Modified Fisher Grading Scale for Subarachnoid Hemorrhage (SAH)
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.
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.
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- Neurological and neurosurgical consultation should be obtained for patients with evidence of any SAH on imaging or lumbar puncture, whether the SAH is likely to be aneurysmal or 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.
- Consider discussing need for cerebrovascular imaging, such as CTA of the head or catheter angiography, with neurological or neurosurgical consultant before ordering.
- Similarly, consider deferring the decision to start medications that have been shown to alter outcomes in aSAH (such as nimodipine and/or aminocaproic acid) to the neurological or neurosurgical consultant.
Selection of appropriate criteria.
Facts & Figures
|Modified Fisher Grade||Risk of symptomatic vasospasm|
- The MFS is based on the findings of J. Claassen and colleagues from Columbia University Medical Center, who first showed that thick cisternal subarachnoid hemorrhage and IVH in 2 lateral ventricles were both independently associated with DCI in a retrospective multivariate analysis of 276 patients with aSAH. They proposed a scale whose grades accounted for thickness of subarachnoid hemorrhage and bilateral lateral ventricular IVH in 4 different combinations (risks for each grade not shown here). (Claassen 2001)
- Frontera et al. further modified the scale, based on data from a retrospective multi-center cohort of 1,355 patients with aSAH, by replacing bilateral ventricular IVH from Claassen et al.’s previous scale with any IVH as a predictor of symptomatic vasospasm.
- Risks of symptomatic vasospasm (Frontera 2006):
- Grade 1 (focal or diffuse, thin SAH, no IVH): 24%
- Grade 2 (focal or diffuse, thin SAH, with IVH): 33%
- Grade 3 (focal or diffuse, thick SAH, no IVH): 33%
- Grade 4 (focal or diffuse, thick, SAH, with IVH):40%
- A retrospective single-center study of 237 patients with aSAH showed a steady increase in the risk of clinical vasospasm, cerebral infarction, and poor neurological outcome with each increase in MFS grade, suggesting that it may also have prognostic value with respect to neurological outcome, in addition to predicting vasospasm. (Kramer 2008)
- This same study also determined the risks of vasospasm:
- Grade 1: 6%
- Grade 2: 15%
- Grade 3: 35%
- Grade 4: 34%
- This same study also determined the risks of vasospasm:
- A single-center retrospective study of factors associated with excellent functional outcome in 373 patients with aSAH found that lower MFS grade was not associated with excellent functional outcome in a multivariate analysis. (Pegoli 2015)
- A retrospective single-center study of 1,200 patients with aSAH showed that higher MFS grade (but not DCI) was associated with a significantly increased odds of in-hospital mortality in a multivariate analysis (OR 1.25, 95%CI 1.0-1.5). (Lantigua 2015)
Original/Primary ReferenceFrontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES, Loch Macdonald R, Mayer SA. Prediction of symptomatic vasospasm after subarachnoid haemorrhage: the modified Fisher scale. Neurosurgery. 2006; 58(7): 21-27.
ValidationKramer AH, Hehir M, Nathan B, Gress D, Dumont AS, Kassell NF, Bleck TP. A comparison of 3 radiographic scales for the prediction of delayed ischemia and prognosis following subarachnoid hemorrhage. Journal of Neurosurgery. 2008; 109:199-207.
Other ReferencesClaassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, Connolly ES, Mayer SA. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke. 2001; 32 (9): 2012-2020.Lantigua H, Ortega-Gutierrez S, Schmidt JM, Lee K, Badjatia N, Agarwal S, Claassen J, Connolly ES, Mayer SA. Subarachnoid hemorrhage: who dies, and why? Critical Care. 2015; 19 (1):1-10.Pegoli M, Mandrekar J, Rabinstein AA, Lanzino G. Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage. 2015; Journal of Neurosurgery 122: 414-418.
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