Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Use and utility of stroke scales and grading systems

Larry B Goldstein, MD, FAAN, FANA, FAHA
Section Editor
Scott E Kasner, MD
Deputy Editor
John F Dashe, MD, PhD


In addition to their importance for assessing the impact of therapeutic interventions in clinical trials, stroke scales are useful in the routine clinical setting as aids to improve diagnostic accuracy, help determine the appropriateness of specific treatments, monitor a patient's neurologic deficits through the continuum of care, and predict and gauge outcomes. Not only are different types of scales needed for these different purposes, but no single scale is suitable for capturing all of the effects of stroke.

This topic will review stroke scales and grading systems that are used for ischemic and hemorrhagic stroke. Grading systems used to classify patients with subarachnoid hemorrhage are reviewed separately. (See "Subarachnoid hemorrhage grading scales".)

Categorization systems used in the classification and etiology of stroke are discussed elsewhere. (See "Etiology, classification, and epidemiology of stroke", section on 'TOAST classification' and "Etiology, classification, and epidemiology of stroke", section on 'SSS-TOAST and CCS classification'.)


Stroke scales are useful for clinical and research purposes as aids to improve diagnostic accuracy, determine the suitability of specific treatments, monitor change in neurologic impairments, and predict and measure outcomes. There has been considerable progress in the clinimetrics of stroke since the 1980s [1]. Although there are numerous general and stroke-specific scales that have established reliability and validity, no single scale is suitable for all clinical or research situations.

The International Classification of Functioning and Disability and Health, developed by the World Health Organization, categorizes the impact of disease into to three dimensions [2]:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Jan 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Asplund K. Clinimetrics in stroke research. Stroke 1987; 18:528.
  2. World Health Organization. International Classification of Functioning, Disability and Health (ICF). http://www.who.int/classifications/icf/en/ (Accessed on April 21, 2011).
  3. Orgogozo JM. The concepts of impairment, disability, and handicap. Cerebrovasc Dis 1994; 4 (Suppl 2):2.
  4. Duncan PW, Samsa GP, Weinberger M, et al. Health status of individuals with mild stroke. Stroke 1997; 28:740.
  5. Generalized efficacy of t-PA for acute stroke. Subgroup analysis of the NINDS t-PA Stroke Trial. Stroke 1997; 28:2119.
  6. Adams HP Jr, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology 1999; 53:126.
  7. Kelly-Hayes M, Robertson JT, Broderick JP, et al. The American Heart Association Stroke Outcome Classification. Stroke 1998; 29:1274.
  8. Lai SM, Duncan PW. Evaluation of the American Heart Association Stroke Outcome Classification. Stroke 1999; 30:1840.
  9. Dawson J, Walters M. Development and validation of a stroke recognition tool. Lancet Neurol 2005; 4:691.
  10. Harbison J, Hossain O, Jenkinson D, et al. Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke 2003; 34:71.
  11. Nor AM, McAllister C, Louw SJ, et al. Agreement between ambulance paramedic- and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke 2004; 35:1355.
  12. Kothari R, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med 1997; 4:986.
  13. Kothari RU, Pancioli A, Liu T, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med 1999; 33:373.
  14. Goldstein LB, Simel DL. Is this patient having a stroke? JAMA 2005; 293:2391.
  15. Kidwell CS, Starkman S, Eckstein M, et al. Identifying stroke in the field. Prospective validation of the Los Angeles prehospital stroke screen (LAPSS). Stroke 2000; 31:71.
  16. Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale: development and validation of a stroke recognition instrument. Lancet Neurol 2005; 4:727.
  17. Whiteley WN, Wardlaw JM, Dennis MS, Sandercock PA. Clinical scores for the identification of stroke and transient ischaemic attack in the emergency department: a cross-sectional study. J Neurol Neurosurg Psychiatry 2011; 82:1006.
  18. Bergs J, Sabbe M, Moons P. Prehospital stroke scales in a Belgian prehospital setting: a pilot study. Eur J Emerg Med 2010; 17:2.
  19. Brott T, Adams HP Jr, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20:864.
  20. Goldstein LB, Bertels C, Davis JN. Interrater reliability of the NIH stroke scale. Arch Neurol 1989; 46:660.
  21. Wityk RJ, Pessin MS, Kaplan RF, Caplan LR. Serial assessment of acute stroke using the NIH Stroke Scale. Stroke 1994; 25:362.
  22. Leifer D, Bravata DM, Connors JJ 3rd, et al. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42:849.
  23. Goldstein LB, Samsa GP. Reliability of the National Institutes of Health Stroke Scale. Extension to non-neurologists in the context of a clinical trial. Stroke 1997; 28:307.
  24. Lyden P, Brott T, Tilley B, et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke 1994; 25:2220.
  25. Albanese MA, Clarke WR, Adams HP Jr, Woolson RF. Ensuring reliability of outcome measures in multicenter clinical trials of treatments for acute ischemic stroke. The program developed for the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Stroke 1994; 25:1746.
  26. Kasner SE, Chalela JA, Luciano JM, et al. Reliability and validity of estimating the NIH stroke scale score from medical records. Stroke 1999; 30:1534.
  27. Williams LS, Yilmaz EY, Lopez-Yunez AM. Retrospective assessment of initial stroke severity with the NIH Stroke Scale. Stroke 2000; 31:858.
  28. Bushnell CD, Johnston DC, Goldstein LB. Retrospective assessment of initial stroke severity: comparison of the NIH Stroke Scale and the Canadian Neurological Scale. Stroke 2001; 32:656.
  29. Lindsell CJ, Alwell K, Moomaw CJ, et al. Validity of a retrospective National Institutes of Health Stroke Scale scoring methodology in patients with severe stroke. J Stroke Cerebrovasc Dis 2005; 14:281.
  30. Wang S, Lee SB, Pardue C, et al. Remote evaluation of acute ischemic stroke: reliability of National Institutes of Health Stroke Scale via telestroke. Stroke 2003; 34:e188.
  31. Kasner SE. Clinical interpretation and use of stroke scales. Lancet Neurol 2006; 5:603.
  32. Martin-Schild S, Albright KC, Tanksley J, et al. Zero on the NIHSS does not equal the absence of stroke. Ann Emerg Med 2011; 57:42.
  33. 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; 33:1261.
  34. Tirschwell DL, Longstreth WT Jr, Becker KJ, et al. Shortening the NIH Stroke scale for use in the prehospital setting. Stroke 2002; 33:2801.
  35. Ichord RN, Bastian R, Abraham L, et al. Interrater reliability of the Pediatric National Institutes of Health Stroke Scale (PedNIHSS) in a multicenter study. Stroke 2011; 42:613.
  36. Hantson L, De Weerdt W, De Keyser J, et al. The European Stroke Scale. Stroke 1994; 25:2215.
  37. Côté R, Hachinski VC, Shurvell BL, et al. The Canadian Neurological Scale: a preliminary study in acute stroke. Stroke 1986; 17:731.
  38. Côté R, Battista RN, Wolfson C, et al. The Canadian Neurological Scale: validation and reliability assessment. Neurology 1989; 39:638.
  39. Goldstein LB, Chilukuri V. Retrospective assessment of initial stroke severity with the Canadian Neurological Scale. Stroke 1997; 28:1181.
  40. Lindenstrom E, et al. Reliability of Scandinavian Neurological Stroke Scale. Cerebrovasc Dis 1991; 1:103.
  41. Barber M, Fail M, Shields M, et al. Validity and reliability of estimating the scandinavian stroke scale score from medical records. Cerebrovasc Dis 2004; 17:224.
  42. Fugl-Meyer AR, Jääskö L, Leyman I, et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975; 7:13.
  43. Duncan PW, Propst M, Nelson SG. Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Phys Ther 1983; 63:1606.
  44. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985; 65:175.
  45. Collin C, Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry 1990; 53:576.
  46. Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol 1980; 19:382.
  47. Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil 1992; 73:1073.
  48. De Weerdt WJG, Harrison MA. Measuring recovery of arm-hand function in stroke patients: a comparison of the Brunnstom-Fugl-Meyer test and the Action Research Arm test. Physiother Can 1985; 37:65.
  49. Heller A, Wade DT, Wood VA, et al. Arm function after stroke: measurement and recovery over the first three months. J Neurol Neurosurg Psychiatry 1987; 50:714.
  50. Sunderland A, Tinson D, Bradley L, Hewer RL. Arm function after stroke. An evaluation of grip strength as a measure of recovery and a prognostic indicator. J Neurol Neurosurg Psychiatry 1989; 52:1267.
  51. Sharpless JW. The Nine-Hole Peg Test of finger-hand coordination for the hemiplegic patient. In: Mossman's Problem Oriented Approach to Stroke Rehabilitation, 2nd edition, Charles C Thomas, Springfeld, IL 1982. p.470.
  52. Wade DT, Collen FM, Robb GF, Warlow CP. Physiotherapy intervention late after stroke and mobility. BMJ 1992; 304:609.
  53. Salter K, Jutai J, Foley N, et al. Identification of aphasia post stroke: a review of screening assessment tools. Brain Inj 2006; 20:559.
  54. Enderby PM, Wood VA, Wade DT, Hewer RL. The Frenchay Aphasia Screening Test: a short, simple test for aphasia appropriate for non-specialists. Int Rehabil Med 1987; 8:166.
  55. Porch BE. The Porch Index of Communicative Ability. Administration, Scoring, and Interpretation, 3rd edition, Consulting Psychologists Press, Palo Alto 1981.
  56. Koski L. Validity and applications of the Montreal cognitive assessment for the assessment of vascular cognitive impairment. Cerebrovasc Dis 2013; 36:6.
  57. Hachinski V, Iadecola C, Petersen RC, et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards. Stroke 2006; 37:2220.
  58. BECK AT, WARD CH, MENDELSON M, et al. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561.
  59. Radloff LS. The CES-D scale: a self-report depression scale for reserach in the general population. Appl Psychol Meas 1977; 1:385.
  60. HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56.
  61. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606.
  62. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003; 327:1144.
  63. van der Putten JJ, Hobart JC, Freeman JA, Thompson AJ. Measuring change in disability after inpatient rehabilitation: comparison of the responsiveness of the Barthel index and the Functional Independence Measure. J Neurol Neurosurg Psychiatry 1999; 66:480.
  64. Dromerick AW, Edwards DF, Diringer MN. Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials. J Rehabil Res Dev 2003; 40:1.
  65. Lin JH, Lo SK, Chang YY, et al. Validation of comprehensive assessment of activities of daily living in stroke survivors. Kaohsiung J Med Sci 2004; 20:287.
  67. Granger CV, Dewis LS, Peters NC, et al. Stroke rehabilitation: analysis of repeated Barthel index measures. Arch Phys Med Rehabil 1979; 60:14.
  68. Quinn TJ, Langhorne P, Stott DJ. Barthel index for stroke trials: development, properties, and application. Stroke 2011; 42:1146.
  69. Duffy L, Gajree S, Langhorne P, et al. Reliability (inter-rater agreement) of the Barthel Index for assessment of stroke survivors: systematic review and meta-analysis. Stroke 2013; 44:462.
  70. Hertanu JS, Demopoulos JT, Yang WC, et al. Stroke rehabilitation: correlation and prognostic value of computerized tomography and sequential functional assessments. Arch Phys Med Rehabil 1984; 65:505.
  71. Saver JL, Johnston KC, Homer D, et al. Infarct volume as a surrogate or auxiliary outcome measure in ischemic stroke clinical trials. The RANTTAS Investigators. Stroke 1999; 30:293.
  72. Schiemanck SK, Post MW, Witkamp TD, et al. Relationship between ischemic lesion volume and functional status in the 2nd week after middle cerebral artery stroke. Neurorehabil Neural Repair 2005; 19:133.
  73. Schiemanck SK, Post MW, Kwakkel G, et al. Ischemic lesion volume correlates with long-term functional outcome and quality of life of middle cerebral artery stroke survivors. Restor Neurol Neurosci 2005; 23:257.
  74. Huybrechts KF, Caro JJ. The Barthel Index and modified Rankin Scale as prognostic tools for long-term outcomes after stroke: a qualitative review of the literature. Curr Med Res Opin 2007; 23:1627.
  75. Pan SL, Wu SC, Lee TK, Chen TH. Reduction of disability after stroke is a more informative predictor of long-time survival than initial disability status. Disabil Rehabil 2007; 29:417.
  76. Kwakkel G, Veerbeek JM, Harmeling-van der Wel BC, et al. Diagnostic accuracy of the Barthel Index for measuring activities of daily living outcome after ischemic hemispheric stroke: does early poststroke timing of assessment matter? Stroke 2011; 42:342.
  77. Uniform Data System for Medical Rehabilitation. The State Univeristy of New York at Buffalo. http://www.udsmr.org (Accessed on April 22, 2011).
  78. Chumney D, Nollinger K, Shesko K, et al. Ability of Functional Independence Measure to accurately predict functional outcome of stroke-specific population: systematic review. J Rehabil Res Dev 2010; 47:17.
  79. Granger CV, Hamilton BB, Keith RA, et al. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil 1986; 1:59.
  80. Kidd D, Stewart G, Baldry J, et al. The Functional Independence Measure: a comparative validity and reliability study. Disabil Rehabil 1995; 17:10.
  81. Fiedler RC, Granger CV. Uniform data system for medical rehabilitation: report of first admissions for 1995. Am J Phys Med Rehabil 1997; 76:76.
  82. Smith PM, Illig SB, Fiedler RC, et al. Intermodal agreement of follow-up telephone functional assessment using the Functional Independence Measure in patients with stroke. Arch Phys Med Rehabil 1996; 77:431.
  83. Chong DK. Measurement of instrumental activities of daily living in stroke. Stroke 1995; 26:1119.
  84. Schuling J, de Haan R, Limburg M, Groenier KH. The Frenchay Activities Index. Assessment of functional status in stroke patients. Stroke 1993; 24:1173.
  85. Tooth LR, McKenna KT, Smith M, O'Rourke P. Further evidence for the agreement between patients with stroke and their proxies on the Frenchay Activities Index. Clin Rehabil 2003; 17:656.
  86. Post MW, de Witte LP. Good inter-rater reliability of the Frenchay Activities Index in stroke patients. Clin Rehabil 2003; 17:548.
  87. RANKIN J. Cerebral vascular accidents in patients over the age of 60. II. Prognosis. Scott Med J 1957; 2:200.
  88. van Swieten JC, Koudstaal PJ, Visser MC, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19:604.
  89. Bamford JM, Sandercock PA, Warlow CP, Slattery J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1989; 20:828.
  90. New PW, Buchbinder R. Critical appraisal and review of the Rankin scale and its derivatives. Neuroepidemiology 2006; 26:4.
  91. Saver JL, Filip B, Hamilton S, et al. Improving the reliability of stroke disability grading in clinical trials and clinical practice: the Rankin Focused Assessment (RFA). Stroke 2010; 41:992.
  92. Whiteneck GG, Charlifue SW, Gerhart KA, et al. Quantifying handicap: a new measure of long-term rehabilitation outcomes. Arch Phys Med Rehabil 1992; 73:519.
  93. Segal ME, Schall RR. Assessing handicap of stroke survivors. A validation study of the Craig Handicap Assessment and Reporting Technique. Am J Phys Med Rehabil 1995; 74:276.
  94. de Haan R, Limburg M, Bossuyt P, et al. The clinical meaning of Rankin 'handicap' grades after stroke. Stroke 1995; 26:2027.
  95. Kuklina E, Callaghan W. Chronic heart disease and severe obstetric morbidity among hospitalisations for pregnancy in the USA: 1995-2006. BJOG 2011; 118:345.
  96. Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis. Stroke 2007; 38:1091.
  97. Quinn TJ, Dawson J, Walters MR, Lees KR. Exploring the reliability of the modified rankin scale. Stroke 2009; 40:762.
  98. Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale: a systematic review. Stroke 2009; 40:3393.
  99. Lev MH, Segal AZ, Farkas J, et al. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intra-arterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 2001; 32:2021.
  100. Wolfe CD, Taub NA, Woodrow EJ, Burney PG. Assessment of scales of disability and handicap for stroke patients. Stroke 1991; 22:1242.
  101. De Haan R, Horn J, Limburg M, et al. A comparison of five stroke scales with measures of disability, handicap, and quality of life. Stroke 1993; 24:1178.
  102. Burn JP. Reliability of the modified Rankin Scale. Stroke 1992; 23:438.
  103. Williams LS. Health-related quality of life outcomes in stroke. Neuroepidemiology 1998; 17:116.
  104. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care 1981; 19:787.
  105. Rothman ML, Hedrick S, Inui T. The Sickness Impact Profile as a measure of the health status of noncognitively impaired nursing home residents. Med Care 1989; 27:S157.
  106. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30:473.
  107. Mathias SD, Bates MM, Pasta DJ, et al. Use of the Health Utilities Index with stroke patients and their caregivers. Stroke 1997; 28:1888.
  108. Grootendorst P, Feeny D, Furlong W. Health Utilities Index Mark 3: evidence of construct validity for stroke and arthritis in a population health survey. Med Care 2000; 38:290.
  109. Rothman ML, Williams KHR. Validity of the Health Utilities Index in evaluating therapies for acute stroke [abstract]. Qual Life Res 1997; 6:710.
  110. Goldstein LB, Lyden P, Mathias SD, et al. Telephone assessment of functioning and well-being following stroke: is it feasible? J Stroke Cerebrovasc Dis 2002; 11:80.
  111. EuroQol Group. EuroQol--a new facility for the measurement of health-related quality of life. Health Policy 1990; 16:199.
  112. Dorman PJ, Waddell F, Slattery J, et al. Is the EuroQol a valid measure of health-related quality of life after stroke? Stroke 1997; 28:1876.
  113. Dorman P, Slattery J, Farrell B, et al. Qualitative comparison of the reliability of health status assessments with the EuroQol and SF-36 questionnaires after stroke. United Kingdom Collaborators in the International Stroke Trial. Stroke 1998; 29:63.
  114. Sneeuw KC, Aaronson NK, de Haan RJ, Limburg M. Assessing quality of life after stroke. The value and limitations of proxy ratings. Stroke 1997; 28:1541.
  115. de Haan R, Limburg M. The relationship between impairment and functional health scales in the outcome of stroke. Cerebrovasc Dis 1994; 4 (Suppl 2):19.
  116. Duncan PW, Wallace D, Lai SM, et al. The stroke impact scale version 2.0. Evaluation of reliability, validity, and sensitivity to change. Stroke 1999; 30:2131.
  117. Williams LS, Weinberger M, Harris LE, et al. Development of a stroke-specific quality of life scale. Stroke 1999; 30:1362.
  118. Post MW, Boosman H, van Zandvoort MM, et al. Development and validation of a short version of the Stroke Specific Quality of Life Scale. J Neurol Neurosurg Psychiatry 2011; 82:283.
  119. van Straten A, de Haan RJ, Limburg M, et al. A stroke-adapted 30-item version of the Sickness Impact Profile to assess quality of life (SA-SIP30). Stroke 1997; 28:2155.
  120. Lin KC, Fu T, Wu CY, et al. Psychometric comparisons of the Stroke Impact Scale 3.0 and Stroke-Specific Quality of Life Scale. Qual Life Res 2010; 19:435.
  121. Duncan PW, Lai SM, Bode RK, et al. Stroke Impact Scale-16: A brief assessment of physical function. Neurology 2003; 60:291.
  122. Duncan PW, Reker DM, Horner RD, et al. Performance of a mail-administered version of a stroke-specific outcome measure, the Stroke Impact Scale. Clin Rehabil 2002; 16:493.
  123. Duncan PW, Lai SM, Tyler D, et al. Evaluation of proxy responses to the Stroke Impact Scale. Stroke 2002; 33:2593.