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neuro.sah-grade4-5.v1

Aneurysmal SAH — Poor Grade (Hunt-Hess IV–V)

neurologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Poor-grade aSAH (HH IV–V) — stuporous or comatose with decerebrate posturing; high mortality; aggressive vs palliative decision dominant [AHA/ASA 2023 PMID 37212182]

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Advance rule
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Advance when

HH IV or V stratum confirmed

Patient inputs (11)

Age + frailty + premorbid function inform aggressive vs palliative decision [AHA/ASA 2023]

Premorbid function + advance directives critical for goals-of-care discussion in HH IV–V (AHA/ASA 2023)

Confirms SAH + modified Fisher (mFS III–IV in HH IV–V; high DCI risk) + IVH/hydrocephalus [Fisher 1980; AHA/ASA 2023]

Identifies aneurysm for securing decision (if salvageable) [AHA/ASA 2023]

Neurogenic stunned myocardium / Takotsubo common in HH IV–V (AHA/ASA 2023)

q6–8 h Na for SIADH vs CSWS (NCS 2023)

GCS ≤8 mandates intubation; GCS 3–6 = HH V trajectory [Hunt-Hess 1968; AHA/ASA 2023]

Fixed/dilated pupils + decerebrate posturing + apnea trajectory toward brain death (NCS 2023)

HH IV (~30–45% mortality) vs HH V (~50–80% mortality) drives aggressive vs palliative tilt [Hunt-Hess 1968; AHA/ASA 2023]

Pre-secure SBP <160 (Class IIa); HH IV–V may have hemodynamic instability + neurogenic stunned myocardium [Hoh 2023]

Reversal required if securing pursued (AHA/ASA 2023)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningHH_IV_stupor_hemiparesis_decerebrate
    HH IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing; mortality ~30–45% [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningHH_V_deep_coma_decerebrate_rigidity
    HH V — deep coma, decerebrate rigidity, moribund appearance; mortality ~50–80% [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrapid_re-bleeding_pre-securing
    Acute neurologic deterioration before securing — rebleed; mortality ~50–70%; pre-secure window is highest-risk period [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpoor_outcome_anchor
    HH V trajectory → ~80% mortality; prognostic anchor for goals-of-care discussion; early palliative consult mandatory [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtransplant_donor_eligibility_BD_workup
    HH V with brain-death trajectory — formal brain-death exam + ancillary testing + organ donor coordination if family consents [NCS 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_intracranial_hypertension
    Refractory ICP despite EVD + osmotic + sedation in HH IV–V — escalate to barbiturate coma + decompressive craniectomy consideration [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereULTRA_TXA_NOT_routine
    Routine antifibrinolytic TXA NOT recommended in HH IV–V per NCS 2023 — no functional-outcome benefit, thrombotic-event signal [ULTRA NEJM 2021 PMID 33357465; NCS 2023 PMID 37202712]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereIGNUS_aggressive_vs_palliative
    Identifying patients in good neurological-uncertainty state — multidisciplinary trajectory huddle (neurosurgery + neurointerventional + critical care + palliative + family) within 24 h of HH IV–V presentation [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneurogenic_stunned_myocardium_severe
    Severe NSM/Takotsubo in HH IV–V — elevated troponin + ECG changes + reduced LVEF; complicates BP/CPP management [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Poor-grade aSAH (HH IV–V) — intubation + ICP/EVD + aggressive critical care with parallel goals-of-care (AHA/ASA 2023 + NCS 2023)
axis: sah_poor_grade_aggressive_care_bundlestep 1 - Step 1 — Airway + ICP control + EVD
Selected step "Step 1 — Airway + ICP control + EVD" — HH IV–V with GCS ≤8 OR hydrocephalus OR decerebrate posturing
  • rocuronium
    rescue
    NMBA
    0.6–1.2 mg/kg IV • IV • PRN intubation
    triggers: intubation_required
    Use rocuronium + sugammadex; AVOID succinylcholine in raised-ICP (AHA/ASA 2023)
    rxcui 68139
  • etomidate
    rescue
    sedative_hypnotic_induction
    0.2–0.3 mg/kg IV • IV • one-time induction
    Hemodynamically neutral induction in HH IV–V (NCS 2023)
    rxcui 4177
  • hypertonic_saline_3pct
    rescue
    osmotic_therapy
    250 mL IV bolus then continuous to Na 145–150 • IV • bolus + continuous
    triggers: elevated_ICP, herniation_signs
    NCS 2023 — preferred over mannitol for sustained ICP control
    rxcui 9863
  • mannitol
    rescue
    osmotic_diuretic
    0.5–1 g/kg IV bolus • IV • PRN
    triggers: cerebral_edema, herniation
    Cerebral edema bridge (AHA/ASA 2023)
    rxcui 6628
  • external_ventricular_drain
    first line
    neurosurgical
    triggers: acute_hydrocephalus_IVH
    AHA/ASA 2023 Class I — STAT EVD in HH IV–V with hydrocephalus/IVH

outpatient playbook — drug actions (3)

  1. 1. ACEI/ARB + thiazide
    Per BP target • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN
  2. 2. atorvastatin
    40–80 mg PO daily per ASCVD risk • PO • daily
    trigger: ASCVD ≥7.5%
    2026 ACC/AHA Lipid (independent of STASH PMID 24837690 negative DCI signal)
  3. 3. AED taper if seizure-free 1–3 mo
    Per response • PO • per agent
    trigger: Seizure-free 1–3 mo
    AHA/ASA 2023

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Stupor + moderate-to-severe hemiparesis + early decerebrate posturing (HH IV) [Hunt-Hess 1968]; Deep coma + decerebrate rigidity + moribund appearance (HH V) [Hunt-Hess 1968]; Acute neurologic deterioration pre-securing → rebleed (mortality ~50–70%) [AHA/ASA 2023].

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Aneurysmal SAH — Poor Grade (Hunt-Hess IV–V)** (neuro.sah-grade4-5.v1).
Phenotype framing: Aneurysmal HH IV–V vs traumatic SAH vs massive ICH with IVH vs anoxic brain injury post-arrest [AHA/ASA 2023]
Scope: Poor-grade aSAH (HH IV–V) — stuporous or comatose with decerebrate posturing; high mortality; aggressive vs palliative decision dominant [AHA/ASA 2023 PMID 37212182]

No severity triggers fired against current inputs.

Plan

Regimen axis: **Poor-grade aSAH (HH IV–V) — intubation + ICP/EVD + aggressive critical care with parallel goals-of-care (AHA/ASA 2023 + NCS 2023)** — step "Step 1 — Airway + ICP control + EVD".
1. rocuronium 0.6–1.2 mg/kg IV IV PRN intubation (NMBA, rescue) — Use rocuronium + sugammadex; AVOID succinylcholine in raised-ICP (AHA/ASA 2023)
2. etomidate 0.2–0.3 mg/kg IV IV one-time induction (sedative_hypnotic_induction, rescue) — Hemodynamically neutral induction in HH IV–V (NCS 2023)
3. hypertonic_saline_3pct 250 mL IV bolus then continuous to Na 145–150 IV bolus + continuous (osmotic_therapy, rescue) — NCS 2023 — preferred over mannitol for sustained ICP control
4. mannitol 0.5–1 g/kg IV bolus IV PRN (osmotic_diuretic, rescue) — Cerebral edema bridge (AHA/ASA 2023)
5. external_ventricular_drain (neurosurgical, first line) — AHA/ASA 2023 Class I — STAT EVD in HH IV–V with hydrocephalus/IVH

Setting playbook (outpatient) — Long-term HH IV–V survivor follow-up — cerebrovascular clinic + cognitive rehab + caregiver support + repeat MRA 6 mo [AHA/ASA 2023]
6. ACEI/ARB + thiazide Per BP target PO daily — BP ≥130/80 (2025 AHA/ACC HTN)
7. atorvastatin 40–80 mg PO daily per ASCVD risk PO daily — ASCVD ≥7.5% (2026 ACC/AHA Lipid (independent of STASH PMID 24837690 negative DCI signal))
8. AED taper if seizure-free 1–3 mo Per response PO per agent — Seizure-free 1–3 mo (AHA/ASA 2023)

Non-pharmacologic actions:
- Cerebrovascular clinic 6 wk / 3 / 6 / 12 mo (AHA/ASA 2023)
- Family aneurysm MRA screening if ≥2 first-degree relatives or ADPKD (AHA/ASA 2023)
- Long-term PT/OT/Speech (AHA/ASA 2023)
- Caregiver education + respite resources (AHA/ASA 2023)
- Driving evaluation — typically prohibited in HH IV–V survivors (AHA/ASA 2023)
- Return-to-work — usually not feasible in HH V; case-by-case in HH IV (AHA/ASA 2023)
- Annual influenza + pneumococcal + COVID per ACIP 2026

AVOID / contraindication checks:
- No_routine_seizure_prophylaxis (AHA/ASA 2023)
- Abandon_triple H_use_euvolemic_induced_HTN (HIMALAIA 2014 PMID 29158449)
- AVOID_routine_long_course_antifibrinolytic_in_HH_IV_V (ULTRA 2021 PMID 33357465; NCS 2023 PMID 37202712)
- No_statin_for_DCI_prevention (STASH 2014 PMID 24837690)
- Nimodipine_dose_reduce_30mg_q2h_in_HH_IV_V_to_avoid_hypotension (AHA/ASA 2023)
- Nimodipine_PO_NG_only_NEVER_IV (FDA boxed warning)
- Avoid_succinylcholine_in_raised_ICP (AHA/ASA 2023)
- Early_goals_of_care_discussion_in_HH_V (AHA/ASA 2023)

Monitoring

Regimen monitoring:
- Continuous ICP CPP if EVD (AHA/ASA 2023)
- q1h GCS pupil exam (AHA/ASA 2023)
- Continuous arterial BP (AHA/ASA 2023)
- Daily TCD days 3-14 (AHA/ASA 2023)
- cEEG continuous NCSE common in HH IV V (NCS 2023)
- Serum Na q6-8h (NCS 2023)
- Brain death exam q-shift if trajectory toward BD (NCS 2023)
- Troponin serial for NSM (AHA/ASA 2023)

Setting (outpatient) monitoring:
- BP home log + clinic q3 mo (2025 AHA/ACC HTN)
- MRA at 6 mo (AHA/ASA 2023)
- mRS at 90 d / 6 mo / 12 mo (AHA/ASA 2023)
- Caregiver burden screen periodically (AHA/ASA 2023)

Follow-up plan: If survivor — IRF/SNF rehab + long-term cognitive + family support; if death — donor coordination + bereavement [AHA/ASA 2023]
- Close-out criterion: Disposition realized

Monitoring phase: Continuous ICP + CPP; q1 h GCS + pupil exam; daily TCD days 3–14; q6–8 h Na; cEEG (NCSE common); CT perfusion if decline; brain-death exam protocol if trajectory clear [NCS 2023]

Disposition

Current setting: outpatient — Long-term HH IV–V survivor follow-up — cerebrovascular clinic + cognitive rehab + caregiver support + repeat MRA 6 mo [AHA/ASA 2023]

Disposition criteria:
- Indefinite cerebrovascular clinic; transition to PCP after stable year if no residual (AHA/ASA 2023)

Escalation triggers (move to higher acuity):
- Any thunderclap → ED for re-rupture (AHA/ASA 2023)
- New focal deficit → STAT CT/CTA (AHA/ASA 2023)
- Caregiver burnout → social work + respite (AHA/ASA 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] HH IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing; mortality ~30–45% [Hunt-Hess 1968]
- [LIFE_THREATENING] HH V — deep coma, decerebrate rigidity, moribund appearance; mortality ~50–80% [Hunt-Hess 1968]
- [LIFE_THREATENING] Acute neurologic deterioration before securing — rebleed; mortality ~50–70%; pre-secure window is highest-risk period [AHA/ASA 2023]

Citations

- 2023 AHA/ASA aSAH Guideline (Hoh et al, Stroke 2023 PMID 37212182) + 2023 NCS aSAH Management (Treggiari et al, Neurocrit Care 2023 PMID 37202712) [PMID:37212182](https://pubmed.ncbi.nlm.nih.gov/37212182/)
- Cited evidence (PMID 37202712) [PMID:37202712](https://pubmed.ncbi.nlm.nih.gov/37202712/)
- Cited evidence (PMID 33357465) [PMID:33357465](https://pubmed.ncbi.nlm.nih.gov/33357465/)
- Cited evidence (PMID 2496789) [PMID:2496789](https://pubmed.ncbi.nlm.nih.gov/2496789/)
- Cited evidence (PMID 16139655) [PMID:16139655](https://pubmed.ncbi.nlm.nih.gov/16139655/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2023 AHA/ASA aSAH Guideline (Hoh et al, Stroke 2023 PMID 37212182) + 2023 NCS aSAH Management (Treggiari et al, Neurocrit Care 2023 PMID 37202712) — PMID:37212182
  • Cited evidence (PMID 37202712) — PMID:37202712
  • Cited evidence (PMID 33357465) — PMID:33357465
  • Cited evidence (PMID 2496789) — PMID:2496789
  • Cited evidence (PMID 16139655) — PMID:16139655