Hunt & Hess Classification of Subarachnoid Hemorrhage

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Hunt & Hess Classification of Subarachnoid Hemorrhage

Assesses SAH severity and predict patient prognosis

All tools /

Hunt & Hess Classification of Subarachnoid Hemorrhage

Assesses SAH severity and predict patient prognosis

Clinical Presentation

Select the best matching symptoms for SAH severity

Asymptomatic or minimal headache and slight neck stiffnessModerate to severe headache, neck stiffness, no neurologic deficits except for cranial nerve palsyDrowsy with minimal neurologic deficitsStuporous, may have moderate to severe hemiparesis, could show early decerebrate rigidity and vegetative disturbancesIn a deep coma, exhibit decerebrate rigidity, and in a moribund state

Hunt & Hess Grade —

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Instructions

The Hunt and Hess Classification is used to grade the severity of subarachnoid hemorrhage (SAH) based on the patient’s clinical presentation, particularly neurological status.

Overview

When to use

Why use

Evidences

Interpretation

Grade	Clinical Presentation
I	Asymptomatic or mild headache, slight nuchal rigidity
II	Moderate to severe headache, nuchal rigidity, no neurologic deficit except cranial nerve palsy
III	Drowsiness, confusion, or mild focal neurologic deficit
IV	Stupor, moderate-to-severe hemiparesis, early decerebrate rigidity, vegetative disturbances
V	Deep coma, decerebrate posturing, moribund appearance

The Hunt & Hess (H&H) classification grades aneurysmal subarachnoid hemorrhage (aSAH) from 1 to 5 based on clinical condition at presentation to estimate prognosis; it remains widely used alongside WFNS and imaging-based (Fisher/modified Fisher) scales, and contemporary guidelines still reference it for risk stratification and communication.
https://www.ncbi.nlm.nih.gov/books/NBK441958/

H&H has been used for decades to estimate operative risk and outcomes after aSAH, with mortality rising across grades and guiding triage to neurosurgical care; radiographic scales (Fisher/modified Fisher) complement H&H by predicting vasospasm risk based on CT blood burden
https://pmc.ncbi.nlm.nih.gov/articles/PMC3621041/

Prospective and retrospective cohorts show H&H, WFNS (GCS-based), and PAASH all have broadly similar discrimination for poor outcomes, with AUROC values around 0.83–0.84 for 90‑day poor outcome in one multicenter cohort, though individual adjacent-grade separations differ among scales.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10130082/

The 2023 AHA/ASA aSAH guideline endorses using established clinical grading scales (H&H or WFNS) with imaging scales (Fisher/modified Fisher) to stratify severity, communicate risk, and inform monitoring and intervention strategies; none alone dictates management decisions.
https://www.stroke-manual.com/wp-content/uploads/2024/03/2023-AHA-ASA-SAH-guidelines.pdf

Overview

When to use

Why use

Evidences

The Hunt and Hess Classification is a well-established clinical tool used in patients with aneurysmal subarachnoid hemorrhage (SAH) to estimate severity at presentation and guide prognosis. First introduced in 1968, it has remained widely used in neurology, neurosurgery, and critical care as a practical method to stratify risk.

The scale categorizes patients into five grades based on clinical symptoms such as headache, level of alertness, neurological deficits, and signs of increased intracranial pressure. Lower grades (I–II) generally indicate a better prognosis and lower operative risk, while higher grades (IV–V) suggest severe neurological compromise and poor outcomes.

The Hunt and Hess scale helps clinicians communicate the severity of SAH, make treatment decisions, and estimate survival probabilities. For instance, patients with lower grades may be candidates for early surgical or endovascular intervention, while those with higher grades often require stabilization and supportive management before definitive treatment.

Overview

When to use

Why use

Evidences

Interpretation

Grade	Clinical Presentation
I	Asymptomatic or mild headache, slight nuchal rigidity
II	Moderate to severe headache, nuchal rigidity, no neurologic deficit except cranial nerve palsy
III	Drowsiness, confusion, or mild focal neurologic deficit
IV	Stupor, moderate-to-severe hemiparesis, early decerebrate rigidity, vegetative disturbances
V	Deep coma, decerebrate posturing, moribund appearance