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

The aim of the study was to determine whether the Full Outline of UnResponsiveness (FOUR) score, which includes eyes opening (E), motor function (M), brainstem reflex (B), and respiratory pattern (R), can be used as an alternate method to the Glasgow Coma Scale (GCS) in predicting intensive care unit (ICU) mortality in traumatic brain injury (TBI) patients. From January 2015 to June 2015, patients with isolated TBI admitted to the ICU were enrolled. Three advanced practice nurses administered the FOUR score, GCS, Acute Physiology and Chronic Health Evaluation II (APACHE II), and Therapeutic Intervention Scoring System (TISS) concurrently from ICU admissions. The endpoint of observation was mortality when the patients left the ICU. Data are presented as frequency with percentages, mean with standard deviation, or median with interquartile range. Each measurement tool used area under the receiver operating characteristic curve to compare the predictive power between these four tools. In addition, the difference between survival and death was estimated using the Wilcoxon rank sum test. From 55 TBI patients, males (72.73%) were represented more than females, the mean age was 63.1±17.9, and 19 of 55 observations (35%) had a maximum FOUR score of 16. The overall mortality rate was 14.6%. The area under the receiver operating characteristic curve was 74.47% for the FOUR score, 74.73% for the GCS, 81.78% for the APACHE II, and 53.32% for the TISS. The FOUR score has similar predictive power of mortality compared to the GCS and APACHE II. Each of the parameters-E, M, B, and R-of the FOUR score showed a significant difference between mortality and survival group, while the verbal and eye-opening components of the GCS did not. Having similar predictive power of mortality compared to the GCS and APACHE II, the FOUR score can be used as an alternative in the prediction of early mortality in TBI patients in the ICU.

Objectives The Glasgow Coma Scale (GCS) is widely used and considered the gold standard in assessing the consciousness of patients with traumatic brain injury. However, some significant limitations, like the considerable variations in interobserver reliability and predictive validity, were the reason for developing the Full Outline of Unresponsiveness (FOUR) score. The current study aims to compare the prognostic accuracy of the FOUR score with the GCS score for in-hospital mortality and morbidity among patients with traumatic brain injury. Materials and Methods A prospective cohort study was conducted, where 237 participants were selected by consecutive sampling from a tertiary care center. These patients were assessed with the help of GCS and FOUR scores within 6 hours of admission, and other clinical parameters were also noted. The level of consciousness was checked every day with the help of GCS and FOUR scores until their last hospitalization day. Glasgow Outcome Scale was used to assess their outcome on the last day of hospitalization. The GCS and FOUR scores were compared, and data were analyzed by descriptive and inferential statistics. The chi-square test, independent Student's t-test, and receiver operating characteristic analysis were used for inferential analysis. Results The area under the curve (AUC) for the GCS score at the 6th hour for predicting mortality was 0.865 with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 64%. The AUC for FOUR scores at the 6th hour for predicting the mortality was 0.893, with a cutoff value of 5.5, and it yields a sensitivity of 87% and a specificity of 73%. Conclusion The current study shows that, as per the AUC of GCS and FOUR scores, their sensitivity was equal, but specificity was higher in the FOUR score. So, the FOUR score has higher accuracy than the GCS score in the prediction of mortality among traumatic brain injury patients.

To evaluate the Full Outline of Unresponsiveness (FOUR) score as a predictor of outcome in adult patients with bacterial meningitis. We selected 427 patients from a nationwide, prospective cohort on community-acquired bacterial meningitis included from August 2011 to November 2016. Data on patient history, symptoms and signs on admission, treatment, and outcome were collected. We compare the FOUR score with the Glasgow Coma Scale (GCS) score, performed a receiver operator characteristic curve analysis, and calculated the area under the curve (AUC) of the FOUR and GCS scores for the prediction of unfavorable outcome and mortality. The median FOUR score on admission was 14 (interquartile range [IQR] 12-16), and the median GCS score was 12 (IQR 9-14). The outcome was unfavorable in 135 of 427 (32%) patients, of whom 55 (13%) died. There was a strong correlation between the FOUR score and the GCS score (r = 0.85, p < 0.001). AUCs for the GCS and FOUR scores in the prediction of unfavorable outcome (both 0.64) and mortality (both 0.68) were comparable. Logistic regression analysis showed that the FOUR motor, brainstem, and respiration items were individual predictors of unfavorable outcome and mortality. For the GCS score, only the motor component was predictive, while the FOUR score provided a spectrum of clinical abnormalities in patients with a GCS score of 3. The FOUR score adds considerably to the prediction of outcome in patients with severe meningitis by means of better testing of the brainstem reflexes and respiration status. Future studies should consider incorporating the FOUR score into clinical assessment.

Currently, Glasgow Coma Scale (GCS) is used to assess patients' level of consciousness. Although this tool is highly popular in clinical settings, it has various limitations that reduce its applicability in certain situations. This had led researchers to look for alternative scoring systems. This study aims to compare the value of GCS and Full Outline of UnResponsiveness (FOUR) score for prediction of mortality in traumatic brain injury (TBI) patients through a systematic review and meta-analysis. Online databases of Medline, Embase, Scopus, and Web of Science were searched until the end of July 2022 for studies that had compared GCS and FOUR score in TBI patients. Interested outcomes were mortality and unfavorable outcome (mortality + disability). Findings are reported as area under the curve (AUC) sensitivity, specificity, and diagnostic odds ratio. 20 articles (comprised of 2083 patients) were included in this study. AUC of GCS and FOUR score for prediction of in-hospital mortality after TBI was 0.92 (95% CI 0.80-0.91) and 0.91 (95% CI 0.88-0.93) respectively. The diagnostic odds ratio of the two scores for prediction of in-hospital mortality after TBI was 44.51 (95% CI 23.58-84.03) for GCS and 45.16 (95% CI 24.25-84.09) for FOUR score. As for prediction of unfavorable outcome after TBI, AUC of GCS and FOUR score were 0.95 (95% CI 0.93 to 0.97) and 0.93 (95% CI 0.91-0.95), respectively. The diagnostic odds ratios for prediction of unfavorable outcome after TBI were 66.31 (95% CI 35.05-125.45) for GCS and 45.39 (95% CI 23.09-89.23) for FOUR score. Moderate level of evidence showed that the value of GCS and FOUR score in the prediction of in-hospital mortality and unfavorable outcome is comparable. The similar performance of these scores in assessment of TBI patients gives the medical staff the option to use either one of them according to the situation at hand.

Background: For assessment of unconscious state in Medical Intensive Care Unit, physician mostly rely on Glasgow Coma Scale (GCS). But its verbal component has limitations in aphasic and intubated patient. More over its predilection ability to mortality is hardly challenged. The FOUR (Full outline of unresponsiveness) score, a new coma scale, evaluates 4 components: Eye, motor responses, brain stem reflexes and respiration. Aim of this study was to compare Full Outline of Unresponsiveness (FOUR) scale for prediction of mortality among patients admitted in Medical Intensive Care Unit (MICU) of a tertiary care hospital of Bangladesh with Glasgow Coma Scale (GCS). Objectives: To compare prediction of mortality between Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) scale. Methods: This is a prospective observational study was carried out in the Department of Critical Care Medicine, BIRDEM General Hospital to compare the mortality predilection in between FOUR score and GCS score. All consecutive adult unconscious patients over the age of 18 years were included in this study. Sedated patients were examined while they were not getting sedation or during routine sedation window period. Altered conscious level was examined by both GCS and FOUR scales. Data were collected using a check list containing demographic information, preexisting chronic illness, biochemical markers, imaging findings etc. Later patients were followed up and data regarding ICU stay, mortality and time of discharged from ICU were recorded. Both GCS and FOUR score were compared between survivor and non-survivor group and compared both score in between non-survivor group. Ultimately data were analyzed by using Statistical Package for Social Sciences (SPSS) software (version 20). Results: Total 105 unconscious patients were enrolled within the study after fulfilling inclusion &amp; exclusion criteria. Among them 34 patients were survivor and 71 patient were non-survivor. The mean and SD of age in this study were 64 .55 ±14.65 years. The peak age distribution was (61-70) 39%. Among them 54.3 % (n=57) were male and 45.7 % (n=48) were female. DM (82.85%) was the most common comorbidity and the predominant diagnosis was Septic shock 33% followed by Ischemic stroke 29%, Meningo encephalitis 19.04 %, and Electrolytes imbalance 17.14%, Cardiogenic shock 12.38% etc. In both GCS and FOUR score their value significantly differ in case of both survival ([7.15± 1.56]; P&lt;.0001 and [7.74± 2.26]; P&lt;.0001) and non-survival group ([5.38± 1.96]; P &lt;0.0001) and ([5.35± 2.83]; P &lt;0.0001). But comparison of FOUR score (5.35± 2.83) with GCS (5.38± 1.96) in terms of predicting mortality their value not significantly differ (P &lt;0.93). So both GCS and FOUR score is equally effective predicting mortality among unconscious patients. Conclusion: Both GCS and FOUR score significantly vary among survivor and non-survivor groups of unconscious patients but while comparing them regarding predicting mortality there is no significant differences in both score. Finally we conclude that both GCS and FOUR score equally good at predicting in hospital mortality among unconscious patients admitted in MICU. Bangladesh Crit Care J September 2022; 10(2): 76-81

BackgroundThe Glasgow Coma Scale (GCS) is currently the most widely used scoring system for comatose patients. A decade ago, the Full Outline of Unresponsiveness (FOUR) score was devised to better capture four functional aspects of consciousness (eye, motor responses, brainstem reflexes, and respiration). This study aimed to validate the Chinese version of the FOUR score in patients with different levels of consciousness.MethodsThe study had two phases: (1) translation of the FOUR score, and (2) assessment of its reliability and validity. The Chinese version of the FOUR score was developed according to a standardized protocol. One hundred-twenty consecutive patients with acute brain damage, admitted to Nanfang Hospital (Southern Medical University, Guangdong, China) from November 2014 to February 2015, were enrolled. The inter-rater agreement for the FOUR score and GCS was evaluated using intraclass correlation coefficient (ICC). Receiver operating characteristic (ROC) curves were established to determine the scales’ abilities to predict outcome.ResultsThe rater agreement was excellent both for FOUR (ICC = 0.970; p < 0.001) and GCS (ICC = 0.958; p < 0.001). The FOUR score yielded an excellent test-retest reliability (ICC = 0.930; p < 0.001). Spearman’s correlation coefficients between GCS and the FOUR score were high: r = 0.932, first rating; r = 0.887, second rating (all p < 0.001). Areas under the curve (AUC) for mortality were 0.834 (95 % CI, 0.740–0.928) and 0.815 (95 % CI, 0.723–0.908) for the FOUR score and GCS, respectively.ConclusionsThe Chinese version of the FOUR score is a reliable scale for evaluating the level of consciousness in patients with acute brain injury.

To evaluate the effectiveness and the use of Glasgow Coma Score (GCS) and Full Outline of Unresponsiveness (FOUR) score by nurses in the follow-up and evaluation of patients admitted to the neurosurgical intensive care unit for cranial surgery or head trauma. The study was performed at a neurosurgical intensive care unit. Sample size was determined as 47 patients (a= 0.05, power= 0.95). The correlation coefficient less than 0.5 was accepted as weak. In the first 24 hours, Karnofsky Performance Scale was applied and the Acute Physiology and Chronic Health Evaluation II (APACHE II) Score calculated for patients who were admitted to the intensive care unit for cranial surgery or head trauma. Also FOUR and GCS were applied by two different nurses twice a day. Intraclass Correlation Coefficient, Pearson Correlation and Cronbach?s Alpha Security Index analyses were used to evaluate the data. Concordance was above 0.810 and correlation was above 0.837 between GCS and FOUR score evaluation results of nurses. Correlation of two different evaluation at every shift for GCS was 0.887, and for FOUR was 0.827 and above. Karnofsky Performance Scale correlation with FOUR and GCS scores of patients at admission and discharge from the intensive care unit was 0.709 and above. The correlation between APACHE II and FOUR was 0.851; between APACHE II and GCS 0.853. There was no difference between the evaluations of two scores and two nurses statistically. Concordance between nurses was found high both for GCS and FOUR. The FOUR score is as effective as GCS on the follow-up of patients who are managed in the neurosurgical intensive care units.

The utility of the Glasgow Coma Scale (GCS) in intubated patients is limited due to reliance on language function evaluation. The Full Outline of Unresponsiveness (FOUR) Score was designed to circumvent this shortcoming, instead adding evaluations of brainstem reflexes (FOUR B) and specific respiratory patterns (FOUR R). We aimed to determine whether the verbal component of the GCS (GCS V) among nonintubated patients with encephalopathy significantly contributes to mortality prediction and to assess GCS vs FOUR Score performance. All prospectively consented patients ≥18 years of age admitted to the Internal Medicine service at Zambia's University Teaching Hospital from October 3, 2017, to May 21, 2018, with a GCS score ≤10 have undergone simultaneous GCS and FOUR Score assessments. The patients were not eligible for mechanical ventilatory support per local standards. Patients' demographics and clinical characteristics were presented as either percentage frequencies or numerical summaries of spread. The predictive power of the GCS without the Verbal component vs total GCS vs FOUR Score on mortality was estimated with the area under the receiver operating characteristic curve (AU ROC). Two hundred thirty-five patients (50% women, mean age 47.5 years) were enrolled. All patients were Black. Presumed etiology was CNS infection (64, 27%), stroke (63, 27%), systemic infection (39, 16.6%), and metabolic encephalopathy (3, 14.5%); 14.9% had unknown etiology. In-hospital mortality was 83%. AU ROC for GCS Eye + Motor score (0.662) vs total GCS score (0.641) vs total FOUR Score (0.657) did not differ. Odds ratio mortality for GCS score >6 vs ≤6 was 0.32 (95% confidence interval [CI] 0.14-0.72, p = 0.01); for FOUR Score >10 vs ≤10, it was 0.41 (95% CI 0.19-0.86, p = 0.02). Absence of a verbal component of GCS had no significant impact on the performance of the total GCS, and either GCS or FOUR Score is an acceptable scoring tool for mortality prediction in the resource-limited setting. These findings need further validation in the countries with readily available mechanical ventilatory support. This study provides Class I evidence that the verbal component of the GCS does not significantly contribute to a total GCS score in mortality prediction among patients with encephalopathy who are not intubated.

The Glasgow Coma Scale (GCS) has some limitations when evaluating the unconscious patient. This study aims to validate the Persian version of the FOUR (Full Outline of Unresponsiveness) score as a proposed substitute. Two nurses, two nursing students, and two physicians scored the prepared Persian version of the FOUR and GCS in 84 patients with acute brain injury. The inter-rater agreement for the FOUR and the GCS scores was evaluated by the weighted kappa (κ w). The outcome prediction power of the scales was assessed by the area under the curve (AUC) in the ROC curve. The inter-rater agreement of the FOUR was excellent (κ w=0.923, 95% CI, 0.874-0.971) and comparable with the one of the GCS (κ w=0.938, 95% CI, 0.889-0.987). The area under the curve (AUC) for predicting in-hospital mortality (modified Rankin Scale: 6) was 0.835 for the FOUR (95% CI, 0.739-0.907) and 0.772 for the GCS (95% CI, 0.668-0.856) (P=0.01). AUC for predicting poor outcome (modified Rankin Scale: 3-6) for the total FOUR score was 0.983 (95% CI, 0.928-0.999), which is comparable with 0.987 for the total GCS score (95% CI, 0.934-1.000). The researchers conclude that the Persian version of the FOUR score is a reliable and valid scale to assess unconscious patients with traumatic brain injury and can be substituted for the GCS.

Objective: This study evaluated the full outline of Unresponsiveness (FOUR) score and Glasgow Coma Scale (GCS) to predict traumatic brain injury (TBI) outcomes. Methods: Among 107 patients, FOUR and GCS grading systems analyzed emergency department patients within 24 hours. FOUR and GCS were assessed simultaneously. Patients were followed for 15 days/discharge/death to evaluate the results. Modified Rankin scores measured in-hospital mortality, morbidity, and stay. Results: 65.42% of patients were 25–65. 10% were under 25, and 25% were over 65. Patients were 81% male. Road traffic accidents (RTAs) (90%), falls (7.48%), and assaults (1.47%) caused TBI. 19.62% died. 85.7% of 21 non-survivors had GCS &lt;5 and FOUR &lt;4. GCS mortality sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 85.71%, 93.02%, 75, and 96.4 (P &lt; 0.0001). FOUR score mortality sensitivity, specificity, PPV, and NPV were 85.71%, 96.51%, 85.7, and 96.5 (P &lt; 0.0001). GCS and FOUR AUCs matched (P = 0.52). The unadjusted model reduced in-hospital mortality by 14% for every one point increase in GCS. Every 1-point FOUR score increase reduced in-hospital mortality by 40% in the unadjusted model. GCS and FOUR scored 0.9 Spearman. Conclusion: The FOUR score was comparable in the prediction of mortality in these patients.

The Glasgow Coma Scale (GCS) is the most widely used tool for the evaluation of the level of consciousness. The Full Outline of Unresponsiveness (FOUR) Score is a new coma Scale that was developed considering the limitations of the GCS, and has been found to be useful in an intensive care setting. We aimed to compare FOUR Score and GCS in the emergency setting. All patients older than 17 years who presented with an altered level of consciousness, after any trauma to the head or with neurological complaints were included in this study. Three-month mortality, in-hospital mortality, and poor outcome using a Modified Rankin Scale (MRS) of 3-6 points were used as the primary outcome measures. A total of 185 patients were included in the study. Area under the curve (AUC) values in predicting 3-month mortality for GCS was 0.726 [P=0.0001 and 95% confidence interval (CI): 0.656-0.789] and 0.776 (P=0.0001 and 95% CI: 0.709-834) for FOUR Score. AUC in predicting hospital mortality for GCS was 0.735 (P=0.0001 and 95% CI: 0.655-0.797) and 0.788 (P=0.0001 and 95% CI: 0.722-0.844) for FOUR Score. AUC in predicting poor outcome (Modified Rankin Scale: 3-6) was 0.720 (P=0.001 and 95% CI: 0.650-784) for GCS and 0.751 (P=0.0001 and 95% CI: 0.682-0.812) for FOUR Score. The new coma Scale, FOUR Score, is not superior to the GCS. However, the combination of the eye and motor components of FOUR Score is a valuable tool that can be used instead of either the FOUR Score or GCS.

The Glasgow coma scale (GCS) was introduced as a scoring system for patients with impaired consciousness after traumatic brain injury (TBI). Since, it has become the worldwide standard in TBI assessment. The GCS has repeatedly been criticized for its several failures to reflect verbal reaction in intubated patients, and to test brain stem reflexes. Recently, the full outline of unresponsiveness (FOUR) score was introduced, which is composed of four clinically distinct categories of evaluation: eye reaction, motor function, brainstem reflexes and respiratory pattern. This study aims to validate the FOUR score in neurosurgical patients. FOUR score and GCS were assessed in a consecutive series of neurosurgical patients with severely impaired consciousness (GCS < 9). Their correlation with the 30-day Glasgow outcome score (GOS) was compared. Patients admitted for TBI, spontaneous intracranial hemorrhage (intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, cerebellar hemorrhage), or malignant middle cerebral artery infarction were included. We assessed a total of 101 patients (mean age = 64y, SD = 36.1y). The area under the curve (AUC) for mortality was 0.768 (P = 0.0001) for the FOUR Score, and 0.699 (P = 0.001) for the GCS. For poor outcome (GOS = 2-3) the FOUR score AUC was 0.683 (P = 0.018), the GCS AUC was 0.682 (P = 0.019). The FOUR score value for favorable outcome (GOS = 4-5) was 0.748 (P = 0.001), the corresponding GCS value was 0.704 (P = 0.002). The FOUR score was more robust than the GCS in predicting mortality after 30 days in neurosurgical patients with severely impaired consciousness. There was no relevant difference in predicting poor and good outcome.

ABSTRACTAimComparison of the Full Outline of UnResponsiveness (FOUR) score with the Glasgow Coma Scale (GCS) score to find the better scoring system for predicting outcomes among altered sensorium patients in the critical care unit.Materials and methodsThis is a prospective observational study. It included 100 patients of altered sensorium, whose GCS and FOUR scores were calculated at admission and followed up till death or discharge to note the outcome. Individual demographics and diagnosis were recorded, and the results were analyzed statistically.ResultsThe correlation between the two scores was excellent, with the Spearman's correlation coefficient of 0.88. Discrimination ability of the two scoring systems, as assessed by the area under the receiver operating characteristic curve, was 0.778 for GCS score and 0.883 for FOUR score (p <0.001). When area under the curve (AUC) was calculated exclusively in stroke cases, it was 0.836 for GCS score and 0.944 for FOUR score. Among nonstroke cases, the AUC was 0.756 and 0.859, respectively. However, the 95% confidence limits were overlapping among the corresponding scores.ConclusionThe above study concludes that there is a good correlation between GCS and FOUR scores in predicting outcomes. Superiority of FOUR score could not be established statistically in view of overlapping confidence limits. However, it performed at par with GCS in prognosticating mortality among patients with altered sensorium.Clinical significanceIn critically ill patients with altered sensorium, explaining the prognosis to the attendants is a challenge for the physician. The commonly used GCS score has several shortcomings, especially in intubated patients. Use of the FOUR score can overcome these shortcomings and help in prognostication of these patients. In view of its good correlation with GCS score and equal efficacy in predicting outcomes in varied etiologies, it can be used as a good alternative to the GCS score.How to cite this articleJavvaji PK, Nagatham P, Venkata RR, Puttam H, John SK, Karavalla H, et al. A Comparison of Full Outline of UnResponsiveness Score with Glasgow Coma Scale Score in Predicting Outcomes among Patients with Altered Mental Status Admitted to the Critical Care Unit. Indian J Crit Care Med 2022;26(2):210–215.

The Glasgow Coma Scale (GCS) is a routine component of a neurological exam for critically ill traumatic brain injury (TBI) patients, yet has been criticized for not accurately depicting verbal status among intubated patients or including brain stem reflexes. Preliminary research on the Full Outline of UnResponsiveness (FOUR) Scale suggests it overcomes these limitations. Research is needed to determine correlations with patient outcomes. The aims of this study were to: (1) examine correlations between 24 and 72 h FOUR and GCS scores and functional/cognitive outcomes; (2) determine relationship between 24 and 72 h FOUR scores and mortality. Prospective cohort study. Data gathered on adult TBI patients at a Level I trauma center. FOUR scores assigned at 24, 72 h. Functional outcome measured by functional independence measure scores at rehabilitation discharge; cognitive status measured by Weschler Memory Scale scores 3 months post-injury. n = 136. Mean age 53.1. 72 h FOUR and GCS scores correlated with functional outcome (r s = 0.34, p = 0.05; r s = 0.39, p = 0.02), but not cognitive status. Receiver operating characteristic curves were comparable for FOUR and GCS at 24 and 72 h for functional status (24 h FOUR, GCS = 0.625, 0.602, respectively; 72 h FOUR, GCS = 0.640, 0.688), cognitive status (24 h FOUR, GCS = 0.703, 0.731; 72 h FOUR, GCS = 0.837, 0.674), and mortality (24 h FOUR, GCS = 0.913, 0.935; 72 h FOUR, GCS = 0.837, 0.884). FOUR is comparable to GCS in terms of predictive ability for functional status, cognitive outcome 3 months post-injury, and in-hospital mortality.

Objectives: To compare the performance of multivariate predictive models incorporating either the Full Outline of UnResponsiveness (FOUR) score or Glasgow Coma Score (GCS) in order to test whether substituting GCS with the FOUR score in predictive models for outcome in patients after TBI is beneficial. Material and methods: A total of 162 TBI patients were prospectively enrolled in the study. Stepwise logistic regression analysis was conducted to compare the prediction of (1) in-ICU mortality and (2) unfavourable outcome at 3 months post-injury using as predictors either the FOUR score or GCS along with other factors that may affect patient outcome. The areas under the ROC curves (AUCs) were used to compare the discriminant ability and predictive power of the models. The internal validation was performed with bootstrap technique and expressed as accuracy rate (AcR). Results: The FOUR score, age, the CT Rotterdam score, systolic ABP and being placed on ventilator within day one (model 1: AUC: 0.906 ± 0.024; AcR: 80.3 ± 4.8%) performed equally well in predicting in-ICU mortality as the combination of GCS with the same set of predictors plus pupil reactivity (model 2: AUC: 0.913 ± 0.022; AcR: 81.1 ± 4.8%). The CT Rotterdam score, age and either the FOUR score (model 3) or GCS (model 4) equally well predicted unfavourable outcome at 3 months post-injury (AUC: 0.852 ± 0.037 vs. 0.866 ± 0.034; AcR: 72.3 ± 6.6% vs. 71.9%±6.6%, respectively). Adding the FOUR score or GCS at discharge from ICU to predictive models for unfavourable outcome increased significantly their performances (AUC: 0.895 ± 0.029, p = 0.05; AcR: 76.1 ± 6.5%; p < 0.004 when compared with model 3; and AUC: 0.918 ± 0.025, p < 0.05; AcR: 79.6 ± 7.2%, p < 0.009 when compared with model 4), but there was no benefit from substituting GCS with the FOUR score. Conclusion: Results showed that FOUR score and GCS perform equally well in multivariate predictive modelling in TBI.