Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage

We propose a modification to the currently prevailing grading systems in patients with subarachnoid hemorrhage. The changes will make them correlate more strongly with the surgical results.

The relationship between preoperative clinical grades and management outcome was retrospectively investigated in a series of 304 patients with ruptured cerebral aneurysms on the anterior circle of Willis. Preoperatively, every patient was evaluated with the Hunt and Kosnik grading system, the World Federation of Neurological Surgeons Scale, and the Glasgow Coma Scale. All the patients underwent surgical treatment on the aneurysms within 72 hours of the first onset of symptoms. Hyperdynamic therapy was performed after the surgery was evaluated with the Glasgow Outcome Scale.

In the Hunt and Kosnik system, the outcome was significantly different between the patients with Grades II and III and those with Grades III and IV, but there was no significant difference among the adjacent grades except between patients with Glasgow Coma Scale scores of 13 and 14. The outcome of oriented patients was significantly better than that of confused patients. Neither eye opening nor presence of focal deficit was a significant prognostic factor.

To grade patients with subarachnoid hemorrhage objectively, three responses should be recorded separately in the Glasgow Coma Scale score. Patients with confused verbal responses should be graded lower than those who are oriented, even when they have the same total score.