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Modified NIH Stroke Scale/Score (mNIHSS)

Shortened, validated version of the NIHSS.

Note: Numbering scheme is intentional and reflects differences from the original NIHSS (i.e., 1A, 7 and 10 are eliminated, and 3 and 4 are combined).

Management

In patients who present with symptoms concerning for ischemic stroke:

  • Consult Neurology immediately (if available) for all patients presenting with ischemic stroke.
  • Evaluate whether the patient is a potential candidate to receive intravenous thrombolysis (tPA).
  • Determine the onset of stroke symptoms (or time patient last felt or was observed normal).
  • Consider further imaging including CT, CT angiography and MRI/MRA to evaluate for hemorrhagic stroke.
  • In appropriate circumstances and in consultation with both neurology and the patient, consider IV thrombolysis for ischemic strokes in patients with no contraindications.
  • Always consider stroke mimics in the differential diagnosis, especially in cases with atypical features (age, risk factors, history, physical exam), including:
    • Recrudescence of old stroke from metabolic or infectious stress;
    • Todd’s paralysis after seizure;
    • Complex migraine;
    • Pseudoseizure, conversion disorder.

Critical Actions

  • The mNIHSS performs as well as the NIHSS in predicting clinical outcomes, but it is important to recognize that individual cases will vary and that management decisions must be made in consultation with the patient whenever possible.
  • Whenever possible, patients with acute stroke should be transferred to a stroke center for their initial evaluation and treatment, as the holistic care (medical optimization, early initiation of PT and OT, patient and family education and discharge planning) is associated with improved clinical outcomes.
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