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    Attention COACH STUDY participants:

    The principal investigators of the study request that you use the official version of the modified score here.

    Modified Fisher Grading Scale for Subarachnoid Hemorrhage (SAH)

    States severity of SAH based on amount and type of blood on CT with associated vasospasm risk.

    INSTRUCTIONS

    This scale only applies to aneurysmal subarachnoid hemorrhage (aSAH).

    • Thin SAH is classified as < 1mm in depth.
    • Thick SAH is classified as ≥ 1mm in depth.

    Clinician must be able to identify subarachnoid hemorrhage (SAH) and major neuroanatomical landmarks on head CT.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with aSAH.

    • The Modified Fisher Grading Scale (MFS) helps predict the risk of clinical vasospasm and delayed cerebral ischemia (DCI) in aSAH. It improves upon the original Fisher scale by incorporating presence of intraventricular hemorrhage (IVH).
    • The MFS is entirely radiographic and typically determined at initial presentation.
    • Four basic MFS grades (1-4) map to risk of clinical vasospasm.
    • Rates of vasospasm for each MFS grade vary across studies. The MFS grade should not interpreted as an exact probability of developing vasospasm or DCI.
    • Should NOT be used as the sole data point to make decisions on medical management or goals of care.
    • Was not originally developed to predict mortality, but a recent review showed that MFS grade is associated with in-hospital mortality. (Lantigua 2015)
    • Similarly, the MFS was not originally designed to predict neurological outcome, but a retrospective analysis showed that MFS grades are associated with a higher chance of poor neurological outcome. (Kramer 2008)
    • Does NOT apply to SAH due to trauma, arteriovenous malformations, cavernous angiomas, dural arteriovenous fistulae, cortical or sinus venous thromboses, mycotic aneurysms, or septic emboli with hemorrhagic transformation.
    • Allows timely preventative treatment for vasospasm and DCI to be initiated (vasospasm typically occurs between 4 and 14 days (“vasospasm window”) after the onset of aSAH. (Fisher 1983)
    • Vasospasm is common in aSAH and often results in DCI, which occurs in up to 46% of all patients and can cause devastating neurological consequences and/or death. (Claassen 2001)
    • The MFS is widely used and well-known in the critical care and neurocritical care communities.
    No SAH present
    Focal or diffuse thin SAH
    Focal or diffuse thick SAH
    No
    Yes

    Result:

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    Next Steps
    Evidence
    Creator Insights
    Dr. Jan Claassen

    About the Creator

    Jan Claassen, MD, is Associate Professor of Neurology at Columbia University Medical College in New York. He is currently the Head of Neurocritical Care and Medical Director of the Neurological Intensive Care Unit. He has numerous publications in many journals focusing on neurointensive care, cerebrovascular diseases, encephalopathy, and coagulopathy, among other topics.

    To view Dr. Jan Claassen's publications, visit PubMed

    Are you Dr. Jan Claassen? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
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