National Institutes of Health Stroke Scale (NIHSS)

National Institutes of Health Stroke Scale (NIHSS) Evaluation Summary

What does the tool measure? Neurologic outcome and degree of recovery for patients with stroke
What types of clients can the tool be used for? Patients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer It takes less that 10 minutes to complete the NIHSS.
Versions 11-item modified NIHSS (mNIHSS); 5-item NIHSS (sNIHSS-5); 8-item NIHSS (sNIHSS-8).
Other Languages Translated in Cantonese for Hong-Kong; Estonian; Hindi; Hungarian; Italian; Marathi; Portuguese; Telugu. Translated and validated in Chinese; German; Spanish.
Measurement Properties
Reliability – No studies have examined the internal consistency of the NIHSS.
– Only one study has examined the test-retest reliability test-retest.
– Out of 11 studies examining the inter-rater reliability inter-rater.
Out of 3 studies examining the inter-rater reliability of the mNIHSS, two studies reported excellent inter-rater, and one study reported that inter-rater was improved with the mNIHSS in comparison to the original NIHSS.
– Only 1 study has examined the intra-rater reliability intra-rater.

Validity Constuct: mNIHSS. The correlation between the original NIHSS and mNIHSS was excellent.
Criterion: Concurrent (original NIHSS). Poor correlations between NIHSS and the Modified Rankin Scale and Barthel Index; adequate to excellent correlations with infarct volumes using computed tomography and excellent correlations using MRI.
Concurrent (mNIHSS). Excellent correlations between mNIHSS and the Modified Rankin Scale, Barthel Index, and Glasgow Outcome Scale were reported in a retrospective analysis, however, in a prospective analysis the mNIHSS had poor concurrent validity with the Barthel Index and modified Rankin Scale. Adequate to excellent correlations have been reported with infarct volumes using computed tomography and excellent correlations using MRI.
Predictive. The NIHSS was found to predict Barthel Index, Rankin Scale, and Glasgow Outcome Scale scores at 3-month outcome; administered in the first 24 hours after stroke onset, the NIHSS can retrospectively predict the next level of care after acute hospitalization; NIHSS also predicted clinical outcome; recovery; the likelihood of a patient’s recovery after stroke; discharge destination; 3-month mortality; presence and location of a vessel occlusion.
Floor/Ceiling Effects A significant ceiling effect has been detected with the NIHSS.
Does the tool detect change in patients? One study assessed the responsiveness of the original NIHSS by comparing the scale scores on patients with stroke to the patients’ infarction size as measured by computed tomography at 1 week. Although most patients improved clinically, 4/15 items changed only minimally.
Acceptability The NIHSS can be administered to virtually any patient with stroke, however, a potential flaw with the NIHSS is that there may be a ceiling effect below the theoretical limit in patients with very severe stroke because many scale items cannot be tested in these patients (Muir, Weir, Murray, Povey, & Lees, 1996). The scale cannot be completed by proxy or by self-report as it is an observational scale. However, measurement by video telemedicine appears to be reliable and could offer a method for remote assessment.
Feasibility It is important to note that one must be both trained and certified in order to administer the NIHSS. Training and certification can be obtained online at the following website:
No specialized equipment is required and relatively little space is needed to administer the NIHSS.
How to obtain the tool? This measurement tool is available from The Brain Attack Coalition: