Management of Aneurysmal Subarachnoid Hemorrhage

Author: Michelle Lin, MD
Updated: 12/17/2010

Grading and Management of Aneurysmal Subarachnoid Hemorrhage (SAH)

  1. Control rebleeding: 4% incidence in first 24 hrs of bleed
  2. Blood pressure (BP) control:

  3. No evidence for a target BP

  4. “Triple H therapy” to treat vasospasm: Hypervolemia, hypertension, hemodilution

  5. Ventriculostomy, if hydrocephalus (occurs in 33-50% of SAH patients)
  6. Nimodipine: Vasospasm and delayed cerebral ischemia: Usually occurs 7-10 days after bleed.
  7. Definitive treatment: Microvascular aneurysm clipping or endovascular coil embolization

Grading Scales

Hunt-Hess Scale (subjective and poor inter-rater variability)

Grade Description
0 Unruptured
1 Asymptomatic, or mild H/A and slight nuchal rigidity
1a Acute meningeal/brain reaction, but with fixed neuro deficit
2 Cranial nerve palsy, moderate to severe headache, or nuchal rigidity
3 Mild focal deficit, lethargy, or confusion
4 Stupor, moderate to severe hemiparesis, or clearly decerebrate rigidity
5 Deep coma, decerebrate rigidity, moribund appearance

Increase by 1 grade for serious system disease, or severe vasospasm on arteriography

World Federation of Neurosurgical Societies (WFNS)

WFNS Grade Glasgow Coma Score Major Focal Deficit
0 (unruptured) ----- ------
1 15 Absent
2 13-14 Absent
3 13-14 Present
4 7-12 Present/absent
5 3-6 Present/absent


  • Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008 Apr;34(3):237-51. Epub 2007 Dec 26. [PubMed]