Neuropsych Tests For Stroke Patients: Which To Choose?

Neuropsychological tests are used to determine how well a person's brain works by testing a range of mental functions, such as reading, language use, attention, learning, processing speed, reasoning, remembering, and problem-solving, as well as mood and behaviour. These tests can help healthcare providers determine a diagnosis, identify strengths and weaknesses in thinking processes, and develop plans for future treatment and interventions. In the context of stroke patients, neuropsychological tests can be used to distinguish between normal changes due to ageing and neurological issues caused by the stroke.

There are several imaging tests used to diagnose stroke, including computed tomography (CT) scans, magnetic resonance imaging (MRI), digital subtraction angiography (DSA), and positron emission tomography (PET). These tests help determine the type of stroke and the location of the stroke in the brain. Additionally, blood tests and electrocardiograms (EKGs) may be used to assess blood clotting, kidney function, and identify heart problems that could have led to the stroke.

Neuropsychological tests for stroke patients specifically assess mental functions such as reading and reading comprehension, language use and comprehension, attention and concentration, learning and memory, executive functions like planning and problem-solving, visuospatial skills, and mood and personality. These tests do not directly diagnose a condition but provide valuable information to help healthcare providers diagnose and manage conditions like stroke.

Face, Arm, Speech Test (FAST)

The Face, Arm, Speech Test (FAST) is a quick and easy-to-use test to help identify the warning signs of a stroke. It was developed in the UK in 1998 by a group of stroke physicians, ambulance personnel, and an emergency room physician. It is designed to be used by both medical and non-medical professionals and is now used in many countries. FAST is an integral part of a training package for ambulance staff and was created to expedite the administration of intravenous tissue plasminogen activator to patients within 3 hours of acute stroke symptom onset.

The three key elements of the test are:

• Face: Does one side of the face sag when the person smiles?
• Arm: Does one arm droop when both arms are raised?
• Speech: Does the person's speech sound strange or slurred when they say a common phrase?

If any of these symptoms are observed, emergency services should be contacted immediately. FAST does not assess stroke severity, and a person can still be having a stroke even if they do not display any of the above symptoms.

Pre-hospital Scales

Cincinnati Pre-Hospital Stroke Scale (CPSS)

CPSS is used to diagnose a potential stroke in a pre-hospital setting. It involves testing three signs for abnormal findings: facial droop, arm drift, and speech. If any one of these tests shows abnormal findings, the patient may be having a stroke and should be transported to a hospital as soon as possible.

Los Angeles Prehospital Stroke Screen (LAPSS)

LAPSS is a widely used and validated screening tool for the early identification of stroke by Emergency Medical Technicians/Paramedics. It consists of nine items to assess and does not assess stroke severity.

Los Angeles Motor Scale (LAMS)

LAMS is a brief 3-item stroke severity assessment measure designed for pre-hospital and Emergency Department use. It is derived from the Los Angeles Prehospital Stroke Screen and can identify large vessel occlusion.

Rapid Arterial Occlusion Evaluation (RACE)

The RACE scale is used to assess stroke severity and identify patients with acute stroke and large artery occlusion in a pre-hospital setting. It evaluates five items: facial palsy, brachial paresis, crural paresis, oculocephalic deviation, and aphasia/agnosia.

Miami Emergency Neurological Deficit (MEND)

MEND is an easy-to-learn and use checklist that provides key information by incorporating components of the CPSS and the NIH Stroke Scale. It can be used to obtain a baseline exam in the pre-hospital setting and for initial evaluation and subsequent exams in the Emergency Department or ICU.

Acute Hospital Scales

• National Institutes of Health Stroke Scale (NIHSS): This is considered the gold standard for acute stroke assessment. It is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficits. The NIHSS is used to evaluate the acuity of stroke patients, determine appropriate treatment, and predict patient outcomes. It can also be used to monitor neurological status and as a common language for information exchange among healthcare providers.
• Scandinavian Stroke Scale (SSS): An alternative to the NIHSS, the SSS is frequently used in Scandinavian countries and has been validated in Portuguese as well. It is known for its simplicity, which makes it easier to perform repeated measures in the very acute phase after a stroke.
• Canadian Neurological Scale (CNS): Developed as a simple tool to evaluate and monitor the neurological status of patients with stroke in the acute phase. The CNS evaluates 10 clinical domains, including mentation, motor function, and speech. It can be administered in approximately five minutes and has good inter-rater agreement.
• European Stroke Scale (ESS): Designed specifically for clinical stroke trials in patients with middle cerebral artery stroke. The ESS consists of 14 items selected for their specificity and prognostic value, such as level of consciousness, comprehension, speech, visual field, gaze, facial movement, and maintenance of arm and leg position. It is reliable, sensitive, and easy to use, with prognostic value for outcomes.

Functional and Outcome Assessment Scales

Functional assessment scales are used to give a numerical value to abstract concepts such as "disability". They can be used to objectively quantify deficits and track changes over time, which is particularly useful in a rehabilitation setting.

Chedoke Arm and Hand Activity Inventory

The Chedoke Arm and Hand Activity Inventory is a functional assessment scale used to evaluate the functional abilities of a patient's arm and hand.

Fugl-Meyer Assessment of Motor Recovery after Stroke

The Fugl-Meyer Assessment is a performance-based measure of motor function and recovery following a stroke. It assesses motor function and recovery in five areas: the upper extremity, lower extremity, balance, sensation, and joint function in the upper and lower extremities.

Motor Assessment Scale

The Motor Assessment Scale (MAS) is a performance-based measure used to evaluate the motor function of stroke patients. It assesses the patient's ability to perform gross motor tasks such as sitting, standing, and walking.

Rivermead Mobility Index

The Rivermead Mobility Index (RMI) is a performance-based measure used to evaluate the mobility of stroke patients. It assesses the patient's ability to perform functional tasks such as walking, climbing stairs, and transferring from one surface to another.

Outcome Assessment Scales

Outcome assessment scales are used to evaluate the effectiveness of interventions and are considered central to good practice.

National Institutes of Health Stroke Scale (NIHSS)

The NIHSS is a 15-item ordinal, non-linear neurological impairment scale that covers consciousness, ocular movement, vision, coordination, speech and language, sensory function, upper and lower limb strength, facial muscle function, and hemi-neglect. It is a reliable and valid tool that is easy and quick to administer, taking around 5 minutes to complete.

Modified Rankin Scale (mRS)

The mRS is a 6-point, ordinal hierarchical scale that describes "global disability" with a focus on mobility. It is the most commonly used functional assessment measure and is recommended by professional societies and regulatory bodies for outcomes assessment in stroke trials. While it is a brief and broad-ranging assessment of function, it has limitations in terms of inter-observer variability.

Barthel Index (BI)

The BI is a 10-item scale that measures independence in performing basic activities of daily living (ADL). It is the most commonly used functional measure in stroke-rehabilitation settings and the second most commonly used functional outcome measure across stroke trials. While it has moderate to high inter- and intra-rater reliability, it has limitations in terms of responsiveness to change and is vulnerable to floor and ceiling effects.

Outcome Assessment Scales

There are several outcome assessment scales that can be used for stroke patients. Here are some examples:

• The Chedoke Arm and Hand Activity Inventory
• The Fugl-Meyer Assessment of Motor Recovery after Stroke
• The Motor Assessment Scale
• The Rivermead Mobility Index

Additionally, there are also pre-hospital scales and acute hospital scales that can be used to identify a stroke and determine its severity. These scales include:

• Cincinnati Pre-Hospital Stroke Scale (CPSS)
• Face, Arm, Speech Test (FAST)
• Los Angeles Prehospital Stroke Screen (LAPSS)
• National Institutes of Health Stroke Scale (NIHSS)
• Scandinavian Stroke Scale (SSS)
• Canadian Neurological Scale (CNS)
• European Stroke Scale (ESS)

Frequently asked questions