ROSIER scale
Calculate ROSIER Score (Recognition of Stroke in the Emergency Room)
Stroke assessment (ED tool): helps differentiate acute stroke from common mimics.
Always check capillary glucose first - exclude hypoglycaemia and treat urgently if low, then reassess.
|
YES |
NO |
| First confirm: symptoms/signs are NEW and ACUTE onset (including on waking from sleep). |
| Has there been loss of consciousness or syncope? |
-1 |
0 |
| Has there been seizure activity? |
-1 |
0 |
| Asymmetric facial weakness |
+1 |
0 |
| Asymmetric arm weakness |
+1 |
0 |
| Asymmetric leg weakness |
+1 |
0 |
| Speech disturbance (dysphasia or dysarthria) |
+1 |
0 |
| Visual field defect |
+1 |
0 |
| TOTAL (range -2 to +5) |
____ |
Interpretation:
- Score ≥ 1: treat as possible stroke → urgent stroke pathway / senior review / imaging as per local protocol.
- Score ≤ 0: stroke is less likely but not excluded - continue clinical assessment if symptoms/signs suggest stroke.
Important: ROSIER is not designed for patients with suspected TIA who have no neurological signs when assessed (resolved symptoms).
|
Teaching note (why these items matter): The positive items (face/arm/leg weakness, speech and visual field deficits) are “cortical/long-tract” patterns typical of focal cerebral ischaemia or haemorrhage, whereas syncope and seizures push probability toward mimics (e.g., arrhythmia, vasovagal, epilepsy) and so are negatively weighted. Always correct hypoglycaemia first because neuroglycopenia can generate focal deficits that look exactly like stroke, and you want the post-correction exam to reflect true brain function. ROSIER is a decision support tool, not a diagnosis: posterior circulation strokes and atypical presentations can be under-captured, so a low score mustn’t override a convincing story or exam.
Key references:
-
Nor AM, Davis J, Sen B, et al. The Recognition of Stroke in the Emergency Room (ROSIER) scale.
Lancet Neurology 2005;4(11):727–734. doi:10.1016/S1474-4422(05)70201-5.
(Validation performance at cut-off >0 reported: sensitivity ~93%, specificity ~83%, PPV ~90%, NPV ~88.)
-
NICE guideline NG128: Stroke and transient ischaemic attack in over 16s: diagnosis and initial management.
Recommends in ED using a validated tool such as ROSIER and explicitly to exclude hypoglycaemia.
https://www.nice.org.uk/guidance/ng128/chapter/recommendations
-
RCEM Learning: Stroke in the ED (summary of ROSIER interpretation and predictive values in ED practice).
https://www.rcemlearning.co.uk/reference/stroke-in-the-ed/
