1a. Level of consciousness (LOC)*
The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, or orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.
0 = Alert; keenly responsive.
1 = Not alert, but arousable by minor stimulation to obey, answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or is totally unresponsive, flaccid, and areflexic.
1b. LOC questions
The patient is asked the month and his or her age. The answer must be correct—there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions are given a score of 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a score of 1. It is important that only the initial answer be graded and that the examiner not “help” the patient with verbal or nonverbal cues.
0 = Answers both questions correctly.
1 = Answers one question correctly.
2 = Answers neither question correctly.
1c. LOC commands
The patient is asked to open and close the eyes and then to grip and release the nonparetic hand. Substitute another one-step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime) and the result scored (ie, follows no, one, or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored.
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
2. Best gaze
Only horizontal eye movements are tested. Voluntary or reflexive (oculocephalic) eye movements are scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score is 1. If a patient has an isolated peripheral nerve paresis (cranial nerve III, IV, or VI), the score is 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, preexisting blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy.
0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver.
Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If the patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a score of 1, and the results are used to respond to item 11.
0 = No vision loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
4. Facial palsy*
Ask, or use pantomime to encourage, the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or noncomprehending patient. If facial trauma/bandages, orotracheal tube, tape, or other physical barriers obscure the face, these should be removed to the extent possible.
0 = Normal symmetric movements.
1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling).
2 = Partial paralysis (total or near-total paralysis of lower face).
3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face).
5. Motor arm
The limb is placed in the appropriate position: extend the arms (palms down) 90° (if sitting) or 45° (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the nonparetic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice.
- 5a. Left arm
- 5b. Right arm
0 = No drift; limb holds 90° (or 45°) for full 10 seconds.
1 = Drift; limb holds 90° (or 45°), but drifts down before full 10 seconds; does not hit bed or other support.
2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90° (or 45°), drifts down to bed, but has some effort against gravity.
3 = No effort against gravity; limb falls.
4 = No movement.
6. Motor leg
The limb is placed in the appropriate position: hold the leg at 30° (the patient is always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the nonparetic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice.
- 6a. Left leg
- 6b. Right leg
0 = No drift; leg holds 30° position for full 5 seconds.
1 = Drift; leg falls by the end of the 5-second period but does not hit bed.
2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity.
3 = No effort against gravity; leg falls to bed immediately.
4 = No movement.
7. Limb ataxia*
This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with the patient's eyes open. In case of visual defect, ensure that testing is done in the intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice. In case of blindness, test by having the patient touch the nose from an extended arm position.
0 = Absent.
1 = Present in 1 limb.
2 = Present in 2 limbs.
Sensation or grimace to pinprick when tested, or withdrawal from a noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal, and the examiner should test as many body areas [arms (not hands), legs, trunk, face] as needed to check accurately for hemisensory loss. A score of 2, “severe or total sensory loss,” should be given only when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a score = 3) are automatically given a 2 on this item.
0 = Normal; no sensory loss.
1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on affected side, or there is loss of superficial pain with pinprick, but patient is aware of being touched.
2 = Severe to total sensory loss; patient is not aware of being touched on face, arm, and leg.
9. Best language
A great deal of information about comprehension is obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the test picture, to name the items on the test naming sheet, and to read from the test list of sentences. Comprehension is judged from responses here as well as responses to all of the commands in the preceding general neurologic examination. If vision loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a score = 3) automatically scores 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands.
0 = No aphasia; normal.
1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. However, reduction of speech and/or comprehension makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient's response.
2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient's response.
3 = Mute, global aphasia; no usable speech or auditory comprehension.
If the patient is thought to be normal, an adequate sample of speech must be obtained by asking the patient to read or repeat words from the test list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN) and clearly write an explanation for this choice. Do not tell the patient why he or she is being tested.
0 = Normal.
1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty.
2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric.
11. Extinction and inattention
Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe vision loss preventing visual double simultaneous stimulation and the responses to cutaneous stimuli are normal, the score is 0. If the patient has aphasia but does appear to attend to both sides, the score is 0. The presence of visual spatial neglect or anosognosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never scored as UN.
0 = No abnormality.
1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities.
2 = Profound hemi-inattention or extinction in more than one modality; patient does not recognize own hand or orients to only 1 side of space.