# WFNS SAH — WFNS clinical grading of aneurysmal subarachnoid hemorrhage

> Bedside clinical severity grade derived from the post-resuscitation Glasgow Coma Scale and presence of a major focal neurologic deficit: 1 is GCS 15 without deficit; 2 and 3 share GCS 13-14 and are separated by absence versus presence of deficit; 4 is GCS 7-12; and 5 is GCS 3-6. It is not a CT blood-burden scale, an aneurysm-treatment selector, a futility rule or an individualized prognosis.

**Situação:** vigente · **Órgão:** Encéfalo · **Órgão emissor:** World Federation of Neurosurgical Societies · **Versão:** 1988 scale; current aSAH-care context reviewed through 2026 · **Ano:** 1988

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: Clinical
- Fonte primária: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Assign WFNS from a reliable clinical examination at a named timepoint. Preserve confounders and never turn a CT pattern or a poor clinical grade into an automatic treatment or futility decision.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| 1 | Grade 1 | Glasgow Coma Scale total 15 with no major focal neurologic deficit, assessed at a named timepoint after initial resuscitation with examination reliability documented. | Use the grade for severity communication while activating current aneurysmal-SAH care. Identify and secure a ruptured aneurysm as early as feasible, preferably within 24 hours when appropriate; do not let grade 1 replace aneurysm anatomy, hydrocephalus, rebleeding risk or multidisciplinary planning. | This is the least clinically impaired WFNS category and is associated with more favorable group outcomes than higher grades, but it is not a patient-specific survival or functional-outcome probability and does not guarantee an uncomplicated course. | Drake et al., J Neurosurg 1988;68:985-986, DOI 10.3171/jns.1988.68.6.0985, original grade table; Rosen and Macdonald, PMC3621041, Table 3, grade 1; Hoh et al. 2023 and Vergouwen et al. 2026 for current care boundaries. | ✓ |
| 2 | Grade 2 | Glasgow Coma Scale total 13-14 with no major focal neurologic deficit. The absence of the deficit is the decisive distinction from grade 3 at the same GCS range. | Treat the numeral as clinical context, not a delay or intervention rule. Apply prompt specialized aneurysmal-SAH evaluation and aneurysm securing according to current guidance while addressing hydrocephalus, seizures, cardiopulmonary instability and other patient-specific factors. | Grade 2 carries greater clinical impairment than grade 1 in the ordinal scale, but no portable per-grade mortality or disability percentage follows from the code. Timing, reversible confounders and the complete hemorrhage and patient phenotype remain essential. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 2 row showing GCS 13-14 and major focal deficit absent; current-care sources as listed above. | ✓ |
| 3 | Grade 3 | Glasgow Coma Scale total 13-14 with a major focal neurologic deficit present, such as aphasia or hemiparesis when the examination reliably establishes it. | Do not translate grade 3 into a treatment threshold. Use the same urgent aneurysmal-SAH pathway and early aneurysm-treatment evaluation, while separately reporting the focal deficit, its possible mechanism, imaging findings and any reversible examination factors. | The focal deficit separates grade 3 from grade 2 and adds clinically important context, but the grade alone cannot determine the cause, reversibility, individual prognosis or benefit of a specific intervention. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 3 row showing GCS 13-14 and major focal deficit present; current-care sources as listed above. | ✓ |
| 4 | Grade 4 | Glasgow Coma Scale total 7-12, with major focal neurologic deficit either present or absent. The deficit does not move a patient out of this GCS-defined band. | Provide aggressive resuscitation, identify reversible causes of depressed examination and evaluate early aneurysm securing in a specialized center. Grade 4 is not a futility label and does not justify the historical practice of automatically postponing aneurysm treatment. | Grade 4 is a poor clinical grade associated with worse population outcomes than grades 1-3, yet patient outcome cannot be calculated from the numeral. Sedation, intubation, hydrocephalus, seizure, hypoxia, hypotension and assessment timing can materially alter observed grade and prognosis. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 4 row; AHA/ASA 2023 DOI 10.1161/STR.0000000000000436 and ESO/EANS/ESMINT 2026 PMC13151661 for current treatment context. | ✓ |
| 5 | Grade 5 | Glasgow Coma Scale total 3-6, with major focal neurologic deficit either present or absent, after documenting resuscitation state and all factors that limit or depress the examination. | Treat immediately reversible causes, use specialized neurocritical care and assess aneurysm securing and other interventions from the full clinical picture. Grade 5 alone neither establishes neurologic futility nor mandates withdrawal, delay or a particular procedural approach. | This is the most clinically impaired WFNS band and is associated with the least favorable cohort outcomes, but selected patients recover. Do not export single-center grade-5 outcome percentages to an individual or ignore confounding and trajectory. | Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 5 row; current AHA/ASA and ESO/EANS/ESMINT guidance for nonfutile contemporary care. | ✓ |

### Citações por categoria
- **1**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al., J Neurosurg 1988;68:985-986, DOI 10.3171/jns.1988.68.6.0985, original grade table; Rosen and Macdonald, PMC3621041, Table 3, grade 1; Hoh et al. 2023 and Vergouwen et al. 2026 for current care boundaries.
- **2**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 2 row showing GCS 13-14 and major focal deficit absent; current-care sources as listed above.
- **3**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 3 row showing GCS 13-14 and major focal deficit present; current-care sources as listed above.
- **4**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 4 row; AHA/ASA 2023 DOI 10.1161/STR.0000000000000436 and ESO/EANS/ESMINT 2026 PMC13151661 for current treatment context.
- **5**: Drake CG, et al.. Report of World Federation of Neurological Surgeons Committee on a universal SAH grading scale (1988) — https://pubmed.ncbi.nlm.nih.gov/3131498/ · Drake et al. 1988, DOI 10.3171/jns.1988.68.6.0985, original grade table; PMC3621041 Table 3, grade 5 row; current AHA/ASA and ESO/EANS/ESMINT guidance for nonfutile contemporary care.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-07-24 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | dismissed |
| 2026-01-01 | revised | The joint ESO/EANS/ESMINT guideline supplied current European multidisciplinary care context without redefining the WFNS scale. | confirmed |
| 2023-05-22 | revised | The AHA/ASA aneurysmal-SAH guideline supplied current treatment-timing and neurocritical-care context; it did not change the five WFNS grade definitions or make poor grade a futility rule. | confirmed |
| 1988-06-01 | published | The WFNS committee published the five-grade GCS-plus-major-focal-deficit clinical scale for subarachnoid hemorrhage. | 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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