The NIH Stroke Scale (NIHSS) is a 15-item neurological examination scored 0–42 that quantifies stroke severity in real time. It is the single most validated bedside score in acute stroke care — used in every major thrombolysis and thrombectomy trial (NINDS, ECASS, MR CLEAN, DAWN, DEFUSE-3) and recommended by AHA/ASA, ESO, and the Indian Stroke Association.

A trained nurse or resident can complete the scale in under 7 minutes. It directly informs three high-stakes decisions: (1) IV thrombolysis with alteplase or tenecteplase, (2) mechanical thrombectomy for large vessel occlusion, and (3) admission level (stroke unit vs ICU).

• 0: No stroke symptoms
• 1–4: Minor stroke — tPA still indicated if deficit is disabling
• 5–15: Moderate stroke — strong thrombolysis candidate
• 16–20: Moderate-to-severe — high LVO probability, screen with CTA
• 21–42: Severe stroke — high mortality, urgent thrombectomy + neurosurgical consult

Stroke is the 4th leading cause of death in India (Lancet 2022). The AIIMS Code Stroke protocol and Indian Stroke Association consensus mandate NIHSS at:

• ED arrival (within 10 min)
• Pre- and post-tPA (immediately after infusion ends)
• 2 hours post-tPA (look for haemorrhagic conversion: ≥4-point worsening)
• 24 hours, 7 days, and at discharge

Alteplase costs ₹35,000–40,000 in India; tenecteplase ₹25,000–30,000. NIHSS documentation is mandatory for PMJAY reimbursement of stroke thrombolysis and for Ayushman Bharat audit.

• IV alteplase — within 4.5h of onset, NIHSS ≥4 (or disabling deficit any score), no contraindications (recent surgery, GI bleed, INR >1.7, platelets <100k, BP >185/110 uncontrolled)
• Mechanical thrombectomy — anterior circulation LVO (ICA, M1, proximal M2), NIHSS ≥6, ASPECTS ≥6, within 6h standard; extended to 24h if favourable mismatch (DAWN/DEFUSE-3 criteria)
• Tenecteplase — emerging alternative, single bolus, increasingly used in India per AHA 2024 update