Internal and Emergency Medicine

, Volume 7, Issue 2, pp 145–152 | Cite as

Validation of the Italian version of a new coma scale: the FOUR score

  • Eleonora Marcati
  • Silvia Ricci
  • Alfonsina Casalena
  • Danilo Toni
  • Antonio CaroleiEmail author
  • Simona Sacco


The Glasgow Coma Scale (GCS) is the most widely accepted tool for the evaluation of consciousness, despite several reported shortcomings. A new coma scale, named Full Outline of UnResponsiveness (FOUR) score, is now available. The aim of the present study is to provide and validate the Italian version of the FOUR score. The Italian version of the FOUR score was developed according to a standardized protocol, and thereafter validated in a series of patients with acute neurological illness. For each patient, the FOUR and the GCS scores were recorded by two physicians randomly selected. The inter-rater agreement for the FOUR and the GCS scores was evaluated using the weighted kappa (κw). The receiving operating characteristic curve was also calculated to determine the ability of the scales to predict outcome. Eighty-seven consecutive patients with an acute brain injury were enrolled. The inter-rater agreement was excellent both for the FOUR (κw = 0.953; P < 0.0001) and the GCS (κw = 0.943; P < 0.01). The area under the curve for mortality was 0.935 for the FOUR and 0.953 for the GCS. The FOUR score provides greater neurological details than the GCS. Our data indicate that the Italian version of the FOUR score is a valid predictor of outcome, yielding reproducible findings across raters independent of their expertise.


Full Outline of UnResponsiveness score Acute brain injury Coma scale Outcome predictor Glasgow Coma Scale 



We are grateful to Angelo G. Blasetti, Renato Galzio, Tullio Pozone, Gustavo Spadetta and all their staff for kindly supporting the study.

Conflict of interest



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Copyright information

© SIMI 2011

Authors and Affiliations

  • Eleonora Marcati
    • 1
  • Silvia Ricci
    • 1
  • Alfonsina Casalena
    • 1
  • Danilo Toni
    • 2
  • Antonio Carolei
    • 1
    Email author
  • Simona Sacco
    • 1
  1. 1.Department of NeurologyUniversity of L’AquilaL’AquilaItaly
  2. 2.Department of NeurologyLa Sapienza UniversityRomeItaly

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