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

• CCC — Subarachnoid Haemorrhage: Overview
• CCC — Subarachnoid Haemorrhage: ICU Management
• CCC — Monitoring in Subarachnoid Haemorrhage
• CCC — Subarachnoid Haemorrhage Grading Systems
• CCC — Vasospasm in Subarachnoid Haemorrhage
• CCC — Subarachnoid Haemorrhage: Initial Management
• CCC — Subarachnoid Haemorrhage: Prognostication
• CCC — Subarachnoid Haemorrhage: Complications

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]