{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T09:01:43Z","timestamp":1789030903653,"version":"build-2803163510"},"reference-count":60,"publisher":"SAGE Publications","issue":"17","license":[{"start":{"date-parts":[[2019,8,20]],"date-time":"2019-08-20T00:00:00Z","timestamp":1566259200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,8,20]],"date-time":"2019-08-20T00:00:00Z","timestamp":1566259200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Journal of Neurotrauma"],"published-print":{"date-parts":[[2019,9]]},"abstract":"<jats:p>\n                    The Full Outline of UnResponsiveness (FOUR) score assessment of consciousness replaces the Glasgow Coma Scale (GCS) verbal component with assessment of brainstem reflexes. A comprehensive overview studying the relationship between a patient's FOUR score and outcome is lacking. We aim to systematically review published literature reporting the relationship of FOUR score to outcome in adult patients with impaired consciousness. We systematically searched for records of relevant studies: CENTRAL, MEDLINE, EMBASE, Scopus, Web of Science, ClinicalTrials.gov, and OpenGrey. Prospective, observational studies of patients with impaired consciousness were included where consciousness was assessed using FOUR score, and where the outcome in mortality or validated functional outcome scores was reported. Consensus-based screening and quality appraisal were performed. Outcome prognostication was synthesized narratively. Forty records (37 studies) were identified, with overall low (\n                    <jats:italic toggle=\"yes\">n<\/jats:italic>\n                    \u2009=\u20092), moderate (\n                    <jats:italic toggle=\"yes\">n<\/jats:italic>\n                    \u2009=\u200925), or high (\n                    <jats:italic toggle=\"yes\">n<\/jats:italic>\n                    \u2009=\u200913) risk of bias. There was significant heterogeneity in patient characteristics. FOUR score showed good to excellent prognostication of in-hospital mortality in most studies (area under curve [AUC], &gt;0.80). It was good at predicting poor functional outcome (AUC, 0.80\u20130.90). There was some evidence that motor and eye components (also GCS components) had better prognostic ability than brainstem components. Overall, FOUR score relates closely to in-hospital mortality and poor functional outcome. More studies with standardized design are needed to better characterize it in different patient groups, confirm the differences between its four components, and compare it with the performance of GCS and its recently described derivative, the GCS-Pupils, which includes pupil response as a fourth component.\n                  <\/jats:p>","DOI":"10.1089\/neu.2018.6243","type":"journal-article","created":{"date-parts":[[2019,5,2]],"date-time":"2019-05-02T07:58:57Z","timestamp":1556783937000},"page":"2469-2483","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":45,"title":["The Relationship of the FOUR Score to Patient Outcome: A Systematic Review"],"prefix":"10.1177","volume":"36","author":[{"given":"Ching C.","family":"Foo","sequence":"first","affiliation":[{"name":"College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James J.M.","family":"Loan","sequence":"additional","affiliation":[{"name":"Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul M.","family":"Brennan","sequence":"additional","affiliation":[{"name":"Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2019,8,20]]},"reference":[{"key":"e_1_3_4_2_2","doi-asserted-by":"publisher","DOI":"10.1227\/00006123-198612000-00014"},{"key":"e_1_3_4_3_2","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(14)70120-6"},{"key":"e_1_3_4_4_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.injury.2017.05.038"},{"key":"e_1_3_4_5_2","first-page":"362","article-title":"Systematic selection of prognostic features in patients with severe head injury","volume":"6","author":"Braakman R.","year":"1980","unstructured":"Braakman R., , Gelpke G.J., , Habbema J.D., , Maas A.I., , and Minderhoud J.M. (1980). Systematic selection of prognostic features in patients with severe head injury. Neurosurgery, 6, 362\u2013370.","journal-title":"Neurosurgery"},{"key":"e_1_3_4_6_2","doi-asserted-by":"publisher","DOI":"10.1089\/neu.2006.0036"},{"key":"e_1_3_4_7_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.0050165"},{"key":"e_1_3_4_8_2","doi-asserted-by":"publisher","DOI":"10.1002\/ana.20611"},{"key":"e_1_3_4_9_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1000097"},{"key":"e_1_3_4_10_2","doi-asserted-by":"publisher","DOI":"10.1161\/01.STR.19.5.604"},{"key":"e_1_3_4_11_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(75)92830-5"},{"key":"e_1_3_4_12_2","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-158-4-201302190-00009"},{"key":"e_1_3_4_13_2","doi-asserted-by":"publisher","DOI":"10.1089\/neu.1998.15.587"},{"key":"e_1_3_4_14_2","doi-asserted-by":"publisher","DOI":"10.1007\/978-0-387-49053-3"},{"key":"e_1_3_4_15_2","doi-asserted-by":"publisher","DOI":"10.1097\/MEJ.0b013e32830346ab"},{"key":"e_1_3_4_16_2","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0000000000000707"},{"key":"e_1_3_4_17_2","doi-asserted-by":"publisher","DOI":"10.4103\/1658-354X.130708"},{"key":"e_1_3_4_18_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-013-9947-6"},{"key":"e_1_3_4_19_2","first-page":"215","article-title":"Predictive value of Glasgow Coma Score and Full Outline of Unresponsiveness score on the outcome of multiple trauma patients","volume":"19","author":"Baratloo A.","year":"2016","unstructured":"Baratloo A., , Shokravi M., , Safari S., , and Aziz A.K. (2016). Predictive value of Glasgow Coma Score and Full Outline of Unresponsiveness score on the outcome of multiple trauma patients. Arch. Iran. Med. 19, 215\u2013220.","journal-title":"Arch. Iran. Med"},{"key":"e_1_3_4_20_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-014-9995-6"},{"key":"e_1_3_4_21_2","first-page":"205","article-title":"Prediction of discharge outcome with the Full Outline of Unresponsiveness (FOUR) score in neurosurgical patients","volume":"65","author":"Akavipat P.","year":"2011","unstructured":"Akavipat P., , Sookplung P., , Kaewsingha P., , and Maunsaiyat P. (2011). Prediction of discharge outcome with the Full Outline of Unresponsiveness (FOUR) score in neurosurgical patients. Acta Med. Okayama, 65, 205\u2013210.","journal-title":"Acta Med. Okayama"},{"key":"e_1_3_4_22_2","doi-asserted-by":"publisher","DOI":"10.4103\/0972-5229.188199"},{"key":"e_1_3_4_23_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajme.2014.10.002"},{"key":"e_1_3_4_24_2","doi-asserted-by":"publisher","DOI":"10.1186\/s12883-015-0508-9"},{"key":"e_1_3_4_25_2","doi-asserted-by":"publisher","DOI":"10.4065\/82.4.435"},{"key":"e_1_3_4_26_2","doi-asserted-by":"publisher","DOI":"10.4103\/2229-516X.157152"},{"key":"e_1_3_4_27_2","first-page":"e33653","article-title":"Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and acute physiology and chronic health evaluation in prediction of mortality rate among patients with traumatic brain injury admitted to intensive care unit","volume":"7","author":"Hosseini S.H.","year":"2017","unstructured":"Hosseini S.H., , Ayyasi M., , Akbari H., , and Heidari Gorji M.A. (2017). Comparison of Glasgow Coma Scale, Full Outline of Unresponsiveness and acute physiology and chronic health evaluation in prediction of mortality rate among patients with traumatic brain injury admitted to intensive care unit. Anesthesiol. Pain Med. 7, e33653.","journal-title":"Anesthesiol. Pain Med"},{"key":"e_1_3_4_28_2","doi-asserted-by":"publisher","DOI":"10.1097\/JNN.0000000000000225"},{"key":"e_1_3_4_29_2","doi-asserted-by":"publisher","DOI":"10.1177\/0310057X1204000115"},{"key":"e_1_3_4_30_2","doi-asserted-by":"publisher","DOI":"10.1007\/s11739-011-0583-x"},{"key":"e_1_3_4_31_2","doi-asserted-by":"publisher","DOI":"10.4103\/2229-5151.195401"},{"key":"e_1_3_4_32_2","doi-asserted-by":"publisher","DOI":"10.1186\/cc8963"},{"key":"e_1_3_4_33_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.neurol.2015.02.013"},{"key":"e_1_3_4_34_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-010-9407-5"},{"key":"e_1_3_4_35_2","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0176012"},{"key":"e_1_3_4_36_2","doi-asserted-by":"publisher","DOI":"10.3109\/02688697.2016.1161173"},{"key":"e_1_3_4_37_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-011-9617-5"},{"key":"e_1_3_4_38_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00701-015-2469-6"},{"key":"e_1_3_4_39_2","first-page":"289803","article-title":"A comparison of the Glasgow Coma Scale score with Full Outline of Unresponsiveness scale to predict patients' traumatic brain injury outcomes in intensive care units","volume":"2014","author":"Jalali R.","year":"2014","unstructured":"Jalali R., , and Rezaei M. (2014). A comparison of the Glasgow Coma Scale score with Full Outline of Unresponsiveness scale to predict patients' traumatic brain injury outcomes in intensive care units. Crit. Care Res. Pract. 2014, 289803.","journal-title":"Crit. Care Res. Pract"},{"key":"e_1_3_4_40_2","first-page":"720","article-title":"Glasgow Coma Scale versus Full Outline of UnResponsiveness Scale for prediction of outcomes in patients with traumatic brain injury in the intensive care unit","volume":"26","author":"Sepahvand E.","year":"2016","unstructured":"Sepahvand E., , Jalali R., , Mirzaei M., , Ebrahimzadeh F., , Ahmadi M., , and Amraii E. (2016). Glasgow Coma Scale versus Full Outline of UnResponsiveness Scale for prediction of outcomes in patients with traumatic brain injury in the intensive care unit. Turk. Neurosurg. 26, 720\u2013724.","journal-title":"Turk. Neurosurg"},{"key":"e_1_3_4_41_2","doi-asserted-by":"publisher","DOI":"10.14260\/Jemds\/2017\/495"},{"key":"e_1_3_4_42_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-016-0324-0"},{"key":"e_1_3_4_43_2","doi-asserted-by":"publisher","DOI":"10.2147\/OAEM.S144722"},{"key":"e_1_3_4_44_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-011-9547-2"},{"key":"e_1_3_4_45_2","doi-asserted-by":"publisher","DOI":"10.1007\/s00701-013-1854-2"},{"key":"e_1_3_4_46_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcrc.2012.06.009"},{"key":"e_1_3_4_47_2","doi-asserted-by":"publisher","DOI":"10.4065\/84.8.694"},{"key":"e_1_3_4_48_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-008-9145-0"},{"key":"e_1_3_4_49_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jns.2017.10.034"},{"key":"e_1_3_4_50_2","doi-asserted-by":"publisher","DOI":"10.1177\/1024907917724723"},{"key":"e_1_3_4_51_2","first-page":"960","article-title":"Accuracy of Glasgow Coma Score and FOUR score: a prospective study in stroke patients at siriraj hospital","volume":"100","author":"Surabenjawong U.","year":"2017","unstructured":"Surabenjawong U., , Sonmeethong W., , and Nakornchai T. (2017). Accuracy of Glasgow Coma Score and FOUR score: a prospective study in stroke patients at siriraj hospital. J. Med. Assoc. Thail. 100, 960\u2013966.","journal-title":"J. Med. Assoc. Thail"},{"key":"e_1_3_4_52_2","doi-asserted-by":"publisher","DOI":"10.1177\/0885066617738714"},{"key":"e_1_3_4_53_2","doi-asserted-by":"publisher","DOI":"10.1007\/s12028-017-0396-5"},{"key":"e_1_3_4_54_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.apmr.2010.07.218"},{"key":"e_1_3_4_55_2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(07)61602-X"},{"key":"e_1_3_4_56_2","doi-asserted-by":"publisher","DOI":"10.1007\/978-3-540-71915-1_8"},{"key":"e_1_3_4_57_2","first-page":"203","article-title":"Measures of diagnostic accuracy: basic definitions","volume":"19","author":"\u0160imundi\u0107 A.-M.","year":"2009","unstructured":"\u0160imundi\u0107 A.-M. (2009). Measures of diagnostic accuracy: basic definitions. EJIFCC, 19, 203\u2013211.","journal-title":"EJIFCC"},{"key":"e_1_3_4_58_2","doi-asserted-by":"publisher","DOI":"10.1089\/neu.2007.0510"},{"key":"e_1_3_4_59_2","doi-asserted-by":"publisher","DOI":"10.3171\/2017.12.JNS172780"},{"key":"e_1_3_4_60_2","doi-asserted-by":"publisher","DOI":"10.1093\/neuros\/nyw178"},{"key":"e_1_3_4_61_2","first-page":"12","article-title":"Forty years on: updating the Glasgow Coma Scale","volume":"110","author":"Teasdale G.","year":"2014","unstructured":"Teasdale G. (2014). Forty years on: updating the Glasgow Coma Scale. Nurs. Times, 110, 12\u201316.","journal-title":"Nurs. Times"}],"container-title":["Journal of Neurotrauma"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1089\/neu.2018.6243","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1089\/neu.2018.6243","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1089\/neu.2018.6243","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T22:33:23Z","timestamp":1777674803000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1089\/neu.2018.6243"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,8,20]]},"references-count":60,"journal-issue":{"issue":"17","published-print":{"date-parts":[[2019,9]]}},"alternative-id":["10.1089\/neu.2018.6243"],"URL":"https:\/\/doi.org\/10.1089\/neu.2018.6243","relation":{},"ISSN":["0897-7151","1557-9042"],"issn-type":[{"value":"0897-7151","type":"print"},{"value":"1557-9042","type":"electronic"}],"subject":[],"published":{"date-parts":[[2019,8,20]]}}}