NIHSS Facial Palsy 2 — Questions and Answers
Question 1: A patient grimaces asymmetrically when the clinician applies a noxious stimulus. The lower face droops on the left while the upper face appears symmetric. What NIHSS Facial Palsy score is most appropriate?
- 0 – Normal
- 1 – Minor paralysis
- 2 – Partial paralysis (Correct answer)
- 3 – Complete paralysis
Correct answer: 2 – Partial paralysis
Partial paralysis (score 2) describes complete or near-complete lower facial paresis with the upper face relatively spared.
Question 2: Which cranial nerve is specifically assessed when scoring Facial Palsy on the NIHSS?
- CN V (Trigeminal)
- CN VII (Facial) (Correct answer)
- CN IX (Glossopharyngeal)
- CN XII (Hypoglossal)
Correct answer: CN VII (Facial)
The NIHSS Facial Palsy item evaluates the function of cranial nerve VII, the facial nerve.
Question 3: An unresponsive intubated patient cannot follow commands. How should the examiner assess facial symmetry for NIHSS item 4?
- Skip the item and score 9 (untestable)
- Apply noxious stimuli and observe facial grimacing symmetry (Correct answer)
- Ask a family member to describe baseline facial appearance
- Score 0 since no facial droop is visible at rest
Correct answer: Apply noxious stimuli and observe facial grimacing symmetry
In unresponsive patients, noxious stimulation elicits a grimace response that allows assessment of facial symmetry.
Question 4: A score of 3 on the NIHSS Facial Palsy item indicates:
- Minor nasolabial fold flattening only
- Asymmetric smile with preserved eye closure
- Complete palsy with no movement on one or both sides of the face (Correct answer)
- Bilateral mild weakness of upper and lower face
Correct answer: Complete palsy with no movement on one or both sides of the face
A score of 3 represents complete unilateral or bilateral facial paralysis with absence of movement.
Question 5: A patient with a right MCA stroke has left lower facial droop but closes both eyes symmetrically against resistance. Which NIHSS Facial Palsy score applies?
- 0
- 1
- 2 (Correct answer)
- 3
Correct answer: 2
Preserved eye closure with lower facial paresis is characteristic of partial (central) palsy, scored as 2.
Question 6: A NIHSS Facial Palsy score of 1 is BEST described as:
- No detectable asymmetry in any facial movement
- Slight flattening of the nasolabial fold or minor asymmetry on smiling (Correct answer)
- Absent lower facial movement with intact upper facial movement
- Complete absence of voluntary facial movement bilaterally
Correct answer: Slight flattening of the nasolabial fold or minor asymmetry on smiling
Score 1 reflects minor asymmetry such as nasolabial fold flattening or slight asymmetry during volitional movement.
Question 7: Why is the Facial Palsy item important in the NIHSS for localizing stroke?
- It distinguishes brainstem from cortical lesions based on whether upper face is involved (Correct answer)
- It quantifies pain sensation loss on the face
- It measures tongue deviation indicating cranial nerve XII injury
- It identifies cerebellar dysfunction through facial tremor
Correct answer: It distinguishes brainstem from cortical lesions based on whether upper face is involved
Upper facial involvement (peripheral pattern) suggests a lower motor neuron lesion, while sparing of the upper face (central pattern) suggests a cortical or subcortical stroke.
NIHSS Facial Palsy 2
A patient grimaces asymmetrically when the clinician applies a noxious stimulus.
The lower face droops on the left while the upper face appears symmetric.
What NIHSS Facial Palsy score is most appropriate?