Stroke assessment scales are tools doctors use to diagnose and evaluate the severity of strokes, identify any neurological deficits, and measure the effectiveness of stroke interventions. They can also help predict a person’s outlook.
Doctors use these scales in different stages of stroke care, including for prehospital, acute, functional, and outcome assessments.
The scales used in stroke evaluation vary in purpose and scope, but all aim to provide a systematic and standardized way of assessing people with suspected or confirmed stroke.
This article will look at the different stroke scales available.
The National Institutes of Health Stroke Scale (NIHSS) is the primary stroke assessment scale.
According to the
The information obtained from an NIHSS score can help guide treatment decisions, such as whether to administer thrombolytic therapy, which is clot-busting medication, or endovascular therapy, which is the mechanical removal of a blood clot.
The scale evaluates 11 neurological functions, including motor strength, sensation, language ability, and vision. Scores range from 0, meaning no deficit, to 42, meaning severe deficit.
There is also a modified NIHSS scale. This is a simplified version of the scale that only evaluates six neurological functions, including:
- level of consciousness
- motor strength
- language ability
The purpose of a prehospital stroke assessment scale is to quickly and accurately identify people who may be experiencing a stroke.
This helps with getting a person to a stroke center for timely evaluation and treatment.
Some prehospital stroke assessment scales are not used in hospital or emergency department settings. Instead, they are designed for the general public, paramedics, and first responders. These include:
- FAST stroke scale
- Cincinnati Prehospital Stroke Scale (CPSS)
- Los Angeles Prehospital Stroke Scale (LAPSS)
The FAST stroke scale outlines the symptoms of stroke, helping people identify a stroke and contact medical help quickly.
“FAST” stands for:
- Face: One side of a person’s face may droop or become numb. A person’s smile may be uneven.
- Arms: One of the arms may be weak and drift downward if a person lifts it.
- Speech: A person’s speech may be slurred.
- Time: A person should call 911 immediately.
The CPSS is a simple and reliable tool emergency medical services use to identify a stroke quickly. A total score of 2 or 3 suggests a high probability of stroke.
|Facial droop||0: Both sides of the face move equally.|
1: One side of the face does not move.
|Arm drift||0: A person can move both arms equally or not at all.|
1: One arm drifts.
|Speech||0: A person is able to use the correct wording without slurring.|
1: A person’s speech is slurred, they are using inappropriate words, or they are unable to speak.
The LAPSS evaluates the
|Facial droop||No: No facial droop is present.|
Yes: Facial droop is present.
|Hand grip||No: The hand’s grip is normal.|
Yes: The hand’s grip is weak, or the hand is unable to grip.
|Arm strength||No: The arm strength is normal.|
Yes: The arm drifts down or rapidly falls down.
The LAPSS criteria are met if a person experiences the symptoms on one side of the body, not both.
A 2022 article notes that, out of all the prehospital stroke scales, the LAPSS may be the most sensitive and specific test to confirm a stroke diagnosis.
Rapid Arterial oCclusion Evaluation Scale (RACE)
The RACE is a newer prehospital stroke assessment tool that identifies large vessel occlusions requiring urgent treatment. Any score above 0 is a “stroke alert.”
|Facial palsy||0: Absent or symmetrical movement.|
1: Mild or slightly asymmetrical.
2: Moderate or completely asymmetrical.
|Arm motor function||0: A person could hold their arm up for more than 10 seconds.|
1: A person could hold their arm up for less than 10 seconds.
2: A person was unable to raise their arm.
|Leg motor function||0: A person could hold their leg up for more than 5 seconds.|
1: A person could hold their leg up for less than 5 seconds.
2: A person was unable to raise their leg.
|Head and gaze deviation||0: Absent, meaning eye movements were normal and no head deviation occurred.|
1: Present, meaning head and gaze deviation was present.
|Difficulty with language or speech|
A healthcare professional will ask a person to:
1. Close their eyes.
2. Make a fist.
|0: A person was able to perform both orders correctly.|
1: A person was able to perform 1 task correctly.
2: A person was unable to perform either task.
|Ability to recognize and identify people and objects using 1 or more of the senses (agnosia)|
A healthcare professional will ask the questions:
1. “Whose arm is this?” while showing the person their arm (asomatognosia)
2. “Can you move your arm?” (anosognosia)
|0: No signs of agnosia were present.|
1: Anosognosia or asomatognosia was present.
2: Both anosognosia and asomatognosia were present.
Acute assessment scales evaluate the severity of a stroke and identify any neurological deficits that may be present.
Doctors use acute assessment scales in the initial evaluation. The information obtained from an acute assessment scale helps guide treatment decisions.
It can also provide important information about a person’s outlook.
The NIHSS is an acute assessment scale. Other acute assessment scales include:
Glasgow Coma Scale (GCS)
The GCS is a standardized tool used to assess a person’s level of consciousness and neurological function. Scores range from 3, meaning a person is in a deep coma, to 15.
|Opens eyes||4: Opens eyes spontaneously|
3: Opens eyes to verbal command
2: Opens eyes to pain
1: Does not open eyes
|Best motor response||6: Obeys a verbal command|
5: Responds to painful stimuli
4: Pulls limb away from painful stimuli
3: Has abnormal flexion of the limbs due to painful stimuli
2: Shows abnormal extension to pain
1: Has no response to pain
|Best verbal response||5: Oriented, meaning a person is able to converse coherently|
4: Confused conversation, meaning a person is able to respond to a question but confusion is present
3: Inappropriate speech, meaning there is random speech but no conversation
2: Incomprehensible speech, meaning there is moaning but no conversation or words
1: No verbal response
Intracerebral hemorrhage scale (ICH)
The ICH is a specific acute assessment tool that evaluates people with intracerebral hemorrhage or bleeding in the brain. The score ranges from 0–6.
It can help healthcare professionals predict a person’s outlook. A high score suggests a higher chance of mortality, or death.
|GCS||0: A score of 13–15|
1: A score of 5–12
2: A score of 3–4
|Intracerebral hemorrhage volume in milliliters (mL)||0: Less than 30 mL|
1: 30 mL or more
|intraventricular hemorrhage||0: No|
|Infratentorial hemorrhage||0: No|
|Age||0: Under age 80 years|
1: Age 80 years or over
A functional assessment scale can
ADLs are basic self-care tasks that people perform every day,
A functional assessment scale can help identify areas of impairment and determine the level of assistance a person may require to perform these tasks.
These scales are particularly important in stroke rehabilitation, where the goal is to help people regain as much independence as possible.
Therapists can develop a rehabilitation plan tailored to the person’s specific needs and goals. For example, if a person has difficulty with balance and mobility, their rehabilitation plan may include exercises to improve strength and coordination and fall prevention strategies.
There are two functional assessment scales:
- Berg Balance Scale: This assesses a person’s balance and risk of falls. It evaluates
14 differenttasks, such as standing, reaching, and turning. Results indicate the following:
- A score of 0–20 means a person will require a wheelchair.
- A score of 21–40 means a person will be able to walk with assistance.
- A score of 41–56 means a person will be able to walk independently.
- Modified Rankin Scale (mRS): This assesses a person’s
level of disabilityafter a stroke. It evaluates six different levels of disability, which include:
- 0: There are no symptoms.
- 1: There is no significant disability despite the presence of symptoms.
- 2: There is a slight disability.
- 3: There is moderate disability.
- 4: There is moderately severe disability.
- 5: There is severe disability.
Doctors use outcome assessment scales to evaluate a person’s overall functional status and quality of life after treatment.
The purpose of these scales is to measure the effectiveness of stroke interventions and identify areas where further rehabilitation or support may be necessary.
There are two outcome assessment scales:
- Barthel Index: This assesses a person’s
abilityto perform ADLs, such as bathing, dressing, and feeding. It evaluates 10 different tasks, and scores range from 0–100:
- A score of 60 or more means a person requires assistance.
- A score of 40 or less means a person will be severely dependent.
- Glasgow outcomes scale: This assesses a person’s
overall outcomeafter a stroke. It is often used to evaluate outcomes in clinical trials. It evaluates eight different levels of disability, ranging from:
- 1: dead
- 2: vegetative state
- 3: lower severe disability
- 4: upper severe disability
- 5: lower moderate disability
- 6: upper moderate disability
- 7: lower good recovery
- 8: upper good recovery
Stroke assessment scales are tools used to diagnose and evaluate a stroke’s severity and measure the effectiveness of stroke interventions.
There are several different types of stroke assessment scales, including prehospital, acute, functional, and outcome assessment scales.