Validation of a new coma scale: The FOUR score

Eelco F M Wijdicks, William R. Bamlet, Boby V. Maramattom, Edward M. Manno, Robyn L. McClelland

Research output: Contribution to journalArticlepeer-review

619 Scopus citations


The Glasgow Coma Scale (GCS) has been widely adopted. Failure to assess the verbal score in intubated patients and the inability to test brainstem reflexes are shortcomings. We devised a new coma score, the FOUR (Full Outline of UnResponsiveness) score. It consists of four components (eye, motor, brainstem, and respiration), and each component has a maximal score of 4. We prospectively studied the FOUR score in 120 intensive care unit patients and compared it with the GCS score using neuroscience nurses, neurology residents, and neurointensivists. We found that the interrater reliability was excellent with the FOUR score (Kw = 0.82) and good to excellent for physician rater pairs. The agreement among raters was similar with the GCS (Kw = 0.82). Patients with the lowest GCS score could be further distinguished using the FOUR score. We conclude that the agreement among raters was good to excellent. The FOUR score provides greater neurological detail than the GCS, recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation. The probability of in-hospital mortality was higher for the lowest total FOUR score when compared with the lowest total GCS score.

Original languageEnglish (US)
Pages (from-to)585-593
Number of pages9
JournalAnnals of neurology
Issue number4
StatePublished - Oct 2005

ASJC Scopus subject areas

  • Clinical Neurology
  • Neurology


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