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Hunt and Hess Scale for Subarachnoid Hemorrhage

The Hunt and Hess scale grades aneurysmal subarachnoid haemorrhage I–V from the clinical picture (I minimal headache → V deep coma). The original 1968 scale adds one grade for serious systemic disease or severe vasospasm on angiography. Higher grade means higher surgical risk and mortality.

  • Clinical grade: I – Asymptomatic, or minimal headache and slight nuchal rigidity; II – Moderate-to-severe headache, nuchal rigidity, no deficit other than cranial nerve palsy; III – Drowsiness, confusion or mild focal deficit; IV – Stupor, moderate-to-severe hemiparesis, possible early decerebrate rigidity; V – Deep coma, decerebrate rigidity, moribund
  • Serious systemic disease (HTN, DM, severe atherosclerosis, COPD) or severe vasospasm on angiography (yes/no, +1)
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Interpretation

ResultMeaning
IAsymptomatic or minimal headache
IIModerate–severe headache, meningism, ± CN palsy
IIIDrowsy, confused, mild focal deficit
IVStupor, moderate–severe hemiparesis
VDeep coma, decerebrate, moribund

Formula

Grade I–V by clinical description; +1 grade for serious systemic disease or severe angiographic vasospasm (original scale).

Clinical pearls

  • Mortality rises steeply with grade, but published per-grade figures vary widely by era and treatment (the 1968 series predates modern microsurgery, endovascular coiling and nimodipine); use grade for communication and trial eligibility rather than precise prognosis.
  • The systemic-disease modifier is inconsistently applied in modern practice; state whether it was used.
  • Inter-rater reliability is modest; WFNS (GCS-based) is often documented alongside.

Examples

hunt hess: thunderclap headache, neck stiffness, no focal deficitSAH patient who is drowsy and confused with mild arm weakness, hunt and hess grade

FAQ

Which Hunt-Hess grades are considered poor grade?

Grades IV and V.

Is Hunt-Hess the same as WFNS?

No. Hunt-Hess is descriptive; WFNS uses the GCS plus motor deficit. They correlate but are not interchangeable.

Evidence

  1. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968;28:14–20.

Neurology · Reviewed 2026-10-14 · Methodology