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Application of the National Institutes of Health Stroke Scale and common pitfalls

Liz Mackey, Stroke Nurse Practitioner, Western Health MelbourneLizzie Dodd, Clinical Practice Consultant, Acute Stroke Unit Coordinator, The Queen Elizabeth Hospital SA Health

1Introduction to the National Institutes of Health Stroke ScaleCommon pitfalls of the NIHSSDiscuss how the NIHSS can be incorporated into practicePatient assessmentCommunicationDecision makingStroke trial recruitment Reporting outcomes Case examplesTraining options

Aims215-item neurologic examination stroke scale

Ratings for each item are scored with 3 to 5 gradeswith 0 as normal, and there is an allowance for untestable items. Range 0 42 Mild 0-7Moderate 8-16Severe > 16The single patient assessment requires less than 10 minutes to complete.

National Institutes of Health Stroke Scale 3A trained observer rates the patients ability to answer questions and perform activities.

The evaluation of stroke severity depends upon the ability of the observer to accurately and consistently assess the patientNational Institutes of Health Stroke Scale 4National Institutes of Health Stroke Scale Evaluates the effect of stroke on:Level of consciousness Extraocular movement Visual-field loss Facial symmetryMotor strengthAtaxia Sensory loss Language Dysarthria Extinction and Inattention (Neglect)

5http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

6Pitfalls of the NIHSSThree main pitfalls in using the NIHSS:Items with poor reliability Dominant-hemisphere strokesLessened weighting for posterior circulation strokes

7Pitfalls: Items with poor reliability The NIHSS contains FOUR items which are widely acknowledged to have poor reliability 1a Loss of Consciousness4 Facial Palsy7 Ataxia10 Dysarthria

Potential issues if not scored accurately include:Communication difficulties between practitionersDecision making errors (eg in thrombolysis or trial recruitment)Difficulties assessing patient outcomes

Ref 12.

8Review clip 1,6,9,12https://www.youtube.com/watch?v=awscZzCVaqE&list=PLfvzF_UhY1eZhoSn_uox8Fi3wtdku3x7K&index=13Pitfalls: dominant hemisphere strokesCommunication / language impairments in dominant hemisphere strokesHigher scores for more deficits related to language / communication impairmentsTendency for dominant hemisphere strokes to receive a higher rating, approximately 4-points more for the same size stroke, compared with non-dominant hemisphere strokes.Items affected particularly:1b LOC Questions, 1c LOC Commands, 9 Best language, 10 DysarthriaRef 13, 14Pitfalls: Posterior circulationLessened weighting for vertebro-basilar (posterior circulation) strokesItems include:1a LOC3 Visual fields4 Facial palsy5&6 Motor7 Ataxia8 Sensory10 Dysarthria

Other elements that provide more information about the posterior circulation receive no score e.g. diplopiadysphagiagait instabilityhearing nystagmus Ref 12

Another downside is the lessened weighting for posterior circulation strokes, a problem for nearly all neurological deficit scales. Though some items related to the verterbo-basilar system can be scored (e.g. LOC, visual fields, facial palsy, sensory, motor, dysarthria and ataxia), other elements receive no score (e.g. diplopia, dysphagia, gait instability, hearing, and nystagmus).

11Why should we bother doing NIHSS?

Whose job is it to do this?12Why should we bother doing NIHSS?Well-validated, reliableTime efficient & standardised brief neurological examinationAssesses degree of neurological deficitPredictor of mortality & functional outcomes (short- and long-term)Clinical Guidelines for Stroke Management 2010 (NSF p.55) Stroke severity should be assessed & recorded on admission by a trained clinician using a validated tool (e.g. NIHSS or SSS)

Facilitates:Communication (clinicians, patients, care givers)Identification of location of infarct Early understanding of prognosisSelection for interventions / trialsIdentification of potential for complications

Ref 1-9

13Emergency DepartmentWho? Why? Rapid assessment & decision making:Location of stroke Thrombolysis Patient management & prognosisFacilitate coordination of careAdds to the picture of the stroke subtype TACI, PACI, LACI, POCI, haemorrhageTrial recruitmentCommunication when referring to other teamseg. neurointervention, neurosurgeryFacilitates communication to patients and families / care giversNIHSS use in everyday clinical practice14NIHSS use in everyday clinical practiceThrombolysis decision making:Baseline differences in NIHSS scores can affect the response of stroke patients to intravenous tissue plasminogen activatorRisk of haemorrhage is considerable among patients with high NIHSS scores:US FDA labelling: use intravenous tissue-type plasminogen activator in patients with NIHSS scores >22 with caution.

Ref 2,10

15Thrombolysis decision making:The NIHSS is widely used in current clinical practice. 29 These baseline differences in NIHSS scores can affect the response of stroke patients to intravenous tissue plasminogen activator, which is the only FDA-approved medical therapy to reduce disability after acute ischemic stroke. Moreover, federal drug labeling for intravenous tissue-type plasminogen activator incorporates the NIHSS. Because the risk of hemorrhage is considerable among patients with high NIHSS scores, FDA labeling indicates the decision to treat with intravenous tissue-type plasminogen activator in patients with NIHSS scores >22 should be made with caution. Therefore, the AHA/ASA advocates that efforts continue to focus on how to collect and incorporate the NIHSS into a revised version of the 30-day measures.

Acute Stroke Care UnitWho? Why? Facilitate coordination of careCommunication of changes

Recruitment to trials

When?At intervals during acute stay: Thrombolysis: NIHSS at 2-hours, 24-hours, dischargeNIHSS use in everyday clinical practice16Follow-up in Outpatient ClinicCommunication of changesAudit of outcomes for thrombolysis

NIHSS use in everyday clinical practice17Stroke trial recruitment Most stroke trials require NIHSS to be > 4 or < 26NIHSS use in everyday clinical practice18NIHSS use in reviewing hospital morbidity & mortality performanceGrowing interest in ensuring stroke severity is accurately quantifiedBy scoring stroke costs to health services are potentially more accurately identified i.e. adjustment for stroke severity

Fonarow et al (2014): Stroke severity has been documented to be a key mortality risk determinant in acute ischemic stroke. Prior analyses demonstrated that stroke severity, as quantified by the NIHSS, was the strongest predictive variable for in-hospital and 30-day mortality and substantially improved the performance of a model based on clinical variables without stroke severityRef 2

19Fonarow et al (2012):

Among hospitals ranked in the top 20% or bottom 20% of performers by the claims model without NIHSS scores, 26.3% were ranked differently bythe model with NIHSS scores.

Of hospitals initially classified as having worse than expected mortality, 57.7% were reclassified to as expected by the model with NIHSS scores.

Ref 11

NIHSS use in reviewing hospital morbidity & mortality performance20

(L)(R)

Case examples21

(L)(R)Not alert 2x age, x month 2Does not follow commands 2Eyes deviated to left 2Homonymous hemianopia 2R) facial droop 2UL - R) UL no mvmt & L) drift 5LL - R) sev weak L) some effort 5Absent ataxia 0R) Hemiparesis (face,arm) 2Non-verbal 3Dysarthria = mute 2? Inattention 0Total = 29L) MCA infarct (TACI)Large Middle Cerebral Artery Infarct

22Large Middle Cerebral Artery Infarct(L)(R)L) MCA infarct (TACI)Discussion:Mild / moderate/ severe? Prognosis?Treatment options?

23Lacunar Infarct(L)(R)Alert 0Age, Month 0 Follows commands 0Normal gaze 0No visual loss 0L) minor facial droop 1UL - L) UL some effort 2LL - L) some effort 2No ataxia 0L) mild sensory loss face,arm,leg1No aphasia 0Mild dysarthria 1No Inattention 0Total = 7R) internal capsule infarct (LACI)

Image: Stroke July 2012 vol. 43 no. 7 1837-1842 24Lacunar Infarct(L)(R)R) internal capsule infarct (LACI)

Image: Stroke July 2012 vol. 43 no. 7 1837-1842 Discussion:Mild / moderate/ severe? Prognosis?Treatment options?25NIHSS Training26FREE training viahttps://secure.trainingcampus.net/uas/modules/trees/windex.aspx?rx=nihss-english.trainingcampus.net

27Boehringer Ingelheim training offer

In hospital group training and accreditation for NIHSS (can be a 2 hour session or 2 x 1 hour sessions = 1 hour to train + 1 hour for exam)BI sponsor paper exams ($25 each), everyone gets booklet ($3 each), a DVD for the department ($50 worth)The DVD does the teachingGet sent to the National Stroke Association in Colorado for official processing and accreditation, certificates will be providedBenefits are that a group of doctors/nurses can do training in one in-house session, (no need to do it at home)

28Examples of Apps for NIHSS

Canopy Medical TranslatorAndroidhttps://itunes.apple.com/us/app/canopy-medical-translator/id792808936?mt=829

Boehringer Ingelheim AppBoehringer Ingelheim App

ReferencesClinical Guidelines for Stroke Management 2010 (NSF) Fonarow GC, Alberts MJ, Broderick JP, Jauch EC, Kleindorfer DO, Saver JL, Solis P, Suter R, Schwamm LH. Stroke Outcomes Measures Must Be Appropriately Risk Adjusted To Ensure Quality Care of Patients: A Presidential Advisory From the American Heart Association/American Stroke Association Stroke. published online February 12, 2014Nedeltchev K, Renz N, Karameshev A, Haefeli T, Brekenfeld C, Meier N, RemondaL, Schroth G, Arnold M, Mattle HP. Predictors of early mortality after acute ischaemic stroke. Swiss Med Wkly. 2010;140:254-259.Chang KC, Tseng MC, Tan TY, Liou CW. Predicting 3-month mortality among patients hospitalized for first-ever acute ischemic stroke. J Formos Med Assoc. 2006;105:310-317.Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED, Fonarow GC, Schwamm LH. Risk score for in-hospital ischemic stroke mortality derived and validated within the Get With The GuidelinesStroke Program. Circulation. 2010;122:1496-1504.24. Johnston KC, Connors AF Jr, Wagner DP, Knaus WA, Wang X, Haley EC Jr. A predictive risk model for outcomes of ischemic stroke. Stroke. 2000;31:448-455.326. Henon H, Godefroy O, Leys D, Mounier-Vehier F, Lucas C, Rondepierre P, Duhamel A, Pruvo JP. Early predictors of death and disability after acute cerebralischemic event. Stroke 1995;26:392-398.7. Weimar C, Konig IR, Kraywinkel K, Ziegler A, Diener HC. Age and National Institutes of Health Stroke Scale score within 6 hours after onset are accurate predictors of outcome after cerebral ischemia: development and external validation of prognostic models. Stroke 2004;35:158-162.8. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Nursing, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870-947.9. Duncan PW, Zorowitz R, Bates B, Choi JY, Glasberg JJ, Graham GD, Katz RC, PhD; Lamberty K, Reker D. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:e100-e143

10. Fonarow GC, Liang L, Smith EE, Reeves MJ, Saver JL, Xian Y, Hernandez AF, Peterson ED, Schwamm LH; on behalf of the GWTG-Stroke Steering Committee & Investigators. Comparison of performance achievement award recognition with primary stroke center certification for acute ischemic stroke care. J Am Heart Assoc11. Fonarow GC, Pan W, Saver J et al Comparison of 30-Day Mortality Models for Profiling Hospital Performance in Acute Ischemic Stroke With vs Without Adjustment for Stroke Severity JAMA, July 18, 2012Vol 308, No. 3 257-26412. Meyer BC, Lyden PD. "The Modified National Institutes of Health Stroke Scale (mNIHSS): Its Time Has Come" Int J Stroke. 2009 August ; 4(4): 26727313. Lyden P, Claesson L, Havstad S, AshwoodT, Lu M. Factor analysis of the national institutes of health stroke scale in patients with large strokes. Arch Neurol. 2004;61:1677-1680. 14.Woo D, Broderick J, Kothari R, et al.,Group Nr-PSS. Does the national institutes of health stroke scale favor left hemisphere strokes. Stroke. 1999;30:2355-2359.

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