脑卒中评价量表

3 =完全瘫痪
Complete paralysis
美国国立卫生院脑卒中量表
指导 Instruction: NIH Stroke Scale 5. 上肢运动 Motor Arm: 将肢体放至指定位置：伸展上肢（手掌向下）90度（坐位） 或45度（仰卧位）。上肢10秒前下落记录为滑动。
The limb is placed in the appropriate position: extend the arms (palms down) 90° (sitting) or 45° (supine). Drift is scored if the arm falls before 10 seconds.
脑卒中常用评价量表
宣武医院神经内科 宋海庆 2012年8月5日 songhq@vip.sina.com
主要内容


GCS NIHSS mRS TIA常用评分

ABCD ABCD2 ESSEN

房颤患者常用评分
格拉斯哥昏迷评分 (Glasgow Coma Scale,GCS)
睁眼 自己睁眼 大声提问时睁眼 捏患者时睁眼 捏患者时不睁眼 4 3 2 1
量表定义 Scale Definition: 0 =正常,无失语 (No asphasia) 1 =轻到中度失语：流利程度和理解能力有一些缺损，但表达 无明显受限。
Mid-to-moderate aphasia: some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression
Answers both questions correctly
1 =正确回答一个
Answers one question correctly
2 =两个回答都不正确
Answers neither question correctly
美国国立卫生院脑卒中量表
NIH Stroke Scale
指导 Instruction:
Not alert; requires repeated stimulation or painful stimuli ( not stereotyped)
3 =仅有反射活动或自发反应，或完全没有反应、软瘫、 无反射 (Responds only with reflex motor or autonomic effects)
2 =严重失语，所有交流是通过患者破碎的语言表达
美国国立卫生院脑卒中量表
NIH Stroke Scale 指导 Instruction: 1b 意识水平提问 LOC Questions 提问患者现在是几月，和他/她的年龄
The patient is asked the month and his/her age
量表定义 Scale Definition: 0 = 回答都正确
美国国立卫生院脑卒中量表
NIH Stroke Scale
指导 Instruction: 4. 面瘫 Facial Palsy: 要求患者示齿、扬眉和闭眼
Ask the patient to show teeth or raise eyebrows and close eyes
量表定义 Scale Definition: 0 =正常对称动作
3 =不能对抗重力 4 =无运动
No effort against gravity No movement
美国国立卫生院脑卒中量表
NIH Stroke Scale 指导 Instruction: 7. 共济失调
Limb Ataxia:
双侧指鼻、跟膝胫试验，共济失调与无力明显 不成比例时记分。
The finger-nose-finger and heel-shin tests are performed on both sides, ataxia is scored only if present out of proportion to weakness.
格拉斯哥昏迷评分 (Glasgow Coma Scale,GCS)
运动反应 能执行简单命令 捏痛时能拨开医生的手 捏痛时能抽出被捏的肢体 捏痛时呈去皮质强直 捏痛时呈去大脑强直 毫无反应 6 5 4 3 2 1
格拉斯哥昏迷评分 (Glasgow Coma Scale,GCS)
言语反应 能正确会话 言语错乱，定向障碍 语言能被理解，但无意义 能发声，但不能被理解 不发声 5 4 3 2 1
量表定义 Scale Definition:
0 =没有共济失调 1 =一侧肢体有共济失调 2 =两侧肢体有共济失调
Absent Present in one limb Present in two limbs
美国国立卫生院脑卒中量表
指导 Instruction:
NIH Stroke Scale
8. 感觉 Sensory: 用针尖刺激/撤除刺激观察昏迷或失语患者的感觉和表情。
Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored but caloric testing is not done.
NIH Stroke Scale
1c. 意识水平指令 LOC Commands 要求患者睁开、闭上眼睛，并握紧、松开非残障手
The patient is asked to open and close the eyes and then to grip and release the non-paretic hand
Βιβλιοθήκη Baidu
量表定义 Scale Definition: 0 = 两个动作都完成正确
Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient.
量表定义 Scale Definition:
0 =正常 (Normal) 1 =轻到中度感觉缺失，患侧针刺感不明显或为钝性或 仅有触觉
The limb is placed in the appropriate position: hold the leg at 30° (always tested supine). Drift is scored if the leg falls before 5 seconds.
量表定义 Scale Definition: 0 =无下落动 No drift 1 =下落，下肢不能维持5秒；下落不撞击床
3 =不能对抗重力 4 =无运动
No effort against gravity No movement
美国国立卫生院脑卒中量表
NIH Stroke Scale 指导 Instruction: 6. 下肢运动 Motor Leg: 将肢体放至指定位置：伸展下肢30度（只测仰卧位）。 下肢5秒前下落记录为滑动。
Normal symmetrical movements
1 =轻微瘫痪（鼻唇沟变平、微笑时不对称）
Minor paralysis (flattened nasolabial fold)
2 =部分瘫痪（下面部完全或几乎完全瘫痪）
Partial paralysis (total or near-total paralysis of lower face)
Mid-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side
2 =严重到完全感觉缺失，面、上肢、下肢无触觉
Severe to total sensory loss; patient is not aware of being touched
Performs both tasks correctly
1 =正确完成一个动作
Performs one task correctly
2 =两个都不能正确完成
Performs neither task correctly
美国国立卫生院脑卒中量表
指导 Instruction: 2. 凝视 Best Gaze: 只测试水平眼球运动。对自主或反射性（眼头）眼球 运动记分。但不做冷热水反射（眼前庭反射）
Drift; leg falls by the end of the 5 second period but does not hit the bed
2 =能对抗一些重力，5秒内下落到床上
Some effort against gravity; leg falls to bed by 5 seconds
NIH Stroke Scale
量表定义 Scale Definition: 0 =无视野缺失 No visual loss 1 =部分偏盲 Partial hemianopia 2 =完全偏盲 Complete hemianopia 3 =双侧偏盲（全盲，包括皮质盲）
Bilateral hemianopia (blind includingcortical blindness)
Forced deviation, or total gaze paresis not overcome
美国国立卫生院脑卒中量表
指导 Instruction: 3. 视野 Visual: 正视患者，用手指数或视威胁方法检测上、 下象限视野
Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate
美国国立卫生院脑卒中量表
NIH Stroke Scale 指导 Instruction: 9. 命名、阅读测试 Best Language: 请患者描述图片中发生的事情，叫出物品名称、读出句子。
The patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences.
美国国立卫生院脑卒中量表
NIH Stroke Scale
指导 Instruction: 1a. 意识水平 (Level of Consciousness) 研究者必须选择一个反应 (The investigator must choose a response) 量表定义 Scale Definition: 0 =反应敏锐 (Alert) 1 =嗜睡，最小刺激能唤醒患者 (Not Alert, but arousable) 2 =昏睡或反应迟钝，需要强烈反复刺激或疼痛刺激才能 有非固定模式的反应
量表定义 Scale Definition: 0 =正常 Normal 1 =部分凝视麻痹（单眼或双眼凝视异常，但无被动凝 视或完全凝视麻痹）
Partial gaze palsy, gaze is abnormal is one or both eyes
2 =被动凝视或完全凝视麻痹（不能被眼头动作克服）
量表定义 Scale Definition: 0 =无下落 No drift 1 =下落，肢体在90（或45）度能维持不超过10秒，下落
Drift; limb holds 90° (or 45°) but drifts down
2 =能对抗一些重力，但不能达到或维持90（或45）度
Some effort against gravity; limb cannot get to or maintain (if cued) 90° (or 45°)