腦中風(fēng)量表NIHSS2013版本

NIHSS

NationalInstitutesofHealthStrokeScale

腦中風(fēng)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計分說明1.請依項目次序依序填寫(按步就班)

2.每個項目測試完立刻計分，請勿事后再回頭更改分數(shù)(莫回頭)3.請依照受測者之實際表現(xiàn)計分，而不是施測者猜測受測者所能做到的程度

(眼見為實)4.不要反覆教導(dǎo)受測者或重新嘗試，以第一次表現(xiàn)計分(不強求)1aLevelofConsciousness

意識清楚程度

[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,反應(yīng)敏銳1=不清醒,但可藉由輕微的刺激喚醒而遵從指令,反應(yīng),或回答問題2=不清醒,需重復(fù)性刺激才能引起注意;或意識遲鈍,需強大痛刺激才有非重復(fù)性的固定動作3=反應(yīng)僅限于自主或運動神經(jīng)的反射;或?qū)ι钔创碳r完全無反應(yīng),癱弛,甚至失去反射1bLevelofConsciousness

回答問題的意識程度

[Instruction]問兩個問題Askthepatienttheirage…waitfora

response…Askthepatientthecurrentmonth…waitfora

response…Note:Donotcoachorgiveanyverbalornon-verbalcuesOnlyrecordtheinitialanswerThereisnopartialcreditforbeingclose.(答案必須正確無誤,若相近則不算分;ex.問年紀,回答生日)1bLevelofConsciousnessScoring0=Answersbothquestionscorrectly1=Answersonequestioncorrectly2=AnswersneitherquestioncorrectlyScoring0=可正確回答兩個問題1=可正確回答一個問題;或因非失語癥造成的語言障礙,如:氣內(nèi)插管,上呼吸道創(chuàng)傷,嚴重構(gòu)音不全,語言障礙…2=

兩個問題皆無法正確回答;或失語癥或木僵的病人Aphasic,

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

執(zhí)行命令之意識程度

[Instruction]做兩個動作

Askpatient:

-open&closeyoureyes-grip

andreleasethenonparetichand

(若雙手無法使用,如:截肢或創(chuàng)傷,則以其他單一步驟指令取代)Note若病人對指令無反應(yīng)，可以示范動作給他們看(pantomime)

因此檢查是測試consciousness，非musclepower，所以不能以無力肢體的動作計分;也非comprehension，所以可讓病人由模仿動作完成若有熟遵照指令的嘗試性動作出現(xiàn),但由于無力而無法完成整個動作,則仍算”有正確執(zhí)行”Scoreonlythefirstattempt1cLevelofConsciousnessScoring0=Performsbothtaskscorrectly1=Performsonetaskcorrectly2=PerformsneithertaskcorrectlyScoring0=可正確執(zhí)行兩個命令1=可正確執(zhí)行一個命令2=兩個命令均不能正確執(zhí)行昏迷的病人（1a＝3）計2分2.Bestgaze

最佳的眼球運動[Instruction]僅測試眼睛的水平運動(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=部分凝視異常:當(dāng)雙或單眼眼球凝視異常，但并無強迫性偏移或完全癱瘓時(可由反射性眼睛運動所矯正，或單一性周邊神經(jīng)麻痺(第3,4,或6對腦神經(jīng))）2=強直性的偏移,或完全癱瘓而無法用頭眼運動的反射矯正-

Thepatienthasaconjugatedeviationoftheeyesthatcanbeovercomebyvoluntaryorreflexiveactivities(dolleye).-

Thepatienthasanisolatedperipheralnerveparesis(CNIII,IV,VI)3.Visualfield

視野[Instruction]

Testeach

eye

independantly,

upperandlowerquadrants.Confrontationtest,

by

finger

counting

or

visualthreatening

(forpoorconsciousness,aphasia,languagebarrier)Note若病患眼睛能適當(dāng)注視動作中手指的方向，雖未直視檢視者眼睛，以正常計分若單眼盲，用另眼的視野測試做計分。

若兩眼不一致，用較佳者計分?？勺鲰槺阕鰀oublesimultaneousstimulation(foritem11)3.VisualfieldScoring0=Novisualloss1=Partialhemianopia(sectororquadrantanopia)2=Completehemianopia3=Bilateralhemianopia(blind

from

any

cause,includingcorticalblindness)Scoring0=無視覺喪失1=部分偏盲2=完全偏盲3=兩側(cè)偏盲-

Withclear-cutasymmetry-

Hemineglect

by

double

simultaneous

stimulation

(even

if

field

are

intact

by

confrontation，因為當(dāng)病人的hemineglect很嚴重的時候,其visualfield可能會變得比較小4.Facialpalsy

顏面神經(jīng)麻痹[Instruction]

Askthepatientorusepantomime

-Showmeyourteeth

(說”一”)fewerteethshowing?

-Raiseyoureyebrows

(皺眉頭)

-Closeyoureyestightly

(緊閉眼)Intheaphasicorconfusedpatient:

noxiousstimulation

Scoresymmetryofgrimace(tickleeachnasalpassageoneatatimeusingacotton-tippedapplicatorandobservefacialmovement)Note:

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

ormildasymmetry

onsmiling)2=Partialparalysis(totalorneartotalparalysisoflower

face)3=Completeparalysisofoneorbothsides(absenceof

facialmovementintheupperandlowerface)Scoring0=正常1=輕微癱瘓(鼻唇間皺褶變平,微笑時不對稱)2=部分癱瘓(下半部的臉完全或幾乎癱瘓)3=單側(cè)或雙側(cè)完全癱瘓(上和下半部的臉均無法運動)5.Motor:Arms

(a:leftarm,b:rightarm)

運動系統(tǒng):上肢[Instruction]Placethelimbintheappropriateposition:Extendthearms(palmsdown)-45degreeasthepatientissupine

-90degreeasthepatientissittingupScorethedriftbeforefull

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

運動系統(tǒng):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=無下垂,可維持90(或45)度完整10

(5)秒鐘1=晃動,肢體可維持90(或45;30)度,但在10(5)秒鐘內(nèi)會下垂,但不會撞到床上或其他支持物2=可稍抗重力,肢體不能達到或維持(給予暗示)90(或45;30)度,會下垂至床上,但仍有些許抗重力的力量Musclepower:35.Motor:Arms&6.Legs

Scoring3=Noeffortsagainstthegravity-

thearmfalls;butcould“shrugtheshoulders”-thelegfalls;butcouldflexthehiporadduct/abductthefoot4=Nomovement(unabletomakeanyvoluntarymovements;orifIaitemscoredas“3”)Scoring3=無法抗拒重力,肢體落下4=無任何移動Todifferentiatefromscore3to4,mustwaitforsecondstoobservethemovement

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

肢體運動失調(diào)[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=無此現(xiàn)象1=出現(xiàn)于一肢體2=出現(xiàn)于兩只體昏迷的病人（1a＝3）計0分8.Sensory

感覺[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=輕微致中等程度的感覺缺失2=嚴重或完全的感覺缺失昏迷的病人（1a＝3）計2分Brainstem

stroke

with

bilateral

sensory

lossDoes

not

respond

and

quadriplegicComatous

status

(1a=3)9.Bestlanguage

語言[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）計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.

你吃飯了嗎請猜猜看，我是誰再見，下星期三這里見星期六，我們約好要去逛街大頭、大頭，下雨不愁，人家有傘、我有大頭

Describe“whatishappening“inthepicture9.BestLanguage

Scoring

0=Noaphasia,normalfluencyandcomprehension

1=Mildtomoderateaphasia:2=Severeaphasia:3=Mute,globalaphasia:nouseablespeech,noauditorycomprehension.Patientunabletofollowanyonestepcommands.Scoring0=正常1=輕微致中等程度的感覺缺失(在表達上并無侷限性,檢測者仍可從病人的反應(yīng)辨認其卡片或文字)2=嚴重或完全的感覺缺失(零碎及片段的溝通,檢測者需推論.詢問.及猜測病人的表達)3=靜默,完全失語癥(無任何有用的語言或聲音的理解能力)昏迷的病人（1a＝3）計3分someobviouslossoffluencyorcomprehension,butnosignificantlimitationonideaexpressionorformofproduction(ableto“gettheirideasacross”)allthepatient’sexpressioniffragmentary,communicationlimited,examinercannotidentifythecontentfromthepatient’sresponse(mustguesswhatthepatientistryingtocommunicate)10.Dysarthria

構(gòu)音障礙[Instruction]Anadequatesampleofspeechmustbeobtainedbyaskingpatienttoreadorrepeatwordsfromtheattachedlistevenifpatientisthoughttobenormal

Ifthepatienthasaphasia,theclarityofarticulationofspontaneousspeech

canberatedNoteUN(untestable)=IntubatedorotherphysicalbarrierRead/Repeatthewordsfromtheattachedlist爸爸媽媽啦啦隊踢踏舞負負得正絲絲入扣可口可樂MAMATIP-TOPFIFTY-FIFTYTHANKSHUCKLEBERRYBASEBALLPLAYER10.Dysarthria

Scoring0=Normal1=Mildtomoderatedysarthria(patientslurssomewordsbutcanbeunderstood)2=Severedysarth