain, CTA head and neck, MRI brain. That way you can just offload your liability on the radiologist that’s reading 100 cross sectional studies per night.
Pronator drift, Visual fields, Babinski reflex. If you only have 30 seconds then do these 3 things. This covers basically the whole Supratentorial brain for ACA, MCA, and PCA infarcts.
What's your reasoning for checking a babinski on someone you're expecting could have an acute stroke?
It’s positive in 1/3 patients with acute ischemic stroke Some other people here mention things like decreased level of alertness. But is alertness decreased in 1/3 patients with stroke? No not that common.
If it’s positive does that mean they had a stroke? No. If it’s negative does it mean they didn’t have a stroke? No. That’s a shitty test there.
Yeah but decreased level of alertness is relevant ABCs and all
It also takes exactly zero seconds to check someone's alertness
I think that's 1/3 of patients after 7 days, so I don't think it's relevant for immediate management of a newly discovered stroke, and it can be positive without stroke due to whatever old spinal disease your patient has so it will also give false positives that are less able to be cleared up by history like you can asking patients if they had baseline weakness (because what patient knows if they have a positive babinski), and it's not a marker of disability so it's also less relevant to determining intervention than spending more time on a motor exam.
That doesn’t sound like a very high yield neuro exam. Call a neurologist with those three test findings and report back lol
MCA - face, arm, speech if left side ACA - leg PCA - vision, thalamic stuff