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    Hunt & Hess Classification of Subarachnoid Hemorrhage

    Classifies severity of subarachnoid hemorrhage to predict mortality.
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with aSAH.

    • The Hunt-Hess classification system was originally intended to help determine the risk of surgical mortality in patients admitted with aSAH.
    • Higher grades, which are reflective of progressively higher hemorrhage severity and neurological dysfunction, are associated with higher overall mortality.
    • The scale was originally measured at admission and is typically used this way. Because it is purely clinical, the scale can change (for better or worse) during a patient’s hospital course.
    • Each grade corresponds to a specific set of clinical examination findings from 3 areas (level of arousal, reflexes, and meningeal irritation); a patient may present with a different combination of findings than that dictated by a given Hunt-Hess grade. Clinical judgment should be used to determine the final grade in these cases. (Rosen 2005)

    Points to keep in mind:

    • The scale 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.
    • The scale is vulnerable to intra- and inter-observer variability due to the fact that it is solely based on the patient’s subjective reports and the physical examination.
    • The Hunt-Hess scale was not originally conceived to predict morbidity or degree of disability from SAH.

    This scale should NOT be used as the only clinical decision making tool in a patient with aSAH.

    This scale assumes you have a grasp of the neurological clinical examination, such as the assessment of level of consciousness, cranial nerves, and motor examination.

    • The mean case-fatality rate of aSAH is 39% (Nieuwkamp 2009) and the Hunt–Hess classification can help predict mortality in such patients.
    • The Hunt-Hess scale is widely known in the neurocritical care community.
    • The only thing needed for determining Hunt-Hess grade is the clinical examination; radiographic imaging is not necessary.
    Mild Headache, Alert and Oriented, Minimal (if any) Nuchal Rigidity
    +1
    Full Nuchal Rigidity, Moderate-Severe Headache, Alert and Oriented, No Neuro Deficit (Besides CN Palsy)
    +2
    Lethargy or Confusion, Mild Focal Neurological Deficits
    +3
    Stuporous, More Severe Focal Deficit
    +4
    Comatose, showing signs of severe neurological impairment (ex: posturing)
    +5

    Result:

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    Next Steps
    Evidence
    Creator Insights
    Dr. William E. Hunt

    About the Creator

    William E. Hunt, MD (d. 1999) retired in 1991 as a professor emeritus of surgery after 37 years at Ohio State College of Medicine. He received a Lifetime Achievement Award and Gold Medal from the Neurological Society of America. While best known for the Hunt-Hess classification, he also defined the Tolosa-Hunt syndrome of ophthalmoplegia, a painful paralysis of the eye muscles.

    To view Dr. William E. Hunt's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. William E. Hunt
    Content Contributors