A low NIHSS score can hide a proximal occlusion held at bay by collaterals. These patients may look well on arrival and then deteriorate over hours as collaterals fail. A low score is a reason to image the vessels, not a reason to skip it.
Cortical signs out of proportion to the score — aphasia, neglect, gaze preference, visual field loss — are the clues, and fluctuation is a warning.
- Do CT or MR angiography in every suspected acute ischaemic stroke that could be a reperfusion candidate, whatever the NIHSS.
- Look for cortical signs such as aphasia, neglect or gaze deviation even when the total score is low.
- Repeat the NIHSS frequently in the first 24 hours; early worsening calls for urgent reassessment.
- Discuss proven large-vessel occlusion with a thrombectomy centre early rather than after deterioration.
Why it matters
Patients with mild deficits and proximal occlusions are the ones most likely to worsen unexpectedly.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for neurology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free