Comparative Prognostic Performance Of The Four Score And Glasgow Coma Scale For Mortality Prediction In Adults With Traumatic Brain Injury

Abstract

Background

Early prognostication after traumatic brain injury (TBI) is important for clinical decision-making and monitoring. The Glasgow Coma Scale (GCS) has limitations, particularly in intubated patients and assessment of brainstem function. The Full Outline of UnResponsiveness (FOUR) score incorporates eye and motor responses, brainstem reflexes, and respiratory pattern and may provide additional prognostic information.

Objective

To assess the prognostic validity of the FOUR score and compare its diagnostic performance with the GCS for predicting mortality in adults with isolated TBI.

Methods

A prospective observational study included 100 adults with isolated TBI presenting within 48 hours of injury. GCS and FOUR scores were assessed at admission and 6 hours after initial resuscitation. Demographic characteristics, injury mechanism, and survival outcomes were recorded. Pearson correlation assessed the relationship between scores. Receiver operating characteristic analysis evaluated discriminatory performance using area under the curve (AUC), sensitivity, specificity, positive predictive value, and negative predictive value.

Results

The mean age was 39.28 ± 14.53 years, and 81% were male. Road traffic accidents accounted for 85% of injuries. GCS and FOUR scores showed strong positive correlations at admission (r = 0.927, p < 0.001) and 6 hours (r = 0.977, p < 0.001). At admission, GCS ≤ 7 had an AUC of 0.905, sensitivity 97.73%, and specificity 83.33%, while FOUR had an AUC of 0.708, sensitivity 100%, and specificity 41.67%. At 6 hours, GCS had an AUC of 0.989, sensitivity 97.73%, and specificity 100%, whereas FOUR had an AUC of 0.833, sensitivity 100%, and specificity 66.67%. Both scores significantly discriminated mortality (p < 0.001).

Conclusion

Both GCS and FOUR scores demonstrated significant prognostic utility for mortality in adults with isolated TBI. FOUR showed consistently high sensitivity, whereas GCS demonstrated higher observed discriminatory performance and specificity, particularly at 6 hours. Larger multicentre studies are warranted to validate these findings and assess the incremental prognostic value of the FOUR score.