NIHSS za Pracenje Neurološkog Deficita nakon Moždanog Udara
Serijska primena NIH Stroke Scale tokom hospitalizacije omogućava objektivno praćenje dinamike neurološkog deficita i pruža standardizovanu osnovu za kliničke odluke u jedinici za moždani udar. Svaka promena skora od 4 ili više bodova smatra se klinički značajnim neurološkim događajem koji zahteva hitnu reevaluaciju. Mediately platforma pruža pristup NIHSS alatu prilagođenom kliničkom okruženju za brzo i pouzdano izračunavanje u svim vremenskim tačkama pracenja.
Inicijalna procena pre neuroimaging studija i terapijske odluke
2 sata posle trombolize
Rana procena neurološkog odgovora na alteplazu
24 sata
Standardna procena pri dolasku neuroimaging kontrole
72 sata
Pracenje stabilizacije ili dinamike neurološkog statusa
7 dana / pred otpust
Dokumentovanje rezidualnog deficita i planiranje rehabilitacije
Na svakoj klinickoj promeni
Neurološko pogoršanje, nova simptomatologija ili promena stanja svesti
Klinicki Znaci koji Zahtevaju Hitnu Ponovljenu Procenu
Sledeci nalazi tokom hospitalizacije indikuju potrebu za neodložnom ponovnom primenom NIHSS i klinickom reevaluacijom:
Naglo pogoršanje motorike, govora ili stanja svesti
Pojava novih fokalnih neuroloških znakova koji nisu bili prisutni pri inicijalnoj proceni
Glavobolja novog karaktera ili intenziteta kod pacijenta koji je primio trombolizu
Promena obrasca disanja uz pad GCS
Pacijentovi izveštaj ili navodi pratnje o novim simptomima
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.
Dokumentovanje i Pracenje Promena Skora
Konzistentna dokumentacija NIHSS vrednosti u vremenskom nizu pruža nekoliko klinickih koristi:
Objektivizacija odgovora na terapiju
Poređenje NIHSS skora pre i posle reperfuzione terapije pruža merljiv uvid u efikasnost intervencije. Pad skora od 10 ili više bodova ili postizanje vrednosti 0-1 definise se u literaturi kao znacajno neurološko poboljšanje.
Identifikacija pogoršanja
Porast skora od 4 ili više bodova u odnosu na prethodnu procenu koristi se kao prag za aktiviranje protokola neurološkog pogoršanja, ukljucujuci hitno neuroimaging snimanje za isključivanje hemoragijske transformacije, edema ili rekurentnog dogadjaja.
Planiranje rehabilitacije
Vrednosti NIHSS pri otpustu koriste se zajedno sa modifikovanom Rankinovom skalom (mRS) za procenu funkcionalnog statusa i upucivanje na odgovarajuci oblik rehabilitacije (bolnicka, ambulantna, kucna).
Komunikacija između timova
Standardizovana NIHSS vrednost u medicinskoj dokumentaciji pruža jednoznacnu informaciju pri transferu pacijenta, konziliarnim pregledima i multidisciplinarnim timskim razgovorima.
Kada Primeniti Serijski NIHSS
Kao deo rutinskih neuroloških vizita u svakom obilasku smene u jedinici za mozdani udar
Posle svakog dijagnostickog ili terapijskog postupka koji može uticati na neurološki status
Pri proceni za ranu mobilizaciju i uclanjivanje u rehabilitacioni program
Kod planiranja vremena otpusta u cilju dokumentovanja funkcionalnog statusa pri napuštanju bolnicke nege
Ogranicenja Serijskog Pracenja
Razlike u bodovanju između razlicith ispitivaca (interrater varijabilnost) mogu dati lazni utisak promene skora; preporucuje se da isti ispitivac prati pacijenta kada je to moguce ili da svi ispitivaci prođu standardizovanu obuku.
NIHSS ne procenjuje zamor, kognitivne posledice ni neuropsihijatrijske simptome, koji mogu biti relevantni za ukupan oporavak ali ostaju nevidljivi u ukupnom skoru.
Kod pacijenata sa prethodnim neurološkim deficitom, interpretacija promena skora zahteva poznavanje premorbidnih vrednosti.
Cesto Postavljana Pitanja
Koji stepen pogoršanja NIHSS skora je klinički znacajan?
Prema klinickim studijama i smernicama, porast skora od 4 ili više bodova smatra se klinički znacajnim neurološkim pogoršanjem. Promene od 1 do 3 boda mogu biti posledica varijabilnosti merenja ili spontanih fluktuacija simptoma, posebno kod lakunarnih infarkta i TIA. Konsultujte lokalne protokole Vaše ustanove za upravljanje neurološkim pogoršanjem.
Da li se NIHSS koristi za procenu indikacija za rehabilitaciju?
NIHSS je jedan od parametara koji se uzima u obzir pri proceni potreba za rehabilitacijom, ali nije jedini. Modifikovana Rankinova skala (mRS) i Barthel indeks preciznije opisuju funkcionalni kapacitet. Pristupite smernicama ESO i Društva neurologa Srbije za detaljna uputstva o rehabilitacionom putu pacijenta nakon mozdanog udara.
Koliko dugo posle akutnog udara ima smisla primenjivati NIHSS?
U klinickoj praksi, NIHSS se redovno primenjuje tokom akutne i subakutne bolnicke faze. U kontekstu klinickih studija i registara, pracenje može biti organizovano na tromesecnoj i šestomesecnoj kontroli. Za standardnu klinicku upotrebu, ucestalost pracenja nakon otpusta zavisi od klinickih smernica Vaše ustanove i smernica relevantnih strucnih udruženja.
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