Requested DocAlert: A FRESH Approach to Prognosticating Outcomes After Subarachnoid Hemorrhage

Information sourced from NEJM Journal Watch:

A Better Way to Prognosticate Outcomes After Subarachnoid Hemorrhage

The FRESH score provides more-reliable predictions than the Hunt and Hess score alone.

The Hunt & Hess (HH) score is often used to prognosticate about neurological recovery after subarachnoid hemorrhage (SAH), but many patients with high HH scores will nevertheless recover well. To develop a more sophisticated prognostication score, researchers used a prospective registry of more than 1500 SAH patients at a single tertiary-care center between 1996 and 2014 to identify clinical, imaging, and laboratory parameters that best predicted neurological recovery 12 months after SAH.

The identified best prognostic factors were age, HH score, APACHE-II physiologic score, and aneurysmal rebleeding within 48 hours after admission. The researchers used these parameters to develop the Functional Recovery Expected after Subarachnoid Hemorrhage (FRESH) score, which they validated in a separate sample of 413 patients enrolled in the CONSCIOUS-1 trial. The percentage of poor outcomes (modified Rankin Scale scores, 4–6) increased with increasing FRESH score from 1 to 9: 3%, 6%, 12%, 38%, 61%, 83%, 92%, 98%, and 100%. The score showed outstanding discrimination in the derivation cohort (area under the curve, 0.90) and moderate discrimination in the external validation cohort (0.77). The score’s performance was similar when excluding patients for whom care was withdrawn. In the derivation cohort, the discrimination of the FRESH score (0.90) was better than the HH score alone (0.85). The FRESH score also had significantly better discrimination than the recently developed HAIR score in both the derivation (0.90 vs. 0.88) and validation (0.77 vs. 0.72) cohorts.


This report addresses an important gap in neurocritical care, providing a better way to distinguish which patients with severe SAH will eventually recover versus which will be permanently disabled. The FRESH score’s higher accuracy requires inputting slightly more detailed data, which is justified by the implications of prognosticating for these sick patients. Given these findings, clinicians should move away from using just the HH score to prognosticate about SAH. The authors have created a free application for a FRESH score calculator (

Hooman Kamel, MD reviewing Witsch J et al. Ann Neurol 2016 Apr 30.


Witsch J et al. Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH score. Ann Neurol 2016 Apr 30; [e-pub].
[PubMed® abstract]

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