Clinical classification

After the diagnosis of SAH has been established, patients are assigned a clinical grade based on one of the accepted grading systems. Grading systems for SAH have been reported since the 1930s, when Bramwell labelled patients either apoplectic or paralytic.76 Botterell and coworkers introduced a useful scale in 1956 which has undergone several modifications, including one in 1973 by Lougheed and Marshall.77,78 One of the more universally accepted grading systems is that of Hunt and Hess (1968),79 which was later modified by Hunt in 1974 (Box 8.1).80 Both Botterell and Hunt grading scales drop the patient into the next worse grade if serious systemic disease or vasospasm is present. Neither system is felt to be relevant in the face of a moribund patient with a significant intracranial haematoma.

While the Hunt and Hess grading remains the most widely used system for patient assessment, others have considered using new systems to improve predictive value. Oshiro et al. developed a grading system based on the Glasgow Coma Scale (GCS) with GCS scores of 15, 12-14, 9-11, 6-8, and 3-5 replacing the Hunt and Hess scores of 1-5, respectively.81

Box 8.1 Hunt and Hess grading system

Grade 0 Unruptured aneurysm without symptoms

Grade 1 Asymptomatic or minimal headache and slight nuchal rigidity

Grade 1a No acute meningeal or brain reaction, but with fixed neurological deficit Grade 2 Moderate to severe headache, nuchal rigidity, no neurological deficit Grade 3 Drowsy, confused, or mild focal deficit Grade 4 Stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances Grade 5 Deep coma, decerebrate rigidity, moribund appearance

These authors felt their system was at least equal to, if not better than, the Hunt and Hess system at predicting patient outcome while at the same time being more reproducible across observers.

No matter what system of grading is used, it is important to pay close attention to the name and date of the classification system used to ensure comparability of various patients or patient series reported.82

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