Hunt and Hess Scale
Hunt and Hess Scale is a clinical grading system used to assess the severity of aneurysmal subarachnoid hemorrhage (SAH) and to estimate prognosis before treatment.
It stratifies patients based on level of consciousness and neurologic deficit.
Hunt and Hess Scale (Grades I–V)
| Grade | Clinical Features |
|---|---|
| Grade I | Asymptomatic or mild headache with slight nuchal rigidity |
| Grade II | Moderate–severe headache, nuchal rigidity, no neurologic deficit except cranial nerve palsy |
| Grade III | Drowsiness or confusion, mild focal neurologic deficit |
| Grade IV | Stupor, moderate–severe hemiparesis, early decerebrate rigidity, vegetative disturbances |
| Grade V | Deep coma, decerebrate posturing, moribund appearance |
Key Exam Pearls (NEET-SS / DM Neurology)
🧠 Grade III is the critical turning point
- Grades I–II → good prognosis
- Grades IV–V → poor prognosis
🧠 Most surgical/interventional decisions depend on grade
🧠 Mortality rises steeply with grade
Approximate mortality trend:
- Grade I → ~0–5%
- Grade II → ~5–10%
- Grade III → ~15–20%
- Grade IV → ~50%
- Grade V → ~80–90%
Easy Mnemonic
“HHD SC” progression
- H – Headache mild (Grade I)
- H – Headache severe (Grade II)
- D – Drowsy (Grade III)
- S – Stupor (Grade IV)
- C – Coma (Grade V)
Comparison With Another Common SAH Scale
| Scale | What it measures |
|---|---|
| Hunt and Hess Scale | Clinical neurological status |
| Fisher Scale | Amount of blood on CT (vasospasm risk) |
| World Federation of Neurosurgical Societies Scale | Based on GCS + motor deficit |
✅ One-line exam memory:
Hunt–Hess grade reflects neurological condition in aneurysmal SAH and predicts outcome before intervention.
1. Hunt and Hess scale is used to grade:
A. Severity of subarachnoid hemorrhage
B. Intracerebral hemorrhage
C. Subdural hematoma
D. Epidural hematoma
Clinical grading scale used in aneurysmal SAH.
2. Grade I Hunt-Hess is characterized by:
A. Coma
B. Mild headache with minimal nuchal rigidity
C. Severe hemiparesis
D. Deep stupor
Grade I = asymptomatic or mild headache ± slight neck stiffness.
3. Moderate-severe headache with cranial nerve palsy corresponds to:
A. Grade I
B. Grade III
C. Grade II
D. Grade V
Grade II includes severe headache with cranial nerve deficit.
4. Drowsiness or confusion occurs in:
A. Grade I
B. Grade II
C. Grade IV
D. Grade III
Grade III = confusion/drowsiness with mild focal deficit.
5. Stupor with moderate hemiparesis indicates:
A. Grade IV
B. Grade II
C. Grade I
D. Grade III
Grade IV involves stupor and severe neurologic deficit.
6. Deep coma and decerebrate rigidity correspond to:
A. Grade IV
B. Grade V
C. Grade III
D. Grade II
Grade V = coma, decerebrate posture, moribund state.
7. Turning point for prognosis in Hunt-Hess grading:
A. Grade II
B. Grade IV
C. Grade III
D. Grade V
Grades I–II good prognosis, ≥III worse outcomes.
8. Hunt-Hess scale predicts:
A. Vasospasm risk
B. CT blood load
C. Aneurysm size
D. Clinical severity and prognosis
Purely clinical grading predicting mortality.
9. Mortality highest in:
A. Grade V
B. Grade II
C. Grade III
D. Grade IV
Grade V mortality approaches 80–90%.
10. Cranial nerve palsy appears in:
A. Grade IV
B. Grade II
C. Grade I
D. Grade III
Grade II allows isolated cranial nerve deficit.
11. Mild headache only corresponds to:
A. Grade II
B. Grade III
C. Grade I
D. Grade IV
Grade I minimal neurological findings.
12. Vegetative disturbances appear in:
A. Grade II
B. Grade III
C. Grade I
D. Grade IV
Grade IV includes autonomic instability.
13. First described in:
A. 1968
B. 1985
C. 1950
D. 1978
Original description by Hunt and Hess in 1968.
14. Which scale evaluates CT blood volume in SAH?
A. Hunt-Hess
B. Fisher scale
C. Glasgow coma scale
D. WFNS scale
Fisher grading predicts vasospasm risk based on CT blood.
15. Maximum grade in Hunt-Hess:
A. III
B. IV
C. V
D. VI
Scale ranges from Grade I to V.
16. WFNS grading mainly uses:
A. Blood thickness
B. Aneurysm size
C. ICP measurement
D. GCS score
WFNS combines GCS with focal deficit.
17. Early decerebrate rigidity occurs in:
A. Grade IV
B. Grade I
C. Grade II
D. Grade III
Seen in severe neurological compromise.
18. Moribund patient with coma corresponds to:
A. Grade III
B. Grade V
C. Grade II
D. Grade I
Grade V patients are deeply comatose.
19. Mild focal deficit with confusion corresponds to:
A. Grade II
B. Grade I
C. Grade III
D. Grade IV
Typical Grade III clinical picture.
20. Main purpose of Hunt-Hess scale:
A. Predict aneurysm rupture
B. Estimate intracranial pressure
C. Guide CT interpretation
D. Clinical grading of SAH severity
Used to assess severity and prognosis before treatment.
Key Exam Points (for NEET-SS)
🧠 Clinical vs Radiologic
- Hunt–Hess: purely clinical grading
- Fisher: based on CT blood thickness
- WFNS: GCS-based clinical grading
🧠 Number of Grades
- Hunt–Hess → I–V
- Fisher → I–IV
- WFNS → I–V
🧠 Main Purpose
- Hunt–Hess → overall clinical severity & prognosis
- Fisher → predict vasospasm risk
- WFNS → modern neurosurgical outcome prediction
🧠 Key Parameter
- Hunt–Hess → neurologic deficit + consciousness
- Fisher → SAH blood thickness on CT
- WFNS → Glasgow Coma Scale
🧠 Best Prognosis
- Hunt–Hess Grade I–II
- Fisher Grade I
- WFNS Grade I
🧠 Worst Prognosis
- Hunt–Hess Grade V
- Fisher Grade IV
- WFNS Grade V
🧠 Important Exam Pearl
- Fisher grade III → highest vasospasm risk
🧠 Memory Trick
H – F – W rule
- H = Hunt–Hess → How the patient looks
- F = Fisher → Film (CT scan) blood
- W = WFNS → With GCS
