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Screening at a National Scale: NIHSS Plus Test of Gait Plus Test of Skew
In 2020, we recommended that our clinicians perform NIHSS plus test of gait and test of skew in patients with undifferentiated dizziness, vertigo, ataxia, and imbalance, as well as any patient suspected of having a posterior stroke. Our mnemonic for this practice change is “dizziNIHSS,” which seems to resonate with our clinicians.
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ACEP Now: Vol 43 – No 07 – July 2024On a per patient volume basis from 2018–present, malpractice claims for missed posterior stroke presenting as undifferentiated dizziness have decreased by 50 percent (internal data), suggesting the NIHSS plus test of skew plus test of gait is effective in preventing posterior stroke misses and claims.
Summary
We advocate for the use of the NIHSS with a test of skew and test of gait to screen for stroke in patients presenting with dizziness, vertigo, ataxia, imbalance, and other clinical suspicion for posterior circulation stroke. This approach has strong evidence, is well accepted by clinicians, and has cut our predicted malpractice costs by 50 percent.
References
- Pilcher C, Dajer T. How not to miss posterior circulation stroke. ACEP Now. Accessed June 1, 2024.
- Tarnutzer AA, Berkowitz AL, Robinson KA,et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14;183(9):E571-92.
- Searls DE, Pazdera L, Korbel E, et al. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol. 2012 Mar;69(3):346-51.
- Henriksen AC, Hallas P. Inter-rater variability in the interpretation of the head impulse test results. Clin Exp Emerg Med. 2018 Mar 30;5(1):69-70.
- Tarnutzer AA, Edlow JA. Bedside Testing in Acute Vestibular Syndrome-Evaluating HINTS Plus and Beyond-A Critical Review. Audiol Res. 2023 Sep 1;13(5):670-685.
- Eskioglou E, Huchmandzadeh Millotte M, Amiguet M, Michel P. National Institutes of Health Stroke Scale Zero Strokes. Stroke. 2018 Dec;49(12):3057-3059.
- Edlow BL, Hurwitz S, Edlow JA. Diagnosis of DWI-negative acute ischemic stroke: A meta-analysis. Neurology. 2017 Jul 18;89(3):256-262.
- Kim K, Kim BJ, Huh J, et al. Delayed Lesions on Diffusion-Weighted Imaging in Initially Lesion-Negative Stroke Patients. J Stroke. 2021 Jan;23(1):69-81.
- Dunning, K. (2011). National Institutes of Health Stroke Scale. In: Kreutzer, J.S., DeLuca, J., Caplan, B. (eds) Encyclopedia of Clinical Neuropsychology. Springer, New York, NY.
- Cummock JS, Wong KK, Volpi JJ, et al. Reliability of the National Institutes of Health (NIH) Stroke Scale Between Emergency Room and Neurology Physicians for Initial Stroke Severity Scoring. Cureus. 2023 Apr 14;15(4):e37595.
- Martin-Schild S, Albright KC, Tanksley J, et al. Zero on the NIHSS does not equal the absence of stroke. Ann Emerg Med. 2011 Jan;57(1):42-5.
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