NIHSS Facial Palsy 4 — Questions and Answers
Question 1: When should the NIHSS Facial Palsy item be reassessed after the initial stroke evaluation?
- Only at 24 hours post-stroke
- Every 8 hours for the first 48 hours per standard protocol
- At each serial NIHSS assessment per institutional and trial protocol (Correct answer)
- Only if the patient reports facial numbness
Correct answer: At each serial NIHSS assessment per institutional and trial protocol
Serial NIHSS assessments, including Facial Palsy, are performed at each reassessment interval defined by institutional or clinical trial protocol.
Question 2: A patient with a prior right-sided Bell's palsy presents with a new left MCA stroke and shows left lower facial droop. How should the examiner approach NIHSS Facial Palsy scoring?
- Score only the new left-sided weakness; document the old right-sided palsy separately (Correct answer)
- Average the findings from both sides
- Mark both sides as untestable due to confounding prior history
- Score 0 because the examiner cannot attribute findings to the acute stroke
Correct answer: Score only the new left-sided weakness; document the old right-sided palsy separately
The NIHSS scores deficits attributable to the acute stroke; the prior Bell's palsy on the right is documented but does not affect scoring of new left-sided findings.
Question 3: For a patient who is aphasic and cannot follow verbal commands, which technique best evaluates Facial Palsy on the NIHSS?
- Omit the test and assign a score of 0
- Use demonstration gestures and pantomime to elicit facial movement (Correct answer)
- Ask a family member to mimic facial movement for the patient
- Score based on at-rest observations alone without elicitation
Correct answer: Use demonstration gestures and pantomime to elicit facial movement
Gestural demonstration or pantomime can elicit volitional facial movement in aphasic patients who cannot respond to verbal instructions.
Question 4: Which cerebral artery territory infarct most commonly produces an NIHSS Facial Palsy score of 2 with sparing of the forehead?
- Posterior inferior cerebellar artery (PICA)
- Middle cerebral artery (MCA) (Correct answer)
- Posterior cerebral artery (PCA)
- Anterior cerebral artery (ACA)
Correct answer: Middle cerebral artery (MCA)
MCA territory infarcts affecting the facial motor cortex or corticobulbar tracts classically produce contralateral lower facial (central) palsy with forehead sparing.
Question 5: A patient scores 2 on Facial Palsy at baseline. After thrombolysis, the repeat NIHSS shows both nasolabial folds are symmetric and the patient smiles symmetrically. What is the new score?
- 2 – unchanged to document baseline
- 1 – residual minor asymmetry assumed
- 0 – normal symmetric facial movement (Correct answer)
- NT – untestable after thrombolysis
Correct answer: 0 – normal symmetric facial movement
If facial movements are now symmetric and normal, the correct score is 0 regardless of the prior finding.
Question 6: In the context of the NIHSS, 'partial paralysis' of the face (score 2) specifically means:
- Slight asymmetry detectable only with close inspection
- Total absence of facial movement
- Total or near-total paresis of the lower face with upper face relatively spared (Correct answer)
- Bilateral mild weakness affecting upper and lower face equally
Correct answer: Total or near-total paresis of the lower face with upper face relatively spared
Score 2 denotes total or near-total lower facial paresis, contrasting with the minor asymmetry of score 1 and the complete palsy of score 3.
Question 7: A patient after a pontine hemorrhage has complete right-sided facial palsy including inability to close the right eye. What NIHSS Facial Palsy score applies, and why does the upper face involvement not indicate a central lesion here?
- Score 3; pontine lesions affect the facial nucleus/nerve directly (LMN), involving upper face (Correct answer)
- Score 2; pontine lesions always spare the upper face
- Score 1; brainstem strokes produce only minor facial asymmetry
- Score 0; brainstem lesions do not affect the facial nerve
Correct answer: Score 3; pontine lesions affect the facial nucleus/nerve directly (LMN), involving upper face
Pontine lesions at or below the facial nucleus cause lower motor neuron palsy, involving the entire ipsilateral face including the upper division.
NIHSS Facial Palsy 4
When should the NIHSS Facial Palsy item be reassessed after the initial stroke evaluation?