Comparison of the Three Strategies of Verbal Scoring of the Glasgow Coma Scale in Patients with Stroke

Abstract

Presence of aphasia in patients with stroke poses a problem in the use of the full form (eye-motor-verbal) Glasgow Coma Scale (GCS). Stroke investigators and clinicians have used three different strategies to deal with the untestable verbal subscale, i.e. eliminating the verbal subscale; pseudoscoring with ‘one’, and median value substitution; but the predictive accuracy of the strategies has not been compared. To compare the predictive accuracy of the three strategies for acute mortality in stroke, we prospectively applied the GCS to 275 consecutive patients with acute stroke and recorded their survival status before discharge from hospital. 95 (33.8%) patients died. 32 (12%) patients had untestable verbal score. Receiver-Operator-Characteristic curves for predicting mortality were constructed with the GCS sum score and with the multivariate logistic models, and areas under the curves were measured to compare the predictive accuracy. They were all found to be similar (0.87–0.88 sq unit). Specifically, the GCS with eye and motor subscale had 87% accuracy compared to 88% for the model with eye, motor and verbal scale. We conclude that the short-form (eye-motor) GCS is as good a predictor of early mortality (within 2 weeks) as the full form (eye-motor-verbal) GCS in patients with stroke.

Mortality prediction in critical care for acute stroke: Severity of illness–score or coma–scale?

“…In contrast to other studies we had a strict methodology for solving this problem scoring for 1 in intubated patients. This is also the method favored by Prasad et al [14]. They found that the verbal score can be omitted in stroke patients with a good prediction of 2-week mortality.…”

Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population

“…Some investigators have modified the GCS by imputing a verbal score to intubated patients. 42–44 To determine whether an imputed verbal sub-score changed our main findings we performed a sensitivity analysis in which we imputed the verbal sub-score for both intubated patients and, separately, for all patients, using the methodology of Meredith et al 43 …”

Validation of the FOUR Score (Spanish Version) in Acute Stroke: An Interobserver Variability Study

“…The NIH stroke scale broadly defines consciousness as alert, not alert with or without ‘stimulation’, and coma, and subsequently evaluates comprehension and the response to 2 questions. The GCS is the most widely used coma scale, but the verbal component in particular becomes much less reliable in patients with stroke due to dysphasia and dysarthria or is impossible to assess in intubated patients [4,5,6]. Clearly, there is a need for a more comprehensive coma scale that could be useful in evaluating stroke patients, but prior attempts to modify or replace the GCS have not been successful [7,8,9].…”