Neurocritical Care

, Volume 16, Issue 1, pp 95–101 | Cite as

The FOUR Score Predicts Outcome in Patients After Traumatic Brain Injury

  • Farid SadakaEmail author
  • Darshan Patel
  • Rekha Lakshmanan
Original Article



The most widely used and most studied coma score to date is the Glasgow Coma Scale (GCS), which is used worldwide to assess level of consciousness and predict outcome after traumatic brain injury (TBI). Our aim was to determine whether the Full Outline of UnResponsiveness (FOUR) score is an accurate predictor of outcome in TBI patients and to compare its performance to GCS.


We prospectively identified TBI patients admitted to our Neuro-ICU between July 2010 and February 2011. We enrolled 51 patients. The FOUR score and GCS were determined by one of the investigators. Outcomes were in-hospital mortality, and poor neurologic outcome (Glasgow Outcome Scale (GOS) 1–3 and Modified Rankin Scale (mRS) score 3–6) at 3–6 months.


There was a high degree of internal consistency for both the FOUR score (Cronbach’s alpha = 0.89) and GCS (Cronbach’s alpha = 0.85). In terms of predictive power for in-hospital mortality, the area under the receiver operating characteristic (ROC) curve was 0.93 for FOUR score and 0.89 for GCS. In terms of predictive power of poor neurologic outcome at 3–6 months, the area under the ROC curve was 0.85 for FOUR score and 0.83 for GCS as evidenced by GOS 1–3, and 0.80 for FOUR score and 0.78 for GCS as evidenced by mRS 3–6. The odds ratio (OR) for in-hospital mortality was 0.64 (0.46–0.88) from FOUR score and 0.63 (0.45–0.89) from GCS, for poor neurologic outcome was 0.67 (0.53–0.85) from FOUR score and 0.65 (0.51–0.83) from GCS for GOS, and was 0.71 (0.57–0.87) from FOUR score and 0.71 (0.57–0.87) from GCS for mRS.


The FOUR score is an accurate predictor of outcome in TBI patients. It has some advantages over GCS, such as all components of FOUR score but not GCS can be rated in intubated patients.


Coma Traumatic brain injury Full Outline of UnResponsiveness (FOUR) score Glasgow coma scale 



The authors would like to acknowledge Edward Spitznagel, PhD for his statistical support.


This study was not sponsored. None of the authors have anything to disclose.


  1. 1.
    Ghajar J. Traumatic brain injury. Lancet. 2000;356:923–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Rutland-Brown W, Langlois JA, Thomas KE, Xi YL. Incidence of traumatic brain injury in the United States, 2003. J Head Trauma Rehabil. 2006;21:544–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81–4.PubMedCrossRefGoogle Scholar
  4. 4.
    Teasdale GM, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir. 1976;34:45–55.CrossRefGoogle Scholar
  5. 5.
    Rimel RW, Giordani NP, Barth JT, Jane JJ. Moderate head injury: completing the spectrum of brain trauma. Neurosurgery. 1982;11:344–51.PubMedCrossRefGoogle Scholar
  6. 6.
    Rimel RW, Jane JA, Edlich RF. An injury severity scale for comprehensive management of central nervous system trauma. JACEP. 1979;8:64–7.PubMedGoogle Scholar
  7. 7.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.PubMedCrossRefGoogle Scholar
  8. 8.
    Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–63.PubMedCrossRefGoogle Scholar
  9. 9.
    Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flannagan ME. A revision of the trauma score. J Trauma. 1989;29:623–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Gormican SP. CRAMS scale: field triage of trauma victims. Ann Emerg Med. 1982;11:132–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma. 1987;27:370–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Champion HR, Copes WS, Sacco WJ, Frey CF, Holcroft JW, Hoyt DB, Weigelt JA. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma. 1996;40:42–8. discussion 48–9.Google Scholar
  13. 13.
    Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005;58(4):585–93.PubMedCrossRefGoogle Scholar
  14. 14.
    Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EF. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc. 2009;84(8):694–701.PubMedCrossRefGoogle Scholar
  15. 15.
    Stead LG, Wijdicks EF, Bhagra A, et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care. 2009;10(1):50–4.PubMedCrossRefGoogle Scholar
  16. 16.
    Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL. Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc. 2007;82(4):435–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Fugate JE, Rabinstein AA, Claassen DO, White RD, Wijdicks EF. The FOUR score predicts outcome in patients after cardiac arrest. Neurocrit Care. 2010;13(2):205–10.PubMedCrossRefGoogle Scholar
  18. 18.
    Weiss N, Mutlu G, Essardy F, Nacabal C, Sauves C, Bally C, Houbert M, Lecorre C, Germack V, Demeret S, Pierrot-Deseilligny C, Bolgert F. The French version of the FOUR score: a new coma score. Rev Neurol. 2009;165:796–802.PubMedCrossRefGoogle Scholar
  19. 19.
    Akavipat P. Endorsement of the FOUR score for consciousness assessment in neurosurgical patients. Neurol Med Chir. 2009;49:565–71.CrossRefGoogle Scholar
  20. 20.
    Van Swieten J, Koudstaal P, Visser M, Schouten H, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19(5):604–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet. 1975;1:480–4.PubMedCrossRefGoogle Scholar
  22. 22.
    Dombovy ML, Olek AC. Recovery and rehabilitation following traumatic brain injury. Brain Inj. 1997;11(5):305–18.PubMedCrossRefGoogle Scholar
  23. 23.
    Kornbluth J, Bhardwaj A. Evaluation of coma: a critical appraisal of popular scoring systems. Neurocrit Care. 2011;14(1):134–43.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.St. John’s Mercy Medical CenterSt Louis UniversitySt. LouisUSA

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