The FOUR Score: A Reliable Instrument to Assess the Comatose Stroke Patient

neurological status that cannot be recognized by the CGS. Moreover, it gives some hints to identify patients with the locked-in syndrome through the capability, at the eye response item, of tracking and blinking on command as well as patients in the vegetative state since they open their eyes but are unable of tracking or blinking on command. However, since the scale was not developed to evaluate permanently unconscious or severely disabled patients, it is unable to distinguish patients with vegetative state from those in the minimally conscious state [9– 12] . So far, the scale has already been translated into French [13] and we welcome in this issue of European Neurology the Spanish version [14] . Authors from the University of Madrid and from the Mayo Clinic compared the Spanish version of the FOUR score with the GCS in 60 patients with acute stroke or transient ischemic attack [14] . They found a good correlation with the GCS and a high interobserver agreement giving proper validation to the Spanish version for its use in clinical research and practice. Availability of a validated Spanish version of the scale is important since Spanish is the second most diffuse language worldwide. The primacy of the GCS for almost four decades is now challenged by the FOUR score that, in our opinion, will also contribute to fill up some of the grey areas of the National Institutes of Health Stroke Scale (NIHSS). Actually, in the same paper, authors also compared the FOUR score with the standardized NIHSS in the evaluation of The Glasgow Coma Scale (GCS) is a widely known tool for the evaluation of patients with impaired consciousness and coma [1] . The scale has been translated into many languages and is commonly used in clinical research and practice. Nevertheless, some criticism was raised on its enforcement [2–4] . Shortcomings of the GCS included the impossibility of testing the verbal component in intubated patients, the lack of items to graduate the severity of coma (abnormal brainstem reflexes, changing breathing patterns, and the need for mechanical ventilation), and therefore the impossibility to follow subtle changes of the neurological status in comatose patients. Consequently, there have been several attempts to develop new and improved scales over time [5, 6] . In our opinion, the FOUR (Full Outline of UnResponsiveness) score represents an important step forward [7] . The FOUR, as disclosed by the acronym, tests eye response, motor response, brainstem reflexes, and respiration with a score from 0 to 4, where 4 is the best performance, in each category. Inter-observer reliability for the FOUR was good to excellent and was similar to that for the GCS, also in the first study where raters had only little experience with the scale [7–9] . The strengths of the scale are based upon its simplicity to use and to overcome the inadequacy of the CGS for the evaluation of intubated patients since the FOUR score does not include a verbal response. With the inclusion of brainstem reflexes and respiration the scale allows an accurate evaluation of the comatose patient, enabling to track subtle changes in the Published online: June 16, 2010