Pattern of individual National Institutes of Health Stroke Scale item improvements after stroke


Correspondence: Askiel Bruno*, Department of Neurology, Georgia Health Sciences University, 1120 15th Street, BI 3076, Augusta, GA 30912, USA.


After stroke, neurological deficits improve in most patients over the subsequent several months, and the improvements are faster early on [1, 2]. However, individual neurological deficit improvements have rarely been reported [3, 4]. We studied improvements on each National Institutes of Health Stroke Scale (NIHSS) item in the acute stroke clinical trial TOAST (Trial of ORG10172 in Acute Stroke Treatment) [5]. The TOAST trial was a randomized, placebo-controlled trial of anticoagulation therapy in patients with mild to moderate stroke severity, starting within 24 h after symptom onset. No significant treatment effect was found.


The TOAST Data Management Center in Iowa City, Iowa, kindly provided the data. We analyzed the NIHSS scores at baseline, seven-days, and three-months. Percent NIHSS change was (baseline score − subsequent score) / baseline score times 100.


Of 1275 enrolled patients, 1269 had the data needed for this analysis. Table 1 shows the proportions of patients with individual NIHSS deficits and those with improvements at seven-days and at three-months. The majority of patients who improved began to do so during the first week. A smaller proportion of patients improved between seven-days and three-months. This improvement pattern was similar in patients with lacunar (small subcortical, n = 305) and nonlacunar (n = 957) stroke subtypes. The total NIHSS in all patients decreased from baseline by a median 36% at seven-days and by 60% at three-months.

Table 1. Baseline neurological deficits and improvements at seven-days and three-months by at least one point in 1269 patients in the TOAST trial
NIHSS itemDeficit present at baseline, n (%)Percent of patients improved at seven-days/three-months
  1. NIHSS, National Institutes of Health Stroke Scale; LOC, level of consciousness; L, left; R, right.
LOC207 (16.3)76.5/82.0
LOC questions225 (18.4)62.0/67.6
LOC commands126 (10.1)62.6/68.6
Gaze deviation234 (18.4)66.4/76.7
Visual fields298 (24.0)46.7/63.4
Facial palsy990 (78.0)45.1/64.3
Motor L-arm524 (41.3)46.3/60.6
Motor R-arm531 (41.8)48.1/65.1
Motor L-leg468 (36.9)47.3/63.4
Motor R-leg449 (35.5)52.6/65.7
Limb ataxia469 (41.5)52.3/73.1
Sensation635 (51.2)47.3/60.1
Aphasia326 (25.9)48.7/69.0
Dysarthria741 (61.6)46.2/66.9
Neglect311 (25.2)56.5/71.0


Although the mechanisms of recovery of neurological function after stroke in different brain regions may vary, all neurological deficits on the NIHSS appear to follow a similar pattern of improvement. Improvements are considerably faster during the first week than later. Future studies could further evaluate the relative contribution of each neurological deficit or a combination of deficits to favorable clinical outcome.