Comparison of Outcome Prediction Using Full Outline of Unresponsiveness (FOUR) Score and Glasgow Coma Scale (GCS) in Head-Injury Patients

Introduction: Traumatic brain injury (TBI) is a major global health burden, particularly in low- and middle- income countries such as India. Early, reliable neurological assessment is critical for triage and prognostication. The Glasgow Coma Scale (GCS) is long-established but lacks assessment of brainstem reflexes and respiration. The Full Outline of Unresponsiveness (FOUR) score was introduced to overcome these deficiencies. This study compares the predictive performance of the GCS and the FOUR score in patients with head injury. Methods: A prospective observational study was carried out at a tertiary teaching hospital in Puducherry, India (October 2022–November 2024). A sample size of 124 was initially taken; after the exclusion of 24 patients,100 patients were included. One hundred adults (≥ 18 years) with traumatic head injury selected by simple consecutive sampling were assessed serially with GCS and FOUR scores at admission, 6, 12, 24, 48, and 72 hours, and at discharge or death. Clinical, radiologic, and outcome data were analyzed using SPSS version 23 (IBM Corp., Armonk, NY, USA); receiver operating characteristic (ROC) curves were used to compare predictive accuracy for mortality, intubation, and ICU requirement. Binary logistic regression identified predictors of in-hospital mortality. Results: A total of 124 patients were recruited; after exclusion, 100 were included in the study. Mean age ± standard deviation (SD) was 47.8 ± 17.6 years; 81% of the patients were male. All injuries were from road traffic accidents. Subdural hematoma (34%) and cerebral contusion (30%) predominated. Mean ± SD was 8.9 ± 2.6 for admission GCS and 8.1 ± 4.1 for FOUR score. Mortality was 14%, with 49% good recovery. GCS and FOUR were strongly correlated (r = 0.83, P < 0.001); FOUR showed marginally higher area under the curve (AUC) for mortality (0.89 vs. 0.86). Conclusion: Both GCS and FOUR scores effectively predict outcomes in patients with head injury. The FOUR score offers a modest but clinically meaningful advantage through the inclusion of brainstem and respiratory parameters, improving prognostication in intubated or deeply comatose patients.