Neuro Scores

NIH Stroke Scale (NIHSS) Calculator

The standard 15-item stroke examination: scores neurological deficit from 0 to 42.

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

1a. Level of consciousness (choose a response even with an endotracheal tube, language barrier or orotracheal trauma; 3 only if no movement other than reflexive posturing to noxious stimulation)

1b. LOC questions: the month and the patient’s age (unable to speak from intubation, orotracheal trauma, severe dysarthria, language barrier or another problem not due to aphasia = 1; aphasic or stuporous and not comprehending = 2)

1c. LOC commands: open and close the eyes, grip and release the non-paretic hand (substitute another one-step command if the hands cannot be used; pantomime if no response; score only the first attempt)

2. Best gaze: horizontal eye movements (conjugate deviation overcome by voluntary or reflexive activity = 1; isolated CN III, IV or VI paresis = 1; testable in all aphasic patients)

3. Visual fields by confrontation (blind from any cause = 3; one blind eye: score the other eye; extinction on double simultaneous stimulation = 1 and counts toward item 11)

4. Facial palsy (score the symmetry of grimace to noxious stimuli in poorly responsive patients)

5a. Motor arm, left (arms out palms down, 90 degrees sitting or 45 degrees supine; drift if the arm falls before 10 seconds)

5b. Motor arm, right

6a. Motor leg, left (leg held at 30 degrees, always supine; drift if the leg falls before 5 seconds)

6b. Motor leg, right

7. Limb ataxia: finger-nose-finger and heel-shin (only if out of proportion to weakness; absent, 0, if the patient cannot understand or is paralyzed)

8. Sensory: pinprick (coma, 1a = 3, scores 2 automatically; bilateral loss from brainstem stroke = 2; no response and quadriplegic = 2)

9. Best language: picture, naming sheet and sentences (coma, 1a = 3, scores 3 automatically; intubated patients write; 3 only if mute and follows no one-step commands)

10. Dysarthria: read or repeat the word list (UN only if intubated or another physical barrier to speech)

11. Extinction and inattention, formerly neglect (never untestable; severe visual loss with normal skin stimuli = 0; aphasic but attends to both sides = 0)

Enter the values to see the result.

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Formula

Total = 1a + 1b + 1c + 2 + 3 + 4 + 5a + 5b + 6a + 6b + 7 + 8 + 9 + 10 + 11, range 0–42
UN (untestable) exists only for the limbs (5a–6b, amputation or joint fusion at the shoulder or hip), ataxia (7, amputation or joint fusion) and dysarthria (10, intubation or another physical barrier); it adds 0 and the reason is written down
Coma (1a = 3): sensory (8) scores 2 and language (9) scores 3 automatically
Give the items in order, record each as you go and do not go back to change scores

How it is used

Baseline score predicts outcome in ischemic stroke: 6 or less forecasts a good recovery and 16 or more a high probability of death or severe disability; 46% at 7–10 and 23% at 11–15 had an excellent 3-month outcome (Adams 1999, TOAST).
A score of 0 does not rule out stroke: posterior-circulation infarcts with headache, vertigo, nausea or truncal ataxia can score 0 (Martin-Schild 2011).
Seven of the 42 points measure language and only 2 measure neglect, so right-hemisphere strokes score lower: below 20, right-hemisphere infarcts were about twice the median volume of left-hemisphere infarcts with the same score (Woo 1999).
Thrombolysis and thrombectomy eligibility weigh the total with whether the deficit is disabling and with imaging, following the 2026 AHA/ASA acute ischemic stroke guideline (Prabhakaran 2026).

Key points

Score what the patient does, not what you think the patient can do, and do not coach except where an item allows it.
A rising score or any new deficit, especially after thrombolysis or thrombectomy, is an emergency: call the stroke team for urgent imaging.

Same formula as the app. Open it in the web app.

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For education and exam preparation only. Follow your institution’s protocols. For education and exam preparation only. Verify results independently and follow your institution’s protocols. Not a substitute for clinical judgment.

NIH Stroke Scale (NIHSS) Calculator

Formula

How it is used

Key points

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