Scales Used in Neurocritical Care


  1. General
    1. Glasgow Coma Scale
    2. Glasgow Outcome Scale
    3. Glasgow Outcome Scale – Extended version (GOS-E)
    4. Modified Rankin Scale
    5. Modified Oxford Handicap Scale (MOHS)
    6. FOUR Score
  2. Delirium
    1. RASS (Richmond Agitation Sedation Scale)
    2. CAM ICU Scale
  3. Stroke / TIA
    1. The mNIHSS and Scoring Guide
    2. ABCD Score
  4. SAH
    1. WFNS Scale
    2. Hunt and Hess Scale
    3. Fisher and Modified Fisher Scales
  5. MRI Classification of Cavernomas
  6. Spetzler-Martin Grading of AV Malformations
  7. Dural AV Fistulas
    1. Cognard Classification
    2. Borden Classification
    3. Barrow Classificiation (caroticocavernous fistulas)


Glasgow Coma Scale

  6 5 4 3 2 1
Eye Opens eyes spontaneously Opens eyes to voice Opens eyes to Pain Does not open eyes
Verbal Oriented, normal conversation Confused, disoriented Inappropriate wordrs Incomprehen-sible Makes no sounds
Motor Obeys commands Localizes Flexes / withdraws to pain Decorticate Decerebrate No movements

GCS score.JPG



Note: The scale presented here is based on the original article by Jennett and Bond. It has become common practice in clinical trial administration, however, to use a modified version that places the scores in reverse order (i.e., “good recovery” = 1, “moderate disability” =2, etc.).

Score Description
2 PERSISTENT VEGETATIVE STATE Patient exhibits no obvious cortical function.
3 SEVERE DISABILITY (Conscious but disabled). Patient depends upon others for daily support due to mental or physical disability or both.
4 MODERATE DISABILITY (Disabled but independent). Patient is independent as far as daily life is concerned. The disabilities found include varying degrees of dysphasia, hemiparesis, or ataxia, as well as intellectual and memory deficits and personality changes.
5 GOOD RECOVERY Resumption of normal activities even though there may be minor neurological or psychological deficits.

TOTAL (1–5): ______



Glasgow Outcome Scale – Extended version (GOS-E)

  • eight-point scale
  • assesses effects of TBI on function in major areas of life
  • 1 = death
  • 2 = vegetative state
  • 3 or 4 = severe disability
  • 5 or 6 = moderate disability
  • 7 or 8 = good recovery



Score Description 0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual duties and activities without assistance
2 Slight disability; unable to carry out all previous activities, but able to look after own affairs
3 Moderate disability; requiring some help, but able to walk without assistance
4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 Dead

TOTAL (0–6): _______

Rankin and Modififed Rankin


Modified Oxford Handicap Scale (MOHS)

  • 0 = no symptoms
  • 1 = minor symptoms
  • 2 = some restriction
  • 3 = dependent
  • 4 = fully dependent
  • 5 = death





FOUR – Full Outline of UnResponsiveness  (Eelco Wijdicks)



4-opens, tracks, blinks

3-just opens

2-opens to voice

1- opens to pain


MOTOR RESPONSE 4-obeys, thumbs-up




0-NR or myoclonus

BRAINSTEM REFLEXES Pupils Corneals Cough INTUBATION 4-normal


2-irreg respirations

1-tubed, breathes

0-intubated, no breaths

4 2 + +
3 1 + +
2 +/- -/+ NA
1 0 0 +
0 0 0 0


RASS (Richmond Agitation Sedation Scale)

Points Classification Description
4 Combative Overtly combative or violent; immediate danger to staff
3 Very agitated Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff
2 Agitated Frequent nonpurposeful movement or patient–ventilator dyssynchrony
1 Restless Anxious or apprehensive but movements not aggressive or vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice
-2 Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice
-3 Moderate sedation Any movement (but no eye contact) to voice
-4 Deep sedation No response to voice, but any movement to physical stimulation
-5 Unarousable No response to voice or physical stimulation



Acute onset or fluctuating course

A. Is there evidence of an acute change in mental status from the baseline?

B. Or, did the (abnormal) behavior fluctuate during the past 24 hours, that is, tend to come and go or increase and decrease in

severity as evidenced by fluctuations on the Richmond Agitation Sedation Scale (RASS) or the Glasgow Coma Scale?


Did the patient have difficulty focusing attention as evidenced by a score of less than 8 correct answers on either the visual or

auditory components of the Attention Screening Examination (ASE)?

Disorganized thinking

Is there evidence of disorganized or incoherent thinking as evidenced by incorrect answers to three or more of the 4 questions and inability to follow the commands?


1. Will a stone float on water?

2. Are there fish in the sea?

3. Does 1 pound weigh more than 2 pounds?

4. Can you use a hammer to pound a nail?


1. Are you having unclear thinking?

2. Hold up this many fingers. (Examiner holds 2 fingers in front of the patient.)

3. Now do the same thing with the other hand (without holding the 2 fingers in front of the patient).

(If the patient is already extubated from the ventilator, determine whether the patient’s thinking is disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject.)

Altered level of consciousness

Is the patient’s level of consciousness anything other than alert, such as being vigilant or lethargic or in a stupor or coma?

ALERT: spontaneously fully aware of environment and interacts appropriately

VIGILANT: hyperalert

LETHARTIC: drowsy but easily aroused, unaware of some elements in the environment or not spontaneously interacting with the interviewer; becomes fully aware and appropriately interactive when prodded minimally

STUPOR: difficult to arouse, unaware of some or all elements in the environment or not spontaneously interacting with the interviewer; becomes incompletely aware when prodded strongly; can be aroused only by vigorous and repeated stimuli and as soon as the stimulus ceases, stuporous subject lapses back into unresponsive state

COMA: unarousable, unaware of all elements in the environment with no spontaneous interaction or awareness of the interviewer so that the interview is impossible even with maximal prodding

Overall CAM-ICU Assessment (Features 1 and 2 and either Feature 3 or 4): Yes____ No____


The mNIHSS and Scoring Guide

Item Item Name Scoring Guide
1b LOC Questions 0 = Answers both correctly.
1 = Answers one correctly.
2 = Answers neither correctly.
1c LOC Commands 0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task.
2 Gaze 0 = Normal.
1 = Partial gaze palsy.
2 = Total gaze palsy.
3 Visual Fields 0 = No visual loss.
1 = Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia.
5a Left Arm Motor 0 = No drift
1 = Drift before 10 seconds
2 = Falls before 10 seconds
3 = No effort against gravity
4 = No movement
UN = Amputation or joint fusion, explain:
5b Right Arm Motor 0 = No drift
1 = Drift before 10 seconds
2 = Falls before 10 seconds
3 = No effort against gravity
4 = No movement
UN = Amputation or joint fusion, explain:
6a Left Leg Motor 0 = No drift
1 = Drift before 5 seconds
2 = Falls before 5 seconds
3 = No effort against gravity
4 = No movement
UN = Amputation or joint fusion, explain:
6b Right Leg Motor 0 = No drift
1 = Drift before 5 seconds
2 = Falls before 5 seconds
3 = No effort against gravity
4 = No movement
UN = Amputation or joint fusion, explain:
8 Sensory 0 = Normal
1 = Abnormal
9 Language 0 = Normal
1 = Mild aphasia
2 = Severe aphasia
3 = Mute or global aphasia
11 Neglect 0 = Normal
1 = Mild
2 = Severe

Total Score (out of 31):

*Scoring from original scale


ABCD Score

Used to predict the risk of stroke during the first seven days after a TIA. Researchers found there to be over 30% risk of stroke in TIA patients with an ‘ABCD score’ of six, as compared to no strokes in those with a low ABCD score. Can be used in routine clinical practice to identify high-risk individuals who require emergency investigation and treatment.

Risk factor Risk factor Category Score
A Age of patient Age >/= 60 1
Age < 60 0
B Blood pressure at assessment SBP > 140 or DBP >/= 90 1
Other 0
C Clinical Features presented with Unilateral weakness 2
Speech disturbance (no weakness) 1
Other 0
D Duration of TIA symptoms >/= 60 minutes 2
10-59 minutes 1
<10 minutes 0





World Federation of Neurological Surgeons Grading System forSAH (WFNS) Scale

Overview :

The clinical grading system proposed by the World Federation of Neurologic Surgeons is intended to be a simple, reliable and clinically valid way to grade a patient with subarachnoid hemorrhage. This system offers less interobserver variability than some of the earlier classification systems.

Glasgow Coma Score Motor Deficit* Grade
15 Absent 1
13 – 14 Absent 2
13 – 14 Present 3
7 – 12 Present or absent 4
3 – 6 Present or absent 5

*Where a motor deficit refers to a major focal deficit.

WFNS grade



For non-traumatic sub-arachnoid hemorrhage patients.

(Choose single most appropriate grade.)

Grade Description
1 Asymptomatic, mild headache, slight nuchal rigidity
2 Moderate to severe headache, nuchal rigidity , no neurologic deficit other than cranial nerve palsy
3 Drowsiness / confusion, mild focal neurologic deficit
4 Stupor, moderate-severe hemiparesis
5 Coma, decerebrate posturing

GRADE (1–5): ______

Hunt and Hess



Fisher and Modified Fisher.JPG


MRI Classification of Cavernomas

MRI classification of Cavernomas




The Spetzler-Martin AVM grading system allocates points for various features of intracranial arteriovenous malformations to give a grade between 1 and 5. Grade 6 is used to describe inoperable lesions. The score correlates with operative outcome.

Spetzler Martin Grading




The Cognard classification of dural arteriovenous fistulas correlates venous drainage patterns with increasingly aggressive neurological clinical course.

Cognard Classification




The Borden classification of dural arteriovenous fistulas (DAVF) groups these lesions into three types based upon the site of venous drainage and the presence or absence of cortical venous drainage. It is a simplification of the more popularly used Cognard classification system:

Borden Classification



Caroticocavernous fistula can be broadly classified as direct or indirect. Barrow et al. (1985) proposed a four-type classification:Barrow Classification




“Report Of World Federation Of Neurological Surgeons Committee On A Universal Subarachnoid Hemorrhage Grading Scale”. Journal of Neurosurgery 68.6 (1988): n. pag. Web.

Barrow, Daniel L. et al. “Classification And Treatment Of Spontaneous Carotid-Cavernous Sinus Fistulas”. Journal of Neurosurgery 62.2 (1985): 248-256. Web.

Frontera, Jennifer A. et al. “Prediction Of Symptomatic Vasospasm After Subarachnoid Hemorrhage: The Modified Fisher Scale”. Neurosurgery 59.1 (2006): 21-27. Web.

Hunt, William E., and Robert M. Hess. “Surgical Risk As Related To Time Of Intervention In The Repair Of Intracranial Aneurysms”. Journal of Neurosurgery 28.1 (1968): 14-20. Web.

Rothwell, P.M., M.F. Giles, and E. Flossmann. “A Simple Score (ABCD) To Identify Individuals At High Early Risk Of Stroke After Transient Ischaemic Attack”. ACC Current Journal Review 14.10 (2005): 12-13. Web.

Wijdicks, Eelco F. M. et al. “Validation Of A New Coma Scale: The FOUR Score”. Annals of Neurology 58.4 (2005): 585-593. Web.

WILSON, J.T. LINDSAY, LAURA E.L. PETTIGREW, and GRAHAM M. TEASDALE. “Structured Interviews For The Glasgow Outcome Scale And The Extended Glasgow Outcome Scale: Guidelines For Their Use”. Journal of Neurotrauma 15.8 (1998): 573-585. Web.

Zabramski, Joseph M. et al. “The Natural History Of Familial Cavernous Malformations: Results Of An Ongoing Study”. Journal of Neurosurgery 80.3 (1994): 422-432. Web.

Stepladder Management of Increased ICP (ENLS Protocol)

First question to ask in ICP management should be “Does this patient need urgent decompressive hemicraniectomy?”  If ICP crises is progressing rapidly, a neurosurgeon should be consulted urgently to discuss the risks and benefits of surgery.  ICP can be lowered by craniectomy alone (15% decrease) or by craniectomy and dural opening (70% decrease).  Surgical decompression has been shown to improve brain tissue oxgenation, survival in malignant MCA infarction, but does not improve outcomes in TBI.



The Neurocritical Society published guidelines on the management of intracranial hypertension and herniation in 2012.  A summary of the four tiers in the stepwise treatment of ICP crises is listed below.

ENLS ICP Treatment Tiers

Tier Zero:

  • HOB > 30 degrees
  • ensure adequate sedation
  • correct hyponatremia, hyperthermia, and vasogenic edema
  • keep CPP > 60-70 mm Hg
  • **normocarbia (PaCO2 35-45)
  • **good oxygenation (PaO2 >100)

Tier One:

  • secure airway
  • mannitol 0.5-1 gm/kg IV bolus
  • start 3% saline 10-20 cc/hr
  • CSF drainage

Tier Two:

  • hypertonic saline bolus (3%-23.4%)
  • consider propofol bolus and infusion
  • consider decompressive craniotomy

Tier Three:

  • pentobarbital bolus and infusion titrated for ICP goal
  • induce hypothermia
  • hyperventilation if used with cerebral oxygen monitor
  • raise MAP to improve CPP



  1. achieve normothermia by:
    • acetaminophen 325-650 PO or PR q6h
    • ibuprofen 500mg PO q6h
    • surface cooling – ice packs, cool blankets, surface devices (Arctic Sun)
    • intravascular cooling – catheter inserted into IVC that cools blood, effective and quick but increases risk of venous thrombosis and infection
  2. hyperventilation – effective but lasts only 10-20 hours, CO2 levels <25 can increase risk of brain ischemia, sustained hyperventilation x 5 days has been shown to slow recovery of severe TBI at 3 and 6 months
  3. Mannitol – target osmolality to 300-320, dose is 025 to 1.5 g/Kg bolus IV, watch out for hypotension, hypovolemia and renal tubular damage
  4. barbiturates – pentobarbital most commonly used (that is, if barbiturates are used at all), load with 5-20mg/Kg bolus then 1-4mg/Kg/hr infusion; watch out for hypotension; will lose neurologic exam so requires accurate monitoring to guide therapy – EEG, ICP, hemodynamics



See link below for MS Word / PDF document of sample order sheet for management of ICP crisis.

ICP Crisis Order Sheet

ICP Crisis Order Sheet (Sy, MD)


Miller, Chad M, and Michel T Torbey. Neurocritical Care Monitoring. Print.

Stevens, Robert D., Michael Shoykhet, and Rhonda Cadena. “Emergency Neurological Life Support: Intracranial Hypertension And Herniation”. Neurocritical Care 23.S2 (2015): 76-82. Web.

Rapid Sequence Intubation Meds (cheat sheet)

Dose 110 lbs 154 lbs 220 lbs
50 Kg 70 Kg 100 Kg
Fentanyl 2-3 μ/kg IV push over 1-2 min 100-150 140-210 200-300 μ IV push over 1-2 min
Lidocaine 1.5 mg/kg IV 2-3 min before intubation 75 105 150 mg IV 2-3 min before intubation
Esmolol 1-2 mg/kg IV 50-100 70-140 100-200 mg IV
Etomidate 0.3 mg/kg IV push 15 21 30 mg IV push
Propofol 2 mg/kg IV push 100 140 200 mg IV push
Ketamine 1.5-2 mg/kg IV push 75-100 105-40 150-200 mg IV push
Thiopental 3 mg/kg IV push 150 210 300 mg IV push
Succinylcholine 1.5-2 mg/kg IV 75-100 105-40 150-200 mg IV
Rocuronium 1.2 mg/kg 60 84 120 mg
Vecuronium 0.2 mg/kg 10 14 20 mg