Subarachnoid Haemorrhage Grading Systems

OVERVIEW

  • 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

CLINICAL

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

RADIOLOGICAL

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

LITFL

Journals

  • 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

Compendium

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