title: The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status.
abstract: OBJECTIVE
  The National Institute of Health Stroke Scale (NIHSS) is rapid and reproducible, a seemingly attractive metric for the documentation of clinical progress in patients presenting with ischemic stroke. Many institutions have adopted it into daily clinical practice. Unfortunately, the scale may not adequately capture all forms of functional change. We evaluate its utility as a measure of recovery in patients treated with intravenous tissue plasminogen activator (IV tPA) for ischemic stroke.
  
  
  METHODS
  We prospectively evaluated the difference in the rate of improvement based on NIHSS (a ≥4 point change based on previous trials) versus physician-documented subjective and objective measures in 41 patients' status post IV tPA treatment. The NIHSS 24 hours posttreatment, on discharge, and at follow-up were compared to NIHSS on admission using tests of proportions and McNemar tests of paired data. Secondary analyses were performed defining significant improvement as NIHSS changes of 1 to 3 points.
  
  
  RESULTS
  The mean NIHSS improved from 9 to 6, 24 hours post-tPA. Of the 41 patients, 29 improved by physician documentation, although only 11 of the 29 met the NIHSS criteria (P < .001; McNemar P < .001). On discharge, 20 of the 41 patients met the NIHSS criteria; however, the proportion "better" by physician documentation (71%) remained significantly higher (P = .04; McNemar P = .004). The mean postdischarge follow-up NIHSS was 2. Twenty of the 21 patients improved by documentation versus 16 of the 21 by NIHSS (P = .08, McNemar P = .125). Using NIHSS changes of 1 to 3 increased sensitivity for detecting improvement but remained lower than physician documentation.
  
  
  CONCLUSIONS
  The NIHSS has many advantages; however, it may miss functional changes when used in place of a comprehensive neurological examination to measure improvement poststroke.
authors.affiliation: Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Elisabeth B
authors.initials: EB
authors.lastname: Marsh
authors.affiliation: Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Erin
authors.initials: E
authors.lastname: Lawrence
authors.affiliation: Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Rebecca F
authors.initials: RF
authors.lastname: Gottesman
authors.affiliation: Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
authors.forename: Rafael H
authors.initials: RH
authors.lastname: Llinas
keywords: outcomes; recovery; stroke; tissue plasminogen activator (tPA)