How do you know how badly a person has suffered from a stroke? One arm doesn’t move – is it strong or not very strong? What if we have lost the ability to live in our reality?

There is no need to guess: there are special scales that allow you to assess how severely the brain is affected. Using them in the initial stages, doctors receive a fairly accurate prognosis of stroke. Next, these scales are used to assess whether there is any progress in the patient’s condition.

NIHHS scale

This is a scale that is used from the first minutes of the disease. They work with her immediately after the diagnosis is established, based on the number of points, they decide in the first hour whether thrombolysis can be performed or whether 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 is carried out in 10-15 minutes. It is important to evaluate all points in order, without first instructing the patient. The point is awarded for the person's actual reactions, not possible ones. As a result, the number of points is summed up.

Question	Points
1. Clarity of consciousness	0 – Does not sleep, answers 2-3 questions clearly and unambiguously
	1 – Somnolence: answers correctly, with pauses, but after you have woken him up with light stimulation
	2 – Sopor. Opens eyes only in response to strong tapping or pain (for example, squeezing urine on the ear). Doesn't answer questions
	3 – Deep stupor. In response to a painful stimulus, a series of defensive movements or increased breathing occurs
2. Level of consciousness - speech You need to ask: “What month is it now?” And how old are you?"	0 – Answers both questions correctly the first time
	1 – Answers only 1 question correctly, or the tube of the breathing apparatus prevents him from answering, or his speech is simply blurred and incomprehensible
	2 – Doesn’t respond at all
3. Follow simple instructions You need to ask to open and close your eyes, move your fist on the hand that can move. If a person does not understand what they want from him, he must demonstrate action. Only the first effort is evaluated	0 – Completed everything exactly
	1 – Executed one instruction or made an explicit attempt to do so
	2 – Didn’t do anything
4. How the eyes move horizontally To check, make eye contact with the person, and then you need to step aside, watching how he looks at you. People in a clear consciousness can be asked to follow the handle, which you will move horizontally	0 – Eyes move normally
	1 – Eyeballs do not move enough. This point is awarded without a test if strabismus develops as a result of a stroke
	2- No eye movement
5. Fields of view	0 – Visual fields are fine
	1 – Partial loss of one half of the visual field - closest to the nose or on the other side
	2 – Complete loss of half of the visual field
	3 – Blindness, even if it was before the stroke
6. How the facial nerve works To check, you need to ask in words or pantomime that you need to bare your teeth, puff out your cheeks, close your eyes	0 – When following these instructions, everything on the face contracts symmetrically
	1 – The fold between the nose and lip on one side is slightly smoothed, when puffing out the cheeks, one corner of the mouth drops slightly and air comes out, the smile is slightly asymmetrical
	2 – The smile is clearly asymmetrical; it is impossible to hold air with puffed out cheeks
	3 – One or both eyes cannot be closed, the cheek(s) cannot be inflated, and when teeth are shown, the corner(s) of the mouth drops sharply
7. Arm muscle strength The arm needs to be extended and placed at a right angle when sitting or at 45° when lying down, with the palm turned down. Ask to hold your hand for 10 seconds while counting down the time The non-paralyzed arm is examined first. If there is no arm or there is a disease of the shoulder joint, the test is not performed	0 – Hands held for 10 seconds
	1 – The hand lowers before the required time, but by the 10th second it does not touch the bed (support)
	2 – The hand is held a little, but before the 10th second it touches the surface
	3 – He can raise his arm himself, but cannot hold it
	4 – Independent movements are impossible
8. Leg muscle strength To do this, you need the person to lift his leg and hold it at an angle of 30° for 5 seconds. Research rules - as in point No. 7	0 – Leg is held for 5 s
	1 – Before the 5th second expires, the leg is lowered, but does not touch the bed
	2 – Touches the bed before the 5th second
	3 – The leg cannot be supported, but the patient lifted it himself
	4 – The leg does not move on its own
9. Determination of cerebellar damage This is a finger-nose test, which is performed with open eyes. Carry out only on the side where there is no loss of visual field If the person is not clearly conscious or paralyzed, the test is scored as 0 points. If there are no limbs, there is a fracture or the joints do not work, the test is not performed	0 – Touches the nose with the fingers of one and the other hand
	1 – Does not reach the nose with only one hand
	2 – Misses the nose with both hands
10.Sensitivity It is examined by tingling the arms and legs with a toothpick, starting with the foot/hand and moving higher. Injections are given alternately on one and the other limb If consciousness is unclear, then a grimace that occurs in response to pain is assessed	0 – No sensory impairment
	1 – On the sore side, the tingling sensation is felt less sharp
	2 – No pricks or touches are felt on one or both sides. If a person is in a coma, he is automatically awarded 2 points
11. Speech To do this, take a picture and ask to describe the events depicted in it. You can ask to read the text. If the patient is conscious, but the machine is breathing for him, then they are asked to describe the events in writing	0 – No deviations
	1 – Minor violations
	2 – Can’t say anything coherently
	3 – Says nothing or is in a coma
12. Articulation disorders Evaluated by the intelligibility of speech when repeating text or words: Football player Oil Clumsiness Descend from heaven to earth Near the dining table in the dining room They heard him speak on the radio last night	0 – Speech is intelligible
	1 – Speech is understandable, but only some sounds are not clearly pronounced
	2 – There is speech, but it is almost impossible to understand it, and the patient hears it himself
	Not carried out – If the person is on artificial ventilation or has severely injured face
13. Complex perception of sensory signals on one half of the body It is carried out only if there is normal sensitivity on both sides	0 – Nothing damaged
	1 – On the one hand, one type of signal is not perceived: sounds, smells, vision of objects
	2 – On one side, 2 or more signals of different types are not perceived. Doesn't recognize his hand, understands only half of the space

Interpretation

If the assessment is carried out in the acute period, when the issue of thrombolysis (drug dissolution of the blood clot 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 affect the prognosis and development of disability.

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

less than 10 points – 60-70% chance;
more than 20 points – chance 4-16%.

Scandinavian scale

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

Scandinavian scale

Interpretation

If, when comparing the initial and second indicators, the difference is 10 points or more, this is considered a significant improvement. Moderate positive dynamics – if 3-10 points. Minor improvement – a difference of 1-2 points.

Simultaneously with the Scandavian scale, laboratory results and functional research methods are assessed.

Rankin scale

It is used to understand the long term: what care the patient will need.

Rankin scale

Interpretation

Level 0: no help around the house required.
Stage 1: need help once a month.
Stage 2: no more than 1 week without help.
Stage 3: need help several times a week. Plus, the person needs psychological help.
Stage 4: help is needed daily, but the person can be left alone for a short period of time.
Grade 5: constant care is needed.

Rivermead scale

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

The calculation is as follows: for each “Yes” answer – 1 point. The points are then summed up.

Rivermead scale

Interpretation

0-1 points: need a 24-hour nurse or continued hospital stay;
2-3 points: restoration measures are needed in a hospital setting at a clinic;
4-7 points: recovery is carried out either without hospitalization, or with a short stay in the hospital with continued rehabilitation in the clinic;
8 or more points: outpatient rehabilitation is sufficient.

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

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

SCALES IN GENERAL

NEUROLOGY

SCALES FOR ASSESSING THE DEGREE OF SEVERITY

ISCHEMIC STROKE IN ACUTE PERIOD

NIHSS scale

Severity of neurological symptoms in the acute period

It is advisable to evaluate ischemic stroke over time using specially developed scales. Widespread

of Health Stroke Scale). The NIHSS score is also important 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 have a significant effect on the outcome of the disease.

National Institutes of Health Stroke Scale (NIHSS)

1. Level of consciousness (scored in points):

0 - conscious, actively reacting;

1 - somnolence, but can be awakened with minimal irritation, follows commands, answers questions;

2 - stupor - requires repeated stimulation to maintain activity, or inhibited - requires strong and painful stimulation 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 - correct answer to both questions;

1 - correct answer to one question;

2 - no correct answers were given.

3. Level of consciousness - execution of commands.

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

0 - both commands were executed correctly;

1 - one command was executed correctly;

2 - not a single command was executed correctly.

4. Movements 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, which cannot be overcome by inducing oculocephalic reflexes.

5. Visual field examination:

1 - partial hemianopsia;

2 - complete hemianopia.

6. Paresis of 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 an angle of 45° in a lying position, at an angle of 90° in a 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 a supine 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. Limb ataxia.

Finger and heel-knee tests are carried out 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 hemitype disorder is taken into account.

1 - mild or moderate impairment;

2 - significant or complete loss of sensitivity.

11. Aphasia.

The patient is asked to describe a picture, name an object, and read a sentence.

0 - no aphasia;

1 - mild aphasia;

2 - severe aphasia;

3 - complete aphasia.

12. Dysarthria:

0 - normal articulation;

15 1 - mild or moderate dysarthria. Can't pronounce some words;

2 - severe dysarthria;

3 - intubated or other physical barrier.

13. Agnosia (ignoring):

0 - no agnosia;

1 - ignoring 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 - mild neurological disorders;

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 us to objectively approach the condition of a patient with a stroke and assess the neurological status during the patient’s hospital stay. 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, the 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 used today in many cities of Ukraine. The NIHSS scale, introduced into practical neurology, has shown its effectiveness.

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

Clinical example. Patient K., 50 years old, was admitted to the neurological department of the thrombolytic therapy center of City Hospital No. 5.

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

When examining the neurological status - left-sided prosoparesis, severe left-sided hemiparesis, left-sided hemihypesthesia (NIHSS scale - 10 points). A CT scan, ECG, duplex scanning of the great vessels, and express blood and urine tests were performed.

Thrombolytic therapy was started:

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

At the end of TLT, the patient still has mild left-sided prosoparesis, left-sided moderately severe hemiparesis, left-sided hemihypesthesia (NIHSS - 4 points);

After 24 hours, the patient still has mild left-sided prosoparesis and mild paresis of the left arm (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 treatment, the European Stroke Initiative also recommends using the Scandinavian Stroke Scale, according to which significant improvement is noted if regression of neurological symptoms is observed on this scale (10 points or more) and at the same time, there is a positive trend in laboratory and functional research methods. 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. Minor improvement - with minimal regression of neurological symptoms (1–2 points) and the absence of positive dynamics in laboratory and functional research methods.

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

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Sign Number of 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 Deficiency Rating Scale (Zacharia)

Range of motion	Number of points
Absence of all movements	0
Contraction of a part of the muscle without motor effect in the corresponding joint	1
Muscle contraction with a motor effect in the joint without the ability to lift the limb	2
Muscle contraction with lifting of the limb without the ability to overcome the additional load applied by the examining hand	3
Active movement of the limb with the ability to overcome additional load applied by the examining hand	4
Normal strength. The examiner cannot overcome the resistance of the examinee when extending the arm	5

Glasgow Emergency Outcome Scale

1 point	Death in the first 24 hours.
2 points	Death in more than 24 hours.
3 points	Persistent vegetative state: vital functions are stable; neuromuscular and communication functions are deeply impaired; the phases of sleep and wakefulness are preserved; the patient may be in the special care of the intensive care unit.
4 points	Neuromuscular failure: mental status is within normal limits, but profound motor deficits (tetraplegia) and bulbar disorders force the patient to remain in a specialized intensive care unit.
5 points	Severe disability: severe physical, cognitive and/or emotional impairment that precludes self-care. The patient can sit and feed himself. Immobile and needs nursing care.
6 points	Moderate lack of independence: mental status is within normal limits. Can perform some daily functions himself. Communication problems. Can move with assistance or special devices. Needs outpatient monitoring.
7 points	Mild lack of independence: mental status is within normal limits. The patient cares for himself and can walk alone or with outside support. Needs special employment.
8 points	Good recovery: the patient returns to his previous pattern of life, although not everything is working out yet. Complete independence, although residual neurological impairment is possible. Walks independently without assistance.
9 points	Complete recovery: complete recovery to premorbid levels without residual effects in the somatic and neurological status.

National Institutes of Health 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 condition of a patient with ischemic stroke upon admission, in the dynamics of the process and outcome of the stroke by the 21st day of hospital stay.

The scale contains 15 points that characterize the basic functions most often impaired due to cerebral stroke. Functions are assessed in points. The scale is distinguished by its obvious simplicity, filling it out requires no more than 5-10 minutes, disciplines the doctor in terms of the need for a comprehensive examination of the neurological status, and allows recording the dynamics of the patient’s condition in the acute period of the disease. The internal consistency and test-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.

Sign	Point	Description
Consciousness: level of wakefulness	0	Clear Stupefaction (inhibited, drowsy, but reacts even to a minor stimulus - a command, a question) Stupor (requires repeated, strong or painful stimulation to move or become temporarily available for contact) Coma (inaccessible to speech contact, responds to stimulation only with reflex motor or autonomic reactions)
Consciousness: answers to questions. Ask the patient to name the month of the year and his age	0	Correct answers to both questions Correct answer to one question Wrong answers to both questions
Consciousness: following instructions Ask the patient to open and close his eyes, clench his fingers into a fist and unclench them	0	Executes both commands correctly Executes one command correctly Both commands run incorrectly
Eyeball movements	0	Norm Partial gaze paralysis (but no fixed gaze deviation) Fixed deviation of the eyeballs
Fields of view (examined using finger movements, which the researcher performs simultaneously on both sides)	0	No violations Partial hemianopsia Complete hemianopsia Bilateral hemianopsia
Facial paralysis	0	No Moderately expressed Full
Movements in the hand on the side of paresis The hand is asked to be held for 10 seconds in a position of 90° flexion at the shoulder joint if the patient is sitting; and in a 45° flexion position if the patient is lying down	0	The hand doesn't go down No active movements
Movements in the opposite hand (trunk stroke)	0	The hand doesn't go down The patient first holds his hand in a given position, then the hand begins to lower The hand begins to fall immediately, but the patient still holds it somewhat against gravity The hand immediately falls, the patient is completely unable to overcome gravity No active movements
Movements in the leg on the paresis side The patient, lying on his back, is asked to hold his leg raised (bent at the hip joint) at an angle of 30° for 5 seconds.	0	No active movements
Movements in the opposite leg (trunk stroke)	0	The leg does not lower for 5 seconds The patient first holds the leg in a given position, then the leg begins to lower The leg begins to fall immediately, but the patient still holds it somewhat against gravity The leg immediately falls, the patient is completely unable to overcome gravity No active movements
Ataxia in the limbs Finger-nose and heel-knee tests (ataxia is scored in cases where it is disproportionate to the degree of paresis; in case of complete paralysis, it is coded with the letter “H”) 14	0	No Present in either the upper or lower limb Available in both upper and lower limbs
Sensitivity Examined using a pin, only hemitype disorders are taken into account	0	Norm Slight decrease Significantly reduced
Denial syndrome	0	No Partial Full
Dysarthria	0	Normal articulation Mild to moderate dysarthria Slurred speech
Aphasia Evaluated by the patient’s verbal responses during the examination process	0	No Mild to moderate aphasia Severe aphasia Mutism

Classification of the severity of the condition in subarachnoid hemorrhage according to Hunt-Hess

(Henry J.M.Barnett, Stroke: Pathophysiology, Diagnosis and Management, 1986)

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

Degree	Characteristic
0	Unruptured aneurysm
I	Asymptomatic or minimal headache and mild neck stiffness
I.A.	Absence of meningeal or cerebral symptoms, but presence of persistent neurological deficit
II	Moderate to severe headache, stiff neck; no neurological deficit other than cranial nerve palsy
III	Stunning-stupor, confusion (disorientation in time and space), or mild local deficits
IV	Stupor, moderate to profound hemiparesis, possible early decerebrate rigidity and autonomic disturbances
V	Deep coma, decerebrate rigidity and signs of agony

Barthel ADL index

(F. Mahoney, D. Barthel, 1965; C. Granger et al, 1979; D. Wade, 1992)

Instructions

The index should reflect the patient’s actual actions, and not supposed ones (not how the patient could perform certain functions).
The main purpose of testing is to establish the degree of independence from any assistance, physical or verbal, no matter how insignificant this assistance may be and for whatever reasons.
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).
The level of functioning should be determined in the best possible way for a particular situation: most often by questioning the patient, his friends/relatives or caring staff, but direct observation and common sense are also important. No direct testing is required.
Typically, the patient's functioning is assessed over the previous 24-48 hours, but sometimes a longer assessment period is warranted.
Average categories mean that the patient makes more than 50% of the efforts required to perform a particular function.
The “independent” category allows the use of auxiliary aids.

^ Controlling bowel movements

0 – incontinence (or requires an enema administered by a caregiver);

5 – random incidents (no more than once a week) or assistance is required when using an enema or suppository;

10 – complete control of bowel movements, can use an enema or suppositories if necessary, does not need assistance;

^ Controlling urination

0 – incontinence or a catheter is used, which the patient cannot control independently;

5 – random incidents (maximum once in 24 hours);

10 – complete control of urination (including those cases of bladder catheterization when the patient independently controls the catheter).

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

0 – needs assistance with personal hygiene procedures;

5 – independent when washing your face, combing your hair, brushing your teeth, shaving (tools for this are provided)

^ Visiting the toilet (moving in the toilet, undressing, cleansing the skin, dressing, leaving the toilet)

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

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

^Eating

0 – completely dependent on the help of others (feeding with assistance is required);

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 just soft food; independently uses all necessary cutlery; food is prepared and served by others, but is not cut);

^ Moving (from bed to chair and back)

0 – movement is impossible, unable to sit (maintain balance), assistance from two people is required to get out of bed;

5 – requires significant physical assistance (one strong/trained person or two ordinary people) when getting out of bed, can sit up in bed independently;

10 – when getting out of bed, little assistance is required (physical, from one person), or supervision or verbal assistance is required;

15 – does not need help.

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

0 – unable to move;

5 – can move around using 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 assistance (but can use aids, 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 it;

10 – does not need help, incl. when fastening buttons, snaps, tying shoelaces, etc., can choose and put on any clothes.

^ 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 (gets in and out of it, washes itself) without assistance or supervision or washes in the shower without requiring supervision or assistance;

5 – needs help.

(NIHSS, NATIONAL INSTITUTES OF HEALTH STROKE SCALE BROTT T., ADAMS H.P., 1989)

It is carried out to determine the level of neurological deficit after a stroke. A high score corresponds to a more severe stroke, even if it is not detected on early neuroimaging. This scale is used in most clinical studies and is also necessary for assessing the condition of patients after thrombolysis or anticoagulant therapy. This scale should be assessed for all patients with stroke. Follow-up assessment will help assess changes in the patient's condition.

Level of consciousness	Grade
Conscious, answers questions clearly
Drowsy, but reacts even to the minimum stimulus - a command, question
Reaction only in the form of motor or autonomic reflexes or complete areflexia
Level of consciousness: answers to questions. The patient is asked to name the month of the year and his age
	0
	1
	2
Level of consciousness: execution of commands. the patient is asked to close his eyes and clench his fist
Correct answers to both questions or there is a language barrier	0
Correct answer to one question	1
Answers both questions incorrectly or cannot answer	2
Eyeball movements
Full range of motion	0
Partial gaze paralysis or isolated paralysis	1
Fixed deviation of the eyeballs or complete paralysis of gaze, irresistible using the “doll’s eye” technique.	2
Visual fields: examined in each field using finger movements, which the researcher performs simultaneously on both sides.
Normal or long-standing blindness	0
Asymmetry or partial hemianopsia	1
Complete hemianopsia	2
Bilateral hemianopia or coma	3
Facial paralysis
None or sedation	0
Minimal (only smoothness of the nasolabial fold)	1
Partial (lower half of face)	2
Complete (entire half of face involved) or coma	3
D movement in the left arm: the patient holds the outstretched arm at an angle of 90°
	0
	1
	2
	3
No movement	4
D movement in the right hand: the patient holds the outstretched arm at an angle of 90°
Patient holds arm at 90° for 10 seconds, swelling or amputation	0
The patient first holds the hand in a given position, the hand begins to lower before 10 seconds have elapsed	1
The patient does not hold the arm in position for 10 seconds, but still holds it somewhat against gravity	2
The arm falls immediately, the patient cannot overcome gravity	3
No movement	4
Movements in the left leg: the patient raises the leg 30° for 5 seconds
	0
	1
	2
	3
No movement	4
Movements in the right leg: the patient raises the leg 30° for 5 seconds
Patient holds leg in position for 5 seconds, swelling or amputation	0
The leg drops to an intermediate position at the end of 5 seconds	1
The leg falls within 5 seconds, but the patient still holds it somewhat against gravity	2
The leg falls immediately, the patient cannot overcome gravity	3
No movement	4
RESULT:
Speech: assessed when naming standard pictures.
Normal	0
Mild to moderate errors in naming, word selection, or paraphasia	1
Severe: complete Broca's (motor) or Wernicke's (sensory) aphasia	2
Mutism, or total aphasia, or coma	3
Dysarthria
	0
Mild to moderate slurred speech, patient can be understood	1
Severe dysarthria (speech is slurred, unintelligible)	2
A Taxi in the extremities: finger-to-nose and heel-knee tests
No (no movement in the limbs), cannot be assessed	0
Ataxia is present in one limb	1
Ataxia in two limbs	2
Sensitivity: tested using a pin. if the level of consciousness is reduced, assessed only if there is a grimace or asymmetric withdrawal
Normal, sedation or amputation	0
Light and moderate. The patient feels the injection less acutely, but is aware of the touch	1
Significant or complete loss of sensation, unaware of touch	2
Syndrome of "denial" (ignoring)
None or sedation	0
Visual, tactile or auditory ignoring of half the space	1
Profound neglect of half the space in two or more modalities	2
RESULT:

Every neurologist is familiar with the NIHSS (National Institutes of Health Stroke Scale). After all, it is its data that is used to decide on the advisability of thrombolytic therapy, assess its effectiveness, and also to determine the prognosis of the disease. The principle is this: the higher the NIHSS score, the more severe the condition.

In the case of a neurological deficit of more than 3 points on the NIHSS scale, this is regarded as an indication for thrombolytic therapy. If the patient's condition corresponds to more than 25 points on this scale, this is a relative contraindication to thrombolysis. There is evidence that with a score of less than 10 points, the probability of a favorable outcome after 1 year = 60-70%, and with a score of more than 20 points = 4-16%.

Evgeny Chernyshkov helped ensure that the popular scale appeared in the smartphones of medical workers. So, back in 2012, the NIHSS application appeared for Android devices, working safely on both smartphones and tablets.

Compatible with Android devices only.

Language: Russian, English.

National Institutes of Health Stroke Scale (NIHSS)

1. Level of consciousness:

0- conscious, actively reacting;
1 - somnolence, but can be awakened with minimal irritation, follows commands, answers questions;
2 - stupor, requires repeated stimulation to maintain activity or lethargy and requires strong and painful stimulation to produce non-stereotypical movements;
3 - coma, reacts only with reflex actions or completely does not respond to stimuli

2. Level of consciousness – questions:

Ask the patient what month it is and his age. Write down the first answer.

If aphasia and stupor - score 2.

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

0 - correct answer to both questions;
1 - correct answer to one question;
2 - no correct answer was given to any question

3. Level of consciousness – execution of commands:

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

0 - both commands were executed correctly;
1 - one command was executed correctly;
2 - no command executed correctly

4. Movements of the eyeballs:

Only horizontal eye movements are taken into account:

0 - normal;
1 - partial gaze paralysis;
2 - tonic abduction of the eyes or complete gaze paralysis, not overcome by inducing oculocephalic reflexes

5. Visual field examination:

0 - normal;
1 - partial hemianopsia;
2- complete hemianopsia

6. Paresis of facial muscles:

0 - normal;
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 for 10 seconds at an angle of 45 degrees if the patient is lying down, and 90 degrees if the patient is sitting. If the patient does not understand, then the doctor must place the arms in the position himself. Scores are recorded separately for the right and left limbs:

On right:

4 - no active movements;

Left:

0 - no lowering for 10 seconds;
1 - lowers after a short hold (before 10 seconds);
2 - limbs cannot rise or maintain an elevated position, but produce some resistance to gravity;
3 - limbs fall without resistance to gravity;
4 - no active movements;
9 - impossible to check (limb amputated, artificial joint)

8. Movements in the lower extremities:

If the patient is lying down, raise the paretic leg for 5 seconds at an angle of 30º.

Scores are recorded separately for the right and left limbs.

On right:

3 - limbs fall without resistance to gravity;
4 - no active movements;
9 - impossible to check (limb amputated, artificial joint)

Left:

0 - no lowering for 5 seconds;
1 — lowers after a short hold (before 5 seconds);
2 - limbs cannot rise or maintain an elevated position, but produce some resistance to gravity;
3 - limbs fall without resistance to gravity;
4 - no active movements;
9 - impossible to check (limb amputated, artificial joint)

9. Limb ataxia:

Finger-toe and heel-knee tests are carried out on both sides. Ataxia is counted if it is not due to weakness:

0—absent;
1 - in one limb;
2 - in two limbs

10. Sensitivity:

Only hemitype disorder is taken into account:

0 - normal;
1 - mild or moderate impairment;
2 - significant or complete loss of sensitivity.

11. Aphasia:

Ask the patient 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;
1 - soft or medium. May not pronounce some words;
2 - severe dysarthria
9 - intubated or other physical barrier

13. Agnosia (ignoring):

0 - no agnosia;
1 — ignoring bilateral sequential stimulation of one sensory modality;
2 - severe hemiagnosia or hemiagnosia in more than one modality.

Total score:

Interview with Nathan Bornstein

Interview with Nathan Bornstein

Nathan M. Bornstein (IL), MD

Neurological Department, Medical Center named after. Soraski, Tel Aviv

Nathan M. Bornstein is Professor and Chief of the Department of Neurology at Johns Medical Center. Elias Soraski, Faculty of Medicine. Sackler, Tel Aviv University, Israel.

Dr. Bornstein's scientific interests include the following areas: lateralized epileptiform discharges (PLEDs) developed after stroke and associated with metabolic disorders, non-valvular atrial fibrillation, menopause and ischemic stroke, the role of hormone replacement therapy, antiplatelet agents in the treatment of strokes, infections as a trigger for ischemic stroke, transcranial Doppler sonography, dynamics and treatment of asymptomatic carotid stenosis and the clinical significance of hemorrhages in carotid plaques.

Dr. Bornstein is a principal investigator for the Tel Aviv Stroke Registry and the Mediterranean Stroke Society, and a member of the European Stroke Registry. Author and co-author of more than 90 scientific articles on the problems of cerebrovascular diseases, published in journals such as Stroke, Neurology, Adverse Neurology, Cardiology, Acta Diabetologica, Cerebrovascular Diseases, Lancet, Archives of Neurology, Headache, The Journal of Neurological Sciences, The European Journal of Neurology.

— Professor Bornstein, you recently visited Seoul and took part in the International Congress on Stroke. What would you highlight as the most significant scientific and clinical studies?

— This year was not marked by such advanced research as ECASS III in 2008, conducted in Vienna. However, the congress presented the results of several important studies, namely the SENTIS study on the use of the NeuroFlo catheter to enhance cerebral circulation in acute ischemic stroke, and the CASTA study on the use of the drug Cerebrolysin for the treatment of acute ischemic stroke. Also of note were the excellent lectures by Dr. Cohen and Dr. Dirnagl on the impressive results of preclinical research in stroke models.

— Professor Bornstein, you personally participated in the CASTA study. How would you comment on the main findings of the study?

- Yes, that's right. I served on the Steering Committee and am therefore partially responsible for the design of this study. More than 1,060 patients were enrolled, of whom more than 900 completed the study. The final results of the study regarding the primary effectiveness indicators were neutral. However, we think that this was likely due to the fact that a large proportion of the study patients experienced mild strokes, with a median NIHSS score of 9, because too many mild cases were included in the study , then the “ceiling effect” could be strongly manifested.

— Professor Geiss, an ardent supporter of evidence-based medicine, presented the results of the CASTA study from an optimistic and positive point of view. What are the reasons for these conclusions?

“I think that during the presentation of the data, it was correct to point out the possible existence of a ceiling effect, which may explain the neutral results of the study.” However, Cerebrolysin showed significant beneficial effects in the subgroup of patients with baseline NIHSS scores > 12 or even higher (NIHSS > 17). These effects should be taken into account by clinicians as this is the first time in a stroke clinical trial that a neuroprotective agent has demonstrated such robust clinical efficacy.

— Could you tell us a little more about these beneficial effects?

— In a subgroup of 246 people enrolled in the CASTA study with NIHSS scores > 12, the study drug group experienced an improvement of approximately 5 points on the NIHSS after 90 days, compared with the control group, which had a decrease of less than 2 points . This difference of 3 points indicates the development of a very pronounced clinical improvement when patients were treated with Cerebrolysin. It is also important to note that positive effects were observed as early as day 10 of treatment, a point in time when clinicians may decide to intensify neurorehabilitation if the patient's biological condition is stable. For many patients, this reduction means that if rehabilitation is started early, instead of a prolonged course of the disease, their condition will continuously improve.

— Were the results obtained in patients with strokes in the right or left hemispheres different?

- As far as I know, no. This indicates that improvement occurs in any case, regardless of the side of the damage. However, we must wait until the final report of the study results, due sometime in late December, to more definitively answer the question of which subgroups of patients benefited most from Cerebrolysin therapy.

— Please explain whether any positive effect can be expected in patients with mild stroke, since CASTA does not provide a clear answer to this question.

— A positive effect can also be determined in patients suffering from mild forms of stroke and having, accordingly, low values on the NIHSS scale. However, for this to happen, the study must include many more patients. Imagine, for example, two mild stroke patients, one in the placebo group and one in the Cerebrolysin group, with an NIHSS score of 8. As you are well aware, mild strokes usually improve within 90 days to the point where there is very little neurological impairment and the patient's cognitive/motor function can be restored. As a result, it is difficult to detect a significant treatment effect in this group

Previous studies have demonstrated that Cerebrolysin helps these patients recover faster, which improves the quality of life of patients and their caregivers. We can also assume that patients who recover more quickly do not develop post-stroke depression, which often occurs with long-term disorders.

“Another important aspect of stroke research is data on the safety of treatment. What were they like in the CASTA study?

“One of the most important benefits of Cerebrolysin has always been its safety profile, and this was again confirmed in the CASTA study, for the first time in more than 1000 patients. In particular, there was a trend towards a decrease in mortality in the Cerebrolysin group by 1.3%. I think that in the final report, in the subgroup of patients with more severe lesions, this figure will be even higher. But for now all this is just speculation.

— Do you believe that, in the end, convincing data can be obtained about the possibility of achieving a significant neuroprotective effect in ischemic stroke?

- Yes, I believe. However, we must understand that for many years, neurologists around the world had high hopes that neuroprotection could become an established therapy for acute stroke in addition to r-tPA. But the results of several studies did not live up to these expectations.

— What research do you mean?

— Among the latest studies, we can mention the SAINT study, devoted to the study of the substance NXY-059, and the EAST study, devoted to the study of the free radical scavenger called Edaravone. In both cases negative results were obtained. We can also recall a large review by James Grotta in 2004, which looked at drugs tested as neuroprotective agents, with negative results in almost all cases.

— Do you believe in the future of Cerebrolysin?

- From my point of view, it is necessary to carry out more scientific research on the use of Cerebrolysin in acute ischemic stroke. However, the pronounced positive trends in the subgroups of the CASTA study should impress both the pharmaceutical company and the medical community. As is known, only a small number of drugs have achieved certainty in terms of evidence in a single step. However, the first step is always the hardest, and the first step taken in this Cerebrolysin study was very exciting for both the pharmaceutical company and for us stroke specialists.

— Cerebrolysin is a biological drug with complex multimodal action. Do you think this complexity is part of the answer to why Cerebrolysin is a good candidate to look for compelling evidence?

— You raised a very interesting question. In parallel with conducting clinical trials, we must also study the mechanisms of action of Cerebrolysin in acute stroke. Preclinical data indicate that Cerebrolysin is a multimodal drug that is useful for both neuroprotection in acute stroke and long-term neurorehabilitation. In addition, due to its ability to influence the ischemic cascade at various levels (pleiotropic effect), it is the most suitable candidate for neuroprotection in the acute period of stroke.

If you remember Stephen Davis's lecture at the International Stroke Congress in Seoul, he noted that the proof of concept associated with Cerebrolysin has already been established, the only thing missing is data from randomized controlled trials (RCTs). We already know that the mechanism of action of Cerebrolysin is pleiotropic and multimodal in nature. In this regard, it is worth recalling that back in 2006, Marc Fisher expressed the opinion that the best candidates for detecting effectiveness in large RCTs are drugs with multimodal action, including neurotrophic factors.

Cerebrolysin may be an even better candidate than neurotrophic factors themselves due to its greater multimodal properties. This is due to the fact that it mimics the effects of neurotrophic factors, and the active peptides contained in the drug are small enough to pass through the blood-brain barrier, which enhances the effect.

- Well, let's end this interview with a look into the future. What new things do you think will happen in Cerebrolysin research in the near future?

“Over the past few weeks, I have been discussing the CASTA study and its results with my colleagues. The message I received is quite clear: everyone hopes that the sponsor will soon initiate a new trial whose design will be adjusted to focus only on patients with moderate to severe strokes, which may require higher doses. drug or increasing the duration of treatment.

We must learn important lessons from the CASTA study. And if the subgroup analysis is justified, then the next study has a high probability of finding positive, reliable results, which would be an excellent advance in the treatment of strokes.

— Professor Bornstein, we would like to thank you for sharing with us information about this important congress held in Seoul, and in particular about the CASTA study.

Thank you for your questions. I was glad to help.