Grading Scales for Subarachnoid Hemorrhage - Animal Models of Acute Neurological Injuries: Injury and Mechanistic Assessments - page 280

The “perfect” predictive scale should be one that has the fewest
input variables that provides for a reliable prediction of desired out-
come. As the scoring systems grow to include more data, they can
become cumbersome providing little additional prognostic value
in the stratifi cation of patients. A standardized scale also has the benefi t
of providing information between institutions to aide in patient care
and scientifi c study. This “perfect” scale has eluded detection as of
present time but much research is ongoing in this area.

2. Historically
Signifi cant SAH
Scales

Since the early 1930s, many scales have been developed de novo
with the more recent studies aimed at modifying existing scales to
provide the additional information that is needed to improve long-
term clinical outcome. Bramwell ( 1, 2 ), Botterell ( 3 ), Nishioka ( 4 ),
and Cooperative aneurysm study ( 5 ) scales have all been historically
signifi cant providing the backbone for the development of the
scales in common use today and are briefl y discussed.
Dr. Byrom Bramwell fi rst described the symptoms associated
with SAH in 1886 ( 1 ) and was later one of the fi rst physicians to
develop a simple stratifi cation system based on a patient either
being apoplectic or paralytic. The Botterell scale ( 3 ) was published
in 1956 and attempted to provide a fi ve tiered grading scale rang-
ing from a grade one with clear consciousness to grade fi ve with
moribund appearance. Its signifi cance can be linked to the similari-
ties to the Hunt and Hess scale in use today. Nishioka ( 4 ) in 1966
examined the outcomes of conservatively treated SAH patients and
looked for patterns existing in those patients who did poorly use a
modifi ed Botterell scale to stratify patients. The cooperative aneu-
rysm study of 1982 demonstrated a high degree of inter-operator
variability between the Hunt and Hess scale (which will be described
further) and the modifi ed Botterell scale and stimulated the devel-
opment of newer scale.
Since Dr. Bramwell's time in the early part of the twentieth
century upward of 40 scales have been utilized and continue to be
developed into the present day and although a “perfect” SAH pre-
dictive scale remains elusive the ideal components of said scale have
been proposed ( 6 ).

3. Hunt and Hess
Grading of SAH

Historically, the most frequently used scale has been the Hunt and
Hess classifi cation (Table 1 ). This is in part due to ease to administer
and prevalence in neurosurgical literature. Botterell et al. ( 3 ) in 1956
fi rst developed a scale that was to be used to assess surgical risk and