Comparison of the Prognostic Accuracy of Full Outline of Unresponsiveness (FOUR) Score with Glasgow Coma Scale (GCS) Score among Patients with Traumatic Brain Injury in a Tertiary Care Center

Abstract

Objectives The Glasgow Coma Scale (GCS) is widely used and considered the gold standard in assessing the consciousness of patients with traumatic brain injury. However, some significant limitations, like the considerable variations in interobserver reliability and predictive validity, were the reason for developing the Full Outline of Unresponsiveness (FOUR) score. The current study aims to compare the prognostic accuracy of the FOUR score with the GCS score for in-hospital mortality and morbidity among patients with traumatic brain injury.

Materials and Methods A prospective cohort study was conducted, where 237 participants were selected by consecutive sampling from a tertiary care center. These patients were assessed with the help of GCS and FOUR scores within 6 hours of admission, and other clinical parameters were also noted. The level of consciousness was checked every day with the help of GCS and FOUR scores until their last hospitalization day. Glasgow Outcome Scale was used to assess their outcome on the last day of hospitalization. The GCS and FOUR scores were compared, and data were analyzed by descriptive and inferential statistics. The chi-square test, independent Student's t-test, and receiver operating characteristic analysis were used for inferential analysis.

Results The area under the curve (AUC) for the GCS score at the 6th hour for predicting mortality was 0.865 with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 64%. The AUC for FOUR scores at the 6th hour for predicting the mortality was 0.893, with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 73%.

Conclusion The current study shows that, as per the AUC of GCS and FOUR scores, their sensitivity was equal, but specificity was higher in the FOUR score. So, the FOUR score has higher accuracy than the GCS score in the prediction of mortality among traumatic brain injury patients.

Keywords

traumatic brain injury - Glasgow Coma Scale - Full Outline of Unresponsiveness - sensitivity and specificity - ROC curve

• References

• 1 Hickey J. The Clinical Practice of Neurological and Neurosurgical Nursing. 6th ed. Philadelphia, USA: Wolters Kluwer Health | Lippincott Williams & Wilkins; 2009
• 2 Adcock AK, Kosiorek H, Parikh P, Chauncey A, Wu Q, Demaerschalk BM. Reliability of robotic telemedicine for assessing critically ill patients with the Full Outline of Unresponsiveness score and Glasgow Coma Scale. Telemed J E Health 2017; 23 (07) 555-560
• 3 Ghelichkhani P, Esmaeili M, Hosseini M, Seylani K. Glasgow Coma Scale and FOUR score in predicting the mortality of trauma patients; a diagnostic accuracy study. Emergency (Tehran) 2018; 6 (01) e42
• 4 Bledsoe BE, Casey MJ, Feldman J. et al. Glasgow Coma Scale scoring is often inaccurate. Prehosp Disaster Med 2015; 30 (01) 46-53
• 5 Mishra RK, Mahajan C, Kapoor I, Prabhakar H, Bithal PK. Comparison of Full Outline of Unresponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients. Indian J Anaesth 2019; 63 (04) 295-299
• 6 Bayraktar YS, Sahinoglu M, Cicekci F. et al. Comparison of Glasgow Coma Scale and Full Outline of Unresponsiveness (FOUR) score: a prospective study. Turk Neurosurg 2019; 29 (02) 285-288
• 7 Abdallah A, Demaerschalk BM, Kimweri D. et al. A comparison of the Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) scores in predicting mortality among patients with reduced level of consciousness in Uganda. Neurocrit Care 2020; 32 (03) 734-741
• 8 Wijdicks EFM, Kramer AA, Rohs Jr T. et al. Comparison of the Full Outline of Unresponsiveness score and the Glasgow Coma Scale in predicting mortality in critically ill patients. Crit Care Med 2015; 43 (02) 439-444
• 9 Baratloo A, Mirbaha S, Bahreini M, Banaie M, Safaie A. Outcome of trauma patients admitted to emergency department based on Full Outline of Unresponsiveness score. Adv J Emerg Med 2017; 1 (01) e2
• 10 McNett MM, Amato S, Philippbar SA. A comparative study of Glasgow Coma Scale and Full Outline of Unresponsiveness scores for predicting long-term outcome after brain injury. J Neurosci Nurs 2016; 48 (04) 207-214
• 11 Oh H, Shin S, Kim S, Seo W. Construct validity and reliability of the Full Outline of Unresponsiveness (FOUR) score in spontaneous subarachnoid haemorrhage caused by aneurysm rupture. J Clin Nurs 2019; 28 (21-22): 3776-3785
• 12 Suresh V, Yaddanapudi LN, Podder S. Full Outline of UnResponsiveness score versus Glasgow Coma Scale in critically ill patients with altered sensorium: a comparison of inter-observer variability and outcomes. Indian J Anaesth 2019; 63 (08) 640-647
• 13 Temiz NC, Kose G, Tehli O, Acikel C, Hatipoglu S. A comparison between the effectiveness of Full Outline of Unresponsiveness and Glasgow Coma Score at neurosurgical intensive care unit patients. Turk Neurosurg 2018; 28 (02) 248-250
• 14 Ramazani J, Hosseini M. Prediction of mortality in the medical intensive care unit with serial Full Outline of Unresponsiveness score in elderly patients. Indian J Crit Care Med 2022; 26 (01) 94-99
• 15 Saika A, Bansal S, Philip M, Devi BI, Shukla DP. Prognostic value of FOUR and GCS scores in determining mortality in patients with traumatic brain injury. Acta Neurochir 2015; 157: 1323-8
• 16 Babu BVM, Bhashyam S, Lakshmi BS. Comparison of predictive value of Glasgow Coma Scale versus Full Outline of Unresponsiveness (FOUR) scale on the outcome of head injury patients admitted to the intensive care unit. J Evol Med Dent Sci 2017; 6 (28) 2300-2304
• 17 Meredith W, Rutledge R, Fakhry SM, Emery S, Kromhout-Schiro S. The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma 1998; 44 (05) 839-844 , discussion 844–845
• 18 Fitzgerald M, Tan T, Rosenfeld JV. et al. An initial Glasgow Coma Scale score of 8 or less does not define severe brain injury. Emerg Med Australas 2022; 34 (03) 459-461
• 19 Mahmoud F, Mansour D, Roshdy A, Srour O. Comparative study between Glasgow Coma Scale and Full Outline of Unresponsiveness scale in clinical outcomes prediction of neurological disorders patients. Egypt J Hosp Med 2022; 89: 5248-5257
• 20 Nair SS, Surendran A, Prabhakar RB, Chisthi MM. Comparison between FOUR score and GCS in assessing patients with traumatic head injury: a tertiary centre study. Int Surg J 2017; 4 (02) 656
• 21 Foo CC, Loan JJM, Brennan PM. The relationship of the FOUR score to patient outcome: a systematic review. J Neurotrauma 2019; 36 (17) 2469-2483
• 22 Ahmadi S, Sarveazad A, Babahajian A, Ahmadzadeh K, Yousefifard M. Comparison of Glasgow Coma Scale and Full Outline of Unresponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2023; 49 (04) 1693-1706
• 23 Gorji MA, Hoseini SH, Gholipur A, Mohammadpur RA. A comparison of the diagnostic power of the Full Outline of Unresponsiveness scale and the Glasgow coma scale in the discharge outcome prediction of patients with traumatic brain injury admitted to the intensive care unit. Saudi J Anaesth 2014; 8 (02) 193-197
• 24 Ansari F, Rai A. Assessing the effectiveness of the Full Outline of Unresponsiveness scale and the Glasgow Coma Scale in patients of traumatic head injury. Int Surg J 2021; 8 (12) 3583-3586