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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.

    Fisher Grading Scale for Subarachnoid Hemorrhage (SAH)

    Rates risk of vasospasm in aSAH based on amount and distribution of blood on CT.
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    INSTRUCTIONS

    This scale only applies to aneurysmal subarachnoid hemorrhage (aSAH). We recommend using the Modified Fisher Grading Scale based on more recent studies.

    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 Fisher Grading Scale was originally designed to predict risk of cerebral arterial vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH) based on radiographic distribution of subarachnoid hemorrhage.
    • The Fisher scale is entirely radiographic and typically determined at presentation.
    • Variable rates of vasospasm corresponding to each Fisher grade have been reported in studies; therefore, the scale should not be used to quote an exact probability of vasospasm or delayed cerebral ischemia (DCI).
    • The Fisher scale should also NOT be used as the sole clinical data point to make decisions on medical management or goals of care.

    Points to Keep in Mind:

    • The Fisher scale has a number of shortcomings:
      • It does not consider the effect of thick cisternal subarachnoid blood or intraventricular hemorrhage (IVH), which are both known risk factors for vasospasm (Claassen et al 2001, Wilson et al 2012). For this reason, the Modified Fisher Grading Scale is often preferred by many neurocritical care providers.
      • Higher Fisher scale grades do not necessarily correlate with increasing probability of vasospasm. Studies show little to no difference between grades 1 and 2 (Claassen 2001), and that grade 4 is associated with a lower rate of clinical vasospasm than grade 3 (Fisher 1980 & 1983, Smith 2005, Frontera 2006, Kramer 2008).
      • The original Fisher scale was developed based on measurements on paper printouts from a low-resolution EMI CT scanner, which was not reflective of true SAH thickness. In reality, most SAH is >1 mm thick, so Grades 1 and 2 are rare. (Rosen 2005)
    • 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.
    • Angiographic vasospasm occurs in at least 50% of patients with aSAH and often results in DCI, which occurs in up to 46% of all patients with aSAH and can cause devastating neurological consequences and/or death (Claassen 2001).
    • Because vasospasm typically occurs between 4 and 14 days (“vasospasm window”) after the onset of aSAH, the Fisher scale may allow timely preventative treatment for vasospasm and DCI to be initiated (Fisher 1983).
    • Despite its well-documented shortcomings, the Fisher grading scale remains widely used and well-known in critical care and neurocritical care communities.
    No SAH detected
    Diffuse or vertical layer of subarachnoid blood < 1mm thick
    Localized clot and/or vertical layer within the subarachnoid space > 1mm thick
    Intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) with diffuse or no SAH

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • Immediate neurological and neurosurgical consultation should be obtained for patients with evidence of any SAH on imaging or lumbar puncture, even if the SAH is likely to be non-aneurysmal in nature.
    • Computed tomographic angiography (CTA) of the head is helpful to determine the presence of a lesion suitable for surgical or endovascular intervention.
    • The need for obtaining cerebrovascular imaging, such as CTA of the head or catheter angiography, should be discussed with a neurological or neurosurgical consultant first.
    • Similarly, the decision to start medications that have been shown to alter outcomes in aSAH (such as nimodipine and/or aminocaproic acid) should be deferred to the neurological or neurosurgical consultant.
    Content Contributors
    About the Creator
    Dr. C. Miller Fisher
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