NIHSS Best Gaze 5 — Questions and Answers
Question 1: A patient with acute stroke scores 2 on Best Gaze. Which statement about prognosis is most accurate based on this finding?
- Gaze palsy has no prognostic significance
- A score of 2 suggests severe stroke and is associated with worse outcomes (Correct answer)
- A score of 2 only occurs in mild strokes
- Best Gaze score does not contribute to total NIHSS
Correct answer: A score of 2 suggests severe stroke and is associated with worse outcomes
Higher NIHSS Best Gaze scores reflect more severe stroke and are associated with larger infarct volume and worse functional outcomes.
Question 2: Which phrase best describes 'forced deviation' as used in the NIHSS Best Gaze item?
- Eyes that can be manually returned to midline by pressing on them
- Persistent tonic eye deviation that resists voluntary and reflex correction (Correct answer)
- Eyes that deviate downward during sleep
- Nystagmus triggered by lateral gaze
Correct answer: Persistent tonic eye deviation that resists voluntary and reflex correction
Forced deviation is persistent conjugate deviation that resists voluntary effort and cannot be overcome by the oculocephalic reflex.
Question 3: A patient with basilar artery occlusion has bilateral eye deviation downward and inward ('ocular bobbing'). How is this captured on NIHSS Best Gaze?
- Scored as 2 (forced deviation)
- Scored as 1 (partial palsy)
- Not captured — Best Gaze only tests horizontal movements (Correct answer)
- Scored as 0 since horizontal gaze may be intact
Correct answer: Not captured — Best Gaze only tests horizontal movements
NIHSS Best Gaze tests only horizontal eye movements; vertical and other abnormal eye movements are not scored in this item.
Question 4: A nurse is rechecking NIHSS serially every 4 hours. On the second check, the patient's previously forced gaze deviation (score 2) is now partial (score 1). This change most likely indicates:
- Worsening stroke
- Improvement in the acute gaze deficit (Correct answer)
- Examiner error — scores cannot change
- Rebleed
Correct answer: Improvement in the acute gaze deficit
A decrease in Best Gaze score from 2 to 1 during serial NIHSS monitoring reflects neurological improvement.
Question 5: Which of the following findings would score a 0 on NIHSS Best Gaze?
- Gaze limited to midline bilaterally
- Eyes that deviate left but correct with head turning
- Full and symmetric horizontal gaze bilaterally (Correct answer)
- Adduction deficit in the right eye
Correct answer: Full and symmetric horizontal gaze bilaterally
Normal (full, symmetric, conjugate) horizontal eye movements in both directions = score 0.
Question 6: During NIHSS training, a trainee assigns a score of 1 to a patient whose gaze is fully normal but who has a minor head turn preference. The correct action is:
- Accept the score — head turn indicates gaze preference
- Correct it to 0 — NIHSS Best Gaze scores eye movement, not head position (Correct answer)
- Correct it to 2 — any asymmetry is maximal
- Leave it at 1 and note the head turn separately
Correct answer: Correct it to 0 — NIHSS Best Gaze scores eye movement, not head position
Best Gaze scores only the movement of the eyes, not head posture; normal eye movements score 0 regardless of head position.
Question 7: A patient with acute stroke is intubated and sedated. The team needs an NIHSS Best Gaze score. Which approach is appropriate?
- Mark the item as untestable (UN) and exclude it from total
- Perform the oculocephalic maneuver to assess horizontal eye movement (Correct answer)
- Assume a score of 0 since sedation causes no gaze deviation
- Skip the item — sedated patients cannot be scored on any NIHSS item
Correct answer: Perform the oculocephalic maneuver to assess horizontal eye movement
In unconscious or sedated patients, the oculocephalic (doll's eye) maneuver is the accepted method for testing Best Gaze.
NIHSS Best Gaze 5
A patient with acute stroke scores 2 on Best Gaze.
Which statement about prognosis is most accurate based on this finding?