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February 01, 2022; 98 (5) Research Article

Association of the Verbal Component of the GCS With Mortality in Patients With Encephalopathy Who Are Not Undergoing Mechanical Ventilation

Olga Selioutski, Peggy Auinger, Omar K. Siddiqi, View ORCID ProfileBenedict Daniel Michael, View ORCID ProfileClayton Buback, View ORCID ProfileGretchen L. Birbeck
First published November 29, 2021, DOI: https://doi.org/10.1212/WNL.0000000000013127
Olga Selioutski
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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Peggy Auinger
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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Omar K. Siddiqi
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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Benedict Daniel Michael
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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  • ORCID record for Benedict Daniel Michael
Clayton Buback
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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Gretchen L. Birbeck
From the Department of Neurology (O.S., G.L.B.), Epilepsy Division, and Department of Neurology (P.A.), Center for Health and Technology, University of Rochester School of Medicine and Dentistry, NY; Department of Neurology (O.K.S.), Global Neurology Program, and Department of Internal Medicine (O.K.S.), Center for Vaccines and Virology Research, Beth Israel Deaconess Medical Center, Boston, MA; University of Zambia School of Medicine (O.K.S., G.L.B.), Lusaka; Department of Neurology (B.D.M.), Walton Centre NHS Foundation Trust; NIHR Health Protection Research Unit for Emerging and Zoonotic Infection (B.D.M.); Clinical Infection Microbiology and Immunology (B.D.M.), Institute of Infection, Veterinary, and Zoological Science, University of Liverpool, UK; Department of Neurology (C.B.), University of California San Francisco; and University Teaching Hospitals Children's Hospital (G.L.B.), Lusaka, Zambia.
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  • ORCID record for Gretchen L. Birbeck
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Association of the Verbal Component of the GCS With Mortality in Patients With Encephalopathy Who Are Not Undergoing Mechanical Ventilation
Olga Selioutski, Peggy Auinger, Omar K. Siddiqi, Benedict Daniel Michael, Clayton Buback, Gretchen L. Birbeck
Neurology Feb 2022, 98 (5) e533-e540; DOI: 10.1212/WNL.0000000000013127

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Abstract

Background and Objectives 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.

Methods 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).

Results 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).

Discussion 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.

Classification of Evidence 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.

Glossary

AU ROC=
area under the receiver operating characteristic curve;
CI=
confidence interval;
FOUR=
Full Outline of Unresponsiveness;
FOUR B=
FOUR Score Brainstem;
FOUR E=
FOUR Score Eye Response;
FOUR M=
FOUR Score Motor Response;
FOUR R=
FOUR Score Respiration Pattern;
GCS=
Glasgow Coma Scale;
GCS E=
GCS Eye Response;
GCS M=
GCS Motor Abilities;
GCS V=
GCS Verbal Response;
UTH=
University Teaching Hospitals

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Class of Evidence: NPub.org/coe

  • Received April 9, 2021.
  • Accepted in final form November 16, 2021.
  • © 2022 American Academy of Neurology
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