Performing the NIHSS on an intubated patient follows the same 15-item framework as in any other patient, but the endotracheal tube forces specific scoring adaptations on a handful of items. The most straightforward change involves dysarthria (item 10), which is scored “UN” for untestable. The rest of the scale can still be administered, though several items require creative workarounds because the patient cannot speak. Understanding which items genuinely change and which remain identical is the core skill, and it is less complicated than many clinicians assume when they first encounter the scenario.
Which Items Stay the Same
Most of the NIHSS does not depend on the patient’s ability to talk. Motor testing of the arms (item 5) and legs (item 6), limb ataxia (item 7), sensory testing (item 8), best gaze (item 2), visual fields (item 3), and extinction or inattention (item 11) are all scored exactly as they would be in a non-intubated patient. You position the limbs, observe for drift, test for neglect with simultaneous stimulation, and grade what you see. The tube does not interfere with any of these assessments.
Level of consciousness commands (item 1c) also remain largely unchanged. The standard instructions ask the patient to open and close their eyes, then grip and release with the non-paretic hand. Neither action requires speech. If the patient follows both commands correctly, score it 0. If only one, score it 1. If neither, score it 2. This item works the same regardless of whether a tube is in place.
Dysarthria Gets Scored as Untestable
Item 10, dysarthria, evaluates the clarity of speech by having the patient read or repeat words. An intubated patient physically cannot produce speech, so the NIHSS guidelines direct you to score this item as “UN” rather than assigning a numerical value. This is one of only two items on the scale that allow an untestable designation (the other is limb ataxia, which gets a UN if the limb is amputated or fused). The UN score means the item is excluded from the total rather than counted as zero or as the maximum deficit. This distinction matters when you compare scores over time or when thresholds are used for treatment decisions.
A common mistake is scoring dysarthria as a 2 (severe or mute) simply because the patient cannot vocalize. That conflates a physical barrier with a neurological deficit. The tube is preventing speech, not the stroke. Scoring it as UN keeps the total score honest about what the stroke itself is doing.
Assessing Language Without Speech
Item 9, best language, is the most nuanced challenge in an intubated patient, but it is not scored as untestable. The NIHSS was designed to allow language assessment even when a patient cannot speak, because it evaluates more than just verbal output. You are testing whether the patient comprehends language and whether they can produce meaningful communication through any channel, not just their mouth.
Start with comprehension. Show the patient the standard NIHSS picture card depicting a domestic scene and the naming card with common objects. Ask them to point to items or nod in response to yes-or-no questions about the pictures. If they can follow written commands, hand them a pen and paper or a communication board. A patient who writes coherent responses, even with poor handwriting, is demonstrating intact language function. Someone who writes jumbled, paraphasic nonsense or who cannot follow any written or gestural prompts is showing a language deficit that warrants a higher score on item 9.
The key distinction is between a patient who understands everything but simply cannot speak because of the tube and a patient whose language networks are genuinely impaired. The first patient will nod appropriately, follow written instructions, write coherently, and point to correct items. The second will fail these tasks regardless of the tube. Score item 9 based on that functional difference.
Level of Consciousness Questions Require Adaptation
Item 1b asks the patient two questions: their age and the current month. Under standard scoring, the patient must say the correct answers. An intubated patient cannot say anything, so you need to adapt the delivery while preserving the intent of the item. The standard approach is to ask the patient to indicate their answers through writing, holding up fingers, or pointing to a number board. If you ask “How old are you?” and the patient holds up the correct number of fingers on two hands or writes the number, that counts as a correct response.
The strict NIHSS scoring rules, however, state that only the first attempt counts and that close answers are wrong. If the patient writes “63” when they are 64, that answer is scored as incorrect, just as it would be if spoken aloud. This matters because intubated patients often have some degree of sedation or confusion, and the extra cognitive effort of communicating nonverbally can slow their response. Give them a reasonable window to produce the answer, but do not coach them or accept approximations.
Some training programs teach that if the patient is too obtunded to attempt the questions at all, you score 1b as a 2, which is the same approach used for any unresponsive patient. Intubation alone should never push this score higher. A fully alert intubated patient who accurately communicates both answers should score 0 on item 1b.
Facial Palsy Around the Tube
Item 4, facial palsy, asks you to observe symmetry of facial movements, often by asking the patient to show their teeth or smile. An endotracheal tube taped to the face can obscure parts of the lower face and physically distort the cheek and lip on one side, making asymmetry harder to judge. The tube holder or tape configuration may even mimic mild facial droop if you are not careful.
Work around this by focusing on what you can see clearly. Ask the patient to raise their eyebrows and squeeze their eyes shut, which tests the upper face and is not affected by the tube. For the lower face, observe any spontaneous emotional expressions, such as grimacing during suctioning or reacting to a family member. If the patient is alert enough, ask them to puff out their cheeks. Compare both sides carefully, mentally discounting asymmetry that tracks with the physical presence of the tube rather than muscle weakness. If one side of the face clearly moves less than the other in a way that the tape cannot explain, score accordingly.
When Sedation Muddies the Picture
Intubated patients are frequently on sedative infusions, and this is where the NIHSS in the intubated population gets genuinely complicated. A patient on propofol or dexmedetomidine who is drowsy and slow to respond may appear to have deficits in consciousness, language, and motor function that are partly or entirely pharmacological rather than neurological. The NIHSS does not have a built-in mechanism for separating drug effects from stroke effects. You score what you observe.
The practical approach most neurocritical care teams use is to time the assessment for a period when sedation is at its lightest. Many units perform a daily sedation interruption or “wake-up test” during which infusions are paused briefly. This is the ideal window for an NIHSS assessment because you are seeing the patient’s neurological baseline with minimal pharmacological confounding. If a wake-up test is not safe or feasible, document the sedation level alongside the NIHSS score so that anyone reading the chart understands the context.
Even with this approach, some degree of sedation often remains. A patient who is mildly drowsy but arousable to voice scores a 1 on item 1a (level of consciousness). If they only respond to painful stimulation, that is a 2. If they are completely unresponsive, score 3. The challenge is knowing whether that unresponsiveness is the stroke, the fentanyl, or both. The honest answer is that you often cannot fully separate them at the bedside, and the score should be interpreted with that limitation in mind.
Interpreting the Total Score
The standard NIHSS ranges from 0 to 42. When dysarthria is scored as UN, the functional maximum drops to 40, because that item’s 2-point range is removed from the scale. This means an intubated patient’s total score is not directly comparable to a non-intubated patient’s score on a one-to-one basis. In practice, the difference of up to 2 points is small enough that it rarely changes clinical decision-making, but it is worth noting in documentation.
More significantly, the overall predictive accuracy of the NIHSS can be diminished in mechanically ventilated patients because items requiring patient cooperation, such as language comprehension and command-following, cannot always be accurately assessed through the tube and sedation barrier.1Annals of Medicine and Medical Sciences. Functional Prognostic Scores Following Stroke in Intubated and Mechanically Ventilated Patients: A Narrative Review A score of 14 in an intubated, sedated patient carries more uncertainty about actual neurological function than the same score in an awake, cooperative patient in the emergency department. This does not mean the score is useless. It means you should treat it as one data point alongside imaging, clinical trajectory, and post-extubation reassessment rather than as a standalone verdict.
Why Serial Assessments Matter More Than a Single Score
A single NIHSS score in an intubated patient is a snapshot taken under imperfect conditions. The real value comes from trending scores over hours and days. If the NIHSS is 18 on day one and drops to 12 by day three despite no change in sedation, that trajectory tells you more than either number alone. Conversely, a score that climbs from 10 to 16 suggests worsening that may warrant repeat imaging or a change in management.
Consistency in how you score is more important than perfection on any single assessment. If the same examiner uses the same adaptations each time, such as always using a number board for item 1b and always timing assessments during the sedation lightening window, the trend line becomes reliable even if the absolute numbers carry more noise than usual. Switching examiners or methods between assessments introduces variability that can be mistaken for neurological change.
Post-extubation reassessment is particularly valuable. Once the tube is out, you can test dysarthria properly, assess language through speech, and ask the LOC questions verbally. A review of prognostic scoring in ventilated stroke patients noted that early post-extubation reassessment may sometimes yield superior prognostic information compared to scores obtained while the patient remains intubated.1Annals of Medicine and Medical Sciences. Functional Prognostic Scores Following Stroke in Intubated and Mechanically Ventilated Patients: A Narrative Review Plan for a formal NIHSS as soon as the patient is extubated and alert enough to participate.
Common Scoring Mistakes in Intubated Patients
Several errors come up repeatedly in practice and in NIHSS certification courses. Knowing them in advance makes you a more accurate scorer.
- Scoring dysarthria as 2 instead of UN: This inflates the total score by attributing a mechanical limitation to the stroke. Always use UN for item 10 when the patient is intubated.
- Scoring language as untestable: Item 9 does not get a UN score just because the patient cannot talk. You assess comprehension and written output. Only if the patient is completely unresponsive and you truly cannot test any aspect of language do you score the maximum deficit, which is a 3, not a UN.
- Confusing sedation with aphasia: A patient who is too drowsy to follow commands may look aphasic when they are actually just sedated. If you are uncertain, note the sedation level and retest when the patient is more awake rather than locking in a high language score.
- Ignoring the tube during facial palsy scoring: Tape pulling on one cheek can create the illusion of asymmetry. Always check upper facial movements, which are unaffected by the tube, before concluding there is a lower facial deficit.
- Overcrediting motor responses to pain: In an obtunded intubated patient, you may need to use noxious stimulation to test motor function. Flexion withdrawal to pain is not the same as purposeful antigravity movement. Score motor items based on the best response you actually observe, not what you hope the patient could do if more awake.
Documentation Tips for the Medical Record
Because so much of the NIHSS in an intubated patient involves judgment calls and adaptations, clear documentation protects both the patient and the clinician. At minimum, your note should state that the patient was intubated at the time of assessment and specify the sedation regimen and the patient’s arousal level when tested. If you timed the assessment to coincide with a sedation pause, say so.
For each adapted item, a brief note explaining how you tested it helps the next examiner replicate your method. Something as simple as “1b assessed via finger-counting, patient correctly indicated age and month” or “item 9 assessed via written output, patient wrote coherent sentences” gives the next person a clear picture. When dysarthria is scored as UN, documenting the reason (intubated, unable to produce speech) prevents confusion downstream. Some electronic health record systems have a dedicated field for noting untestable items, while others require a free-text addendum.
NIHSS Components That Correlate With Imaging Findings
Whether a patient is intubated or not, the individual items on the NIHSS do not all carry equal weight when it comes to reflecting the size or location of the stroke on brain imaging. In patients with minor acute strokes, deficits in neglect, language, and visual fields were each associated with significantly larger infarct volumes on diffusion-weighted MRI, while other NIHSS components such as motor or sensory deficits did not show the same relationship to lesion size.2PubMed Central. The Association between Diffusion MRI-Defined Infarct Volume and NIHSS Score in Patients with Minor Acute Stroke This is relevant for intubated patients because two of those three high-yield items, language and neglect, are among the hardest to assess through the tube and sedation. If you are uncertain about language or neglect scores in an intubated patient, imaging becomes an especially important complement. A large infarct on MRI in a patient whose bedside NIHSS looks moderate may indicate that the true neurological burden is being obscured by the limitations of bedside testing.
This is not to say you should skip trying to assess language or neglect at the bedside. Even an imperfect assessment gives you directional information. But when the scores on these items feel unreliable because of sedation or inability to cooperate, lean on the imaging data more heavily than you might in a patient who can fully participate in the exam.
Patients Who Are Intubated for Reasons Other Than Stroke
Not every intubated patient receiving an NIHSS has a primary stroke diagnosis. You might be called to evaluate a trauma patient with a suspected concurrent stroke, a post-cardiac-arrest patient being screened for hypoxic brain injury, or a patient who was intubated for airway protection during a large hemispheric infarction with swelling. The adaptations described above apply regardless of why the patient was intubated, but the clinical context changes how much weight the score carries.
In a patient intubated purely for airway protection after a massive stroke, the NIHSS is still useful for tracking whether the deficit is stable, worsening, or improving. In a post-cardiac-arrest patient, though, the NIHSS was not designed to quantify global hypoxic injury, and its items may not map cleanly onto the pattern of deficits you see. You can still administer it for consistency and documentation, but recognize that the score may not predict outcomes in the same way it does for ischemic stroke.
Similarly, in trauma patients with polytrauma, casts, or splints on limbs, you may encounter additional untestable items beyond dysarthria. A patient with a casted right arm cannot perform the arm drift test on that side. Score that arm’s motor item as UN, document the reason, and interpret the total score knowing that more items than usual are excluded. The more items scored as UN, the less the total number means by itself, and the more you rely on the items you could test plus the imaging and clinical picture.