NIHSS Best Gaze 4 — Questions and Answers
Question 1: An examiner asks a stroke patient to follow a finger moving to the far right and then far left. The patient's left eye stops at midline while the right eye reaches full lateral gaze. No forced deviation is present. What Best Gaze score applies?
- 0 — one eye is normal
- 1 — partial gaze palsy present (Correct answer)
- 2 — total gaze paresis
- Untestable
Correct answer: 1 — partial gaze palsy present
When gaze is abnormal in one or both eyes but forced deviation is absent, the score is 1 (partial gaze palsy).
Question 2: Which of the following best describes an internuclear ophthalmoplegia (INO) and its NIHSS Best Gaze score?
- Impaired adduction of one eye on lateral gaze; scores 1 (Correct answer)
- Forced contralateral deviation; scores 2
- Loss of both upward and downward gaze; scores 2
- Normal horizontal gaze; scores 0
Correct answer: Impaired adduction of one eye on lateral gaze; scores 1
INO causes impaired adduction of the ipsilateral eye on lateral gaze, representing a partial gaze abnormality that scores 1.
Question 3: The NIHSS Best Gaze item is scored ONLY on:
- The patient's best attempt after repeated trials (Correct answer)
- A single observation at the time of testing
- The average of three attempts
- The worst performance recorded during the exam
Correct answer: The patient's best attempt after repeated trials
NIHSS principles direct the examiner to score the patient's best performance on the tested item.
Question 4: A patient with acute stroke has eyes deviated to the left, but with vigorous oculocephalic stimulation the eyes briefly cross midline to the right before returning to the deviated position. What is the Best Gaze score?
- 0
- 1 (Correct answer)
- 2
- 3
Correct answer: 1
If the forced deviation can be partially or fully overcome by the oculocephalic maneuver, the score is 1, not 2.
Question 5: A clinician is testing Best Gaze in a patient with known bilateral blindness. Which technique should be used?
- Use a loud sound to the side to elicit gaze
- Test only with the oculocephalic maneuver
- Skip Best Gaze — it cannot be tested in blind patients
- Test voluntary horizontal gaze using command ('look left/right') without a visual target (Correct answer)
Correct answer: Test voluntary horizontal gaze using command ('look left/right') without a visual target
Blind patients can still perform voluntary horizontal gaze on verbal command, so the item remains testable without a visual target.
Question 6: Hemispheric stroke causing gaze deviation typically resolves within:
- Minutes to a few hours (Correct answer)
- 1–2 days
- 1–2 weeks
- It is permanent
Correct answer: Minutes to a few hours
Gaze deviation from hemispheric stroke often resolves within minutes to hours as the contralateral hemisphere and brainstem compensate.
Question 7: A patient with a left frontal lobe stroke is admitted. The examiner expects gaze to deviate toward which side?
- Right — toward the paralyzed limbs
- Left — toward the lesion (Correct answer)
- Upward
- Downward
Correct answer: Left — toward the lesion
Left frontal eye field damage causes loss of rightward gaze drive, and the unopposed right hemisphere pushes gaze to the left (toward the lesion).
NIHSS Best Gaze 4
An examiner asks a stroke patient to follow a finger moving to the far right and then far left.
The patient's left eye stops at midline while the right eye reaches full lateral gaze.
No forced deviation is present.
What Best Gaze score applies?