Published Online
on November 14, 2002

A more recent version of this article appeared on December 1, 2002

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Submitted on July 8, 2002
Accepted on July 24, 2002

Shortening the NIH Stroke Scale for Use in the Prehospital Setting

David L. Tirschwell MD^*; W. T. Longstreth Jr MD; Kyra J. Becker MD; Richard E. Gammans Sr PhD; LuAnn A. Sabounjian RN, BSN; Scott Hamilton MD; and Lewis B. Morgenstern PhD

From the Departments of Neurology (D.L.T., W.T.L., K.J.B.) and Epidemiology (W.T.L.), Harborview Medical Center, University of Washington School of Medicine, Seattle; MSM INCARA Pharmaceutical Corp and Aeolus Pharmaceuticals, Inc (R.E.G.), Research Triangle Park, NC; Interneuron Pharmaceuticals, Inc (L.A.S.), Lexington, Mass; the Department of Neurology (S.H.), Stanford University School of Medicine, Stanford, Calif; and the Department of Neurology (L.B.M.), University of Michigan, Ann Arbor.

^* To whom correspondence should be addressed. E-mail: tirsch{at}u.washington.edu.

Background and Purpose—Prehospital stroke scales should identify stroke patients and measure stroke severity. The goal of this study was to identify a subset of the 15 items in the National Institutes of Health Stroke Scale (NIHSS-15) that measures stroke severity and predicts outcomes.

Methods—Using 2 distinct data sets from acute stroke clinical trials, we derived and validated shortened versions of the NIHSS (sNIHSS). Stepwise logistic regression and bootstrap techniques were used in selection of NIHSS-15 items. Areas under the receiver operator characteristic curve (C statistics) were used to compare predictive performance of logistic models incorporating differing versions of the NIHSS.

Results—The derivation analyses suggested the 8 NIHSS-15 items that were most predictive of "good outcome" 3 months after stroke, in order of decreasing importance: right leg item, left leg, gaze, visual fields, language, level of consciousness, facial palsy, and dysarthria. The sNIHSS-8 comprises all 8 and the sNIHSS-5, the first 5. In the validation models, C statistics were NIHSS-15=0.80, sNIHSS-8=0.77, and sNIHSS-5=0.76. Statistical comparisons suggested that the NIHSS-15 had better predictive performance than the sNIHSS-8 or the sNIHSS-5; the absolute difference in C statistics was small. There was no significant difference between the sNIHSS-8 and the sNIHSS-5.

Conclusions—Much of the predictive performance of the full NIHSS-15 was retained with a shortened scale, the sNIHSS-5. Shortening the NIHSS-15 will facilitate its use during prehospital evaluations. The sNIHSS severity information may be useful to triage acute stroke patients in communities and to provide a baseline stroke severity for prehospital acute stroke trials.

Key words: cerebrovascular accident • emergency medical services

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