Dynamic assessment of the prognostic value of scoring systems FOUR, GCS and CRS-R in patients with chronic critical illness after acute brain injury

Introduction. Prognostication in patients with chronic critical illness (CCI) remains a major clinical challenge. Traditional severity scores designed for admission assessment progressively lose their predictive accuracy with longer ICU stays. In contrast, consciousness assessment scales such as the Glasgow Coma Scale (GCS), Full Outline of UnResponsiveness (FOUR) score, and Coma Recovery Scale-Revised (CRS-R) were primarily developed for clinical characterization of patient status, while their prognostic potential in long-term ICU patients has not been sufficiently investigated.

The objective was to evaluate the prognostic value of consciousness level assessment scales in patients with chronic critical illness relative to the time period preceding the outcome (recovery or death).

Materials and methods. An analysis of real-world clinical data from the RICD v 2.0 database was conducted. The study included patients with chronic critical illness following acute brain injury. Level of consciousness was assessed using the FOUR, GCS, and CRS-R scales within three timeframes relative to the outcome: within 7 days, 8–14 days, and more than 14 days prior to death or discharge from the ICU. The prognostic value of the scores for the clinical outcome was assessed using ROC analysis and comparative statistics.

Results. The study included 1,239 patients. A total of 4,773 sequential FOUR score, 4,875 GCS, and 2,437 CRS-R assessments were analyzed. A progressive increase in the prognostic value of the GCS was observed as the assessment timepoint moved closer to the outcome: the AUROC was 0.571 for assessments performed more than 14 days before the outcome, 0.622 for the 8–14 day period, and 0.718 for the period within 7 days of the outcome. For the FOUR scale, the AUROC values for the corresponding time periods were 0.607, 0.685, and 0.756, respectively. For the CRS-R, the values were 0.555, 0.556, and 0.699.

Conclusion. The prognostic accuracy of the FOUR, GCS, and CRS-R scales for mortality in patients with chronic critical illness increases as the outcome approaches, peaking within 7 days prior to the event.

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