Subarachnoid hemorrhage grading scales - UpToDate 2/16/17, 6(26 AM

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Subarachnoid hemorrhage grading scales

Authors: Robert J Singer, MD, Christopher S Ogilvy, MD, Guy Rordorf, MD

Section Editor: Jose Biller, MD, FACP, FAAN, FAHA
Deputy Editor: Janet L Wilterdink, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2017. | This topic last updated: Jan 14, 2014.

INTRODUCTION Subarachnoid hemorrhage (SAH) is often a devastating event. The appropriate therapy for
SAH depends in part upon the severity of hemorrhage. Level of consciousness on admission, patient age, and
the amount of blood on initial head computed tomography (CT) scan are the most important prognostic factors
for SAH at presentation [1].

A number of grading systems are used in practice to standardize the clinical classification of patients with SAH
based upon the initial neurologic examination and the appearance of blood on the initial head CT. This topic will
provide an overview of the more commonly used clinical and radiologic grading scales for SAH. Treatment and
other aspects of SAH are discussed separately. (See "Treatment of aneurysmal subarachnoid hemorrhage" and
"Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage".)

INDIVIDUAL GRADING SCALES An ideal SAH grading scale would provide the following capabilities [2-4]:

Guide management decisions that are influenced by the severity of SAH

Provide prognosis for clinicians, patients, and family members

Assist practitioners in their ability to compare individual patients and groups of similar patients regarding
studies that examine the impact of new treatments

Enable practitioners to detect and quantify changes in disease severity while following an individual patient

While a number of SAH grading scales have been proposed, none meets all these requirements or is universally
accepted [4]. Furthermore, there is a paucity of validation studies, and no prospective controlled comparison
studies have been performed.

Glasgow Coma Scale The Glasgow Coma Scale (GCS) (table 1) was devised in the early 1970s [5]. The
GCS is not a true SAH grading scale, but is rather a standardized method for evaluating the level of
consciousness in a number of neurologic conditions including SAH. The GCS assigns points based on three
parameters of neurologic function:

Eye opening (spontaneous = 4, response to verbal command = 3, response to pain = 2, no eye opening = 1)
Best verbal response (oriented = 5, confused = 4, inappropriate words = 3, incomprehensible sounds = 2, no

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verbal response = 1)
Best motor response (obeys commands = 6, localizing response to pain = 5, withdrawal response to pain =
4, flexion to pain = 3, extension to pain = 2, no motor response = 1)

In a prospective series of 765 patients with SAH, a higher GCS correlated with better outcome after aneurysm
surgery [6]. However, a significant difference in outcome was observed only between patients with GCS scores
of 15 and 14, while no significant differences were found between the remaining adjacent GCS scores.

The interobserver variability of the GCS for patients with SAH is moderate (kappa 0.46) [7].

The GCS has been incorporated into several additional SAH grading systems. (See 'World Federation of
Neurological Surgeons grading scale' below and 'Ogilvy and Carter grading system' below.)

It should be recognized that sedating medications and intubation can confound interpretation of the clinical SAH
scales, particularly the GCS and those that incorporate it, since such interventions will reduce the level of
consciousness and impair verbal responses.

Hunt and Hess grading system The grading system proposed by Hunt and Hess in 1968 (table 2) [8] is one
of the most widely used [9]. The scale was intended as an index of surgical risk. The initial clinical grade
correlates with the severity of hemorrhage.

Grade 1: Asymptomatic or mild headache and slight nuchal rigidity

Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
Grade 3: Drowsy or confused, mild focal neurologic deficit
Grade 4: Stupor, moderate or severe hemiparesis
Grade 5: Deep coma, decerebrate posturing
The grade is advanced one level for the presence of serious systemic disease (hypertension, diabetes,
severe arteriosclerosis, chronic pulmonary disease) or vasospasm on angiography

A subsequent modification proposed by Hunt and Kosnik added a Grade 0 for unruptured aneurysms and a
Grade 1a for a fixed neurologic deficit without other signs of SAH [10].

Although the Hunt and Hess scale is easy to administer, the classifications are arbitrary, some of the terms are
vague (eg, drowsy, stupor, and deep coma) and some patients may present with initial features that defy
placement within a single grade [4]. As an example, a rare presentation of SAH may include severe headache
(ie, Grade 2), normal level of consciousness, and severe hemiparesis (ie, Grade 4). In such cases, the clinician
must subjectively decide which of the presenting features is most important for determining the grade.

A systematic review of SAH grading scales found conflicting data regarding the utility of the Hunt and Hess scale
for prognosis [4]. In a study assessing a series of 185 patients with SAH, the Hunt and Hess score correlated
more strongly with outcome at six months than the GCS or World Federation of Neurological Surgeons Scale
[11]. However, individual grades for all three scales demonstrated suboptimal sensitivity, specificity, and
predictive value. In addition, nearly half of the patients with poor scale grades on admission had a good outcome.

Furthermore, it is unclear if there are significant differences in outcome for adjacent Hunt and Hess grades.

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Some studies evaluating Hunt and Hess grades found significant differences in outcome for some adjacent
grades and not others [7,12]

A study of 230 patients with SAH found a significant difference in outcome for compressed but not adjacent
Hunt and Hess grades; patients with grades 1 to 3 had better outcomes compared with those with grades 4
and 5 [13]

Another study of 405 patients with SAH found no significant difference for the risk of poor outcome or death
between patients with Hunt and Hess grades 0 to 2 [2]. Furthermore, the risk was significantly different only
when comparing patients with Hunt and Hess grade 3 to those with grade 0.

The interobserver variability for the Hunt and Hess scale is moderate (kappa 0.41 to 0.48) [7,14,15].

World Federation of Neurological Surgeons grading scale The grading system of the World Federation of
Neurological Surgeons (WFNS) (table 3) was proposed in 1988 [16]. It is based on the Glasgow Coma Scale
(GCS) score (see 'Glasgow Coma Scale' above) and the presence of motor deficits.

Grade 1: GCS score 15, no motor deficit

Grade 2: GCS score 13 to 14, no motor deficit
Grade 3: GCS score 13 to 14, with motor deficit
Grade 4: GCS score 7 to 12, with or without motor deficit
Grade 5: GCS score 3 to 6, with or without motor deficit

Unlike the Hunt and Hess scale, the WFNS scale uses objective terminology to assign grades [4]. However, it is
also more complex to administer than the Hunt and Hess scale.

A systematic review of SAH grading scales found conflicting data regarding the prognostic power of the WFNS
grades [4]; two studies showed a stepwise increase in the likelihood of poor outcome with increasing WFNS
grade [7,17], while others did not find consistent significant differences in outcome between adjacent WFNS
grades [6,12,18].

One study involving prospective evaluation of 15 patients with SAH found that interobserver variability for the
WFNS scale was fair (kappa 0.27) [7], however another study in 50 patients with SAH reported a kappa of 0.6
[15].

Fisher scale The Fisher scale (table 4) was devised in 1980 as an index of vasospasm risk (but not clinical
outcome) based upon the hemorrhage pattern seen on initial head CT scan [19].

Group 1: No blood detected

Group 2: Diffuse deposition or thin layer with all vertical layers of blood (in interhemispheric fissure, insular
cistern, or ambient cistern) less than 1 mm thick
Group 3: Localized clots and/or vertical layers of blood 1 mm or more in thickness
Group 4: Intracerebral or intraventricular clots with diffuse or no subarachnoid blood

The Fisher scale was validated in a small prospective series of 41 patients with SAH [20]. The interobserver
variability for the Fisher scale indicates excellent agreement between observers (kappa 0.90) [2].

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The Fisher scale has also been incorporated into other SAH grading systems (see 'Ogilvy and Carter grading
system' below).

Claassen CT rating scale Like the Fisher scale, the Claassen grading system (table 5) proposed in 2001 is
an index of the risk of delayed cerebral ischemia due to vasospasm after SAH [21]. It does not address clinical
outcome. Unlike the Fisher scale, the Claassen scale takes into account the separate and additive risk of SAH
and intraventricular hemorrhage (IVH).

Ten cisterns or fissures are evaluated for blood with the Claassen scale. These include the frontal
interhemispheric fissure, the quadrigeminal cistern, the bilateral suprasellar and ambient cisterns, and the
bilateral basal sylvian and lateral sylvian fissures. The scale is graded as follows:

Grade 0: No SAH or IVH

Grade 1: Minimal SAH and no IVH
Grade 2: Minimal SAH with bilateral IVH
Grade 3: Thick SAH (completely filling one or more cistern or fissure) without bilateral IVH
Grade 4: Thick SAH (completely filling one or more cistern or fissure) with bilateral IVH

The Claassen scale was derived from analysis of data from 276 patients with SAH who had a head CT scan
within 72 hours of onset [21]. The best predictors of delayed cerebral ischemia due to vasospasm were thick
SAH completely filling any cistern or fissure (odds ratio [OR] 2.3, 95% CI 1.5-9.5) and bilateral IVH (OR 4.1, 95%
CI 1.7-9.8 ).

This scale awaits prospective validation.

Ogilvy and Carter grading system A SAH classification system proposed by Ogilvy and Carter (table 6) in
1998 stratifies patients based upon age, Hunt and Hess grade (clinical condition), Fisher grade (SAH volume and
vasospasm risk), and aneurysm size [2]. (See 'Hunt and Hess grading system' above and 'Fisher scale' above.)

One point is given for each of the following variables:

Age greater than 50

Hunt and Hess grade 4 to 5 (in coma)
Fisher grade score 3 to 4
Aneurysm size >10 mm
An additional point is added for a giant posterior circulation aneurysm (25 mm)

The total score ranges from 0 to 5, corresponding to grades 0 to 5.

The Ogilvy and Carter scale mitigates the potential subjectivity inherent in the Hunt and Hess system by
compressing it into two grades (coma or no coma). Similarly, it compresses the Fisher scale into two grades.
Nonetheless, it is more complex to administer than the Hunt and Hess scale, and requires knowledge of
aneurysm size.

In a prospective evaluation of this system in 72 patients with SAH, the authors reported good to excellent

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outcomes in greater than 78 percent of patients with grades 0 to 2 [2]. In comparison, good outcomes were seen
in 67 percent of grade 3 and 25 percent of grade 4 patients. Of note, there was no statistical difference in
outcomes between grades 0 and 1. However, patients with grades 2, 3, and 4 had statistically worse outcomes
compared with those in the adjacent lower grade. Only surgically treated patients were included in the study, and
none with grade 5 had surgery.

The interobserver variability for the Ogilvy and Carter scale is very good, reflecting substantial observer
agreement (kappa 0.69) [2].

SUMMARY While a number of subarachnoid hemorrhage (SAH) grading scales have been proposed, there
are few validation studies of these scales and no prospective controlled comparison studies [4]. Furthermore, the
available data concerning SAH grading scales are limited and often conflicting. As a result, none of the existing
scales is universally accepted or clearly established. Thus, the use of any particular SAH grading scale is largely
a matter of individual or institutional preference. (See 'Individual grading scales' above.)

The Glasgow Coma Scale (GCS) (table 1) is not a true SAH grading scale but is rather a standardized scale
for evaluating the level of consciousness. However, it is widely known and has some utility for predicting
outcome after SAH. Sedating medications and intubation can confound interpretation of the GCS. It has
moderately good interobserver variability. (See 'Glasgow Coma Scale' above.)

The Hunt and Hess grading scale (table 2) is one of the most widely used, and is easy to administer, but the
terminology is subjective and atypical presentations of SAH may be difficult to classify. Data regarding its
utility for prognosis are conflicting. The interobserver variability for the Hunt and Hess scale is moderately
good. (See 'Hunt and Hess grading system' above.)

The World Federation of Neurological Surgeons (WFNS) grading scale (table 3) is also widely used and
uses objective terminology to assign grades. Like the Hunt and Hess scale, data regarding the prognostic
power of the WFNS grades are conflicting. Interobserver variability for the WFNS scale is fair. (See 'World
Federation of Neurological Surgeons grading scale' above.)

The Fisher scale (table 4) is an index of vasospasm risk (but not clinical outcome) based upon the
hemorrhage pattern seen on initial head CT scan. It has been validated in a small prospective study and
interobserver variability is excellent. The Claassen grading system (table 5) is an index of the risk of delayed
cerebral ischemia due to vasospasm after SAH. Unlike the Fisher scale, the Claassen scale takes into
account the separate and additive risk of SAH and intraventricular hemorrhage (IVH). This Claassen scale
awaits prospective validation. (See 'Fisher scale' above and 'Claassen CT rating scale' above.)

The Ogilvy and Carter scale (table 6) incorporates a number of features that may impact on outcome,
including age, Hunt and Hess grade (clinical condition), Fisher grade (SAH volume and vasospasm risk),
and aneurysm size. The potential subjectivity inherent in the Hunt and Hess system is mitigated by
compressing it into two grades (coma or no coma). However, it is more complex to administer than Hunt and
Hess and has been applied only to patients who have had aneurysm surgery. In a single prospective study,
patients with Ogilvy and Carter grades 2, 3, and 4 had statistically worse outcomes compared with those in
the adjacent lower grade. Interobserver variability for the Ogilvy and Carter scale is very good, reflecting
substantial observer agreement. (See 'Ogilvy and Carter grading system' above.)

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