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Chapter 2. Subarachnoid Hemorrhage

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A 46-year-old African American woman with an extensive smoking history presents to the emergency department with the “worst headache” of her life that started abruptly 2 hours ago. Aside from a headache, she endorses mild nausea and “blurry vision.” She denies a history of headache. Her blood pressure at the time of presentation is 220/110 mm Hg. On physical examination, a right third nerve palsy is found. An emergent head computed tomography (CT) is obtained and shown below.

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Head computed tomography: Axial noncontrast head CT at the level of the midbrain demonstrating diffuse subarachnoid hemorrhage left > right Sylvian fissure involvement. There are no areas of intraparenchymal or intraventricular hemorrhage.

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Based on this description, what is the Hunt and Hess grade?

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A. 1

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B. 2

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C. 3

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D. 4

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E. 5

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B. The Hunt and Hess scale is a widely used clinical grading system to predict prognosis and outcome in patients with SAH (Table 2-1). It is one of several available grading scales, is easy to use, but has been criticized for its interobserver variability. The scale ranges from 1 to 5. A lower score implies a better outcome and lower mortality.

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Table 2-1. Hunt and Hess Scale for Subarachnoid Hemorrhage
Hunt and Hess Grade Description Mortality (%) Follow-Up Mortality (%)
1 Asymptomatic or minimal headache and slight nuchal rigidity  11  3
2 Moderate or severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy  26  3
3 Drowsiness, confusion, or mild focal deficit  37  9
4 Stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity, and vegetative disturbance  71 24
5 Deep coma, decerebrate posturing, moribund appearance 100 71

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A 46-year-old African American woman with an extensive smoking history presents to the emergency department with the “worst headache” of her life that started abruptly 2 hours ago. Aside from a headache, she endorses mild nausea and “blurry vision.” She denies a history of headache. Her blood pressure at the time of presentation is 220/110 mm Hg. On physical examination, a right third nerve palsy is found. An emergent head computed tomography (CT) is obtained and shown below. You immediately consult the neurosurgical service. To deliver precise and objective information to your neurosurgical colleague, you determine the World Federation of Neurological Surgeons (WFNS) grade prior to initiating the call. Based on the earlier vignette, what is the patient’s WFNS grade?

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Image not available.

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Head computed tomography: Axial noncontrast head CT at the level of the midbrain demonstrating ...

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