What does the neurological exam for stroke consist of?
A neurological examination for stroke evaluates your level of awareness and brain function. Different parts of the brain control different functions like language, speech, vision, eye movement, muscle control, and sense of touch. Each section of the exam tests a different function of the brain.
Using the information from your medical history and physical exam, the doctor will ask you a series of questions and give you a few physical and mental tasks to determine which areas of your brain have been affected by stroke and how severely. Your responses will be measured using a stroke scale, usually the National Institutes of Health Stroke Scale (NIHSS)—see below for more.
The doctor will test your level of awareness and alertness by asking you your name, the current date, and to open and close your eyes. Your language and comprehension will be assessed by having you repeat a short list of words and describe a picture.
Other tasks test key nerves in the brain that control movement, vision, muscle strength, and sensation. The doctor will check your face to see if one side of your mouth or one of your eyelids is drooping. You will be checked for loss of vision and abnormal eye movement. Your muscle strength and coordination will be evaluated by holding your arms and legs out to see if one of them drifts down or cannot be lifted, and by touching your nose with your right index finger.
You may also be lightly pricked with a sharp pin first and then touched with something blunter to see if you can feel the difference. Different areas of your body, including your arms, legs, and face, will be tested to see if you have lost feeling on one side.
What is the NIHSS Stroke Scale?
The neurological examination is scored using the National Institutes of Health Stroke Scale (NIHSS). The NIHSS is an evaluation tool that measures how your brain has been affected by stroke. On this test, a score of zero indicates you are completely normal; the higher your score, the more severe your stroke was.3
| Stroke Severity | NIHSS Stroke Score |
| Normal | 0 |
| Mild | Less than 5 |
| Moderate | 5 to 15 |
| Severe | 15 to 25 |
| Very Severe | More than 25 |
The following table shows some of the questions you may be asked during a neurological examination and how they affect your stroke score. The test takes 5 to 10 minutes to perform.
| Stroke Scale Sample Questions | |
| Question | Score |
| Is the patient alert? | No +3 points |
| How old is the patient? What is the current month? | One correct +1 point Neither correct +2 points |
| Can patient open and close eyes, grip and release hand? | One +1 point Neither +2 points |
| Are both eyes looking in the same direction? | No +2 points |
| Is there loss of vision? | No vision +3 points Partial Loss +1 point |
| Does face move evenly on both sides when smiling? | Minor paralysis +1 points Complete paralysis +3 points |
| Does arm drift downward 10 seconds after extending? | Yes +1-4 points |
| Does leg drift downward 5 seconds after extending? | Yes +1-4 points |
| Is there loss of coordination when touching heels to shins on both legs? | One leg +1 point Both legs +2 points |
| Does patient feel pain when pricked with a pin? | Some pain +1 point No feeling +2 points |
| Describe what is happening in the picture | Unable to speak +3 points Very limited speech +2 points |
| Read from a list/repeat a sentence | Severely slurred speech +2 points Slurs some words +1 points |
What do the results mean?
The neurological exam shows how the stroke has affected your mental and physical abilities. Loss of an ability indicates where in the brain the stroke may have occurred and how much damage was done.
One of the first clues to the location of a stroke is whether or not both sides of your body are working equally well. The right side of your brain controls the left side of your body, and the left side of your brain controls the right side of your body. If you have weakness or paralysis on only one side of your body, the doctor will know that the stroke occurred in the opposite side of your brain. Paralysis on both sides of the body may indicate that the stroke occurred in the base of the brain (the brain stem); all signals traveling from the brain to the body must pass through the brain stem.
Changes in specific mental abilities, such as understanding or talking, can also help doctors get a better idea of the location of the stroke, since these skills are controlled by particular areas of the brain. Further screening with imaging tests such as MRI and angiography can confirm the exact location of the stroke.
The neurological exam also provides a score that indicates how severely your mental and physical abilities have been affected by stroke. This score enables doctors to estimate your chances of recovery and determine the best treatment for your type of stroke. A high score means you have had a severe stroke and may take longer to recover or may not recover completely.
