Subarachnoid Haemorrhage Grading Systems


  • clinical and radiological grading systems exist
  • none of the grading systems have high sensitivity or specificity
  • grading inaccurate if there is acute hydrocephalus, post-ictal state and medications
  • half of patients with poor grades on admission have good outcomes
  • clinical grades are better at predicting outcomes, radiological grades are better at predicting vasospasm


GCS (Teasdale and Jennett, 1974)

  • not a true SAH grading scale
  • only GCS 14 and 15 correlate with good outcomes, lower scores have poor predictive power
  • motor score is most important

Hunt and Hess (1968)

  • I – asymptomatic or mild headache
  • II – moderate-severe headache, meningism and no weakness
  • III – mild alteration in mental status
  • IV – depressed LOC and/or hemiparesis
  • V – posturing or comatose

subjective, was intended as a guide to surgical risk

WFNS (1998)

  • I – GCS 15, no motor deficit
  • II – GCS 13-14, no motor deficit
  • III – GCS 13-14, motor deficit
  • IV – GCS 7-12 +/- motor deficit
  • V – GCS 3-6, motor deficit present or absent

more objective, but reliant on accurate GCS


Fisher (1980)

  • I – no blood
  • II – diffuse deposition of SAH without clots or layers of blood >1mm
  • III – localized clots and/or vertical layers of blood 1mm or > thickness
  • IV – diffuse or no subarachnoid blood but intracerebral or intraventricular clots

validated to predict likelihood of vasospasm, minimal inter-observer variability

Claassen Scale (2004)

  • 5 grades

predicts risk of delayed cerebral ischemia, combines additive risk from SAH and IVH

Ogilvy and Carter (1998)

  • combines clinical and radiological findings
  • combination of age, Hunt-Hess grade, Fisher grade, and aneurysm size and age
  • studies of this are flawed
  • minimal inter-observer variability

References and Links



  • Claassen J, Vu A, Kreiter KT. Effect of acute physiologic derangements on outcome after subarachnoid hemorrhage. Critical care medicine. 32(3):832-8. 2004. [PMID 15090970]
  • Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 6(1):1-9. 1980. [PMID 7354892]
  • Ogilvy CS, Carter BS. A proposed comprehensive grading system to predict outcome for surgical management of intracranial aneurysms. Neurosurgery. 42(5):959-68; discussion 968-70. 1998. [PMID 9588539]
  • Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. Journal of neurosurgery. 68(6):985-6. 1988. [PMID 3131498]
  • Rosen DS, Macdonald RL. Subarachnoid hemorrhage grading scales: a systematic review. Neurocritical care. 2(2):110-8. 2005. [PMID 16159052]
  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet (London, England). 2(7872):81-4. 1974. [PMID 4136544]

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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