[en] In nearly all clinical and research contexts, the initial severity of a traumatic brain injury (TBI) is measured
using the Glasgow Coma Scale (GCS) total score. The GCS total score however, may not accurately reflect
level of consciousness, a critical indicator of injury severity. We investigated the relationship between GCS
total scores and level of consciousness in a consecutive sample of 2455 adult subjects assessed with the
GCS 69,487 times as part of the multi-center Transforming Research and Clinical Knowledge in TBI (TRACKTBI) study. We assigned each GCS subscale score combination a level of consciousness rating based on published criteria for the following disorders of consciousness (DoC) diagnoses: coma, vegetative state/
unresponsive wakefulness syndrome, minimally conscious state, and post-traumatic confusional state, and present our findings using summary statistics and four illustrative cases. Participants had the following characteristics: mean (standard deviation) age 41.9 (17.6) years, 69% male, initial GCS 3–8 = 13%; 9–12 = 5%; 13–15 = 82%.
All GCS total scores between 4–14 were associated with more than one DoC diagnosis; the greatest variability
was observed for scores of 7–11. Further, a wide range of total scores was associated with identical DoC diagnoses. Importantly, a diagnosis of coma was only possible with GCS total scores of 3–6. The GCS total score does
not accurately reflect level of consciousness based on published DoC diagnostic criteria. To improve the classification of patients with TBI and to inform the design of future clinical trials, clinicians and investigators should
consider individual subscale behaviors and more comprehensive assessments when evaluating TBI severity
Research center :
GIGA-COMA - GIGA Consciousness-Coma Science Group - ULiège CHU de Liège-Centre du Cerveau² - ULiège
Disciplines :
Neurology
Author, co-author :
Bodien, Yelena G ✱; Massachussetts General Hospital > Spaulding Rehabilitation Hospital, > Neurorehabilitation Lab > Associate researcher
Barra, Alice ✱; Université de Liège - ULiège > GIGA Consciousness - Coma Science Group
✱ These authors have contributed equally to this work.
Language :
English
Title :
Diagnosing Level of Consciousness: Limits of the Glasgow Coma Scale Total Score
Publication date :
23 November 2021
Journal title :
Journal of Neurotrauma
ISSN :
0897-7151
eISSN :
1557-9042
Publisher :
Mary Ann Liebert, United States - New York
Volume :
38
Peer reviewed :
Peer Reviewed verified by ORBi
Name of the research project :
TRACK-TBI
Funders :
NINDS - National Institute of Neurological Disorders and Stroke [US-MD] [US-MD] NIDILRR - National Institute on Disability, Independent Living, and Rehabilitation Research [US-WA] [US-WA] ACL - Administration for Community Living [US-DC] [US-DC] JSMF - James S McDonnell Foundation [US-MO] [US-MO] Tiny Blue Dot Foundation [US-CA] [US-CA] USDOD - United States Department of Defense [US-DC] [US-DC] NSF - National Science Foundation [US-VA] [US-VA]
Funding text :
This study was supported by the NIH National Institute of Neurological Disorders and Stroke (R21NS109627, RF1NS115268, UH3NS095554, U01 NS1365885, U01- NS086090), NIH Director’s Office (DP2 HD101400), National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR), Administration for Community Living (90DPCP0008-01-00, 90DP0039), James S. McDonnell Foundation, and Tiny Blue Dot Foundation, U.S. Department of Defense (W81XWH14-2-0176, X81XWH-18-DMRDP-PTCRA), National Science Foundation (1014552)
Teasdale, G., and Jennett, B. (1974). Assessment of coma and impaired consciousness. A practical scale. Lancet 2, 81 84.
Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., and Murray, G. (2014). The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol. 13, 844 854.
Reith, F.C., Brennan, P.M., Maas, A.I., and Teasdale, G.M. (2016). Lack of standardization in the use of the Glasgow Coma Scale: results of international surveys. J. Neurotrauma 33, 89 94.
Marmarou, A., Lu, J., Butcher, I., McHugh, G.S., Murray, G.D., Steyerberg, E.W., Mushkudiani, N.A., Choi, S., and Maas, A.I. (2007). Prognostic value of the Glasgow Coma Scale and pupil reactivity in traumatic brain injury assessed pre-hospital and on enrollment: an IMPACT analysis. J. Neurotrauma 24, 270-280.
Wilde, E.A., Whiteneck, G.G., Bogner, J., Bushnik, T., Cifu, D.X., Dikmen, S., French, L., Giacino, J.T., Hart, T., Malec, J.F., Millis, S.R., Novack, T.A., Sherer, M., Tulsky, D.S., Vanderploeg, R.D., and von Steinbuechel, N. (2010). Recommendations for the use of common outcome measures in traumatic brain injury research. Arch. Phys. Med. Rehabil. 91, 1650 1660.e1617.
Maas, A.I., Roozenbeek, B., and Manley, G.T. (2010). Clinical trials in traumatic brain injury: past experience and current developments. Neurotherapeutics 7, 115 126.
Teasdale, G., Murray, G., Parker, L. and Jennett, B. (1979). Adding up the Glasgow Coma Score. Acta Neurochir Suppl (Wien) 28, 13-16.
Jennett, B. (1979). Defining brain damage after head injury. J R Coll Physicians Lond 13, 197-200.
Fischer, M., Ru egg, S., Czaplinski, A., Strohmeier, M., Lehmann, A., Tschan, F., Hunziker, P.R. and Marsch, S.C. (2010). Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care 14, R64.
Teasdale, G., and Jennett, B. (1976). Assessment and prognosis of coma after head injury. Acta Neurochir. 34, 45 55.
Healey, C., Osler, T.M., Rogers, F.B., Healey, M.A., Glance, L.G., Kilgo, P.D., Shackford, S.R., and Meredith, J.W. (2003). Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J. Trauma 54, 671 678.
Steyerberg, E.W., Mushkudiani, N., Perel, P., Butcher, I., Lu, J., McHugh, G.S., Murray, G.D., Marmarou, A., Roberts, I., Habbema, J.D., and Maas, A.I. (2008). Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 5, e165.
Teasdale, G., Jennett, B., Murray, L., and Murray, G. (1983). Glasgow Coma Scale: To sum or not to sum? Lancet 322, 678.
Bhatty, G.B., and Kapoor, N. (1993). The Glasgow Coma Scale: a mathematical critique. Acta Neurochir. 120, 132 135.
Reith, F.C.M., Lingsma, H.F., Gabbe, B.J., Lecky, F.E., Roberts, I., and Maas, A.I.R. (2017). Differential effects of the Glasgow Coma Scale Score and its components: an analysis of 54,069 patients with traumatic brain injury. Injury 48, 1932 1943.
Teoh, L.S., Gowardman, J.R., Larsen, P.D., Green, R., and Galletly, D.C. (2000). Glasgow Coma Scale: variation in mortality among permutations of specific total scores. Intensive Care Med. 26, 157 161.
McCrea, M.A., Giacino, J.T., Barber, J., Temkin, N.R., Nelson, L.D., Levin, H.S., Dikmen, S., Stein, M., Bodien, Y.G., Boase, K., Taylor, S.R., Vassar, M., Mukherjee, P., Robertson, C., Diaz-Arrastia, R., Okonkwo, D.O., Markowitz, A.J., Manley, G.T., Adeoye, O., Badjatia, N., Bullock, M.R., Chesnut, R., Corrigan, J.D., Crawford, K., Duhaime, A.C., Ellenbogen, R., Feeser, V.R., Ferguson, A.R., Foreman, B., Gardner, R., Gaudette, E., Goldman, D., Gonzalez, L., Gopinath, S., Gullapalli, R., Hemphill, J.C., Hotz, G., Jain, S., Keene, C.D., Korley, F.K., Kramer, J., Kreitzer, N., Lindsell, C., Machamer, J., Madden, C., Martin, A., McAllister, T., Merchant, R., Ngwenya, L.B., Noel, F., Nolan, A., Palacios, E., Perl, D., Puccio, A., Rabinowitz, M., Rosand, J., Sander, A., Satris, G., Schnyer, D., Seabury, S., Sherer, M., Toga, A., Valadka, A., Wang, K., Yue, J.K., Yuh, E., and Zafonte, R. (2021). Functional outcomes over the first year after moderate to severe traumatic brain injury in the prospective, longitudinal TRACK-TBI Study. JAMA Neurol. 78, 982 992.
Nelson, L.D., Temkin, N.R., Dikmen, S., Barber, J., Giacino, J.T., Yuh, E., Levin, H.S., McCrea, M.A., Stein, M.B., Mukherjee, P., Okonkwo, D.O., Diaz- Arrastia, R., Manley, G.T., Adeoye, O., Badjatia, N., Boase, K., Bodien, Y., Bullock, M.R., Chesnut, R., Corrigan, J.D., Crawford, K., Duhaime, A.C., Ellenbogen, R., Feeser, V.R., Ferguson, A., Foreman, B., Gardner, R., Gaudette, E., Gonzalez, L., Gopinath, S., Gullapalli, R., Hemphill, J.C., Hotz, G., Jain, S., Korley, F., Kramer, J., Kreitzer, N., Lindsell, C., Machamer, J., Madden, C., Martin, A., McAllister, T., Merchant, R., Noel, F., Palacios, E., Perl, D., Puccio, A., Rabinowitz, M., Robertson, C.S., Rosand, J., Sander, A., Satris, G., Schnyer, D., Seabury, S., Sherer, M., Taylor, S., Toga, A., Valadka, A., Vassar, M.J., Vespa, P., Wang, K., Yue, J.K., and Zafonte, R. (2019). Recovery after mild traumatic brain injury in patients presenting to US level i trauma centers: a transforming research and clinical knowledge in traumatic brain injury (TRACK-TBI) Study. JAMA Neurol. 76, 1049 1059.
Giacino, J., Ashwal, S., Childs, N., Cranford, R., Jennett, B., Katz, D.I., Kelly, J.P., Rosenberg, J.H., Whyte, J., Zafonte, R.D., and Zasler, N.D. (2002). The minimally conscious state: definition and diagnostic criteria. Neurology 58, 349 353.
Thibaut, A., Bodien, Y.G., Laureys, S. and Giacino, J.T. (2020). Minimally conscious state plus : diagnostic criteria and relation to functional recovery. Journal of Neurology 267, 1245-1254.
Giacino, J.T., Sherer, M., Christoforou, A., Maurer-Karattup, P., Hammond, F.M., Long, D. and Bagiella, E. (2020). Behavioral Recovery and Early Decision Making in Patients with Prolonged Disturbance in Consciousness after Traumatic Brain Injury. Journal of neurotrauma 37, 357-365.
Martens, G., Bodien, Y., Sheau, K., Christoforou, A. and Giacino, J.T. (2020). Which behaviours are first to emerge during recovery of consciousness after severe brain injury? Ann Phys Rehabil Med 63, 263-269.
Schnakers, C., Giacino, J., Kalmar, K., Piret, S., Lopez, E., Boly, M., Malone, R. and Laureys, S. (2006). Does the FOUR score correctly diagnose the vegetative and minimally conscious states? Ann Neurol 60, 744-745; author reply 745.
Sherer, M., Katz, D.I., Bodien, Y.G., Arciniegas, D.B., Block, C., Blum, S., Doiron, M., Frey, K., Giacino, J.T., Graf, M.J.P., Greenwald, B., Hammond, F.M., Kalmar, K., Kean, J., Kraus, M.F., Richardson, R.N., Pavawalla, S., Rosenbaum, A., Stuss, D.T. and Yablon, S.A. (2020). The Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria. Arch Phys Med Rehabil. 26. TRACK-TBI Webpage for Researchers. http://tracktbi.ucsf.edu/ researchers. Last accessed October 20, 2021.
Rutledge, R., Lentz, C.W., Fakhry, S. and Hunt, J. (1996). Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores. J Trauma 41, 514-522.
Posner, J.B., Saper, C.B., Schiff, N.D. and Plum, F. (2013). Plum and Posner s Diagnosis of Stupor and Coma. In: Pathophysiology of Signs and Symptoms of Coma. Oxford University Press. 29. Giacino, J.T., Zasler Nathan D., Whyte J, Katz Doug I., Glen M., and Andary M. (1995). Recommendations for use of uniform nomenclature pertinent to patients with severe alterations in consciousness. American Congress of Rehabilitation Medicine. Arch Phys Med Rehabil 76, 205 209.
Giacino, J.T., Kalmar, K. and Whyte, J. (2004). The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil 85, 2020 2029.
Royal College of Physicians and Surgeons of Glasgow Website on the Glasgow Coma Scale. http://www.glasgowcomascale.org. Last accessed October 20, 2021.
Giacino, J.T., Katz, D.I., Schiff, N.D., Whyte, J., Ashman, E.J., Ashwal, S., Barbano, R., Hammond, F.M., Laureys, S., Ling, G.S.F., Nakase- Richardson, R., Seel, R.T., Yablon, S., Getchius, T.S.D., Gronseth, G.S. and Armstrong, M.J. (2018). Practice guideline update recommendations summary: Disorders of consciousness. Neurology 91, 450.
Wijdicks, E.F., Kramer, A.A., Rohs, T., Jr., Hanna, S., Sadaka, F., O Brien, J., Bible, S., Dickess, S.M. and Foss, M. (2015). Comparison of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in predicting mortality in critically ill patients*. Crit. Care Med. 43, 439 444.
Kupas, D.F., Melnychuk, E.M., and Young, A.J. (2016). Glasgow Coma Scale motor component ( Patient does not follow commands ) performs similarly to total Glasgow Coma Scale in predicting severe injury in trauma patients. Ann. Emerg. Med. 68, 744 750.e3.
Ross, S.E., Leipold, C., Terregino, C., and O Malley, K.F. (1998). Efficacy of the motor component of the Glasgow Coma Scale in trauma triage. J. Trauma 45, 42 44.
Deeb, A.P., Phelos, H.M., Peitzman, A.B., Billiar, T.R., Sperry, J.L., and Brown, J.B. (2021). The whole is greater than the sum of its parts: GCS versus GCS-motor for triage in geriatric trauma. J. Surg. Res. 261, 385 393.
Carney, N., Totten, A.M., O Reilly, C., Ullman, J.S., Hawryluk, G.W., Bell, M.J., Bratton, S.L., Chesnut, R., Harris, O.A., Kissoon, N., Rubiano, A.M., Shutter, L., Tasker, R.C., Vavilala, M.S., Wilberger, J., Wright, D.W., and Ghajar, J. (2017). Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 80, 6 15.
Zafonte, R.D., Hammond, F.M., Mann, N.R., Wood, D.L., Black, K.L., and Millis, S.R. (1996). Relationship between Glasgow coma scale and functional outcome. Am. J. Phys. Med. Rehabil. 75, 364 369.
