Methods for assessing the severity of stroke: we determine the prognosis of the disease. Annex D4

National Institutes of Health Stroke Scale / NIH Stroke Scale

Developed by the American National Institutes of Health (National Institutes of Health Stroke Scale - NIH Stroke Scale) T. Brott et al, 1989, J. Biller et al, 1990.

It is used to objectify the state of a patient with ischemic stroke at admission, in the dynamics of the process and the outcome of a stroke by the 21st day of hospitalization.

The scale contains 15 points that characterize the main functions that are most often impaired due to cerebral stroke. Functions are evaluated in points. The scale is notable for its obvious simplicity, filling it takes no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive study. neurological status, allows you to record the dynamics of the patient's condition in the acute period of the disease. The internal consistency and retest reliability of the scale has been confirmed by a number of studies (Goldstein J.C. et al 1989). The absence of changes in the neurological status is provided as 0 points, the death of the patient is 31 points.

1. Eye opening:

2. Motor reaction 12 :

^ 3. Verbal response 13

The sum of points in three sections and its correspondence to the level of consciousness

^

Motor Deficits Rating Scale (Zacharia)

^

Glasgow Immediate Outcome Scale

^

National Institutes of Health Stroke Scale

(National Institutes of Health Stroke Scale - NIH Stroke Scale)

T. Brott et al, 1989, J. Biller et al, 1990.

It is used to objectify the state of a patient with ischemic stroke at admission, in the dynamics of the process and the outcome of a stroke by the 21st day of hospitalization.

The scale contains 15 points that characterize the main functions that are most often impaired due to cerebral stroke. Functions are evaluated in points. The scale is notable for its obvious simplicity, filling it out takes no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive study of the neurological status, and allows you to record the dynamics of the patient's condition in the acute period of the disease. The internal consistency and retest reliability of the scale has been confirmed by a number of studies (Goldstein J.C. et al 1989). The absence of changes in the neurological status is provided as 0 points, the death of the patient - 31 points.

This scale is additionally used to assess the severity of the patient's condition when intracranial hemorrhage or cerebellar infarction (0-V degree); patients whose condition corresponds to grade 0-III have no contraindications on this scale for hospitalization in neurosurgical department.

^

Barthel ADL index of daily life activity

Instruction

1. 
   The index should reflect the real actions of the patient, and not the intended ones (not how the patient could perform certain functions).
2. 
   The main purpose of testing is to establish the degree of independence from any help, physical or verbal, no matter how insignificant this help is and no matter what the reasons are.
3. 
   The need for supervision means that the patient does not belong to the category of those who do not need help (the patient is not independent).
4. 
   The level of functioning should be determined in the most optimal way possible for the particular situation, most commonly by questioning the patient, their friends/relatives, or caregivers, but direct observation and common sense are also important. Direct testing is not required.
5. 
   Usually, the patient's functioning is assessed in the period preceding 24-48 hours, but sometimes a longer assessment period is justified.
6. 
   Medium categories mean that the patient performs more than 50% of the effort required to perform a particular function.
7. 
   The category "independent" allows the use of aids.

0 - incontinence (or needs to use an enema, which is put by the caregiver);

5 - random incidents (not more than once a week) or assistance is required when using an enema, suppositories;

10 - complete control of defecation, if necessary, can use an enema or suppositories, does not need help;

^ Urination control

0 - incontinence or a catheter is used, which the patient cannot manage independently;

5 - random incidents (maximum once per 24 hours);

10 - complete control of urination (including those cases of catheterization Bladder when the patient is self-managed with the catheter).

^ Personal hygiene (brushing teeth, handling dentures, combing, shaving, washing face)

0 - needs help with personal hygiene procedures;

5 - independent when washing the face, combing, brushing teeth, shaving (tools for this are provided)

^ Going to the toilet (moving around the toilet, undressing, cleaning skin dressing, leaving the toilet)

5 - needs some help, but some of the actions, incl. hygiene procedures, can perform independently;

10 - does not need help (when moving, taking off and putting on clothes, performing hygiene procedures);

^ Eating

0 - completely dependent on the help of others (feeding with assistance is necessary);

5 - partially needs help, for example, when cutting food, spreading butter on bread, etc., while eating independently;

10 - does not need help (able to eat any normal food, not only soft; independently uses all the necessary cutlery; food is prepared and served by others, but not cut);

^ Transfer (from bed to chair and back)

0 - movement is impossible, unable to sit (balance), two people are required to get out of bed;

5 - when getting out of bed, significant physical assistance is required (one strong / trained person or two ordinary persons), can sit up on his own in bed;

10 - when getting out of bed, little help is required (physical, one person), or supervision, verbal help is required;

15 - does not need help.

^ Mobility (movements within the home/room and outside the home; assistive devices may be used)

0 - unable to move;

5 - can move around with the help of a wheelchair, incl. go around corners and use doors;

10 - can walk with the help of one person (physical support or supervision and moral support);

15 - does not need help (but can use assistive devices, such as a cane).

Dressing

0 - completely dependent on the help of others;

5 - partially needs help (for example, when fastening buttons, buttons, etc.), but performs more than half of the actions independently, can put on some types of clothing completely independently, spending a reasonable amount of time on this;

10 - does not need help, incl. when fastening buttons, buttons, tying shoelaces, etc., can choose and wear any clothing.

^ Climbing stairs

0 - unable to climb stairs, even with support;

5 - needs supervision or physical support;

10 - does not need help (can use aids).

^ Taking a bath

0 - takes a bath (enters and leaves it, washes) without assistance and supervision or washes in the shower without requiring supervision and assistance;

5 - needs help.

"SCALES FOR ASSESSING THE SEVERITY OF ISCHEMIC STROKE IN THE ACUTE PERIOD NIHSS Scale Severity neurological symptoms in the acute period of ischemic stroke ... "

SCALE IN GENERAL

NEUROLOGY

SCALES FOR ASSESSING THE DEGREE OF SEVERITY

ISCHEMIC STROKE IN THE ACUTE PERIOD

NIHSS scale

The severity of neurological symptoms in the acute period

ischemic stroke, it is advisable to evaluate in dynamics using specially designed scales. Widespread

of Health Stroke Scale). The NIHSS score also has importance for planning thrombolytic therapy (TLT) and monitoring its effectiveness. The indication for thrombolytic therapy is the presence of a neurological deficit (from 3 points on the NIHSS scale), suggesting the development of disability. Severe neurological deficit (more than 25 points on this scale) is a relative contraindication to thrombolysis and does not significantly affect the outcome of the disease.

National Institutes of Health Stroke Severity Scale (NIHSS)

1. Level of consciousness (assessed in points):

0 - conscious, actively reacting;

1 - doubt, but can be awakened with minimal irritation, executes commands, answers questions;

2 - sopor - repeated stimulation is required to maintain activity, or inhibited - strong and painful stimulation is required to produce non-stereotypical movements;

3 - coma, reacts only with reflex actions or does not respond to stimuli.

2. Level of consciousness - answers to questions.

Ask the patient what month it is and his age. Write down the first answer. If aphasia or stupor - score 2.

If endotracheal tube, severe dysarthria, language barrier - 1.

0 - the correct answer to both questions;

1 - the correct answer to one question;

2 - no correct answers given.

3. Level of consciousness - execution of commands.

The patient is asked to open and close his eyes, to squeeze and unclench his non-paralyzed hand. Only the first attempt counts.

0 - both commands are executed correctly;

1 - one command is executed correctly;

2 - none of the commands were executed correctly.

4. Movement of the eyeballs.

Only horizontal eye movements are taken into account.

1 - partial gaze paralysis;

2 - tonic abduction of the eyes or complete gaze paralysis, not overcome by the induction of oculocephalic reflexes.

5. Examination of visual fields:

1 - partial hemianopsia;

2 - complete hemianopia.

6. Paresis of the facial muscles:

1 - minimal paralysis (asymmetry);

2 - partial paralysis - complete or almost complete paralysis of the lower muscle group;

3 - complete paralysis (lack of movement in the upper and lower muscle groups).

7. Movements in the upper limbs.

The arms are raised at a 45° angle in the supine position, at an angle of 90° in the sitting position. If the patient does not understand the task, the doctor must place his hands in the required position himself. Scores are recorded separately for the right and left limbs.

0 - limbs are held for 10 s;

1 - limbs are held for less than 10 s;

13 2 - limbs do not rise or do not maintain a given position, but produce some resistance to gravity;

4 - no active movements;

8. Movements in the lower extremities.

In the prone position, raise the paretic limb for 5 seconds at an angle of 30°. Scores are recorded separately for the right and left limbs.

0 - limbs are held for 5 s;

1 - limbs are held for less than 5 s;

2 - limbs do not rise or do not maintain an elevated position, but produce some resistance to gravity;

3 - limbs fall without resistance to gravity;

4 - no active movements;

5 - impossible to check (limb amputated, artificial joint).

9. Ataxia of the limbs.

Finger-nose and heel-to-knee tests are performed on both sides, ataxia is counted if it is not caused by paresis.

0 - absent;

1 - in one limb;

2 - in two limbs.

10. Sensitivity.

Only hemitetype disorder is taken into account.

1 - mild or moderate violations;

2 - significant or complete violation of sensitivity.

11. Aphasia.

The patient is asked to describe the picture, name the object, read the sentence.

0 - no aphasia;

1 - mild aphasia;

2 - severe aphasia;

3 - complete aphasia.

12. Dysarthria:

0 - normal articulation;

15 1 - mild or moderate dysarthria. Does not pronounce some words;

2 - severe dysarthria;

3 - intubated or other physical barrier.

13. Agnosia (ignorance):

0 - no agnosia;

1 - ignoring to bilateral sequential stimulation of one sensory modality;

2 - severe hemiagnosia or hemiagnosia in more than one modality.

The data obtained correspond to the following severity of neurological deficit:

0 - satisfactory condition;

3–8 - neurological disorders mild degree;

9–12 - moderate neurological disorders;

13–15 - severe neurological disorders;

16–34 - neurological disorders of extreme severity;

The use of the NIHSS scale will allow an objective approach to the condition of a patient with a stroke and assess the neurological status during the patient's stay in the hospital. The total score determines the severity and prognosis of the disease. With a score of less than 10 points, the probability of a favorable outcome after 1 year is 60-70%, and with a score of more than 20 points - 4-16%. This assessment is also important for planning thrombolytic therapy and monitoring its effectiveness. Thus, an indication for thrombolytic therapy is the presence of a neurological deficit (no more than 3–5 points). Severe neurological deficit (more than 25 points on this scale) is a contraindication to thrombolysis, since this manipulation may not have a significant effect on the outcome of the disease.

Systemic thrombolytic therapy is currently used in many cities of Ukraine. The NIHSS scale introduced into practical neurology has shown its effectiveness.

On the first day in patients after thrombolytic therapy, changes in the dynamics of the neurological status are assessed according to the NIHSS scale.

Clinical example. Patient K., aged 50, was admitted to neurological department Center for Thrombolytic Therapy GB No. 5

Mariupol with complaints of weakness and numbness of the left limbs.

When examining the neurological status - left-sided prosoparesis, pronounced left-sided hemiparesis, left-sided hemihypesthesia (according to the NIHSS scale - 10 points). Conducted CT, ECG, duplex scanning main vessels, express blood and urine tests.

Thrombolytic therapy started:

Bolus administration - the patient retains moderate left-sided prosoparesis, left-sided hemiparesis: expressed in the arm, moderately expressed in the leg; left-sided hemihypesthesia (NIHSS - 6 points);

At the end of TLT, the patient retains mild left-sided prosoparesis, left-sided moderate hemiparesis, left-sided hemihypesthesia (NIHSS - 4 points);

After 24 hours, the patient retains mild left-sided prosoparesis and mild paresis of the left hand (NIHSS - 2 points).

Scandinavian Stroke Scale For a combined assessment of the severity of patients in the acute period of ischemic stroke and the effectiveness of the treatment, the European Stroke Initiative also recommends using the Scandinavian Stroke Scale, according to which a significant improvement is noted if regression of neurological symptoms is observed on this scale (scores of 10 or more) and at the same time, there is a positive dynamics of laboratory and functional research methods. A moderate improvement can be judged if the regression of the neurological deficit is less than 10 points. At the same time, it is possible to improve some indicators of paraclinical research methods. A slight improvement - with minimal regression of neurological symptoms (1-2 points) and the absence of positive dynamics of laboratory and functional research methods.

19 Table 1. Scandinavian Stroke Study Group (SSS; Scandinavian Stroke Study Group, 1985)

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Cardiologist

Higher education:

Cardiologist

Kabardino-Balkarian State University them. HM. Berbekova, Faculty of Medicine (KBGU)

Level of education - Specialist

Additional education:

"Cardiology"

State Educational Institution "Institute for the Improvement of Doctors" of the Ministry of Health and Social Development of Chuvashia

Every neurologist should know what the nihss stroke severity rating scale is. The data obtained with its help are important for making a decision on the advisability of prescribing thrombolytic therapy, its expected effectiveness, and the prognosis of the disease itself. Its principle is that the more points the patient gains, the more difficult his state of health.

If, as a result of the assessment, the patient has more than 3 points, this is an indication for the appointment of thrombolytic therapy, and if more than 25 points are scored, such treatment is strongly not recommended.

nihss scale

The patient can be assessed using the nihss or the National Institutes of Health Stroke Scale. It includes 15 tasks that must be completed and scored. At the same time, the assessment takes place in a strict order, it is impossible to swap subsections or return to unfulfilled ones. Unless required by the conditions of the task, it is also forbidden to prepare the patient for the passage of a particular task.

Vigor level

If it is not possible to make an accurate assessment for a number of reasons, then the overall result of the answers is examined, as well as the reaction to them. Maximum score is placed if the patient is in a coma or the reaction and reflexes are completely absent.

0 - clear;

1 - stunning (slight lethargy or drowsiness, but a complete reaction to even the slightest stimulus);

2 - stupor (repetition or stronger stimulation is necessary for the manifestation of the reaction);

3 - coma ( complete absence speech contact).

Answers on questions

A person is asked two questions: his age, and what month it is. Answers must be complete and clear, even the slightest error in the numbers must be taken into account. In this case, only the first response received is taken into account.

0 - answers to all two questions;

1 - the correct answer to only one of the questions;

2 - incorrect answers to all two questions.

Command execution

A person must first close and then open their eyes. Next, you will need to clench and unclench the fist of the hand that is not paralyzed. If for some reason the second action is not possible, you can ask to execute another similar command. If there is no reaction to speech, you can show by your own example what is required of the victim. Evaluation occurs on the first attempt:

0 – correct execution both tasks;

1 - execution of one task;

2 - complete or incorrect failure to complete the tasks.

Eyeball movement

0 - norm;

1 - partial paralysis;

2 - complete paralysis of the eyeball.

line of sight

The study is carried out by confrontation and counting the number of fingers, starting from the periphery and ending with the center of the eye.

0 - no violations, the pupils move in the direction of the fingers;

1 - the presence of asymmetry or partial hemianopsia;

2 - blindness or complete hemianopsia.

Identification of disorders of the facial nerve

0 - no violations detected;

1 - slight asymmetry of the face;

2 - moderate paralysis of the facial muscles;

3 - complete paralysis of the face.

Strength of the muscles of the left arm

The arm from the extended state is made at an angle of 90 ° (sitting) or 45 ° (lying down). In this case, it is necessary that the palms are turned down. In this position, the patient needs to hold out for 10 seconds, after which the nihss scale is filled.

2 - Strength cannot be tested due to missing limb or broken joint.

Right hand muscle strength

The same actions are performed as with the left hand and points are calculated based on the result.

0 - if the hand is held in this position for the required amount of time;

1 - if the hand is first held at the desired angle, and then begins to fall;

2 - it is impossible to examine the strength due to the absence of a limb or a fracture of the joint;

3 - the hand falls almost immediately after lifting, there is no way to fight against gravity;

4 - complete absence of movement.

Muscular strength of the left leg

The study is performed in the supine position. The specialist asks to raise the patient's leg at an angle of 30 ° and hold out in this position for 5 seconds. Points are awarded based on the result.

Strength of the muscles of the right leg

This task, derived by the Institute of Health, is identical to the previous one (for the left leg). The scoring is the same.

0 - The leg is in the right position for the required time;

1 - at first the limb is in the desired position, but then it falls;

2 - the limb immediately descends, holding in the desired position for an extremely short time;

3 - the fall of the leg occurs immediately, the person cannot cope with gravity;

4 - the limb does not rise.

Limb ataxia

This task allows you to determine if there is a violation of the cerebellum of one of the parties. In the presence of violations of the visual fields, the study is carried out in the one that is not affected, the victim's eyes are open. A knee-heel test is performed, as well as a toe-nose-heel test.

0 - no ataxia;

1 - ataxia in the upper or lower extremities;

2 - ataxia of all limbs.

Degree of sensitivity

The study is carried out by light pricks with a pin or needle, as well as by touch.

0 - sensitivity is normal;

1 - there is a slight decrease in sensitivity;

2 - the patient is in a coma or his sensitivity is significantly reduced.

Speech

The stroke scale involves determining the state of speech. To do this, the victim is offered a description of the picture or a reading of some text. If such requests are not possible due to lack of vision, the patient can be asked to name objects that will fit in his palm.

0 - the entire task was completed;

1 - partial ignoring or violation of speech;

2 - coma, as well as complete failure to complete the task.

The area of ​​study is not voiced to the person at this stage. Dialogue is expected.

0 - correct articulation with intelligible pronunciation;

1 – mild dysarthria or moderate form, in which the patient may slur some words;

2 - coma or incomprehensible pronunciation of all words.

Neglect

At this stage, the perception of half of the body (in most cases, the left) is assessed. Usually, the data obtained from the previous paragraphs is sufficient.

0 - the perception of stimuli is not impaired;

1 - slight deviations;

2 - gross deviations from the norm;

3 - total absence of reflexes and reactions to external stimuli.

The nihss test or stroke severity rating scale is quite simple, and most importantly, effective way determining the patient's condition after a stroke. The probability of a lethal outcome of the patient increases to the limit if the number of points is at least 31.

How to understand how badly a person suffered from a stroke? One hand does not move - is it strong or not very? And if the ability to live in our reality is lost?

There is no need to guess: there are special scales that allow you to assess how badly the brain is affected. Using them in the initial stages, doctors get a fairly accurate prognosis of a stroke. Further, according to these scales, it is assessed whether there are any changes in the patient's condition.

NIHHS scale

This is a scale that is applied from the first minutes of the disease. They work with her immediately after the diagnosis is established, by the number of points they decide already in the first hour whether thrombolysis can be performed or it will be dangerous. The NIHHS scale from the US National Institutes of Health is the most common method for assessing the severity of a person's condition after a stroke.

The test takes 10-15 minutes. It is important to evaluate all items in order, without first instructing the patient. The point is awarded for the person's actual reactions, not possible ones. As a result, the points are summed up.

Interpretation

If the assessment is carried out in the acute period, when the issue of thrombolysis (drug dissolution of the thrombus that caused the stroke) is being decided, then the assessment is as follows:

• 5-24 points - the procedure can be performed;
• 0-4 points - thrombolysis will not be able to affect the prognosis and development of disability.

If you need to estimate the chance of a full recovery in a year, then look like this:

• less than 10 points - a chance of 60-70%;
• more than 20 points - a chance of 4-16%.

Scandinavian scale

It assesses the severity of ischemic stroke in its acute period (that is, from the moment of occurrence to 7 days) and then in dynamics:

Interpretation

If the difference between the original and second score is 10 points or more, it is considered a significant improvement. Moderate positive dynamics - if 3-10 points. Slight improvement - a difference of 1-2 points.

Simultaneously with the Scandinavian scale, laboratory results and functional research methods are evaluated.

Rankin scale

It is used to understand the long-term perspective: what kind of care the patient will need.

Interpretation

• Grade 0: No household help required.
• 1 degree: need help 1 time per month.
• Grade 2: Without help, he can do no more than 1 week.
• Grade 3: Need help several times a week. Plus, the person needs psychological help.
• Grade 4: help is needed daily, but you can leave a person alone - for a short period of time.
• Grade 5: care is needed constantly.

Rivermead scale

It measures a person's ability to move after a stroke. It does not mean movement with the help of improvised means or a wheelchair.

The calculation is as follows: for each answer "Yes" - 1 point. The scores are then added up.

Interpretation

• 0-1 points: Need a 24-hour caregiver or continued stay in the hospital;
• 2-3 points: rehabilitation measures are needed in a hospital at a polyclinic;
• 4-7 points: recovery is carried out either without hospitalization, or with a short stay in a hospital with continued rehabilitation in a polyclinic;
• 8 or more points: polyclinic rehabilitation is enough.

You can independently evaluate the condition of your relative who suffered from a stroke using these scales. This will help you draw your own conclusions about his condition.