Hunt and Hess Grade III
This patient presenting with severe headache, drowsiness, confusion, and oculomotor nerve palsy with confirmed subarachnoid hemorrhage is classified as Hunt and Hess Grade III.
Rationale for Grade III Classification
The Hunt and Hess scale defines Grade III as "lethargy, confusion, mild focal deficit" 1. This patient's clinical presentation matches these criteria precisely:
- Altered mental status: Drowsiness and confusion indicate lethargy and altered consciousness 1
- Focal neurological deficit: Oculomotor nerve palsy (cranial nerve III) represents a focal deficit 1
- Severe headache: Consistent with subarachnoid hemorrhage presentation 1
Why Not Other Grades
Grade II is excluded because it is defined as "moderate to severe headache, cranial nerve palsy, nuchal rigidity" without altered consciousness 1. This patient has drowsiness and confusion, which exceeds Grade II criteria.
Grade IV is excluded because it requires "stupor, hemiparesis, early decerebrate posturing" 1. While this patient has altered consciousness (drowsiness/confusion), they do not demonstrate stupor or decerebrate posturing, and the oculomotor palsy is a cranial nerve deficit rather than hemiparesis.
Clinical Significance
The Hunt and Hess grade is the most useful indicator of outcome after aneurysmal SAH and should be determined rapidly to guide treatment decisions 1, 2. Grade III patients have intermediate prognosis and require:
- Urgent aneurysm securing: Early surgical clipping or endovascular coiling should be performed to reduce rebleeding risk 1
- Intensive monitoring: Serial neurological assessments are mandatory as clinical deterioration may occur from rebleeding, hydrocephalus, or vasospasm 2
- Blood pressure control: Maintain systolic blood pressure <160 mmHg with titratable agents to prevent rebleeding while maintaining cerebral perfusion 1, 3
Grade III patients can achieve favorable outcomes with aggressive early treatment, though outcomes are generally better than Grade IV-V patients 4, 5.