II. Criteria

  1. Assess Level of Consciousness (0-3 points)
    1. Alert: 0
    2. Alerts to voice: 1
    3. Alerts to pain: 2
    4. Unresponsive: 3
  2. Assess Orientation (0-2 points)
    1. Current Month (1 point if fails)
    2. Patient's own Age (1 point if fails)
  3. Follow Commands (0-2 points)
    1. Open and close eyes (1 point if fails)
    2. Make fist and release (1 point if fails)
  4. Follow my finger (0-2 points)
    1. Normal: 0
    2. Partial gaze palsy: 1
    3. Forced deviation: 2
  5. Visual field (0-3 points)
    1. No visual loss: 0
    2. Partial Hemianopsia: 1
    3. Complete Hemianopsia: 2
    4. Bilateral Hemianopsia: 3
  6. Facial palsy (0-3 points)
    1. Testing: Show teeth, Raise eyebrows, Squeeze eyes shut
    2. Normal symmetric movements: 0
    3. Minor paralysis: 1
    4. Partial paralysis: 2
    5. Complete paralysis: 3
  7. Motor: Left Arm (0-4 points)
    1. Testing: Elevation limb to 90 degrees for 10 seconds
    2. No drift: 0
    3. Drifts (within 10 seconds): 1
    4. Unable to get to and maintain full limb elevation: 2
    5. Unable to move against gravity (limb falls): 3
    6. No movement: 4
  8. Motor: Right Arm (0-4 points)
    1. Testing: Elevation limb to 90 degrees for 10 seconds
    2. No drift: 0
    3. Drifts (within 10 seconds): 1
    4. Unable to get to and maintain full limb elevation: 2
    5. Unable to move against gravity (limb falls): 3
    6. No movement: 4
  9. Motor: Left Leg (0-4 points)
    1. Testing: Elevation limb to 30 degrees for 5 seconds
    2. No drift: 0
    3. Drifts (within 5 seconds): 1
    4. Unable to get to and maintain full limb elevation: 2
    5. Unable to move against gravity (limb falls): 3
    6. No movement: 4
  10. Motor: Right Leg (0-4 points)
    1. Testing: Elevation limb to 30 degrees for 5 seconds
    2. No drift: 0
    3. Drifts (within 5 seconds): 1
    4. Unable to get to and maintain full limb elevation: 2
    5. Unable to move against gravity (limb falls): 3
    6. No movement: 4
  11. Coordination or limb Ataxia (0-2 points)
    1. Testing: Finger-Nose-Finger, Heel-knee-shin
    2. Absent: 0
    3. Present in one limb: 1
    4. Present in both limbs: 2
  12. Sensory (0-2 points)
    1. Test: Pin prick to face, arm, trunk, and legs
    2. Normal: 0
    3. Mild to moderate sensory loss (reduced, dull): 1
    4. Severe or total sensory loss (unaware of touch): 2
  13. Aphasia or Best Language (0-3 points)
    1. Test: Name items, Describe picture, Read sentences
    2. No Aphasia: 0
    3. Mild to moderate Aphasia: 1
    4. Severe Aphasia: 2
    5. Global Aphasia (Mute): 3
  14. Dysarthria (0-2 points)
    1. Normal articulation: 0
    2. Mild to moderate Dysarthria: 1
    3. Severe Dysarthria (nearly unintelligible): 2
    4. Intubated or other physical barrier: N/A
  15. Extinction and Inattention or Neglect (0-2 points)
    1. Testing: Bilateral simultaneous stimulation using one or more sensory modalities (vision, touch, hearing)
    2. No abnormality: 0
    3. Inattention or extinction to single sensory modality: 1
    4. Profound inattention or extinction or to multiple sensory modalities: 2

III. Interpretation

  1. Score 0
    1. No Stroke Symptoms
  2. Score 1-4
    1. Minor Stroke
  3. Score 5-15
    1. Moderate Stroke
  4. Score 16-20
    1. Moderate to Severe Stroke
  5. Score 21-42
    1. Severe Stroke

IV. Resources

V. Reference

  1. Spilker (2000) Stroke Intervent 2:7-14
  2. (2000) Circulation 102(suppl I):I-204 to I-216 [PubMed]

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