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
CCC Neurocritical Care Series
Emergencies: Brain Herniation, Eclampsia, Elevated ICP, Status Epilepticus, Status Epilepticus in Paeds
DDx: Acute Non-Traumatic Weakness, Bulbar Dysfunction, Coma, Coma-like Syndromes, Delayed Awakening, Hearing Loss in ICU, ICU acquired Weakness, Post-Op Confusion, Pseudocoma, Pupillary Abnormalities
Neurology: Anti-NMDA Encephalitis, Basilar Artery Occlusion, Central Diabetes Insipidus, Cerebral Oedema, Cerebral Venous Sinus Thrombosis, Cervical (Carotid / Vertebral) Artery Dissections, Delirium, GBS vs CIP, GBS vs MG vs MND, Guillain-Barre Syndrome, Horner’s Syndrome, Hypoxic Brain Injury, Intracerebral Haemorrhage (ICH), Myasthenia Gravis, Non-convulsive Status Epilepticus, Post-Hypoxic Myoclonus, PRES, Stroke Thrombolysis, Transverse Myelitis, Watershed Infarcts, Wernicke’s Encephalopathy
Neurosurgery: Cerebral Salt Wasting, Decompressive Craniectomy, Decompressive Craniectomy for Malignant MCA Syndrome, Intracerebral Haemorrhage (ICH)
— SCI: Anatomy and Syndromes, Acute Traumatic Spinal Cord Injury, C-Spine Assessment, C-Spine Fractures, Spinal Cord Infarction, Syndomes,
— SAH: Acute management, Coiling vs Clipping, Complications, Grading Systems, Literature Summaries, ICU Management, Monitoring, Overview, Prognostication, Vasospasm
— TBI: Assessment, Base of skull fracture, Brain Impact Apnoea, Cerebral Perfusion Pressure (CPP), DI in TBI, Elevated ICP, Limitations of CT, Lund Concept, Management, Moderate Head Injury, Monitoring, Overview, Paediatric TBI, Polyuria incl. CSW, Prognosis, Seizures, Temperature
ID in NeuroCrit. Care: Aseptic Meningitis, Bacterial Meningitis, Botulism, Cryptococcosis, Encephalitis, HSV Encephalitis, Meningococcaemia, Spinal Epidural Abscess
Equipment/Investigations: BIS Monitoring, Codman ICP Monitor, Continuous EEG, CSF Analysis, CT Head, CT Head Interpretation, EEG, Extradural ICP Monitors, External Ventricular Drain (EVD), Evoked Potentials, Jugular Bulb Oxygen Saturation, MRI Head, MRI and the Critically Ill, Train of Four (TOF), Transcranial Doppler
Pharmacology: Desmopressin, Hypertonic Saline, Levetiracetam (Keppra), Mannitol, Midazolam, Sedation in ICU, Thiopentone
MISC: Brainstem Rules of 4, Cognitive Impairment in Critically Ill, Eye Movements in Coma, Examination of the Unconscious Patient, Glasgow Coma Scale (GCS), Hiccoughs, Myopathy vs Neuropathy, Neurology Literature Summaries, NSx Literature Summaries, Occulocephalic and occulovestibular reflexes, Prognosis after Cardiac Arrest, SIADH vs Cerebral Salt Wasting, Sleep in ICU
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]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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