NIHSS Group B Patient Examination — Questions and Answers
Question 1: A patient in the NIHSS Group B category is BEST described as someone who:
- Has fully intact language and consciousness but is uncooperative
- Has a known communication barrier, altered consciousness, intubation, or significant aphasia that limits the standard exam (Correct answer)
- Has a prior stroke deficit but is otherwise alert and conversational
- Is being assessed more than 24 hours after symptom onset
Correct answer: Has a known communication barrier, altered consciousness, intubation, or significant aphasia that limits the standard exam
Group B patients are those whose neurological deficits or medical status (e.g., intubation, profound aphasia, altered consciousness) create barriers to the standard NIHSS examination format. Group A patients are cooperative and able to follow standard instructions.
Question 2: When administering the NIHSS to an intubated patient, how should the examiner score the Dysarthria item?
- Score 0 because the patient's airway is protected
- Score 2 (severe dysarthria) by default for all intubated patients
- Score 1 (mild dysarthria) as a standard approximation
- Mark the item as UN (untestable) and do not penalize the patient (Correct answer)
Correct answer: Mark the item as UN (untestable) and do not penalize the patient
Dysarthria cannot be evaluated in an intubated patient. The NIHSS protocol requires marking the item as UN (untestable) in this case. UN items are not counted against the patient's score.
Question 3: For a Group B patient who has a pre-existing language barrier (speaks no English and no interpreter is available), how should the examiner approach the Language/Aphasia item?
- Score 3 (mute/global aphasia) because the patient cannot produce English
- Skip the item and do not record a score
- Score 0 only if the patient gestures appropriately to visual stimuli and writing samples
- Mark as UN (untestable) and note the language barrier (Correct answer)
Correct answer: Mark as UN (untestable) and note the language barrier
When the patient has a language barrier and no interpreter is available, the item is marked UN. The NIHSS is designed to measure neurological deficits, not language differences, so a pure language barrier without neurological cause renders the item untestable.
Question 4: A Group B patient is deeply stuporous and does not respond to voice but does withdraw to painful stimuli. How should Level of Consciousness (item 1a) be scored?
- 0 — Alert
- 1 — Not alert but arousable by minor stimulation
- 2 — Not alert and requires repeated stimulation or painful stimuli to make purposeful movements (Correct answer)
- 3 — Unresponsive or responds only with reflex posturing
Correct answer: 2 — Not alert and requires repeated stimulation or painful stimuli to make purposeful movements
A score of 2 is assigned when the patient is not alert and requires repeated or painful stimulation to make non-reflex (purposeful) movements. Withdrawal to pain is considered a purposeful response, distinguishing this from a score of 3.
Question 5: When scoring the Best Gaze item on a Group B patient who cannot follow verbal commands, which approach is correct?
- Score 0 because gaze cannot be tested without command-following
- Use oculocephalic (doll's-eye) maneuver to assess eye movement and score based on observed range of motion (Correct answer)
- Automatically score 2 (forced deviation) for all unresponsive patients
- Skip the item and mark it as UN
Correct answer: Use oculocephalic (doll's-eye) maneuver to assess eye movement and score based on observed range of motion
The NIHSS explicitly allows the use of oculocephalic (doll's-eye) testing when a patient cannot voluntarily follow gaze commands. The examiner scores based on the range and conjugacy of eye movement observed, making the item testable even in unresponsive patients.
Question 6: A Group B patient with global aphasia cannot name or read aloud. How should the examiner assess the Language item for this patient?
- Score 3 (mute/no usable speech) immediately without further testing
- Observe comprehension responses to written commands, pictures, and gestures to determine the best possible score (Correct answer)
- Score 2 (severe aphasia) by default for all patients with global aphasia
- Mark as UN because aphasia patients cannot participate in language testing
Correct answer: Observe comprehension responses to written commands, pictures, and gestures to determine the best possible score
For Group B patients who cannot speak, the examiner assesses all components available — comprehension of written commands, picture identification, and gesture responses — to assign the most accurate score rather than defaulting to the maximum. The score should reflect the best performance observed.
NIHSS Group B Patient Examination
A patient in the NIHSS Group B category is BEST described as someone who: