Comparison of Full Outline of UnResponsiveness (FOUR) score and the conventional scores in predicting outcome in aneurysmal subarachnoid haemorrhage patients

Abstract

Background and Aims: Full Outline of UnResponsiveness (FOUR) score is a more comprehensive score used to assess eye response, motor response, brainstem reflexes, and respiration that was introduced to overcome the drawbacks of Glasgow coma scale (GCS) score. Our aim was to assess which score best predicts mortality and poor outcome in aneurysmal subarachnoid haemorrhage (aSAH) patients. Methods: This cohort study, prospectively evaluated the use of FOUR score to assess the mortality and outcome in aSAH patients during the period from November 2015 to November 2016. For each patient of aSAH, GCS, FOUR score, Hunt and Hess (HH) score and World Federation of Neurological Surgeons (WFNS) score were determined at the time of admission to neurosurgical intensive care unit. All patients were followed till 28 days post-SAH and their outcome were assessed by Glasgow outcome scale (GOS). We calculated the sensitivity (Sn) and specificity (Sp) for each of these scores. We generated the receiver operating characteristic curve (ROC), quantified the accuracy by the area under curve (AUC), and also calculated their 95% confidence interval (95% CI). Results: A total of 75 aSAH patients were enrolled for the study. The mortality was 24/75 (32%) with 23 in-hospital deaths. FOUR score was highly specific (86.27%) and sensitive (75%) for the prediction of mortality. However, for predicting 28-day outcome, WFNS and HH grade were most specific (92.5%), whereas FOUR and HH score was moderately specific (68.57%). Conclusion: FOUR score is among the most specific and moderately sensitive tool for prediction of mortality. However, WFNS and HH grade are more specific in predicting the 28-day outcome.

Association of the Verbal Component of the GCS With Mortality in Patients With Encephalopathy Who Are Not Undergoing Mechanical Ventilation

“…2 In addition, it has become part of the serial bedside evaluation and is used as a communication tool for day-to-day and hour-to-hour assessments of clinical status in critically ill patients. 3 The main components of GCS evaluate patients' language comprehension and verbal response (GCS V), eye response (GCS E), and gross motor abilities (GCS M) on a 15-point scale (range [3][4][5][6][7][8][9][10][11][12][13][14][15] in which a score of ≤8 usually warrants intubation and mechanical ventilation 4 when such supportive care is readily available. Despite being the most widely used tool to communicate patients' global neurologic status, its accuracy and utility in intubated patients are limited due to the inability to fully assess the verbal component.…”

“…9 In addition, some studies applied strict selection criteria and excluded patients who were deemed too sedated; who had psychiatric illnesses, alcoholism, or drug addiction 10 ; or who had a personal or family history of neuromuscular diseases. 11 In highly developed medical settings, most comatose patients will be intubated for airway protection and respiratory management. In contrast, a small minority of encephalopathic and comatose patients presenting to most hospitals in sub-Saharan Africa are able to receive mechanical ventilatory support.…”

“…8 FOUR Score is a 17-point scale (ranging from 0–16) assessing eye (FOUR E), motor (FOUR M), respiratory (FOUR R), and brainstem (FOUR B) responses. 8 The FOUR Score has been validated in various clinical settings 9 and compared to the GCS as a tool for predicting mortality in critically ill patients with etiologies such as intracerebral hemorrhage, 10 aneurysmal subarachnoid hemorrhage, 11 traumatic brain injury, 12 and bacterial meningitis. 13 These studies were performed in major academic settings with full access to state-of-the-art medical care, including neurocritical care specialized units, which contributed to relatively lower mortality compared to resource-limited communities.…”

“…9 In addition, some studies applied strict selection criteria and excluded patients who were deemed too sedated; who had psychiatric illnesses, alcoholism, or drug addiction 10 ; or who had a personal or family history of neuromuscular diseases. 11…”

Evaluation of consciousness: the FOUR scale or the Glasgow coma scale? Review

“…Важнейшей является перспектива использования FOUR для определения лечебной стратегии, как, например, GCS при нетравматических субарахноидальных кровоизлияниях (САК). В апреле 2019 г. опубликованы результаты проспективного когортного исследования, проводившегося у пациентов с САК [24]. В результатах показано, что FOUR (86,2 %) более чувствительна и специфична для прогноза смертности 28-дневного неврологического статуса, чем GCS (85 %), однако менее специфична в плане 28-дневного исхода по сравнению с Хант-Хесс и шкалой всемирной ассоциации нейрохирургов WFNS (86,27 vs 92,5 %) [9,24,25].…”