NIHSS Skala za Procenu Težine Moždanog Udara
National Institutes of Health Stroke Scale (NIHSS) je međunarodno prihvaćena klinička skala za standardizovanu procenu neurološkog deficita kod akutnog moždanog udara. Ukupni skor, koji se kreće od 0 do 42, pruža objektivnu osnovu za stratifikaciju pacijenata prema težini kliničke slike i za praćenje dinamike neurološkog statusa u toku lečenja.
Interpretacija NIHSS Skora
| Skor | Kategorija | Klinička karakteristika |
|---|---|---|
| 0 | Bez deficita | Neurološki nalaz u granicama normale |
| 1-4 | Blagi moždani udar | Minimalni neurološki deficit; pacijent obično svestan i komunikativan |
| 5-15 | Umereni moždani udar | Značajni fokalni znaci; komunikacija može biti otežana |
| 16-20 | Umereno teški moždani udar | Izraženi deficit motorike, govora ili svesti |
| 21-42 | Teški moždani udar | Teška poremećenost svesti ili totalna hemiplegija; visok rizik od smrtnog ishoda |
Skor izračunat u prvim satima od nastanka simptoma korelira sa funkcionalnim ishodom u periodu oporavka, a promene vrednosti tokom hospitalizacije pružaju uvid u dinamiku bolesti.
Domen po Domen: Šta NIHSS Procenjuje
NIHSS obuhvata 11 kliničkih domena grupisanih u tri oblasti:
Svest i kognitivna funkcija
- Nivo svesti (budnost, odgovor na stimuluse)
- Odgovori na orijentaciona pitanja (mesec, starost)
- Izvršavanje verbalnih naloga (dvostepenih motornih komandi)
Motorika i koordinacija
- Pokreti pogleda (konjugatna devijacija)
- Vidno polje (hemianopsija)
- Pareza lica (centralna ili periferna)
- Motorika ruku i nogu (graduirani pad pri otporu)
- Ataksija udova (dismetrija)
Senzorni, govorni i perceptivni domeni
- Senzorna funkcija (hemihipestezija)
- Afazija (imenovanje, razumevanje, ponavljanje)
- Dizartrija (artikulacija govora)
- Ekstinkcija i inpažnja (heminegligencija)
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.
Kada Primeniti NIHSS Procenu Težine
- Na urgentnom prijemu pri svakom pacijentu sa akutnim neurološkim deficitom, pre dobijanja rezultata neuroimaging studija
- Kao deo rutinske dokumentacije u jedinicama za moždani udar pri prijemu, nakon 24 sata i pred otpust
- Kod porovnjavanja kliničkog statusa pre i posle intervencije (tromboliza, trombektomija)
- Za standardizovanu komunikaciju između kliničkih timova pri transferu pacijenta
- U kontekstu kliničkih studija i registara moždanog udara koji zahtevaju validovanu meru ozbiljnosti
Ograničenja Skale
- Skala nije podjednako osetljiva za sve lokalizacije infarkta; lezije zadnje jame i malog mozga mogu dati niske NIHSS vrednosti uprkos značajnom kliničkom deficitu.
- NIHSS ne procenjuje depresiju, kognitivne posledice, umor niti kvalitet života, koji su relevantni za dugoročni ishod.
- Lateralnost lezije može uticati na skor: dominantna hemisfera tipično daje viši NIHSS zbog afazije nego lezija nedominantne hemisfere.
- Vrednost skora ne zamenjuje celokupnu kliničku procenu niti neuroimaging nalaz.
Često Postavljana Pitanja
Koji NIHSS skor ukazuje na povoljnu prognozu? Pacijenti sa skorom 1-4 (blagi moždani udar) u proseku imaju bolji funkcionalni ishod. Konsultujte odgovarajuće smernice i klinički kontekst svakog pacijenta jer prognoza zavisi od više faktora, uključujući lokalizaciju lezije, starost i komorbiditete.
Može li NIHSS skor porasti posle inicijalnog pada? Da. Neurološko pogoršanje definiše se kao porast skora od 4 ili više bodova u odnosu na prethodnu procenu i zahteva hitnu kliničku reevaluaciju uz razmatranje neuroimaging studija. Pristupite protokolima Vaše ustanove za upravljanje neurološkim pogoršanjem.
Kako NIHSS korelira sa modifikovanom Rankinovom skalom (mRS)? Inicijalni NIHSS skor statistički korelira sa mRS pri otpustu i na tromesečnoj kontroli. Pacijenti sa visokim NIHSS skorom pri prijemu imaju veću verovatnoću lošeg funkcionalnog ishoda (mRS 3-5), ali korelacija nije apsolutna i klinički ishod zavisi i od vrste terapijskog pristupa i brzine intervencije.
Izvori
- Brott T, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989.
- Adams HP Jr, et al. Classification of subtype of acute ischemic stroke. Stroke. 1993.
- European Stroke Organisation (ESO). Guidelines for Management of Ischaemic Stroke and TIA. 2021.
- American Heart Association / American Stroke Association (AHA/ASA). Early Management of Acute Ischemic Stroke. Stroke. 2019.
- Sulter G, et al. Use of the Barthel Index and Modified Rankin Scale in acute stroke trials. Stroke. 1999.
