After rupture: subarachnoid hemorrhage (SAH), grading, and outcomes
Aneurysmal SAH is a neurological emergency. Early severity grading helps predict outcomes and guide urgency, ICU intensity, and counseling.
Early mortality can be substantial, including pre-hospital deaths
Grades correlate with outcomes (Hunt‑Hess, WFNS)
Prevent secondary injury (rebleed, vasospasm, hydrocephalus)
What is Hunt‑Hess grading?
The Hunt‑Hess scale grades clinical severity on presentation (from mild headache/meningism to deep coma). It is one of several commonly used grading systems.
| Grade | Typical clinical picture (simplified) |
|---|---|
| I | Asymptomatic or mild headache; mild meningism |
| II | Moderate–severe headache; stiff neck; no major neurological deficit (may have cranial nerve palsy) |
| III | Drowsiness/confusion; mild focal deficit |
| IV | Stupor; moderate–severe hemiparesis; early decerebrate rigidity |
| V | Deep coma; decerebrate posturing; moribund appearance |
Clinicians also use WFNS grade (based on GCS and deficits) and CT blood burden scales (Fisher / modified Fisher) to estimate vasospasm risk.
Outcomes: mortality and disability
Even in modern cohorts, outcomes depend strongly on initial grade, age, and complications.
- A significant minority die before hospital arrival in population-based data.
- Among hospitalized patients, in-hospital mortality can be around the high teens in some contemporary series, but varies widely by cohort and severity mix.
- Many survivors have persistent issues: fatigue, headaches, cognitive slowing, mood changes, and focal deficits.
High-grade SAH is often survivable with aggressive critical care and early aneurysm securing, but prognosis worsens substantially as grade increases.
Example: in-hospital mortality by Hunt‑Hess grade (illustrative cohort)
One large prospective cohort reported in-hospital mortality approximately:
| Hunt‑Hess grade | In‑hospital mortality (approx.) |
|---|---|
| I–II | ~3% |
| III | ~9% |
| IV | ~24% |
| V | ~71% |
Numbers vary by era, referral patterns, and inclusion of pre-hospital deaths. See References for the underlying study.
Major early complications (why ICU matters)
| Complication | What it is | Why it matters |
|---|---|---|
| Rebleeding | Re-rupture before aneurysm is secured | Often catastrophic; drives urgency of definitive treatment |
| Vasospasm / delayed cerebral ischemia | Constricted arteries days later; reduced perfusion | Major cause of delayed stroke; monitored closely; treated with protocols |
| Hydrocephalus | CSF flow obstruction → raised intracranial pressure | May require external ventricular drain (EVD) |
| Seizures | Acute or delayed seizures | Can worsen brain injury; prophylaxis varies |
| Hyponatremia | Low sodium due to neuroendocrine effects | Can worsen confusion; managed carefully |
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