WFNS grade |
GCS score |
Major focal deficit (aphasia, hemiparesis, hemiplegia |
0 = intact aneurysm |
 |
|
1 |
15 |
- |
2 |
13-14 |
- |
3 |
13-15 |
+ |
4 |
7-12 |
+ / - |
5 |
3-6 |
+ /- |
Add 1 grade if there is serious systemic disease or vasospasm on angiogram (Serious systemic disease: hypertension, diabetes, COPD, severe artherosclerosis) |
|
0 |
unruptured aneurysm |
1 |
asymtomatic or mild headache and nuchal rigidity |
1a |
no acute meningeal/brain reaction but, fixed neurological deficit |
2 |
Cranial nerve palsy, modrate to severe headache, nuchal rigidity |
3 |
mild focal deficit, drowsiness or confusion |
4 |
stupor, moderate to severe hemiparesis, possible early decerebrate rigidity and vegetative disturbances |
5 |
rigidity deep coma, decerebrate rigidity, moribund appearence |
Fisher group |
Blood on CT (measurement were made on printed EMI CT scans. The measurements were not scaled to the actual thickness) |
1 |
No sah detected |
2 |
Diffuse or vertical layer of subarachnoid blood < 1mm thick |
3 |
Localised clot and/or vertical layer within the subarachnoid spasce > 1mm thick |
4 |
ICH or IVH with diffuse or no sah |
|
No sah |
Focal or diffuse thin sah |
Focal or diffuse thick sah |
IVH |
|
0 |
+ |
- |
- |
- |
No subarachnoid haemorrhage; no intraventricular blood |
1 |
- |
+ |
- |
- |
Thin diffuse or focal subarachnoid blood but, no intraventricular blood |
2 |
- |
+ |
- |
+ |
Thin diffuse or local subarachnoid blood with intraventricular blood |
3 |
- |
- |
+ |
- |
Thick focal or diffuse subarachnoid blood but no intraventricular blood |
4 |
- |
- |
+ |
+ |
Thick local or diffuse subrachnoid blood with intraventricular lood |
Average middle cerebral artery velocity (cm/sec) |
velocity in middle cerebral artery/velocity in internal carotid atery |
Description |
< 120 |
< 3 |
Normal |
120-200 |
3-6 |
mild vasospasm |
> 200 |
> 6 |
severe vasospasm |
Eye opening spontaneously |
4 |
Eye opening to voice |
3 |
Eye opening to pain |
2 |
No eye opening |
1 |
Orinted in place, person and time |
5 |
Confused |
4 |
Inapppropriate words |
3 |
Incomprehensible words |
2 |
No verbal response |
1 |
Obeying commands |
6 |
Localising to pian |
5 |
Withdrawing to pain |
4 |
Abnormal flexion to pain |
3 |
Extension to pain |
2 |
No motor resonse to pain |
1 |
Size of nidus |
Eloquence of adjacent brain |
Venous drainage |
< 3 cm = 1 |
non-eloquent = 0 |
superficial = 0 |
3-6 cm = 2 |
eloquent = 1 |
deep =1 |
> 6 cm = 3 |
|
|
Venous drainage directly into dural venous sinus or meningeal vein |
1 |
Venous drainage into dural venous sinus with corticalvenous reflux |
2 |
venous drainage directly into subarachnoid veins |
3 |
Venous drainage into dural venous sinus with antegrade flow |
I |
Venous drainage into dural venous sinus with retrograde flow |
IIa |
Venous drainage into dural venous sinus with antegrade flow and cortical venous reflux |
IIb |
Venous drainage into dural venous sinus with retrograde flow and cortical venous reflux |
IIa+b |
Venous drainage directly into subarachnoid veins (cortical venous reflux only) |
III |
Type III with venous extasias of the draining subrachnoid veins |
IV |
Venous drainage into the perimedullary plexus |
V |
Death |
1 |
Persistent vegetative state |
2 |
Severe disability |
3 |
Moderate disability |
4 |
Good recovery |
5 |
No symptom at all |
Grade 0 |
No significant disability despite symptoms: able to carry out all usual duties and activities |
1 |
Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance |
2 |
Moderate disability: requiring some help, but able to walk with assistance |
3 |
Moderate severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance |
4 |
Severe disability: bedridden, incontinent, and requiring constant nursing care and attention |
5 |
No symptoms |
0 |
Minor symptoms |
1 |
Some restriction in life style |
2 |
Significant restriction in life style |
3 |
Partly dependent |
4 |
Fully dependent |
5 |
Dead |
6 |
Useful scales in vascular neurosurgery and neurovascular radiology
Compiled by:
G Narenthiran MRCSE
J Duffill FRCS(SN)
Deaprtment of Neurosurgery,Wessex Neurological Centre, Southampton, UK
g_narenthiran@hotmail.com; 2007
Lesion type |
MRI signal characteristics |
Type IA |
T1: hyperintense focus of hemorrhage T2: hyper or hypointense focus of haemorrhage extending through at least one wall of the hypointense rim that surrounds the lesion. Focal odema may be present |
Type 1B |
T1: hyperintense focus of hemorrhage T2: hyperor hypointense focus of hemorrhage surrouned by a hypointense rim |
Type II |
T1: reticulated mixed signal core T2: reticulated mixed signal core surrounded by a hypointense rim |
Type III |
T1: iso or hypointense T2: hypointense with a hypointensse rim that magnifies size of lesion GE: hypointense with greater magnification that T2 |
Type IV |
T1: poorly seen or not visualised at all T2: poorly seen or not visualised at all GE: punctate hypointense lesion |
Based on the table from: Fein-Erfan I, Zabramski JM, Kim LJ, Klopfenstein JD. Natural history of cavernous malformations of the central nervous system. In: Cavernous mlformations of the brain and spinal cord. Eds.: Lanzino G, Spetzler R. Thieme, New York 2008 p 6; The authors note that from their review of the literature that there is increased risk of haemorrhage with type I and type Iv cavenomas.
Original paper: Zabramski JM, Wascher TM, Spetzler RF et al. The natural history of familiar cavernous malformations:results of an ongoing study. J Neurosurg 1994; 80: 422-432.
Category |
Definition |
Type A |
Direct high flow fistulas resulting from a tear between internal carotid artery and the cavernous sinus. Usually traumatic |
Type B |
Dural shunts between meningeal branches of the internal carotid artery and the cavernou ssinus. Spontaneous. |
Type C |
Dural shunts betweenmeningeal branches of the external carotid artery and the cavernou ssiinus. Spontaneous |
Type D |
Dural shunts between meningeal branches of both the internal and external carotid arteries and the cavernous sinus. Spontaneous |
Based on the table from: Dowling JL, Brown AP, Dacey RG. Chapter 45: Cerebrovascular complications in the head-injued patient. In: Neurotrauma. Eds: Narayan R, Wilberger JE, Povlishock JT. McGraw-Hill, New York, 1996 p664.
Original paper: Barrow Dl, Spector RH, Braun IF et al. Classification and treatment o fspontaneous carotid-cavenous sinus fistulas. J neurosurg 1985; 62: 248-256
Frontera JA, Claasen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES, Loch Macdonald R, Mayer SA. Prediction of symtomatic vasospasm after subarachnoid haemorrhage: the modified Fisher scale. Neurosurgery 2006, 58(7): 21-27
On the commentary section of the paper Dr Christopher S Ogilvy correctly noted that "same incidence of vasospasm for Grade 2 and 3 patients with identical odds ratios". He further suggested because of this the grading system should have had one less grade.
Note: What grade does a patient who is alert, obeying commands and has dysphasia be assigned to? What grade does a patient with GCS but has pronator drift or mild weakness be assigne to?. For more regading possible confusion with WFNS grade please click here.