# Hunt-Hess — Hunt and Hess clinical grading of aneurysmal subarachnoid hemorrhage

> Time-stamped bedside clinical grade for the presenting condition after aneurysmal subarachnoid hemorrhage. It is not derived from CT blood burden, is vulnerable to examination confounding and supplies communication/prognostic context rather than a grade-only treatment algorithm.

**Situação:** vigente · **Órgão:** Encéfalo · **Órgão emissor:** Hunt and Hess / neurosurgical practice · **Versão:** 1968 five-grade scale; 2023 AHA/ASA care context · **Ano:** 1968

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: Clinical
- Fonte primária: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Grade a real, time-stamped clinical examination only. Keep CT blood burden separate, expose confounders and uncertainty, and never translate a poor Hunt-Hess grade into autonomous treatment limitation or futility.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | At a documented clinical assessment time after aneurysmal subarachnoid hemorrhage, the patient is asymptomatic or has only mild headache and at most slight nuchal rigidity, remains alert, and has no focal neurologic deficit. This is a bedside clinical grade and cannot be inferred from a small CT blood burden. | Treat confirmed aneurysmal SAH as a neurovascular emergency even at grade 1 and follow current aneurysm-securing, rebleeding-prevention and neurocritical pathways. The grade communicates clinical state but does not choose clipping versus coiling, blood-pressure targets, nimodipine, monitoring intensity or disposition by itself. | Grade 1 is the least impaired canonical clinical category, but it does not mean benign disease. In one 1,200-patient single-center spontaneous-SAH cohort from 1996-2009, in-hospital mortality was 3 percent for grades 1 and 2 combined; that historical combined figure is not an individual estimate or a grade-1-specific current rate. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade I clinical definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, current aSAH care context; Lantigua et al. 2015, PMC4556224, Abstract and Table 2 for combined grade 1-2 cohort mortality. | ✓ |
| 2 | Grade 2 | The patient is alert with moderate-to-severe headache and nuchal rigidity and has no neurologic deficit other than a possible cranial-nerve palsy. Drowsiness/confusion moves the state toward grade 3; a non-cranial focal deficit conflicts with canonical grade 2 and should be exposed rather than hidden. | Grade 2 still requires the full emergency aneurysmal-SAH pathway and definitive aneurysm assessment/management. Use the time-stamped examination with aneurysm, hydrocephalus, rebleeding, CT blood burden and systemic data; do not convert grade 2 into a treatment shortcut. | Population prognosis is generally more favorable than in poor-grade SAH, but grade 2 is not low risk in isolation. The cited 1,200-patient cohort reported 3 percent in-hospital mortality for grades 1-2 combined, not separately, and cannot provide a contemporary personal forecast. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade II definition including possible cranial-nerve palsy; Hoh et al. 2023 AHA/ASA guideline; Lantigua et al. 2015, PMC4556224, cohort methods/results. | ✓ |
| 3 | Grade 3 | The time-stamped examination shows drowsiness or confusion and/or a mild focal neurologic deficit. Document consciousness, orientation, motor findings, Glasgow Coma Scale and any sedation, seizure, hydrocephalus, hypoxia or other confounder instead of recording only the numeral. | Urgently evaluate and treat the aneurysmal SAH and reversible contributors to deterioration, including hydrocephalus, rebleeding, seizure and physiologic disturbance, under current neurovascular/neurocritical guidance. Hunt-Hess 3 alone does not specify an aneurysm procedure or forecast response. | Grade 3 indicates an impaired clinical state and is associated with worse population outcomes than grades 1-2. The historical single-center cohort reported 9 percent in-hospital mortality for grade 3, but age, GCS, CT burden, aneurysm factors, complications and care decisions materially affect outcome, so the number must not be individualized. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade III definition; Lantigua et al. 2015, PMC4556224, Abstract, Methods and multivariable mortality findings; Hoh et al. 2023 AHA/ASA guideline for current management. | ✓ |
| 4 | Grade 4 | The patient is stuporous with moderate-to-severe hemiparesis and may have early decerebrate rigidity and vegetative disturbance. Distinguish stupor from deep coma and record whether sedation, intubation, paralysis or another reversible factor prevents a valid examination. | Grade 4 is poor-grade SAH requiring immediate specialist neurovascular and neurocritical evaluation, investigation of reversible causes and patient-specific aneurysm treatment planning. It is not a futility category and must not independently trigger non-intervention or withdrawal of life support. | Severe neurologic impairment carries substantial population risk. A 1996-2009 single-center spontaneous-SAH cohort reported 24 percent in-hospital mortality for grade 4, but this is a cohort-specific historical association affected by subsequent complications and treatment-limitation decisions, not an individual probability. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade IV definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, patient-centric current care; Lantigua et al. 2015, PMC4556224, mortality and mode-of-death analyses. | ✓ |
| 5 | Grade 5 | The patient is in deep coma with decerebrate rigidity and appears moribund or has failing vital centers on the contemporaneous examination. Assign only from a reliable clinical state; if sedatives, neuromuscular blockade, intubation or postictal suppression obscure the examination, return confounded rather than assuming grade 5. | Grade 5 demands immediate expert evaluation, resuscitation and assessment of reversible factors and aneurysm-treatment options under current guidance. The category alone cannot establish irreversibility, deny intervention, determine goals of care or justify withdrawal of life-sustaining treatment. | Grade 5 is the most impaired canonical clinical state and has the worst population prognosis, yet survivors exist and the grade is not deterministic. The cited historical cohort reported 71 percent in-hospital mortality, with many deaths involving brain death or withdrawal decisions; use this only as cohort context, never a personal probability or futility threshold. | Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade V definition; Hoh et al. 2023 AHA/ASA guideline for current care; Lantigua et al. 2015, PMC4556224, grade-specific mortality and mode-of-death results. | ✓ |

### Citações por categoria
- **1**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade I clinical definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, current aSAH care context; Lantigua et al. 2015, PMC4556224, Abstract and Table 2 for combined grade 1-2 cohort mortality.
- **2**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade II definition including possible cranial-nerve palsy; Hoh et al. 2023 AHA/ASA guideline; Lantigua et al. 2015, PMC4556224, cohort methods/results.
- **3**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade III definition; Lantigua et al. 2015, PMC4556224, Abstract, Methods and multivariable mortality findings; Hoh et al. 2023 AHA/ASA guideline for current management.
- **4**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade IV definition; Hoh et al. 2023, DOI 10.1161/STR.0000000000000436, patient-centric current care; Lantigua et al. 2015, PMC4556224, mortality and mode-of-death analyses.
- **5**: Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms (1968) — https://doi.org/10.3171/jns.1968.28.1.0014 · Hunt and Hess 1968, DOI 10.3171/jns.1968.28.1.0014, grade V definition; Hoh et al. 2023 AHA/ASA guideline for current care; Lantigua et al. 2015, PMC4556224, grade-specific mortality and mode-of-death results.

## Referências cruzadas
- _fronteira compartilhada_ → [Modified Fisher — Modified Fisher CT scale for aneurysmal subarachnoid hemorrhage](https://radcommons.laudos.ai/systems/modified-fisher.md) — Both grade aneurysmal subarachnoid hemorrhage: Hunt and Hess by clinical state, modified Fisher by CT blood burden.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 1968-01-01 | published | Hunt and Hess published the five-grade clinical condition scale for patients with ruptured intracranial aneurysms. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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