NIHSS u Neurologiji: Standardizovana Procena Akutnog Ishemijskog Moždanog Udara
NIH Stroke Scale je referentni instrument neurološke procene u akutnoj fazi moždanog udara i deo je standardnih radnih protokola jedinica za mozdani udar u Srbiji i celom svetu. Skala kvantifikuje neurološki deficit kroz 11 sistematizovanih kliničkih testova i pruža numeričku vrednost koja omogućava objektivno poređenje između vremenskih tačaka, ispitivača i ustanova. Mediately platforma pruža digitalni NIHSS alat prilagođen kliničkom okruženju, sa strukturisanim protokolom procene korak po korak.
Zasto je NIHSS Standardni Instrument u Neurologiji
NIHSS je jedina skala procene tezine mozdanog udara sa visokim nivoom dokaza o pouzdanosti, validnosti i kliničkoj korisnosti u akutnoj fazi. Nekoliko karakteristika čine je nezamenjivom u neurološkoj praksi:
Visoka interrater pouzdanost
Kada se primenjuje od strane uvežbanih ispitivača, koeficijent interrater saglasnosti za NIHSS je visok (kappa iznad 0,6 za vecinu stavki). Standardizovana obuka i video-sertifikacija dodatno povecavaju konzistentnost.
Prediktorska vrednost
Inicijalni NIHSS skor statistički korelira sa funkcionalnim ishodom na tromesečnoj kontroli. Pacijenti sa skorom ispod 6 pri prijemu imaju veće šanse za dobar funkcionalni oporavak (mRS 0-2), dok pacijenti sa skorom iznad 20 imaju znacajno veći rizik od lošeg ishoda.
Integracija u terapijske smernice
ESO i AHA/ASA smernice eksplicitno pominju NIHSS skor kao kriterijum u algoritmima za trombolizu, trombektomiju i pracenje. Koriscenje standardizovane skale olakšava primenu ovih smernica u kliničkoj praksi.
Komunikacija i dokumentacija
Numerička vrednost skora pruža jednoznačnu informaciju pri konziliarnim pregledima, multidisciplinarnim razgovorima i medicinskoj dokumentaciji, bez potrebe za opisnim parafraziranjem neurološkog nalaza.
Primena u Razlicitim Klinickim Okruženjima
Klinicko okruženje
Primena NIHSS
Urgentni prijem
Inicijalna trijaza i dokumentacija pre neuroimaging
Jedinica za mozdani udar
Serijsko pracenje, posttrombolitička procena
Neurointenzivna nega
Detekcija pogoršanja, procena efekta intervencije
Rehabilitaciono odeljenje
Kvantifikacija rezidualnog deficita pri ulasku u program
Ambulantna kontrola
Pracenje dugorocnog oporavka i funkcionalne reintegracije
NIHSS — procena težine moždanog udara
NIH Stroke Scale — neurološka procena akutnog ishemijskog moždanog udara
No stroke symptoms
0
1. a) Level of Consciousness
Alert; keenly responsive
The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation.
1. b) Ask for the current month and his/her age
Both questions correct
The answer must be correct - there is no partial credit for being close. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues.
1. c) Ask to blink eyes and squeeze hands
Performs both tasks correctly
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 (i.e., follow s none, 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.
2. Test horizontal extraocular movements
Normal
If a patient has an isolated peripheral nerve paresis(CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing 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.
3. Test visual fields
No visual loss
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.
4. Test facial palsy
Normal (symmetrical movements)
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 non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible.
5. a) Test left arm motor drift
No drift for 10 Seconds
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (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 non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).
5. b) Test right arm motor drift
No drift for 10 Seconds
The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (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 non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN).
6. a) Test left leg motor drift
No drift for 5 seconds
The limb is placed in the appropriate position: hold the leg at 30 degrees (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 non-paretic 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.
6. b) Test right leg motor drift
No drift for 5 seconds
The limb is placed in the appropriate position: hold the leg at 30 degrees (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 non-paretic 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.
7. Test limb ataxia
No ataxia
This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in 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. In case of blindness, test by having the patient touch nose from extended arm position.
8. Test sensation
Normal (no sensory loss)
Sensation or grimace to pinprick when tested, or withdrawal from 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 accurately check for hemisensory loss.
9. Test language
No aphasia; normal
If visual 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 examiner must choose a score for the patient with stupor or limited cooperation, but global aphasia answer should be used only if the patient is mute and follows no one-step commands.
10. Test dysarthria
Normal
If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words. 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. Do not tell the patient why he or she is being tested.
11. Test extinction and inattention
No abnormality
Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable.
NIHSS i Klasifikacija po TOAST Kriterijumima
NIHSS skor se u klinickoj praksi cesto koristi paralelno sa TOAST klasifikacijom podtipova ishemijskog mozdanog udara (kardioembolijski, lakunarni, aterosklerotska bolest velikih sudova, druge i neodređene etiologije). Inicijalni NIHSS profil može ukazati na verovatniji podtip, mada je dijagnoza podtipa odredjena neuroimaging i kardiološkim nalazima, a ne iskljucivo klinickim skorom.
Kada Primeniti NIHSS u Neurološkoj Praksi
Na urgentnom neurološkom pregledu svakog pacijenta sa akutnim fokalnim neurološkim deficitom, bez obzira na vreme nastanka simptoma
U okviru timskih vizita u jedinici za mozdani udar u standardnim vremenskim tackama tokom hospitalizacije
Pri neurološkom konzilijarnom pregledu pacijenta transferovanog iz druge ustanove radi standardizacije polazne vrednosti
Kao deo dokumentacije pri ukljucivanju pacijenta u registar mozdanog udara ili klinicku studiju
Pri proceni indikacija za uputivanje na sekundarnu preventivnu obradu i rehabilitacijski tretman
Ogranicenja u Klinickoj Neurologiji
NIHSS nije podjednako osetljiva za sve anatomske lokalizacije; infarkti zadnje jame (cerebelum, mozdano stablo) mogu biti klinički znacajni uz NIHSS vrednost ispod 4.
Skala ne procenjuje domene koji su relevantni za funkcionalni oporavak poput egzekutivnih funkcija, memorije, pažnje i neuropsihijatrijskih posledica mozdanog udara.
Prisustvo afazije ili poremecaja svesti ogranicava mogucnost procene nekih stavki i zahteva pažljivo beleženje svake neocenjive stavke.
Skala nije validovana za pedijatrijske pacijente niti za procenu tranzitornog ishemijskog ataka (TIA) bez rezidualnog deficita.
Cesto Postavljana Pitanja
Postoji li razlika izmedju originalnog i modifikovanog NIHSS?
Modifikovanani NIHSS (mNIHSS) ukljucuje 11 od originalnih 15 stavki (u ranijim verzijama skala je imala više stavki) i beleži slicnu prediktorsku vrednost uz nešto manje varijabilnosti. U Srbiji i vecini zemalja, primenjuje se standardna forma skale od 11 stavki sa ukupnim rasponom od 0 do 42. Konsultujte protokole Vaše ustanove o tome koja verzija skale je u upotrebi.
Da li NIHSS može biti primenjen u telemedicinskom okruženju?
Telestroke programi omogucavaju primenu NIHSS putem video veze u ustanovama bez neurologa u dežurstvu. Validacione studije pokazuju da je pouzdanost NIHSS procene putem telemedicine prihvatljiva kada su tehnickih uslovi odgovarajuci. Pristupite smernicama ESO za telemedicinu u mozdanom udaru za detalje o implementaciji.
Kakav je znacaj NIHSS u kontekstu posteriornog cirkulatornog mozdanog udara?
Infarkti zadnje jame, posebno cerbelarni, mogu dovesti do klinički znacajnog deficita (mućnina, vrtoglavica, ataksija, disfagija) uz NIHSS skor od 0 do 3. Stavka ataksije i dizartrije delimicno hvata ove deficite, ali skala nije optimizovana za posterior cirkulaciju. Pristupite specijalizovanim skoring sistemima za zadnju jamu (npr. pc-NIHSS) i ESO smernicama za posterior cirkulaciju.
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