Modified NIH Stroke Scale/Score (mNIHSS)
Shortened, validated version of the NIHSS.
id
1756
full_title
Modified NIH Stroke Scale/Score (mNIHSS)
short_title
Modified NIH Stroke Scale
med_description
Shortened, validated version of the NIHSS.
description
The Modified NIH Stroke Scale/Score (mNIHSS) calculates the shortened, validated version of NIH Stroke Scale for quantifying stroke severity.
keywords
modified NIHSS, mnihss, stroke scale, new stroke scale, rule out stroke, stroke prognosis, modified stroke scale, nihss modified, mnihss stroke score, nih stroke scale, nih stroke score modified, nih stroke scale modified, nih stroke score, stroke rule out nih, stroke r/o nih, short nih stroke, short nih stroke score, stroke nih scale short, r/o stroke nih, r/o cva nih, r/o cva short nih, mnihss cva, modified NIH stroke score, modified nih CVA scale, modified nih stroke scale, modified nih CVA score
complaint
[ "Headache", "Weakness" ]
formula
Addition of the selected points.
evidence
- Several trials have prospectively validated the mNIHSS and found it to perform as well as the original score in predicting which patients are at high risk of hemorrhage if given tPA and which patients are likely to have good clinical outcomes.
- The mNIHSS has superior interrater reliability, with studies showing that >90% of its items have excellent agreement between raters, as opposed to ~66% of the items in the
NIHSS . - The mNIHSS appears to be more reliable in multiple settings, including calculating scores from medical records, when used via telemedicine, and when used in clinical trials.
- The mNIHSS was developed using individual item analysis of the
NIHSS to identify items that had poor reliability or were redundant. The mNIHSS was then evaluated by scoring it against video recordings originally made forNIHSS scoring certification for participants in the NINDS trials. These tapes consisted of of 11 stroke patients being evaluated by 4 different examiners (Lyden 2001).- The number of items with poor interrater reliability decreased 6% when the mNIHSS was applied (from 20% with the NIHSS to 14%).
- The ORs for predicting clinical outcomes at three months were essentially identical for the mNIHSS compared to the original score.
- A review article examining several studies comparing the mNIHSS to the NIHSS found that mNIHSS has consistently superior interrater reliability in a variety of settings.
- 71% vs. 54% of items had excellent agreement.
- Only 5% vs. 12% of items had poor agreement.
- A study found that when using the medical record to estimate a patient’s stroke score that the mNIHSS gave an estimate that was closer to the patient’s actual score than the the mNIHSS (70% vs. 62% for being within 1 point of the actual score) (Kasner 2003).
measurements
[]
information
In 2001, Lyden et. al proposed to modify the NIH Stroke Scale, 'deleting poorly reproducible or redundant items (level of consciousness, face weakness, ataxia, dysarthria) and collapsing the sensory item into 2 responses,'' with the goal of both simplifying the scale, improving its reproducibility and providing more relevance to each assigned point.
This modified NIH Stroke Scale (mNIHSS) has now been evaluated in several trials (see below) and has begun to achieve acceptance in the stroke community as a reliable tool — even more reliable and valid, in some studies, than the NIHSS itself (better Kappa scores, suggesting higher levels of agreement in point assignments between raters).
Language/Aphasia Test
refrences
{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/11387492", "text": "Lyden PD, Lu M, Levine SR, Brott TG, Broderick J; NINDS rtPA Stroke Study Group. A modified National Institutes of Health Stroke Scale for use in stroke clinical trials: preliminary reliability and validity. Stroke. 2001 Jun;32(6):1310-7." } ], "Other References": [ { "href": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729912/", "text": "Meyer BC, Lyden PD. The Modified National Institutes of Health Stroke Scale (mNIHSS): Its Time Has Come. Int J Stroke. Aug 2009; 4(4): 267–273. doi: 10.1111/j.1747-4949.2009.00294.x" }, { "href": "https://www.ncbi.nlm.nih.gov/pubmed/12574577", "text": "Kasner SE, Cucchiara BL, McGarvey ML, Luciano JM, Liebeskind DS, Chalela JA. Modified National Institutes of Health Stroke Scale can be estimated from medical records. Stroke. 2003 Feb;34(2):568-70. PubMed PMID:12574577" } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/11988601", "text": "Meyer BC, Hemmen TM, Jackson CM, Lyden PD. Modified National Institutes of Health Stroke Scale for use in stroke clinical trials: prospective reliability and validity. Stroke. 2002 May;33(5):1261-6." } ], "Validations": [] }
pearls
The Modified National Institutes of Health Stroke Scale (mNIHSS) was designed to eliminate the parts of the
- Lower is better; increasing mNIHSS scores are correlated with more severe strokes and worsened clinical outcomes.
- The mNIHSS performs as well as the original score in predicting patients at high risk of hemorrhage if given tPA and which patients are likely to have good clinical outcomes.
- The mNIHSS has superior interrater reliability (>90%) compared to the original NIHSS (~66%).
- The mNIHSS is more reliable in multiple settings, including calculating scores from medical records, when used via telemedicine, and when used in clinical trials.
Points to keep in mind:
- Currently, the mNIHSS is used much less frequently than the NIHSS in both the clinical setting and in trials.
- Many guidelines make reference to the NIHSS rather than the mNIHSS, including those making recommendations concerning tPA administration.
- The NIHSS only takes an average of 6 minutes to complete, so some who question the clinical utility of altering a well-validated and widely used scale.
usecase
The mNIHSS can help physicians quantify the severity of a stroke in the acute setting.
reasons
There are nearly 800,000 cases of acute stroke in the United States every year, with 130,000 associated deaths (4th leading cause of death in Americans). The mNIHSS can help physicians determine the severity of a stroke, predict clinical outcomes and can help guide management. The mNIHSS has the same correlation with clinical outcomes as theNIHSSbut with better interrater reliability.
next_advice
next_actions
- The mNIHSS performs as well as the
NIHSS in predicting clinical outcomes, but it is important to recognize that individual cases will vary and that management decisions must be made in consultation with the patient whenever possible. - Whenever possible, patients with acute stroke should be transferred to a stroke center for their initial evaluation and treatment, as the holistic care (medical optimization, early initiation of PT and OT, patient and family education and discharge planning) is associated with improved clinical outcomes.
next_management
In patients who present with symptoms concerning for ischemic stroke:
- Consult Neurology immediately (if available) for all patients presenting with ischemic stroke.
- Evaluate whether the patient is a potential candidate to receive intravenous thrombolysis (tPA).
- Determine the onset of stroke symptoms (or time patient last felt or was observed normal).
- Consider further imaging including CT, CT angiography and MRI/MRA to evaluate for hemorrhagic stroke.
- In appropriate circumstances and in consultation with both neurology and the patient, consider IV thrombolysis for ischemic strokes in patients with no contraindications.
- Always consider stroke mimics in the differential diagnosis, especially in cases with atypical features (age, risk factors, history, physical exam), including:
- Recrudescence of old stroke from metabolic or infectious stress.
- Todd’s paralysis after seizure.
- Complex migraine.
- Pseudoseizure, conversion disorder.
diseases
[ "Stroke / Transient Ischemic Attack (TIA)" ]
instructions
Note: numbering scheme is intentional and reflects differences from the
published
2022-04-21T20:29:00.637Z
purpose
[ "Diagnosis", "Prognosis" ]
search_terms
[ "tia", "cva", "ich" ]
seo
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specialty
[ "Critical Care", "Critical Care (Neurologic)", "Emergency Medicine", "Hospitalist Medicine", "Internal Medicine", "Neurology" ]
departments
[ "Cardiac", "Neurologic" ]
tags
[]
version_number
1
versions
[]
related
[ { "calcId": 715, "short_title_en": "NIH Stroke Scale (NIHSS)", "slug": "nih-stroke-scale-score-nihss" }, { "calcId": 3802, "short_title_en": "sICH Score", "slug": "secondary-intracerebral-hemorrhage-sich-score" }, { "calcId": 402, "short_title_en": "Intracerebral Hemorrhage (ICH) Score", "slug": "intracerebral-hemorrhage-ich-score" } ]
ismed
true
section
[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]
cleaned_departments
[ "cardiology", "neurology" ]
cleaned_use
[ "The mNIHSS can help physicians quantify the severity of a stroke in the acute setting." ]
pub
true