Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    Pediatric NIH Stroke Scale (NIHSS)

    Quantifies stroke severity using a child-specific version of the NIH Stroke Score.
    Favorite

    INSTRUCTIONS

    Administer the questions in the order below. In order to improve score accuracy, emphasize with family members the need to refrain from hinting at the correct responses to questions asked.

    When to Use
    Pearls/Pitfalls
    Why Use

    Pediatric patients 2-18 years old with clinical and radiologic signs of acute ischemic stroke.

    • The presentation of stroke in younger children can be subtle and include altered mental status, depressed level of consciousness, and apneas, among others.

    • Posing the questions and tasks in the PedNIHSS as a game may aid motivation in patients, especially younger children.

    • The developmental age of the child in their pre-morbid state must be considered. Consultation with the child’s primary pediatrician may be useful in estimating the child’s developmental age; performing a validated developmental screening tool using parental recall may also be helpful.

    • Assessment of muscle strength in uncooperative patients may be made by careful observation of spontaneous movement, or elicited movement, as compared to a developmentally and neurologically appropriate child of the same age as the patient being evaluated.

    • Pediatric stroke is relatively uncommon, but remains an important cause of morbidity and mortality. 

    • Adult stroke scales have limited sensitivity when translated to a pediatric population (62-67% sensitivity according to one analysis by Mackay et al, 2016). PedNIHSS is up to 87% sensitive (Beslow 2012). 

    • Determines the severity of pediatric stroke and can be trended over time to assess recovery.

    • Initial PedNIHSS may be predictive of future disability at 90 days.

    Alert; keenly responsive
    0
    Not alert but arousable by minor stimulation to obey, answer, or respond
    +1
    Not alert, requires repeated stimulation, or is obtunded and requires strong/painful stimulation to make movements (not stereotyped)
    +2
    Responds only with reflex motor or autonomic effects or totally unresponsive, flaccid, areflexic
    +3
    Answers both questions correctly
    0
    Answers one question correctly
    +1
    Answers neither question correctly
    +2
    Performs both tasks correctly
    0
    Performs one task correctly
    +1
    Performs neither task correctly
    +2
    Normal
    0
    Partial gaze palsy (abnormal gaze in one or both eyes but no forced deviation or total gaze paresis)
    +1
    Forced deviation or total gaze paresis not overcome by oculocephalic maneuver
    +2
    No visual loss
    0
    Partial hemianopia
    +1
    Complete hemianopia
    +2
    Bilateral hemianopia (blind including cortical blindness)
    +3
    Normal symmetrical movement
    0
    Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
    +1
    Partial paralysis (total or near total paralysis of lower face)
    +2
    Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)
    +3
    No drift, limb holds 90 (or 45) degrees for full 10 seconds
    0
    Drift, limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
    +1
    Some effort against gravity, limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
    +2
    No effort against gravity, limb falls
    +3
    No movement
    +4
    Amputation, joint fusion
    +9
    No drift, limb holds 90 (or 45) degrees for full 10 seconds
    0
    Drift, limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
    +1
    Some effort against gravity, limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
    +2
    No effort against gravity, limb falls
    +3
    No movement
    +4
    Amputation, joint fusion
    +9
    No drift, leg holds 30 degrees position for full 5 seconds
    0
    Drift, leg falls by the end of the 5 second period but does not hit bed
    +1
    Leg falls to bed by 5 seconds, but has some effort against gravity
    +2
    No effort against gravity, leg falls to bed immediately
    +3
    No movement
    +4
    Amputation, joint fusion
    +9
    No drift, leg holds 30 degrees position for full 5 seconds
    0
    Drift, leg falls by the end of the 5 second period but does not hit bed
    +1
    Leg falls to bed by 5 seconds, but has some effort against gravity
    +2
    No effort against gravity, leg falls to bed immediately
    +3
    No movement
    +4
    Amputation, joint fusion
    +9
    Absent
    0
    Present in one limb
    +1
    Present in two limbs
    +2
    Normal; no sensory loss
    0
    Mild to moderate sensory loss; patient feels pinprick is less sharp or dull on the affected side, or there is a loss of superficial pain with pinprick but patient is aware he/she is being touched
    +1
    Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg
    +2
    No aphasia, normal
    0
    Mild to moderate aphasia
    +1
    Severe aphasia
    +2
    Mute, global aphasia; no usable speech or auditory comprehension
    +3

    Repetition test:

    Reading test:

    Fluency test:

    Naming test:

    Normal
    0
    Mild to moderate; patient slurs at least some words and, at worst, can be understood with some difficulty
    +1
    Severe; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric
    +2
    Intubated or other physical barrier
    +9
    No abnormality
    0
    Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities
    +1
    Profound hemi-inattention or hemi-inattention to >1 modality; does not recognize own hand or orients to only one side of space
    +2

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    Pediatric stroke is overall rare, and the true predictive value of the PedNIHSS is subject to change as the scale continues to be studied. Retrospective application of the PedNIHSS has been shown to be valid and reliable in one cross-sectional study (see Beslow 2012).

    Management

    • This score has not been validated in hemorrhagic stroke; in such cases, the need for emergent neurosurgical consult is clear.

    • Given the overall rarity of pediatric stroke, the benefit of tPA is not well defined in the literature, emphasizing the importance of expert consultation.

    Critical Actions

    Children with sickle cell disease presenting with acute ischemic stroke will likely benefit from emergent blood transfusion to reduce hyperviscosity caused by sickled cells. Early consultation with a pediatric hematologist is recommended in addition to child neurology consult.

    Content Contributors
    Reviewed By
    • Gary McAbee, DO
    • Steven Pavlakis, MD
    About the Creator
    Dr. Rebecca N. Ichord
    Are you Dr. Rebecca N. Ichord?
    Partner Content
    Content Contributors
    Reviewed By
    • Gary McAbee, DO
    • Steven Pavlakis, MD