Validation of the FOUR Score (Spanish Version) in acute stroke: an interobserver variability study.
BACKGROUND
Methods to assess impaired consciousness in acute stroke typically include the Glasgow Coma Scale (GCS), but the verbal component has limitations in aphasic or intubated patients. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale, evaluates 4 components: eye and motor responses, brainstem reflexes and respiration. We aimed to study the interobserver variability of the FOUR score in acute stroke patients.


METHODS
We prospectively enrolled consecutive patients with acute stroke admitted from February to July 2008 to the stroke unit of our Neurology Department. Patients were evaluated by neurology residents and nurses using the FOUR score and the GCS. For both scales, we obtained paired and total weighted kappa values (Kw) and intraclass correlation coefficients (ICC). NIH stroke scale was also recorded on admission.


RESULTS
We obtained a total of 75 paired evaluations in 60 patients (41 cerebral infarctions, 15 cerebral hemorrhages and 4 transient ischemic attacks). Thirty-three (55%) patients were alert, 17 (28.3%) drowsy and 10 (16.7%) stuporous or comatose. The overall rater agreement was excellent in the FOUR score (Kw 0.93; 95% CI 0.89-0.97) with an ICC of 0.94 (95% CI 0.91-0.96) and in the GCS (Kw 0.96; 95% CI 0.94-0.98) with an ICC of 0.96 (95% CI 0.93-0.97). A good correlation was found between the FOUR score and the GCS (rho 0.83; p < 0.01) and between the FOUR score and the NIH stroke scale (rho -0.78; p < 0.001).


CONCLUSIONS
The FOUR score is a reliable scale for evaluating the level of consciousness in acute stroke patients, showing a good correlation with the GCS and the NIH stroke scale.
Idrovo
Luis
L
Department of Neurology, Stroke Unit, La Paz University Hospital, Autonoma University of Madrid, IdiPAZ, Madrid, Spain.
Fuentes
Blanca
B
Medina
Josmarlin
J
Gabaldón
Laura
L
Ruiz-Ares
Gerardo
G
Abenza
María José
MJ
Aguilar-Amat
María José
MJ
Martínez-Sánchez
Patricia
P
Rodríguez
Luis
L
Cazorla
Rubén
R
Martínez
Marta
M
Tafur
Alfonso
A
Wijdicks
Eelco F M
EF
Diez-Tejedor
Exuperio
E
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005133:Eye Movements / Q000502:physiology; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D008297:Male; D008875:Middle Aged; D009043:Motor Activity / Q000502:physiology; D015588:Observer Variation; D011446:Prospective Studies; D015203:Reproducibility of Results; D013223:Statistics as Topic; D020521:Stroke / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology*