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Grading scales used in the management of aneurysmal subarachnoid hemorrhage: a critical review.

Abstract: The use of grading scales to predict clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is commonplace. In recent times management of aSAH patients has developed such that surgical intervention is taking place earlier in the course of the illness. Given the complex and multifactoral clinical picture of these patients, there is an increased impetus to examine and reevaluate the relative merits and predictive characteristics of grading scales. The measurement characteristics and predictive power of the following instruments were reviewed: Fisher Scale (FS), Glasgow Coma Scale (GCS), Glasgow Outcome Score (GOS), Hunt and Hess (HH) Scale, Karnovsky Performance Scale (KPS), and the World Federation of Neurological Surgeons (WFNS) Scale. No uniformly conclusive findings were found when the HH Scale, GCS, and WFNS Scale were used to predict clinical outcomes. No instrument consistently outperformed any other across age or severity. Contradictory findings were reported. Difficulties were encountered in comparing instruments because of administration, scoring schemes, timing of assessments, and psychometric properties, such as interrater reliability. Reports on newly developed instruments often lacked the replication data necessary to effectively compare measures currently in use. The timing of measurements and the use of serial measures emerged as important factors in the prediction of clinical outcomes. Assessments taken close to the time of surgical intervention were found to have superior predictive abilities.


Most prevalent in the 40- to 60-year age range, aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. Risk increases with age (King, 1997). Incidence for women is generally higher than that in men and higher in African American individuals (Davis, 1994; Ingall & Wiebers, 1993). Grading scales have been used to predict clinical outcomes of patients. These scales include the Fisher Scale (FS), Glasgow Coma Scale (GCS), Glasgow Outcome Score (GOS), Hunt and Hess (HH) Scale, and the Karnovsky Performance Scale (KPS). Historically, these scales were used when the surgical management of aneurysms was performed later in the illness trajectory, usually after complications from vasospasm or rebleeding were thought to have passed (Chiang, Claus, & Awad, 2000). Treatment today, however, is likely to occur much earlier in the course of illness. Given this change, it is timely to review the measurement tools frequently used to predict clinical outcomes. Reliable and accurate methods to determine which groups of patients would benefit from the most invasive, technically demanding, and challenging procedures are needed.

Numerous studies have identified potential prognostic factors following aSAH surgery (Ogilvy & Carter, 1998). One of the most widely used prognostic indicators is the patient's presenting clinical condition. This has led to the development of several clinical classification systems, with more than 30 being recorded (Oshiro, Walter, Piantadosi, Witham, & Tamargo, 1997). Clinical presentation following aSAH is not the sole determinant of clinical outcome; comorbidities such as age, gender, chronic diseases, smoking, and alcohol and drug abuse must be considered that are not included in some of the assessment measures (Lang & Galbraith, 1993; Rinne, Hernesniemi, Niskanen, & Vapalahti, 1995; Thomeer, Taal, Voormolen, & Wintzen, 1994; Zentner, Hoffmann, & Schramm, 1996). Additional clinical factors include the location of blood collection in the brain, characteristics of the aneurysm (e.g., size, shape, location), presence of enlarged ventricles, or evidence of vasospasm. With the exception of enlarged ventricles on computed tomography (CT) scan, aneurysm characteristics were not found to be a statistically significant factor in predicting outcome. Postsurgical factors such as hydrocephalus, duration of intubation, and use of a tracheostomy also have been studied. These factors were not statistically significant, although age, cardiac history, and alcohol and drug abuse were found to be important factors in determining clinical outcomes (Chiang et al., 2000). Some researchers have reported that age is a risk factor for aSAH that can show an effect at age 50 years (Sibayan, 1998), whereas others report older ages (Gotoh et al., 1996). Given this complex and multifactoral clinical picture, there is an increased impetus to examine and reevaluate the relative merits and predictive characteristics of scales.

Scales in Use

The HH Scale, FS, GCS, GOS, KPS, and World Federation of Neurological Surgeons (WFNS) Scale are grading systems that have been used to predict outcomes following aSAH. Researchers have found that only 19% of reported studies used clearly described grading scales (van Gijn, Bromberg, Lindsay, Hasan, & Vermeulen, 1994).

An ideal scale has the following characteristics: (a) clear objective criteria for when to use the scale, (b) delineation of each progressive scale, (c) inter- and intrarater reliability, and (d) strong predictive value for outcomes (Oshiro et al., 1997). Other considerations include ease of application in the acute phases of a disease process and sensitivity to differences in outcome even in relatively small study populations (Takagi et al., 1999).

Hunt and Hess Scale

The HH Scale (Hunt & Hess, 1968) was originally developed to predict mortality after aSAH surgery but is currently used as a clinical grading tool for assessing subarachnoid hemorrhage. It is the most commonly used aSAH grading scale (Ogilvy & Carter, 1998), with a 71% utilization rate by neurosurgeons (Oshiro et al., 1997). It comprises a series of grades corresponding to neurological deficits, ranging from none to moribund, with consciousness and focal defects assessed (Table 1). Ogilvy and Carter have reported interrater reliability for the HH Scale ([kappa] = 1.00) in a sample of 100 patients. Kappa values provide a measure of scale agreement, in this case, between different raters. Kappa values range from 1 (complete agreement) to 0 (no agreement).

The HH Scale has two advantages in measurement terms: it is relatively easy to administer and it is widely used in the neuroscience community, leading to ease of comparison between studies. However, there are problems with the scale. It derives a score only from the clinical neurological condition without consideration of comorbidities or other individual differences, and unruptured aneurysms scoring can be ambiguous. The scale was originally scored I-V; however, a zero score was added for unruptured aneurysms. This zero score does not, however, distinguish between symptomatic and asymptomatic patients. Problems with the discriminatory power of HH as a predictor of clinical outcomes exist. Studies have found no difference in clinical outcomes between HH grades 0 and III (Ogilvy & Carter, 1998). To overcome this, researchers have chosen to dichotomize their scores into 0-III and IV-V, with improved predictive performance.

Terms on the tool also are difficult to define. The clinical identification definition of "stupor" and "drowsiness" remains problematic (Hirai, Ono, & Yamaura, 1996). As a result of some of these shortcomings, changes to the original HH Scale have been suggested. If a patient has severe systemic disease (e.g., chronic obstructive pulmonary disease [COPD], diabetes), the grade is increased to the next worse level. With this modification, the HH Scale was found to be a good predictor of mortality and length of hospital stay (Oshiro et al., 1997).

When to use the HH Scale (and others) for patient assessment remains a contentious issue, although less so with early aneurysm surgery. Grades determined on the day of surgery have been shown to be more prognostic than the values determined at admission or immediately after hospitalization (Aulmann, Steudl, & Feldmann, 1998). Fabregas et al. (1998) studied 62 aSAH patients using HH scores preoperatively, intraoperatively, and postoperatively. They found that level of immediate postoperative consciousness was an accurate indicator of clinical outcome at discharge and at 6 months after discharge.

A number of recent studies have shown the predictive ability of the HH Scale. Aulmann et al. (1998) prospectively studied 185 patients who experienced ruptured cerebral aneurysm to compare the predictive ability of the HH Scale, GCS, and WFNS Scale. Scores were determined immediately postoperatively and after hospitalization; the GOS was the long-term clinical outcome measure. The sensitivities and predictive values of the three scales were poor; however, the HH Scale had the best correlation with clinical outcomes (Aulmann et al.). The effect of age and level of consciousness (LOC) on the outcomes of 74 patients with a ruptured cerebral aneurysm following aSAH has been studied (Deruty, Pelissou-Guyotat, Mottolese, Amat, & Bognar, 1995). Patients were divided into three groups based on their admission LOC and HH Scale scores: HH I-II (Group 1: alert), HH III-IV (Group 2: drowsy), and HH V (Group 3: comatose). Surgery occurred between day 1 and 7 following admission, with 51% of patients having surgery by day 3. Age was dichotomized into younger than 50 years or 50 years and older. Outcomes were statistically related to LOC, with age being less clear as a predictor of clinical outcome. The overall outcome was "good" (alert) for 71% of Group 1 patients, 14% of Group 2 (drowsy) patients, and 0% of Group 3 (comatose) patients postoperatively.

Morbidity and mortality after ruptured aneurysm surgery were investigated by using the HH Scale to assess preoperative status and outcomes measured with the GOS (Proust, Hannequin, Langlois, Freger, & Creissard, 1995). In this study of 230 surgical patients, a GOS I-II (excellent or good) was obtained in 77% of the patients, whereas 7% were disabled (GOS III) and 16% were vegetative or dead. These findings add support to the predictive ability of the HH Scale. Statistically different outcomes in patients with HH scores between II and III and between III and IV have been reported (Hirai et al., 1996). In a study of 60 HH grade V patients, 49 patients died shortly after hemorrhage; of the remaining 11, 1 made a good recovery, 1 was moderately disabled, 8 were severely disabled, and 1 was in a vegetative state (Komiyama et al., 1990). Good outcomes have been reported in aSAH patients with HH I-III scores. Worse outcomes were likely with advanced age (>70 years), cerebral atherosclerosis, HH scores of IV-V, and symptomatic vasospasm (Yoshikai et al., 1996).

The Fisher Scale

The FS (Fisher, Kistler, & Davis, 1980) was originally developed to quantify the relationship of cerebral vasospasm to subarachnoid hemorrhage. Following aSAH, the scale is used to estimate the density of subarachnoid blood shown by CT scanning (Table 2). A Fisher score is usually obtained at the time of admission. Interrater reliability data has been reported for the FS ([kappa] = .9) on a sample of 48 patients (Ogilvy & Carter, 1998). Higher FS scores on admission have been found to be associated with poorer clinical outcome using the GOS at 1 year follow-up (Ogilvy & Carter). Attempts to enhance the predictability of the HH Scale have been made including admission FS scores. Saveland et al. (1986) used a combination of the HH grade and amount of blood visualized on CT scan to assess prognosis. The FS score was used in a study of 65 consecutive patients who had undergone aneurysm surgery (Lin, Kwan, & Howng, 1998). The addition of the FS score enhanced the predictive power of the HH Scale in determining clinical outcomes. FS scores of 1-2 did not increase mortality risks in aSAH patients, but scores of 34 were found to significantly increase the likelihood of poor outcomes (Ogilvy & Carter).

Glasgow Coma Scale

The GCS (Teasdale & Jennett, 1974) is probably the best-known scale in the neuroscience repertoire. It is well-known, well-understood, and simple to administer and score (Table 3). The scale was developed as a reliable and simple bedside instrument for assessing the patient's level of consciousness following traumatic brain injury in adults (Groswasser, Schab, & Salazar, 1997). Interrater reliability of GCS has been reported as statistically significant (Heron, Davis, Gillies, & Courtney; 2001; Menegazzi, Davis, Sucov, & Paris, 1993). GCS also is reported to be an important tool in assessing the patient's level of consciousness following aSAH (Gotoh et al., 1996). The interrater reliability of GCS has been reported as statistically significant when used in the aSAH population ([kappa] = .46; Oshiro et al., 1997).

Modifications to the GCS scoring system have been suggested based on preoperative clinical scores and outcomes for aSAH patients. When the GCS is used with head-injured patients, eye scores are a measure of arousal. Patients with aSAH experience headaches and meningeal irritation that can affect eye opening; a patient may be alert but hold eyes closed to avoid light or pain. Hirai et al. (1996) recommends that patients with confused verbal responses should be graded lower than those who are oriented when they have the same total score, because of eye-opening ability.

A simplified grading system based on the GCS that compressed the 15-point GCS into five grades has been reported by Oshiro et al. (1997). These researchers used the following scheme:

* Deep coma, decerebrate rigidy, moribund (GCS = 3-6) recoded as V

* Stupor, moderate to severe hemiparesis, early decerebrate rigidity (GCS = 6-8) recoded as IV

* Lethargy, confusion, mild focal deficit (GCS = 9-11) recoded as III

* Moderate/severe headache, nuchal rigidity, cranial nerve palsy (GCS = 12-14) recoded as II

* Asymptomatic or mild headache (GCS = 15) recoded as I

* Unruptured aneurysm was scored as 0.

With this system the GCS grades were the best predictor of discharge status when compared with the HH and WFNS scales. Interrater reliability for this 5-point GCS was reported as statistically significant ([kappa] = .63).

A psychometric concern with the GCS is the meaning of the scores. With a maximum score of 15, there are many possible combinations of different scores (e.g., between 13 and 14,14 and 15) that could be used to predict outcomes. In practical terms it is possible for patients to have identical scores but present with different clinical findings. This has led to the discussion of GCS "break points," that is, positions in the scale at which two adjacent scores can be predictive of statistically significant differences in outcomes. The GCS predicted clinical outcome differences between scores of 13 and 14 and 7 and 8 (Hirai et al., 1996) and scores between 15 and 14, 11 and 10, and 7 and 6 (Gotoh et al., 1996). Teasdale (1996), however, does not believe in break points but recognizes a relationship between level of consciousness and outcomes following surgical repair of ruptured intracranial aneurysms. In addition, outcome differences between GCS scores are probably due to a greater number of patients in the 15 and 14 grades, providing more reliable statistics. The GCS, while not originally developed for the aSAH patient, is being used as a reliable indicator of discharge status in these patients. Predictive power is not uniform across all possible GCS scores, and care is required when interpreting scores in the aSAH population.

World Federation of Neurological Surgeons Scale

The majority of studies on aSAH used either the HH Scale or the WFNS Scale. To avoid some of the observer variability in the HH Scale, the WFNS (World Federation of Neurological Surgeons) devised an aSAH grading scale based upon the GCS. Essentially, the WFNS Scale adds a "correction" for motor deficits to the GCS (Table 4). Oshiro et al. (1997) reports interrater reliability on a prospective sample of patients for the WFNS Scale as statistically significant ([kappa] = .27) and for the GCS ([kappa] = .46).

Clinical evaluation of more than 1,300 patients using the WFNS Scale suggested that the instrument was a good predictor of outcomes. Patients scoring a grade I immediately prior to surgery showed an 87.1% recovery, while those with a grade IV or V had poorer results (Sano, 1994). In a study of 137 patients with aSAH, poorer outcomes were associated with an older age, lower WFNS Scale grades on admission, and a FS score of four (Shimoda, Oda, Tsugane, & Sato, 1997). Statistically significant outcome differences were found in surgical patients graded I-II (Hirai et al., 1996).

Not all studies identified the predictive abilities of the WFNS Scale. In a study of 294 patients assessed using the GOS at 1 month after discharge, age, LOC, and hypodensity on brain CT were statistically related variables (Lagares et al., 2001). However, no differentiation in outcomes was found between all the WFNS Scale grades. This finding suggests that either more work is needed to develop the instrument or standardization is required in how it is used and how results are reported.

New Scoring Systems

Attempts have been made to modify or change current grading systems to create entirely new scoring systems and enhance outcome prediction and guide interventions. A grading system has been proposed that is based not only on current classification systems but also on other factors closely associated with outcome (Ogilvy & Carter, 1998). This grading system assigns one point each for an HH IV-V score, FS Score of 3 or 4, aneurysm size >10 mm, age more than 50 years, and whether the aneurysm is giant (>25 mm) and in the posterior circulation. In a prospective assessment of the grading system, the correlation of individual grades and long-term outcome (mean 3.2 years using GOS) was strong. A scoring system calculated on the basis of the distribution of blood seen on a CT scan (FS) and the patients' neurological status (HH grade) on admission has been developed (Gerber, Lang, Neil-Dwyer, & Smith, 1993). The FS score and HH grade were summed to give an overall score. Patients were then assigned to risk groups: low risk (scores 1-3), medium risk (score 4), and high risk (scores 5 and greater). The scoring system was prospectively applied to patients and a strong correlation (p = .000) between the patients' scores and their outcomes at 3 months was reported.

Japanese researchers have been active in developing new grading scales. Takagi et al. (1998) reported the development of the Japan Coma Scale (JCS), a combined scale based on the GCS and the GOS. They developed "break points" at which scale scores would correlate to clinical outcomes using a retrospective analysis of 1,389 consecutive patients with aSAH. The GCS scores were assessed just before surgery and GOS were evaluated 6 months after aSAH. They found the GCS was superior to the JCS for assessing level of consciousness (Takagi et al.).

A classification system based on the presence or absence of vomiting and the duration of unconsciousness also has been developed (Sato, Masuzawa, Shiraishi, Kanazawa, & Kamitani, 1986). Patients were graded as follows: Grade I, headache without vomiting; Grade II, headache, vomiting and/or loss of consciousness lasting less than 1 hour; Grade III, loss of consciousness for over 1 hour; Grade IV, permanent unconsciousness or cerebral herniation signs. In 142 patients the correlation between clinical severity and outcome was statistically significant, but the correlation between clinical severity and the HH grade was not (Sato et al.).

Outcome Scores

Kamofsky Performance Scale

The KPS was originally developed to rate patients' overall functioning in the palliative treatment of cancer using nitrogen mustard (Karnofsky, Abelmann, Craver, & Burchenal, 1948). It is scored from 0 to 100 in units of 10 (Table 5). The KPS is used in patients with chronic conditions and has been used in studies of aSAH patients as a predictor of postsurgical outcome. Chiang et al. (2000) examined the timing of assessments in aSAH patients in relation to predicting clinical outcomes. Patients with mental status changes after aSAH were graded at admission and before and after treatment using the GCS, WFNS, and HH scale. Outcomes at 6 months after treatment were assessed by using the KPS and GOS. These scores were correlated to the worst pretreatment HH score. Also, GCS and WFNS scores were correlated with KPS and GOS scores at all assessment periods. This study has implications for the timing and choice of grading scales used in the postoperative assessment of aSAH patients. First, postoperative outcomes were best predicted before treatment using any of these scales provided assessment was undertaken at the patients' worst clinical condition. Last, KPS can be used in the postoperative assessment of aSAH patients.

Babu, Sekhar, & Wright (1994) studied outcomes using KPS in a sample of 22 patients with complex vascular lesions. Of those who survived surgery, the mean preoperative and postoperative KPS scores were 81 and 93, respectively. Of the four who died, the mean KPS scores were 73 preoperatively and 63 postoperatively. The decrease in scores following surgery may indicate KPS can predict outcomes. However, generalizing findings warrants caution given the small sample size. In another study of 273 aSAH patients followed up between 3 and 48 months, the GOS and KPS scores were used to assess outcomes (Barth, Nabavi, Stein, Behnke, & Mehdorn, 1996). The KPS was used to investigate long-term outcomes of 41 patients with aSAH (Oder et al., 1991). They found that almost 50% of patients had returned to their previous level of work. Unfavorable outcomes were found to be related to hypertension, focal neurological defects, and an HH score >2. Gender, age, headaches, or cognitive deficits were not related to functional levels. The KPS has been shown to be an instrument that can be used to follow the progress of aSAH patients. However, there is a dearth of psychometric information available, and few researchers are using this scale as the primary determinant of patient outcomes.

Glasgow Outcome Scale

The GOS was developed to assess outcomes following head injury (Jennett & Bond, 1975; Table 6). Interrater reliability of structured interviews using the GOS gave weighted kappa values of .89 (Wilson, Pettigrew, & Teasdale, 1998). Rodholm, Starmark, Svensson, and von Essen (2001) reviewed aSAH patients (N = 78) after 1-6 months. They reported interrater reliability of 67% ([kappa] = .52). Anderson, Housley, Jones, Slattery, and Miller (1993) reported that interrater reliability varied in the assessment of head injury with the degree of training and methods of data collection employed. GOS also has been recommended in the assessment of outcomes following aSAH (Oshiro et al., 1997).

Strong associations exist between the GOS and neuropsychological testing and general assessment of health (Teasdale, Pettigrew, Wilson, Murray, and Jennett, 1998; Wilson, Pettigrew & Teasdale, 2000; Woischneck & Firsching, 1998). Correlations also exist between GOS scores and cognitive testing for the first 3 months after a closed head injury (Brooks, Hosie, Bond, Jennett, & Aughton, 1986; Clifton et al., 1993). Problems with the discriminatory power of GOS have been reported in head-injured patients with GOS IV at 6 months follow-up (Satz et al., 1998). This finding may have implications for the reliability of the GOS when it is used in the aSAH population. The assessment format promotes personal impressions entering into the grading (Pettigrew, Wilson, & Teasdale, 1998). This problem can be partly overcome by using a standard interview format. Others report adopting a standard format with a written protocol (Wilson et al., 1998). Modifications to GOS include the Edinburgh Extended Glasgow Outcome Scale (EEGOS), an 8-point scale devised to add further functional, behavioral, cognitive, and physical parameters (Hellawell & Signorini, 1997; Levin et al., 2001). Favorable reliability has been reported for the EEGOS (Wilson et al., 1998).


The use of grading scales to predict clinical outcomes following aSAH surgery is an accepted practice. A number of instruments have been used to guide interventions, patient and family communication, and education. It is evident, however, that no instrument fully meets suggested criteria for an "ideal" instrument (Oshiro et al., 1997; Takagi et al., 1999).

Additional psychometric analysis of these scales is warranted if reliability estimates are to be improved, especially when researchers are continuing to develop new scales based on existing ones. The HH Scale, the most commonly used instrument, has the advantage of simplicity of administration, and because of its widespread use, meaningful comparisons between studies are possible for all instruments. There is some difficulty either in translating physical assessment findings into scores or in managing "floor and ceiling" effects, that is, interpreting and scoring patient assessment findings that are at the extremes of scale ranges. Some of these issues can be effectively managed by using formal training and establishing interrater reliability assessment.

Research reports have documented a wide variety of performance issues for the instruments discussed in this paper. Findings among the HH Scale, GCS, and WFNS Scale are not uniform; no instrument consistently outperforms any other in terms of predicting clinical outcomes. Contradictory findings are reported, raising issues about instrument administration, scoring schemes, and the timing of assessments. Several studies highlighted the need to use a series of measures and reported that assessments taken close to the time of surgical intervention had superior predictive abilities (Aulmann et al., 1998). For example, for a series of measures using the HH Scale, the worst pretreatment scores were correlated with clinical outcomes (Chiang et al., 2000).

Several instruments used with the aSAH population (e.g., GCS, KPS) were not developed specifically for this group. Research studies suggested these instruments can make a useful contribution to the assessment and monitoring of aSAH patients. New instruments or modifications to existing ones are being developed. Unfortunately, these tools are often used only by a single research team or center and have not been subjected to replication or repeated psychometric analysis. This is especially important in determining when it is best to use the instrument. It is clear from the literature that the timing of clinical data collection in this population is an important factor in determining the predictive power of an instrument. The reporting of when instruments were used and psychometric characteristics such as inter- and intrarater reliability were not consistent in the literature.


Neuroscience nurses, along with their neurosurgical colleagues, have relied on classification scales as predictive of potential clinical outcomes. Although these classification scales have been used to evaluate effectiveness of medical care, nursing has not utilized these scales to evaluate nursing interventions in this patient population. The literature is almost devoid of data on the effect of nurse-sensitive interventions in the acute stage of aSAH management. Effective scales may prove useful in evaluating new interventions or changes in nursing practice. These scales must be used with a knowledge of their shortcomings and performance. The neuroscience literature is continually evaluating cutting-edge technology and patient care management strategies. For nurses to evaluate the efficacy and the soundness of the research presented, knowledge of the common scales and their characteristics is essential. These scales also provide nurses with information about potential outcomes to facilitate family awareness of the expected course of illness. Giving accurate and clear information to patients and relatives and setting reasonable expectations are central to a nursing role in a high-technology environment.
Table 1. Hunt and Hess Grading Scheme *

Grade Clinical Condition

 0 Unruptured

 I Asymptomatic or minimal headache, nuchal

 II Moderate to severe headache, nuchal rigidity, no
 neurological deficit other than cranial nerve

 III Drowsiness, confusion, mild focal deficit

 IV Stupor, moderate to severe hemiparesis, possible
 early decerebrate rigidity and vegetative

 V Deep coma, decerebrate rigidity, moribund

* Hunt & Hess, 1968; Ogilvy & Carter, 1998.

Table 2. The Fisher Scale *

Points Description

 0 Unruptured
 1 No blood detected
 2 Diffuse or vertical layers <1 mm thick
 3 Clot and/or vertical layer >1 mm thick
 4 Intracerebral or intraventricular clot

* Fisher, Kistler, & Davis, 1980; Ogilvy & Carter, 1998.

Table 3. Glasgow Coma Scale *

 Category Score Response

Eye opening 4 Spontaneous--Eyes open spontaneously
 without verbal or noxious stimulation

 3 To speech--Eyes open with verbal
 stimuli but not necessarily to command

 2 To pain--Eyes open with various forms
 of noxious stimuli

 1 None--No eye opening with any type of

Verbal response 5 Oriented--Aware of person, place,
 time, reason for hospitalization,
 and personal data

 4 Confused--Answers not appropriate to
 question but correct use of language

 3 Inappropriate words--Disorganized,
 random speech, no sustained

 2 Incomprehensible sounds--Moans,
 groans, and mumbles incomprehensibly

 1 None--No verbalization, even to
 noxious stimulation

Best motor 6 Obeys commands--Performs simple task
response on command and able to repeat task on

 5 Localizes to pain--Organized attempt
 to localize and remove painful stimuli

 4 Withdraws from pain--Withdraws
 extremity from source of painful

 3 Abnormal flexion--Decorticate
 posturing that occurs spontaneously
 or in response to noxious stimuli

 2 Extension--Decerebrate posturing that
 occurs spontaneously or in response to
 noxious stimuli

 1 None--No response to noxious stimuli:

* Teasdale & Jennett, 1974.

Table 4. World Federation of Neurological Surgeons
(WFNS) Grading Scale

WFNS Grade Glasgow Coma Score Motor Deficit

 I 15 Absent
 II 14-13 Absent
 III 14-13 Present
 IV 12-7 Present or absent
 V 6-3 Present or absent

Table 5. Karnofsky Performance Scale *

Score Rating Definition

 100 Normal; no complaints; no evidence of disease
 90 Caries on normal activities; minor symptoms
 80 Normal activities with effort; some symptoms
 70 Cares for self; unable to carry on normal activity
 60 Requires occasional assistance for most of needs
 50 Requires considerable assistance and frequent care
 40 Disabled; requires special care and assistance
 30 Severely disabled; hospitalized; death not imminent
 20 Very sick; active support care needed
 10 Moribund; fatal processes are progressing rapidly
 0 Dead


Table 6: Glasgow Outcome Scale *

Points Definition

 5 Excellent = no neurological deficit; patient able to
 return to previous lifestyle
 4 Good = mild deficit; patient able to return to
 pre-morbid work or lifestyle
 3 Fair = neurological deficit; patient unable to return
 to previous work or lifestyle but able to live at
 home with minimal or no assistance
 2 Poor = significant deficit; patient requiring full-time
 nursing care in an institution or at home
 1 Dead

* Ogilvy & Carter, 1998.


Anderson, S.I., Housley, A.M., Jones, P.A., Slattery, J., & Miller, J.D. (1993). Glasgow Outcome Scale: An inter-rater reliability study. Brain Injury, 7, 309-317.

Aulmann, C., Steudl, W.I., & Feldmann, U. (1998). Validation of the prognostic accuracy of neurosurgical admission scales after rupture of cerebral aneurysms. Zentralblatt fur Neurochirurgie, 59(3), 171-180.

Babu, R.P., Sekhar, L.N., & Wright, D.C. (1994). Extreme lateral transcondylar approach: Technical improvements and lessons learned. Journal of Neurosurgery, 81(1), 49-59.

Barth, H., Nabavi, A., Stein, H., Behnke, A., & Mehdorn, H.M. (1996). Perimesencephalic subarachnoid hemorrhage--An independent clinical picture of non-aneurysmatic subarachnoid hemorrhage with a benign course. Zentralblatt fur Neurochirurgie, 57(2), 108-112.

Brooks, D.N., Hosie, J., Bond, M.R., Jennett, B., & Aughton, M. (1986). Cognitive sequelae of severe head injury in relation to the Glasgow Outcome Scale. Journal of Neurology, Neurosurgery and Psychiatry, 49, 549-553.

Chiang, V.L., Claus, E.B., & Awad, I.A. (2000). Toward more rational prediction of outcome in patients with high-grade subarachnoid hemorrhage. Neurosurgery, 46(1), 28-35; discussion 35-26.

Clifton, G.L., Kreutzer, J.S., Choi, S.C., Devany, C.W., Eisenberg, H.M., Foulkes, et al. (1993). Relationship between Glasgow Outcome Scale and neuropsychological measures after brain injury. Neurosurgery, 33(1), 34-38; discussion 38-39.

Davis, P. (1994). Stroke in women. Current Opinion in Neurology, 7, 36-40.

Deruty, R., Pelissou-Guyotat, I., Mottolese, C., Amat, D., & Bognar, L. (1995). Level of consciousness and age as prognostic factors in aneurysmal SAH. Acta Neurochirurgica (Wien), 132(1-3), 1-8.

Fabregas, N., Valero, R., Carrero, E., Salvador, L., Calas, A., Parra, L., et al. (1998). Outcome of patients who underwent surgical repair of aneurysm after subarachnoid hemorrhage. Medicina Clinica, 111(3), 81-87.

Fisher, C.M., Kistler, J.P., & Davis, J.M. (1980). Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by CT scanning. Neurosurgery, 6, 1-9.

Gerber, C.J., Lang, D.A., Neil-Dwyer, G., & Smith, P.W. (1993). A simple scoring system for accurate prediction of outcome within four days of a subarachnoid haemorrhage. Acta Neurochirurgica (Wien), 122(1-2), 11-22.

Gotoh, O., Tamura, A., Yasui, N., Suzuki, A., Hadeishi, H., & Sano, K. (1996). Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery, 39(1), 19-24; discussion 24-25.

Groswasser, Z., Schab, K., & Salazar, A.M. (1997). Assessment of outcome following traumatic brain injury in adults. In R.M. Herndon (Ed.), Handbook of neurological rating scales (pp. 187-208). New York: Demos Vermande.

Hellawell, D.J., & Signorini, D.F. (1997). The Edinburgh Extended Glasgow Outcome Scale (EEGOS): Rationale and pilot studies. International Journal of Rehabilitation Research, 20, 345-354.

Heron, R., Davis, A., Gillies, R., & Courtney, M. (2001). Interrater reliability of the Glasgow Coma Scale scoring among nurses in subspecialities of critical care. Australian Journal of Critical Care, 14(3), 100-105.

Hirai, S., Ono, J., & Yamaura, A. (1996). Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery, 39, 441-446; discussion 446-447.

Hunt, W.E., & Hess, R.M. (1968). Surgical risk as related to time of intervention in the repair of intracranial aneurysms. Journal of Neurosurgery, 28, 14-20.

Ingall, T.J., & Wiebers, D.O. (1993). Natural history of subarachnoid hemorrhage. In J.P. Whisnant (Ed.), Stroke: Populations, cohorts and clinical trials (pp. 174-186). Boston: Butterworth-Heinemann.

Jennett, B., & Bond, M. (1975). Assessment of outcome after severe brain damage. Lancet, 1(7905), 480-484.

Karnofsky, D.A., Abelmann, W.H., Craver, L.F., and Burchenal, J.H. (1948). The use of nitrogen mustards in the palliative treatment of cancer. Cancer, 1, 634-656.

King, J.T., Jr. (1997). Epidememiology of aneurysmal saubarachnoid hemorrhage. Neuroimaging Clinics of North America, 7, 659-668.

Komiyama, M., Fu, Y., Yagura, H., Yasui, T., Baba, M., Hakuba, A., & Nishimura, S. (1990). Fatal aneurysmal rupture: A survey of 60 grade-5 cases. Acta Neurochirurgica (Wien), 106(3-4), 127-131.

Lagares, A., Gomez, P.A., Lobato, R.D., Alen, J.F., Alday, R., & Campollo, J. (2001): Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochirurgica (Wien), 143(7), 665-672.

Lang, D.A., & Galbraith, S.L. (1993). The management outcome of patients with a ruptured posterior circulation aneurysm. Acta Neurochirurgica (Wien), 125(1-4), 9-14.

Levin, H.S., Boake, C., Song, J., McCauley, S., Contant, C., Diaz-Marchan, P., et al. (2001). Validity and sensitivity to change of the extended Glasgow Outcome Scale in mild to moderate traumatic brain injury. Journal of Neurotrauma, 18, 575-584.

Lin, C.L., Kwan, A.L., & Howng, S.L. (1998). Surgical outcome of anterior communicating artery aneurysms. Kaohsiung Journal of Medical Science, 14, 561-568.

Menegazzi, J.J., Davis, E.A., Sucov, A.N., & Paris, P.M. (1993). Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. Journal of Trauma, 34(1), 46-48.

Oder, W., Kollegger, H., Zeiler, K., Dal-Bianco, P., Wessely, P., & Deecke, L. (1991). Subarachnoid hemorrhage of unknown etiology: Early prognostic factors for long-term functional capacity. Journal of Neurosurgery, 74, 601-605.

Ogilvy, C.S., & Carter, B.S. (1998). A proposed comprehensive grading system to predict outcome for surgical management of intracranial aneurysms. Neurosurgery, 42, 959-968; discussion 968-970.

Oshiro, E.M., Walter, K.A., Piantadosi, S., Witham, T.F., & Tamargo, R.J. (1997). A new subarachnoid hemorrhage grading system based on the Glasgow Coma Scale: A comparison with the Hunt and Hess and World Federation of Neurological Surgeons Scales in a clinical series. Neurosurgery, 41(1), 140-147; discussion 147-148.

Pettigrew, L.E., Wilson, J.T., & Teasdale, G.M. (1998). Assessing disability after head injury: Improved use of the Glasgow Outcome Scale. Journal of Neurosurgery, 89, 939-943.

Proust, F., Hannequin, D., Langlois, O., Freger, P., & Creissard, P. (1995). Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients. The importance of control angiography. Stroke, 26, 1553-1557.

Rinne, J., Hernesniemi, J., Niskanen, M., & Vapalahti, M. (1995). Management outcome for multiple intracranial aneurysms. Neurosurgery, 36(1), 31-37; discussion 37-38.

Rodholm, M., Starmark,. J.E., Svensson, E., & von Essen. (2001). Astheno-emotional disorders after aneurysmal SAH: Reliability, symptomatology and relation to outcome. Acta Neurologica Scandinavica, 103(6), 379-385.

Sano, K. (1994). Grading and timing of surgery for aneurysmal subarachnoid haemorrhage. Neurological Research, 16(1), 23-26.

Sato, J., Masuzawa, H., Shiraishi, K., Kanazawa, I., & Kamitani, H. (1986). New clinical grading in ruptured cerebral aneurysm. No Shinkei Geka, 14, 1183-1187.

Satz, P., Zaucha, K., Forney, D.L., McCleary, C., Asarnow, R.F., Light, R., et al. (1998). Neuropsychological, psychosocial and vocational correlates of the Glasgow Outcome Scale at 6 months post-injury: A study of moderate to severe traumatic brain injury patients. Brain Injury, 12, 555-567.

Saveland, H., Sonesson, B., Ljunggren, B., Brandt, L., Uski, T., Zygmunt, S., et al. (1986). Outcome evaluation following subarachnoid hemorrhage. Journal of Neurosurgery, 64, 191-196.

Shimoda, M., Oda, S., Tsugane, R., & Sato, O. (1997). Prognostic factors in delayed ischaemic deficit with vasospasm in patients undergoing early aneurysm surgery. British Journal of Neurosurgery, 11, 210-215.

Sibayan, R.Q. (1998). Management of non-traumatic subarachnoid hemorrhage in Filipinos. Neurologia Medico-Chirurgica (Tokyo), 38(Suppl.), 124-127.

Takagi, K., Aoki, M., Ishii, T., Nagashima, Y., Narita, K., Nakagomi, T., et al. (1998). Japan Coma Scale as a grading scale of subarachnoid hemorrhage: a way to determine the scale. No Shinkei Geka, 26, 509-515.

Takagi, K., Tamura, A., Nakagomi, T., Nakayama, H., Gotoh, O., Kawai, K., et al. (1999). How should a subarachnoid hemorrhage grading scale be determined? A combinatorial approach based solely on the Glasgow Coma Scale. Journal of Neurosurgery, 90, 680-687.

Teasdale, G.M. (1996). Response to: Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery, 39(1), 25.

Teasdale, G.M., & Jennett, B. (1974). Assessment of coma and impaired consciousnes--A practical scale. Lancet, 2, 81.

Teasdale, G.M., Pettigrew, L.E., Wilson, J.T., Murray, G., & Jennett, B. (1998). Analyzing outcome of treatment of severe head injury: A review and update on advancing the use of the Glasgow Outcome Scale. Journal of Neurotrauma, 15, 587-597.

Thomeer, R.T., Taal, J.C., Voormolen, J.H., & Wintzen, A.R. (1994). Aneurysmal bleeding. A plea for early surgery in good-risk patients. Acta Neurochirurgica (Wien), 128(1-4), 126-131.

van Gijn, J., Bromberg, J.E., Lindsay, K.W., Hasan, D., & Vermeulen, M. (1994). Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey. Stroke, 25, 1623-1627.

Wilson, J.T., Pettigrew, L.E., & Teasdale, G.M. (1998). Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: Guidelines for their use. Journal of Neurotrauma, 15, 573-585.

Wilson, J.T., Pettigrew, L.E., & Teasdale, G.M. (2000). Emotional and cognitive consequences of head injury in relation to the Glasgow outcome scale. Journal of Neurology, Neurosurgery and Psychiatry, 69, 204-209.

Woischneck, D., & Firsching, R. (1998). Efficiency of the Glasgow Outcome Scale (GOS)-Score for the long-term follow-up after severe brain injuries. Acta Neurochirurgica (Wien), 71(Suppl.), 138-141.

Yoshikai, S., Nagata, S., Ohara, S., Yuhi, F., Sakata, S., & Matsuno, H. (1996). A retrospective analysis of the outcomes of patients with aneurysmal subarachnoid hemorrhages: A focus on the prognostic factors. No Shinkei Geka, 24, 733-738.

Zentner, J., Hoffmann, C., & Schramm, J. (1996). Results of early surgery in poor-grade aneurysm patients. Journal of Neurosurgical Science, 40(3-4), 183-188.

Questions or comments about this article may be directed to: Stephen J. Cavanagh, PhD MPA RN, by e-mail at He is the associate dean for academic and clinical affairs and an associate professor at Wayne State University, Detroit, MI.

Vickie L. Gordon, MSN NP, is coordinator of neurosurgical nursing services at the Detroit Medical Center in Detroit, MI.
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Author:Cavanagh, Stephen J.; Gordon, Vickie L.
Publication:Journal of Neuroscience Nursing
Geographic Code:1USA
Date:Dec 1, 2002
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