A Minor Revision of Hunt and Hess Scale
To the Editor:
The following patient who was admitted to our department could not be rated as grade 1 or 2 according to Hunt and Hess (HH) scale for subarachnoid hemorrhage assessment.1
The patient presented with mild headache, unilateral third nerve palsy, and absence of nuchal rigidity. A brain CT scan verified a subarachnoid hemorrhage, and angiography disclosed a posterior communicating artery aneurysm, which was clipped successfully.
The HH subarachnoid hemorrhage grading does not anticipate the above condition. According to the HH scale, the grade 1 patient is “asymptomatic or with minimal headache and slight nuchal rigidity.” Our patient did not fit this description because the neurological examination disclosed a unilateral total loss of third nerve function. The HH grade 2 patient would present with “moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy.” Our patient could not be classified as grade 2 because there were no complaints such as moderate or severe headache, nor was there any nuchal rigidity. On the other hand, he did have a third nerve deficit.
Consequently, we propose that the HH scale should be reconsidered. Grade 1 should include patients who are “asymptomatic or with minimal headache, no or slight nuchal rigidity and with or without cranial nerve palsy,” with grades 2, 3, 4, and 5 as before.