The daily educational pearl – grading SAH

This is the CT brain of a 43 yo man brought in by ambulance after he collapsed at home. GCS is 3. What does the CT show?

CT showing Subarachnoid haemorrhage.

The Neurosurgical Registrar is asking you what grade it is. And you need to speak to the family and tell them the prognosis.

There are several scales used:

Based on the clinical condition – Hunt and Hess scale:

  1. Asymptomatic, mild headache, slight nuchal rigidity
  2. Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
  3. Drowsiness / confusion, mild focal neurologic deficit
  4. Stupor, moderate-severe hemiparesis
  5. Coma, decerebrate posturing
  6. 1 & 2 have good prognosis, while 4 & 5 very poor.

Based on CT findings – Fisher scale:
1. No haemorrhage evident

2. Subarachnoid haemorrhage less than 1 mm thick

3. Subarachnoid haemorrhage more than 1 mm thick

4. Subarachnoid hemorrhage of any thickness with intra-ventricular hemorrhage (IVH) or parenchymal extension.

1 & 2 have good prognosis, while 4 & 5 very poor.

With thanks to Conway.