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Date of assessment
1A. Level of consciousness * If physical obstacles such as tracheal intubation, language barrier, facial or tracheal injury/bandaging prevent a full evaluation, use discretion. Grade “3” should be chosen only in the case when the patient does not react with movements (except for reflex ones) to painful stimuli
0: conscious; reacts quickly
1: stunning; sleepy, but it is possible to wake up with light stimuli, and then follows orders, answers, reacts
2: half-conscious; responds slowly, needs repeated stimulation to participate, is stunned and requires strong or painful stimuli to elicit movements (not patterned)
3: unconscious (coma); reacts only with reflex movements or vegetative manifestations or does not react at all, has low muscle tone, reflexes are absent
1B. Level of consciousness: questions * Ask the patient how old he is and how old he is. The answer must be exact – do not give part of the points for an approximate answer. Patients with aphasia or significant impairment of consciousness who do not understand the question receive a score of “2”. Patients who are unable to speak due to tracheal intubation, facial or tracheal injury/bandage, severe dysarthria (for any reason), language barrier, or other problem not caused by aphasia receive a “1”. It is important to evaluate only the first response and not to help the patient with any words or actions
0: answered both questions correctly
1: answered one question correctly
2: did not give any correct answer
1C. Level of consciousness: commands * Ask the patient to open and close the eyes and make a fist and spread the fingers of the less affected hand. If the fingers cannot be used, give another command that involves one action. When the attempt was clear, but it was not completed due to muscle weakness, a point is awarded for it. If the patient does not understand the verbal command, show the task (using sign language) and evaluate the response (did not perform any, performed both or one of the commands). For a patient with physical injuries, amputation of an arm, or other disabilities, give another simple one-step order. Rate only the first attempt
0: Completed both commands correctly
1: completed one command correctly
2: did not execute any of the commands
2. Eye movements * Assess only horizontal eye movements. Score for voluntary or reflex (oculocephalic reflex) eye movements, without caloric tests. If the patient’s eyeballs are turned sideways in pairs, but during voluntary or reflex movements their position changes, the score is “1”. If the patient has a peripheral lesion of the cranial nerve that provides movements of the eyeball (III, IV or VI), the score is “1”. Assess eye movements in all patients with aphasia. In a patient with eye injuries, bandages, blindness and other violations of acuity or visual fields, reflex movements should be checked – the choice is left to the clinician. Sometimes movements in one direction and in the other direction away from the patient while maintaining contact between the eyes make it possible to detect partial paralysis of the gaze
1: paresis of gaze; movements of one or both eyes are impaired, but there is no tonic abduction of the eyes or complete paralysis of the gaze
2: tonic abduction or complete gaze paralysis persisting during oculocephalic reflex testing
3. Fields of vision * Assess the upper and lower quadrants of the visual fields using a confrontational test (counting fingers or, if not possible, threatening eye movements). You can encourage the patient, but if the patient accordingly looks in the direction of the moving finger, evaluate it as normal. If one eye is blind or removed, assess the visual fields of the other eye. The grade “1” is given only in case of clear asymmetry of the visual fields, including quadrantanopsia. If the patient is blind (for any reason), score “3”. Immediately perform simultaneous double stimulation. If there is a selective lack of attention, give the patient 1 point and take this into account in section 11
0: fields of view are preserved
3: bilateral hemianopsia (blindness, including cortical blindness)
4. Weakness of facial muscles * Ask (or encourage with gestures) that the patient shows his teeth, raises his eyebrows and closes his eyes tightly. In patients with impaired consciousness or those who do not understand speech, assess the symmetry of grimaces and response to painful stimuli. If the face is not visible (due to injury/bandaging, tracheal intubation, or other reasons), remove all obstructions as much as possible
0: normal symmetrical facial expression
1: mild paresis (smoothing of the nasolabial fold, asymmetrical smile)
2: moderate paresis (complete or almost complete paralysis of the lower facial muscles – central type)
3: complete one- or two-sided paralysis (without facial expressions in the upper and lower parts of the face – peripheral type)
5А. Weakness of hands: left hand * Assess each limb in turn, starting with the least affected. Give the patient’s hand the initial position: straighten the patient’s hand (palm down) at an angle of 90 degrees (if the patient is sitting) or 45 degrees (if the patient is lying) to the body – and ask him to hold it like that. Lowering means the downward movement of the hand in the first 10 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of amputation or ankylosis of the shoulder joint only, indicate that this section cannot be assessed (U/A – cannot be assessed) and provide a clear written explanation
0: no lowering; the hand is held in the initial position for 10 seconds
1: lowering; the arm is initially held in the starting position (90 or 45 degrees), but begins to move downward within the first 10 seconds without touching the bed or other support
2: separate attempts to overcome gravity; the patient cannot independently return the arm to the original position or keep it in this position, and the arm falls on the bed, but there are certain efforts against the force of gravity
3: no attempt to overcome gravity; the hand immediately falls
4: no movement whatsoever
Explain: * For example, amputation, joint ankylosis, other
5B. Weakness of hands: right hand *
0: no lowering; the hand is held in the initial position for 10 seconds
1: lowering; the arm is initially held in the starting position (90 or 45 degrees), but begins to move downward within the first 10 seconds without touching the bed or other support
2: separate attempts to overcome gravity; the patient cannot independently return the arm to the original position or keep it in this position, and the arm falls on the bed, but there are certain efforts against the force of gravity
3: no attempt to overcome gravity; the hand immediately falls
4: no movement whatsoever
Explain: * For example, amputation, joint ankylosis, other
6A. Weakness of legs: left leg * Assess each limb in turn, starting with the least affected (always in a horizontal, face-up position on the back). Give the patient’s leg the starting position: at an angle of 30 degrees to the bed – and ask him to hold it like that. Lowering means the downward movement of the leg in the first 5 seconds. Encourage the patient with aphasia with a commanding voice and gestures, but do not cause pain. For cases of hip amputation or ankylosis only, indicate that this section cannot be assessed (U/A) and provide a clear written explanation
0: no lowering; the leg is held at an angle of 30 degrees for 5 seconds
1: lowering; the leg begins to move downward within the first 5 seconds, but does not touch the bed
2: separate attempts to overcome gravity; the leg falls on the bed within the first 5 seconds, but with some effort against gravity
3: no attempt to overcome gravity; the leg immediately falls on the bed
4: no movement whatsoever
Explain: * For example, amputation, joint ankylosis, other
6B. Weakness of legs: right leg *
0: no lowering; the leg is held at an angle of 30 degrees for 5 seconds
1: lowering; the leg begins to move downward within the first 5 seconds, but does not touch the bed
2: separate attempts to overcome gravity; the leg falls on the bed within the first 5 seconds, but with some effort against gravity
3: no attempt to overcome gravity; the leg immediately falls on the bed
4: no movement whatsoever
Explain: * For example, amputation, joint ankylosis, other
7. Ataxia in the limbs * In this section, signs of unilateral damage to the cerebellum are revealed. Ask the patient to keep his eyes open during the examination. In case of visual disturbances, perform the test in the preserved field of vision. Perform “toe-nose-toe” and “heel-knee” tests on both sides; score for ataxia only when the ataxia is greater than the weakness. If the patient does not understand speech or is paralyzed, there is no ataxia (score 0). In cases of amputation or joint ankylosis only, indicate that this section cannot be assessed (U/A) and write a clear explanation
Explain: * For example, amputation, joint ankylosis, other
8. Sensitivity * Assess the patient’s sensitivity or grimaces during injections with a disposable pin or avoidance of painful stimuli (in case of significant impairment of consciousness or aphasia). Consider only the loss of sensitivity from a stroke. Check carefully in different parts of the body (arms, but not hands, legs, torso, face) to reliably rule out hemihypesthesia. Score “2” only when there is no doubt that the patient has a very significant or complete loss of sensitivity. Therefore, rate a patient with impaired consciousness or aphasia as “1” or “0”. Give 2 points to a patient with a truncal stroke and bilateral loss of sensation. If the patient is unresponsive and has tetraplegia, determine the score “2”. Immediately give 2 points to a patient in a coma (score “3” in subsection 1A) in this section
0: norm; there is no loss of sensitivity
1: mild or moderate loss of sensitivity; on the affected side, the patient feels the touch as less sharp or dull; or the patient does not feel pain, but feels it when touched
2: severe or complete loss of sensitivity; the patient does not feel touches on the face, hand and leg
8. Sensitivity * Assess the patient’s sensitivity or grimaces during injections with a disposable pin or avoidance of painful stimuli (in case of significant impairment of consciousness or aphasia). Consider only the loss of sensitivity from a stroke. Check carefully in different parts of the body (arms, but not hands, legs, torso, face) to reliably rule out hemihypesthesia. Score “2” only when there is no doubt that the patient has a very significant or complete loss of sensitivity. Therefore, rate a patient with impaired consciousness or aphasia as “1” or “0”. Give 2 points to a patient with a truncal stroke and bilateral loss of sensation. If the patient is unresponsive and has tetraplegia, determine the score “2”. Immediately give 2 points to a patient in a coma (score “3” in subsection 1A) in this section
9. Language * Ask the patient to describe what is depicted in the proposed picture, name the depicted things and read the sentence. Assess language comprehension based on responses and following commands during a general neurological examination. If visual disturbances interfere with the examination, ask the patient to name things that are placed in his hand, repeat phrases and speak. In the case of tracheal intubation, ask the patient to write. A patient in a coma (score “3” in subsection 1A) immediately receives 3 points in this section. If patient 42 is unconscious or uncooperative, rate the patient at your own discretion, but assign 3 points only when the patient is mute and unresponsive
1: mild or moderate aphasia; there are some clear signs of loss of fluency or comprehension of language, but no significant limitations in expression. Speech and/or language comprehension impairments make it difficult or impossible to talk about what is drawn. However, you can understand from the patient’s answers what is depicted in the picture and the names of the depicted objects
2: severe aphasia; communication is limited to fragments of phrases. It is necessary to guess what the patient means and/or question. The amount of information that can be exchanged is very limited; the burden of communication rests on the listener. From the patient’s answers, you cannot understand what is in the picture and the names of the depicted objects
3: muteness, complete aphasia; there is neither meaningful speech nor language comprehension
9. Language * Ask the patient to describe what is depicted in the proposed picture, name the depicted things and read the sentence. Assess language comprehension based on responses and following commands during a general neurological examination. If visual disturbances interfere with the examination, ask the patient to name things that are placed in his hand, repeat phrases and speak. In the case of tracheal intubation, ask the patient to write. A patient in a coma (score “3” in subsection 1A) immediately receives 3 points in this section. If patient 42 is unconscious or uncooperative, rate the patient at your own discretion, but assign 3 points only when the patient is mute and unresponsive
10. Dysarthria * When there are no significant disturbances, assess the patient’s pronunciation by asking him to read and repeat the words on the page. If the patient has severe aphasia, assess the clarity of pronunciation and spontaneous speech. Only in the case of intubation or other physical barriers to speech, indicate that this section is not assessable (U/A) and provide a clear written explanation. Do not explain to the patient exactly what you are evaluating
1: mild or moderate dysarthria; the patient “smears” some words and sometimes it is difficult to understand him
2: severe dysarthria; the pronunciation is so distorted that the patient cannot be understood (aphasia is absent or its degree is significantly inferior to dysarthria), or the patient does not speak at all (muteness)
Explain: * For example, intubation, physical obstruction, other
11. Exclusion or lack of attention * During the preliminary examination, you may have received quite a bit of information about lack of attention or selective perception. If simultaneous double stimulation is not possible due to significant narrowing of the visual fields (hemianopsia), and skin sensitivity is preserved, choose a score of “0”. If a patient with aphasia pays attention to stimuli from both sides, the score is “0”. If there is a lack of visual attention to part of the space or anosognosia, this confirms the disorder. Since these violations are only assessed when they are present, this section is never unassessable
1: lack of attention to visual, tactile, auditory, spatial or bodily stimuli or exclusion (selective perception) of stimuli of one sensory modality; when stimuli are applied simultaneously on both sides, they are perceived only on one side
2: severe lack of attention or exclusion (selective perception) of stimuli in more than one modality (for example, does not recognize one’s own hand or orients in space from only one side)
Scores
Stroke severity
Stroke severity
Stroke severity
Stroke severity
Stroke severity
