National Institutes of Health Stroke Scale (NIHSS)

Item pemeriksaan ditampilkan dalam bahasa Inggris karena instrumen ini belum punya terjemahan Indonesia yang resmi. National Institute of Neurological Disorders and Stroke (NINDS) dan American Heart Association/American Stroke Association (AHA/ASA) mencantumkan terjemahan tervalidasi ke bahasa Spanyol, Kanton, Mandarin, Jerman, Estonia, Hungaria, Italia, Marathi, Portugis, dan Telugu, tetapi bahasa Indonesia tidak termasuk.

1a. Level of Consciousness (LOC)-0: Alert; keenly responsive.1: Not alert; arousable by minor stimulation to obey, answer, or respond.2: Not alert; requires repeated stimulation to attend, or is obtunded and requires strong/painful stimulation to make movements (not stereotyped).3: Responds only with reflex motor or autonomic effects, or is totally unresponsive, flaccid, and areflexic.

1b. LOC Questions (month, age)-0: Answers both questions correctly.1: Answers one question correctly.2: Answers neither question correctly.

1c. LOC Commands (open/close eyes; grip/release hand)-0: Performs both tasks correctly.1: Performs one task correctly.2: Performs neither task correctly.

2. Best Gaze-0: Normal.1: Partial gaze palsy; gaze abnormal in one or both eyes, but forced deviation or total gaze paresis not present.2: Forced deviation, or total gaze paresis not overcome by the oculocephalic maneuver.

3. Visual Fields-0: No visual loss.1: Partial hemianopia.2: Complete hemianopia.3: Bilateral hemianopia (blind, including cortical blindness).

4. Facial Palsy-0: Normal symmetrical movements.1: Minor paralysis (flattened nasolabial fold, asymmetry on smiling).2: Partial paralysis (total or near-total paralysis of lower face).3: Complete paralysis of one or both sides (absence of facial movement in the upper and lower face).

5a. Motor Arm - Left-0: No drift; limb holds 90° (sitting) / 45° (supine) for full 10 seconds.1: Drift; limb holds position but drifts down before full 10 seconds, does not hit bed/support.2: Some effort against gravity; limb cannot get to or maintain (if cued) position, drifts down to bed, but has some effort against gravity.3: No effort against gravity; limb falls.4: No movement.UN: Untestable (amputation or joint fusion)

5b. Motor Arm - Right-0: No drift; limb holds 90° (sitting) / 45° (supine) for full 10 seconds.1: Drift; limb holds position but drifts down before full 10 seconds, does not hit bed/support.2: Some effort against gravity; limb cannot get to or maintain (if cued) position, drifts down to bed, but has some effort against gravity.3: No effort against gravity; limb falls.4: No movement.UN: Untestable (amputation or joint fusion)

6a. Motor Leg - Left-0: No drift; leg holds 30° position for full 5 seconds (supine).1: Drift; leg falls by the end of the 5-second period but does not hit the bed.2: Some effort against gravity; leg falls to the bed by 5 seconds, but has some effort against gravity.3: No effort against gravity; leg falls to the bed immediately.4: No movement.UN: Untestable (amputation or joint fusion)

6b. Motor Leg - Right-0: No drift; leg holds 30° position for full 5 seconds (supine).1: Drift; leg falls by the end of the 5-second period but does not hit the bed.2: Some effort against gravity; leg falls to the bed by 5 seconds, but has some effort against gravity.3: No effort against gravity; leg falls to the bed immediately.4: No movement.UN: Untestable (amputation or joint fusion)

7. Limb Ataxia-0: Absent.1: Present in one limb.2: Present in two limbs.UN: Untestable (amputation or joint fusion)

8. Sensory-0: Normal; no sensory loss.1: Mild-to-moderate sensory loss; patient feels pinprick less sharp or dull on the affected side, or there is a loss of superficial pain with pinprick but the patient is aware of being touched.2: Severe or total sensory loss; patient is not aware of being touched in the face, arm, and leg.

9. Best Language-0: No aphasia; normal.1: Mild-to-moderate aphasia; some obvious loss of fluency or comprehension, without significant limitation on ideas expressed; examiner can identify picture/naming content from the response.2: Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener; examiner cannot identify materials from the patient's response.3: Mute, global aphasia; no usable speech or auditory comprehension.

10. Dysarthria-0: Normal.1: Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty.2: Severe dysarthria; speech is so slurred as to be unintelligible, in the absence of or out of proportion to any dysphasia, or the patient is mute/anarthric.UN: Untestable (intubated or other physical barrier)

11. Extinction and Inattention (formerly Neglect)-0: No abnormality.1: Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one sensory modality.2: Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space.

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Kriteria penilaian

Item	Poin
1a. Tingkat kesadaran (Level of Consciousness, LOC)	0 sampai 3
1b. Pertanyaan kesadaran, yaitu bulan dan usia (LOC Questions)	0 sampai 2
1c. Perintah kesadaran (LOC Commands)	0 sampai 2
2. Pandangan mata terbaik (Best Gaze)	0 sampai 2
3. Lapang pandang (Visual Fields)	0 sampai 3
4. Paresis wajah (Facial Palsy)	0 sampai 3
5a dan 5b. Motorik lengan kiri dan kanan (Motor Arm), masing-masing	0 sampai 4
6a dan 6b. Motorik tungkai kiri dan kanan (Motor Leg), masing-masing	0 sampai 4
7. Ataksia anggota gerak (Limb Ataxia)	0 sampai 2
8. Sensorik (Sensory)	0 sampai 2
9. Bahasa terbaik (Best Language)	0 sampai 3
10. Disartria (Dysarthria)	0 sampai 2
11. Ekstingsi dan inatensi (Extinction and Inattention)	0 sampai 2
Skor total	0 sampai 42

Keterangan

• NIHSS (National Institutes of Health Stroke Scale) adalah skala yang menilai berat defisit neurologis pada stroke akut. Skor totalnya berkisar dari 0 sampai 42.
• NIH (National Institutes of Health) adalah lembaga penelitian kesehatan di Amerika Serikat yang menyusun skala ini.
• LOC (Level of Consciousness) adalah tingkat kesadaran. Item 1a, 1b, dan 1c menilainya, dengan skor 0 sampai 3 untuk item 1a, serta 0 sampai 2 untuk item 1b dan 1c.
• UN (Untestable) berarti item tidak dapat diuji, misalnya karena amputasi, fusi sendi, atau hambatan fisik seperti intubasi.
• Skor total (Total score) adalah jumlah skor dari 15 item pemeriksaan. Nilainya berkisar dari 0 sampai 42.

Cara membaca skor

• Skor 0 berarti tidak ada gejala stroke.
• Skor 1 sampai 4 berarti stroke ringan.
• Skor 5 sampai 15 berarti stroke sedang.
• Skor 16 sampai 20 berarti stroke sedang hingga berat.
• Skor 21 sampai 42 berarti stroke berat.

Lembar penilaian resmi National Institute of Neurological Disorders and Stroke (NINDS) hanya memuat penilaian per item dan tidak mencantumkan kategori keparahan. Kategori ini dipakai luas di referensi klinis, tetapi bukan bagian dari instrumen NIHSS.

Contoh perhitungan

Sebagai contoh, pasien hanya menjawab satu dari dua pertanyaan kesadaran dengan benar, mengalami hemianopia parsial dan paresis wajah ringan, serta lengan dan tungkai kanannya jatuh ke tempat tidur tetapi masih bisa melawan gravitasi. Ia juga mengalami gangguan sensorik, afasia, dan disartria ringan sampai sedang. Skor totalnya 10, sehingga kategorinya stroke sedang.

Sumber

National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health. NIH Stroke Scale (Rev. 10/1/2003); buklet pelatihan “KnowStroke” NIH Stroke Scale NINDS (pembaruan Maret 2025). Naskah penurunan asli: Brott T, Adams HP, Olinger CP, dkk. “Measurements of acute cerebral infarction: a clinical examination scale.” Stroke. 1989;20(7):864-870. DOI 10.1161/01.str.20.7.864, PMID 2749846.