脑中风量表NIHSS2013版本

NIHSS

NationalInstitutesofHealthStrokeScale

脑中风量表NIHSS2013版本2013.05.11Originallydesignedasaresearchtooltomeasurebaselinedataonpatientsinacutestrokeclinicaltrials15-itemscoringsystemIntegratingcomponentsofneurologicexaminations:LOC,selectcranialnerves,motor,sensory,cerebellarfunction,language,inattention(neglect)Ratingsforeachitemhave

3~5

grades;

0asnormalMaximumscore:42,minimumscore:0Higherscore,severeclinicalconditionAsinglepatientassessmentrequireslessthan10minutestocomplete.

IntroductionUsefulnessofNIHSSAs

a

common

language

amongst

health-care

providersGood

interrater

and

intrarater

agreement,

especially

if

rater

is

neurologistEnhanced

reliability

of

examiner

trained

and

certifiedCould

be

estimated

from

medical

record

reviewStratify

stroke

severity

and

decision

of

thrombolysis>25

very

severe

neurological

impairment15-24

severe5-14

moderately

severe<5

mildICH

after

IV-rtPANIHSS<10:3%ICHafterthrombolysisNIHSS>20:17%ICH

afterthrombolysisThrombolysis

indicated!!(NINDS

stroke

study,

Stroke

1997)(Brottetal,1989)UsefulnessofNIHSSForfollow-up:improvementordeterioration

2-point

or

greater

increase

in

NIHSS

stroke

in

evolutionForprognosispredictionBaselineNIHSSstronglypredictsoutcome

Outcomeby7daysand90days≥16lessthan20%chanceofachievingexellentoutcome,highprobabilityofdeathorseveredisability≤6goodrecoveryPredictorofhospitaldispositionbasedoninitialNIHSS<=580%strokesurvivorsdischargedtohome6-13inpatientrehabilitation>13dischargetonursingfacility(Adamsetal,Neurology1999)(Schlegaletal.,Stroke2003)NihssANDPATIENTOUTCOMENIHSSGuidingPrinciplesThemostreproducibleresponse,acceptforpatient’sfirsteffort(exceptforlanguage~forbestperformance)DonotcoachorcuethepatientsunlessspecifiedintheinstructionsSomeitemsarescoredonlyifdefinitelypresent

(ataxia,hemineglect)Follownumericalorder~donotbackandchangethescoreScorewhatyousee,notwhatyouthinkyoushouldsee.Recordalldeficitsinscoring,includingthosedeficitsthatmayresultfrompreviousstrokes计分说明1.请依项目次序依序填写(按步就班)

2.每个项目测试完立刻计分，请勿事后再回头更改分数(莫回头)3.请依照受测者之实际表现计分，而不是施测者猜测受测者所能做到的程度

(眼见为实)4.不要反覆教导受测者或重新尝试，以第一次表现计分(不强求)1aLevelofConsciousness

意识清楚程度

[Instruction]

Determinedthroughinteractionswiththepatient

Auditorystimulation(normalloudvoice)

TactileordeeppainstimulationTheinvestigatormustchoosearesponseifafullevaluationispreventedbysuchobstaclesas~ETT,languagebarrier,orotrachealtrauma/bandage.1aLevelofConsciousnessScoring0=Alert;keenlyresponsive1=Notalert,butarousablebyminorstimulationtoobey,answerorrespond2=Notalert,requiresrepeatedstimulation

toattend;oris

obtundedandrequiresstrongorpainful,noxiousstimulation

tomakemovements3=Respondsonlywithreflexmotororautonomiceffects

ortotallyunresponsive,flaccidScoring0=清醒,反应敏锐1=不清醒,但可藉由轻微的刺激唤醒而遵从指令,反应,或回答问题2=不清醒,需重复性刺激才能引起注意;或意识迟钝,需强大痛刺激才有非重复性的固定动作3=反应仅限于自主或运动神经的反射;或对深痛刺激时完全无反应,瘫弛,甚至失去反射1bLevelofConsciousness

回答问题的意识程度

[Instruction]问两个问题Askthepatienttheirage…waitfora

response…Askthepatientthecurrentmonth…waitfora

response…Note:Donotcoachorgiveanyverbalornon-verbalcuesOnlyrecordtheinitialanswerThereisnopartialcreditforbeingclose.(答案必须正确无误,若相近则不算分;ex.问年纪,回答生日)1bLevelofConsciousnessScoring0=Answersbothquestionscorrectly1=Answersonequestioncorrectly2=AnswersneitherquestioncorrectlyScoring0=可正确回答两个问题1=可正确回答一个问题;或因非失语症造成的语言障碍,如:气内插管,上呼吸道创伤,严重构音不全,语言障碍…2=

两个问题皆无法正确回答;或失语症或木僵的病人Aphasic,

stuporous,comatous(item1a=3)patientswhodonotcomprehendthequestionPatientunabletospeakduetoETT,orotrachealtrauma,severedysarthriafromanycause,languagebarrier,oranyotherproblemsnotsecondarytoaphasia昏迷的病人（1a＝3）计2分1cLevelofConsciousness

执行命令之意识程度

[Instruction]做两个动作

Askpatient:

-open&closeyoureyes-grip

andreleasethenonparetichand

(若双手无法使用,如:截肢或创伤,则以其他单一步骤指令取代)Note若病人对指令无反应，可以示范动作给他们看(pantomime)

因此检查是测试consciousness，非musclepower，所以不能以无力肢体的动作计分;也非comprehension，所以可让病人由模仿动作完成若有熟遵照指令的尝试性动作出现,但由于无力而无法完成整个动作,则仍算”有正确执行”Scoreonlythefirstattempt1cLevelofConsciousnessScoring0=Performsbothtaskscorrectly1=Performsonetaskcorrectly2=PerformsneithertaskcorrectlyScoring0=可正确执行两个命令1=可正确执行一个命令2=两个命令均不能正确执行昏迷的病人（1a＝3）计2分2.Bestgaze

最佳的眼球运动[Instruction]仅测试眼睛的水平运动(voluntaryorreflexive)Askthepatientto“followmyfinger

(tracking)”fromsidetosidebymovingtheeyesonlySpontaneouseyemovement

(foraphasicorconfusedpatientsUnconscious,trauma,pre-existingblindnesspatients:useoculocephalicmaneuver

(doll’seyesign)Tracking(VOR)

:establishingeyecontactandmovingaboutthepatientfromsidetosideandobservingifthepatient’s

eyesfollow2.BestgazeScoring0=Normalhorizontaleyemovements1=Partialgazepalsy:

abnormalityinoneor

botheyes,butforceddeviationisnotpresent2=Tonicgazedeviation,ortotalgazeparesis(not

overcomewithoculocephalicmaneuver)Scoring0=正常1=部分凝视异常:当双或单眼眼球凝视异常，但并无强迫性偏移或完全瘫痪时(可由反射性眼睛运动所矫正，或单一性周边神经麻痺(第3,4,或6对脑神经)）2=强直性的偏移,或完全瘫痪而无法用头眼运动的反射矫正-

Thepatienthasaconjugatedeviationoftheeyesthatcanbeovercomebyvoluntaryorreflexiveactivities(dolleye).-

Thepatienthasanisolatedperipheralnerveparesis(CNIII,IV,VI)3.Visualfield

视野[Instruction]

Testeach

eye

independantly,

upperandlowerquadrants.Confrontationtest,

by

finger

counting

or

visualthreatening

(forpoorconsciousness,aphasia,languagebarrier)Note若病患眼睛能适当注视动作中手指的方向，虽未直视检视者眼睛，以正常计分若单眼盲，用另眼的视野测试做计分。

若两眼不一致，用较佳者计分。可做顺便做doublesimultaneousstimulation(foritem11)3.VisualfieldScoring0=Novisualloss1=Partialhemianopia(sectororquadrantanopia)2=Completehemianopia3=Bilateralhemianopia(blind

from

any

cause,includingcorticalblindness)Scoring0=无视觉丧失1=部分偏盲2=完全偏盲3=两侧偏盲-

Withclear-cutasymmetry-

Hemineglect

by

double

simultaneous

stimulation

(even

if

field

are

intact

by

confrontation，因为当病人的hemineglect很严重的时候,其visualfield可能会变得比较小4.Facialpalsy

颜面神经麻痹[Instruction]

Askthepatientorusepantomime

-Showmeyourteeth

(说”一”)fewerteethshowing?

-Raiseyoureyebrows

(皱眉头)

-Closeyoureyestightly

(紧闭眼)Intheaphasicorconfusedpatient:

noxiousstimulation

Scoresymmetryofgrimace(tickleeachnasalpassageoneatatimeusingacotton-tippedapplicatorandobservefacialmovement)Note:

Ifthefacialtraumaremovethebandageorotherphysicalbarrierthatmightobscuretheface昏迷的病人（1a＝3）计2分4.FacialpalsyScoring0=Normalsymmetricalmovement1=Minorparalysis:(i.e.,flattenednasolabialfold,

ormildasymmetry

onsmiling)2=Partialparalysis(totalorneartotalparalysisoflower

face)3=Completeparalysisofoneorbothsides(absenceof

facialmovementintheupperandlowerface)Scoring0=正常1=轻微瘫痪(鼻唇间皱褶变平,微笑时不对称)2=部分瘫痪(下半部的脸完全或几乎瘫痪)3=单侧或双侧完全瘫痪(上和下半部的脸均无法运动)5.Motor:Arms

(a:leftarm,b:rightarm)

运动系统:上肢[Instruction]Placethelimbintheappropriateposition:Extendthearms(palmsdown)-45degreeasthepatientissupine

-90degreeasthepatientissittingupScorethedriftbeforefull

10seconds昏迷的病人（1a＝3）计4分6.Motor:Legs(a:leftleg,b:rightleg)

运动系统:下肢[Instruction]Placethelimbintheappropriateposition:Alwaystesttheleginthesupineposition

-extendingthelegat

30degreeScorethedriftbeforefull

5secondsNoteBegincountimmediatelyatthereleaseofthelimbsScorethedriftbefore10seconds(or5sec)Count

down

out

loud

and

with

fingers

in

the

patient’s

view

verbal+visualinputEncouragedusingurgencyinthevoice&pantomine

for

aphasic

patientsBeginfromthenon-pareticlimbsDonottestbotharmssimultaneouslyNoxiousstimulationwasnotallowedUN(untestable

or

usethescore“9”):onlyintheamputation

or

jointfusion5.Motor:Arms&6.Legs

Scoring0=Nodriftandremainthepositionforthefull10(5)

seconds

afteranyinitialdip1=Drift(thearmjerksordroptotheintermediatepositionwithoutencounteringthesupport,suchasthebedbeforefull10

(5)

seconds)2=Someeffortagainstgravity(butthearm/legcannotgettoormaintaintheproperposition,driftdowntosomesupport)Scoring0=无下垂,可维持90(或45)度完整10

(5)秒钟1=晃动,肢体可维持90(或45;30)度,但在10(5)秒钟内会下垂,但不会撞到床上或其他支持物2=可稍抗重力,肢体不能达到或维持(给予暗示)90(或45;30)度,会下垂至床上,但仍有些许抗重力的力量Musclepower:35.Motor:Arms&6.Legs

Scoring3=Noeffortsagainstthegravity-

thearmfalls;butcould“shrugtheshoulders”-thelegfalls;butcouldflexthehiporadduct/abductthefoot4=Nomovement(unabletomakeanyvoluntarymovements;orifIaitemscoredas“3”)Scoring3=无法抗拒重力,肢体落下4=无任何移动Todifferentiatefromscore3to4,mustwaitforsecondstoobservethemovement

Anymovements,includingsmallproximalmovement(shouldershrugorhipflexion)score“3”Musclepower:0,1Musclepower:27.Limbataxia

肢体运动失调[Instruction]Test

all

4

limbs

separatelyFinger-Nose-Finger:

ask

patientto

touch

nose

with

finger,

than

touch

examiner’s

HeeltoShin:ask

patient

to

slideoneheeldownshinoftheoppositelegNoteAtaxiaisonlyscoredifpresentTest

with

eyesopenVisualfielddefect

performthetaskintheintactvisualfieldBlindness

havethepatienttouchnosefromextendedarmpositionUN

(untestable):jointeffusion,amputation7.LimbataxiaScoring0=Absent;normalcoordinationThemovementshouldbewell-performed,smooth,accurate,withoutclumsyToo

weak

or

cannot

obey

(cannot

understand

or

comatous

status)

1=Ataxia,dysmetria,ordyssynergiapresentinonelimbOut

of

proportion

to

weakness2=Presentintwolimbs(botharms,bothlegs,oranarm&andlegonthesamesideofthebodyScoring0=无此现象1=出现于一肢体2=出现于两只体昏迷的病人（1a＝3）计0分8.Sensory

感觉[Instruction]Use

sharp

object

for

pinprickCompare

pinprick

in

same

location

on

both

sidesAphasicorstuporouspatientsusingvigorousnoxiousstimuli,suchasnailpressure

record

grimace

or

withdrawal

NoteTest

as

many

body

parts

as

needed

(arm[not

hand],

leg,

trunk)

toaccurately

check

for

hemisensory

loss8.Sensory

Scoring0=Normal,nosensoryloss1=Mildtomoderatesensoryloss;patientisawareofbeingtouchedbutpinprickislesssharp/dullontheaffectedside2=Severeortotalsensoryloss;patientisnotawareofbeingtouchedintheface,armandlegScoring0=正常1=轻微致中等程度的感觉缺失2=严重或完全的感觉缺失昏迷的病人（1a＝3）计2分Brainstem

stroke

with

bilateral

sensory

lossDoes

not

respond

and

quadriplegicComatous

status

(1a=3)9.Bestlanguage

语言[Instruction]Ask

patient

to

perform

the

following:Describewhatishappeningintheattachedpicture

(Spontaneous

speech)Nametheobjects

ontheattachedcard

(Naming)Read

fromtheattachedlistofsentences(Reading)Comprehension:Judged

from

responses

to

all

of

the

commands

in

the

preceding昏迷的病人（1a＝3）计2分NoteIfvisualloss

preventsstandardexamination:-

Askthepatienttoidentifyobjectsplacedinthehand(Naming)-Repeatthesentenceswhatheheard(Repetition)-Askpatienttoproducespeechbyaskingaquestion.(Spontaneousspeech)Theexamistheexceptionfortheruleofscoringthefirstimpression.

Weencourage,butnotcoachtostimulatethepatient’sbestperformance.Patientcanwriteanswers(ex.Intubation…)Mustchooseascoreforthepatientwithstupororlimitedcooperation

(3onlyifthepatientismuteandfollowsnocommands

at

all)NamealltheobjectsonthecardReadallthesentencesfromtheattachedlistYouknowhow.Downtoearth.Igothomefromwork.Nearthetableinthediningroom.Theyheardhimspeakontheradiolastnight.

你吃饭了吗请猜猜看，我是谁再见，下星期三这里见星期六，我们约好要去逛街大头、大头，下雨不愁，人家有伞、我有大头

Describe“whatishappening“inthepicture9.BestLanguage

Scoring

0=Noaphasia,normalfluencyandcomprehension

1=Mildtomoderateaphasia:2=Severeaphasia:3=Mute,globalaphasia:nouseablespeech,noauditorycomprehension.Patientunabletofollowanyonestepcommands.Scoring0=正常1=轻微致中等程度的感觉缺失(在表达上并无侷限性,检测者仍可从病人的反应辨认其卡片或文字)2=严重或完全的感觉缺失(零碎及片段的沟通,检测者需推论.询问.及猜测病人的表达)3=静默,完全失语症(无任何有用的语言或声音的理解能力)昏迷的病人（1a＝3）计3分someobviouslossoffluencyorcomprehension,butnosignificantlimitationonideaexpressionorformofproduction(ableto“gettheirideasacross”)allthepatient’sexpressioniffragmentary,communicationlimited,examinercannotidentifythecontentfromthepatient’sresponse(mustguesswhatthepatientistryingtocommunicate)10.Dysarthria

构音障碍[Instruction]Anadequatesampleofspeechmustbeobtainedbyaskingpatienttoreadorrepeatwordsfromtheattachedlistevenifpatientisthoughttobenormal

Ifthepatienthasaphasia,theclarityofarticulationofspontaneousspeech

canberatedNoteUN(untestable)=IntubatedorotherphysicalbarrierRead/Repeatthewordsfromtheattachedlist爸爸妈妈啦啦队踢踏舞负负得正丝丝入扣可口可乐MAMATIP-TOPFIFTY-FIFTYTHANKSHUCKLEBERRYBASEBALLPLAYER10.Dysarthria

Scoring0=Normal1=Mildtomoderatedysarthria(patientslurssomewordsbutcanbeunderstood)2=Severedysarth