gms | German Medical Science

65th Annual Meeting of the German Society of Neurosurgery (DGNC)

German Society of Neurosurgery (DGNC)

11 - 14 May 2014, Dresden

Clinical herniation – how to improve differentiation between WFNS grade IV and V

Meeting Abstract

  • Christian Fung - Abteilung für Neurochirurgie, Universitätsklinik Bern
  • Michael Murek - Abteilung für Neurochirurgie, Universitätsklinik Bern
  • Werner Z’Graggen - Abteilung für Neurochirurgie, Universitätsklinik Bern
  • Christoph Ozdoba - Institut für diagnostische und interventionelle Neuroradiologie, Universitätsklinik Bern
  • Jürgen Beck - Abteilung für Neurochirurgie, Universitätsklinik Bern
  • Andreas Raabe - Abteilung für Neurochirurgie, Universitätsklinik Bern

Deutsche Gesellschaft für Neurochirurgie. 65. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC). Dresden, 11.-14.05.2014. Düsseldorf: German Medical Science GMS Publishing House; 2014. DocP 165

doi: 10.3205/14dgnc559, urn:nbn:de:0183-14dgnc5599

Published: May 13, 2014

© 2014 Fung et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Objective: Current data show a favorable outcome after poor grade subarachnoid hemorrhage (SAH) in up to 50% of patients. This limits the use of the WFNS scale for drawing treatment decisions. We therefore analyzed how clinical signs of herniation might improve the existing WFNS grading. Therefore we compared the current WFNS grading and a modified WFNS grading with respect to outcome.

Method: We performed a retrospective study including 182 poor grade SAH patients. Patients were graded according to the original WFNS scale and additionally into a modified classification the “WFNS herniation” (WFNSh grade IV: no herniation; grade V clinical signs of herniation). Outcome was compared between these two grading systems with respect to the dichotomized modified Rankin scale after 6 months.

Results: The WFNS and WFNSh showed a positive predictive value (PPV) for poor outcome of 74.3% (OR 3.79, 95% confidence interval [CI]=1.94, 7.54) and 85.7% (OR 8.27, 95% CI=3.78, 19.47), respectively. With respect to mortality the PPV was 68.3% (OR 3.9, 95% CI=2.01, 7.69) for the WFNS grade V and 77.9% (OR 6.22, 95% CI=3.07, 13.14) for the WFNSh grade V.

Conclusions: Using positive clinical signs of herniation instead of “no response to pain stimuli” (motor Glasgow Coma Scale Score) can improve WFNS V grading. Using this modification, prediction of poor outcome or death improves.