Skip to main content

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

Internal and Emergency Medicine volume 7, pages 145–152 (2012)Cite this article

Abstract

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.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84

    PubMed  Article  CAS  Google Scholar 

  2. Wijdicks EFM, Bamlet WR, Maramattom BV, Manno EM, McClelland RL (2005) Validation of a new coma scale: the FOUR score. Ann Neurol 58:585–593

    PubMed  Article  Google Scholar 

  3. Balestreri M, Czosnyka M, Chatfield DA, Steiner LA, Schmidt EA, Smielewski P, Matta B, Pickard JD (2004) Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry 75:161–162

    PubMed  CAS  Google Scholar 

  4. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE (1981) APACHE—acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 9:591–597

    PubMed  Article  CAS  Google Scholar 

  5. Stanczak DE, White JG 3rd, Gouview WD, Moehle KA, Daniel M, Novack T, Long CJ (1984) Assessment of level of consciousness following severe neurological insult. A comparison of the psychometric qualities of the Glasgow Coma Scale and the Comprehensive Level of Consciousness Scale. J Neurosurg 60:955–960

    PubMed  Article  CAS  Google Scholar 

  6. Starmark JE, Stalhammar D, Holmgren E (1988) The Reaction Level Scale (RLS85). Manual and guidelines. Acta Neurochir 91:12–20

    Article  CAS  Google Scholar 

  7. Benzer A, Mitterschiffthaler G, Marosi M, Luef G, Puhringer F, De La Renotiere K, Lehner H, Schmutzhard E (1991) Prediction of non-survival after trauma: Innsbruck Coma Scale. Lancet 338:977–978

    PubMed  Article  CAS  Google Scholar 

  8. Gill M, Martens K, Lynch EL, Salih A, Green SM (2007) Inter-rater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness. Ann Emerg Med 49:403–407

    PubMed  Article  Google Scholar 

  9. Wijdicks EFM, Varelas PN, Gronseth GS, Greer DM (2010) Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74:1911–1918

    PubMed  Article  Google Scholar 

  10. Lombardi F, Gatta G, Sacco S, Muratori A, Carolei A (2007) The Italian version of the Coma Recovery Scale-Revised (CRS-R). Funct Neurol 22:47–61

    PubMed  Google Scholar 

  11. Schnakers C, Giacino J, Kalmar K, Piret S, Lopez E, Boly M, Malone R, Laureys S (2006) Does the FOUR score correctly diagnose the vegetative and minimally conscious states? Ann Neurol 60:744–745

    PubMed  Article  Google Scholar 

  12. Eken C, Kartal M, Bacanli A, Eray O (2009) Comparison of the Full Outline of UnResponsiveness Score Coma Scale and the Glasgow Coma Scale in an emergency setting population. Eur J Emerg Med 16:29–36

    PubMed  Article  Google Scholar 

  13. Stead LG, Wijdicks EFM, Bhagra A, Kashyap R, Bellolio MF, Nash DL, Enduri S, Schears R, William B (2009) Validation of a new coma scale, the FOUR score, in the emergency department. Neurocrit Care 10:50–54

    PubMed  Article  Google Scholar 

  14. Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EFM (2009) Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 84:694–701

    PubMed  Article  Google Scholar 

  15. Wolf CA, Wijdicks EFM, Bamlet WR, McClelland RL (2007) Further validation of the FOUR score coma scale by intensive care nurses. Mayo Clin Proc 82:435–438

    PubMed  Article  Google Scholar 

  16. 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 (2009) The French version of the FOUR score: a new coma score. Rev Neurol (Paris) 165:796–802

    Article  CAS  Google Scholar 

  17. Idrovo L, Fuentes B, Medina J, Gabaldón L, Ruiz-Ares G, Abenza MJ, Aguilar-Amat MJ, Martínez-Sánchez P, Rodríguez L, Cazorla R, Martínez M, Tafur A, Wijdicks EF, Diez-Tejedor E (2010) Validation of the FOUR Score (Spanish Version) in acute stroke: an interobserver variability study. Eur Neurol 63:364–369

    PubMed  Article  Google Scholar 

  18. Sacco S, Carolei A (2010) The FOUR Score: a reliable instrument to assess the comatose stroke patient. Eur Neurol 63:370–371

    PubMed  Article  Google Scholar 

  19. Ropper AH (1986) Lateral displacement of the brain, level of consciousness in patients with an acute hemispheral mass. N Engl J Med 314:953–958

    PubMed  Article  CAS  Google Scholar 

  20. Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    PubMed  Article  CAS  Google Scholar 

Download references

Acknowledgments

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

None.

Author information

Affiliations

  1. Department of Neurology, University of L’Aquila, Piazzale Salvatore Tommasi 1, 67100, L’Aquila, Italy

    Eleonora Marcati, Silvia Ricci, Alfonsina Casalena, Antonio Carolei & Simona Sacco

  2. Department of Neurology, La Sapienza University, Rome, Italy

    Danilo Toni

Authors
  1. Eleonora Marcati
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Silvia Ricci
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alfonsina Casalena
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Danilo Toni
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Antonio Carolei
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Simona Sacco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Antonio Carolei.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Marcati, E., Ricci, S., Casalena, A. et al. Validation of the Italian version of a new coma scale: the FOUR score. Intern Emerg Med 7, 145–152 (2012). https://doi.org/10.1007/s11739-011-0583-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11739-011-0583-x

Keywords

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