Subarachnoid haemorrhage

World Federation of Neurological Surgeons Grading Scale (adapted from Suarez et al.)[1]Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006 Jan 26;354(4):387-96. http://www.ncbi.nlm.nih.gov/pubmed/16436770?tool=bestpractice.com

Grade I: Glasgow Coma Scale (GCS) score 15. Motor deficit absent.

Grade II: GCS score 14-13. Motor deficit absent.

Grade III: GCS score 14-13. Motor deficit present.

Grade IV: GCS score 12-7. Motor deficit present or absent.

Grade V: GCS score 6-3. Motor deficit present or absent.

Prognosis on Admission of Aneurysmal Subarachnoid Haemorrhage (PAASH)

The PAASH grading scale has been developed based solely on the Glasgow Coma Scale (GCS) and has good discriminatory ability for patient outcome.[118]van Heuven AW, Dorhout Mees SM, Algra A, et al. Validation of a prognostic subarachnoid hemorrhage grading scale derived directly from the Glasgow Coma Scale. Stroke. 2008 Apr;39(4):1347-8. https://www.ahajournals.org/doi/10.1161/STROKEAHA.107.498345 http://www.ncbi.nlm.nih.gov/pubmed/18309166?tool=bestpractice.com [119]Takagi K, Tamura A, Nakagomi T, et al. How should a subarachnoid hemorrhage grading scale be determined? a combinatorial approach based solely on the Glasgow Coma Scale. J Neurosurg. 1999 Apr;90(4):680-7. http://www.ncbi.nlm.nih.gov/pubmed/10193613?tool=bestpractice.com

Grade I: GCS 15 (14.8% poor outcome, as defined by Glasgow outcome scale 1-3 or modified Rankin score 4-6).

Grade II: GCS 11 to 14 (41.3% poor outcome).

Grade III: GCS 8 to 10 (74.4% poor outcome).

Grade IV: GCS 4 to 7 (84.7% poor outcome).

Grade V: GCS 3 (93.9% poor outcome).

Hunt and Hess Grading Scale[120]Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968 Jan;28(1):14-20. http://www.ncbi.nlm.nih.gov/pubmed/5635959?tool=bestpractice.com

Grade I: asymptomatic or minimal headache and slight nuchal rigidity (survival 70%).

Grade II: moderate to severe headache, nuchal rigidity, and no neurological deficits other than cranial nerve palsy (survival 60%).

Grade III: drowsiness, confusion, or mild focal deficits (survival 50%).

Grade IV: stupor, moderate to severe haemiparesis, possibly early decerebrate rigidity, and vegetative disturbances (survival 20%).

Grade V: deep coma, decerebrate rigidity, and moribund appearance (survival 10%).

Modified Fisher Grading Scale[121]Frontera JA, Claassen J, Schmidt JM, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery. 2006 Jul;59(1):21-7. http://www.ncbi.nlm.nih.gov/pubmed/16823296?tool=bestpractice.com

The Modified Fisher and the Fisher grading scales predict the risk of vasospasm and delayed cerebral ischaemia in subarachnoid haemorrhage (SAH) based on the amount and type of blood on computed tomography.[121]Frontera JA, Claassen J, Schmidt JM, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery. 2006 Jul;59(1):21-7. http://www.ncbi.nlm.nih.gov/pubmed/16823296?tool=bestpractice.com [122]Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980 Jan;6(1):1-9. http://www.ncbi.nlm.nih.gov/pubmed/7354892?tool=bestpractice.com The modified version improves the original by incorporating the presence of intraventricular haemorrhage (IVH).[121]Frontera JA, Claassen J, Schmidt JM, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery. 2006 Jul;59(1):21-7. http://www.ncbi.nlm.nih.gov/pubmed/16823296?tool=bestpractice.com

Grade I: focal or diffuse thin SAH, no IVH.

Grade II: focal or diffuse thin SAH, with IVH.

Grade III: thick SAH present, no IVH.

Grade IV: thick SAH present, with IVH.

CT Fisher Scale[122]Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980 Jan;6(1):1-9. http://www.ncbi.nlm.nih.gov/pubmed/7354892?tool=bestpractice.com

Grade I: distribution of blood - none.

Grade II: distribution of blood - minimal diffuse subarachnoid blood or vertical layers <1 mm.

Grade III: distribution of blood - localised clot and/or vertical layer ≥1 mm.

Grade IV: distribution of blood - intracerebral or intraventricular clot with diffuse or no SAH.