Grading of hepatic encephalopathy categorizes it in clinical stages of stepwise worsening. The description of each grade varies somewhat in the literature, but differences between adjacent grades are clear enough to be helpful in clinical practice, although neurologic descriptors are sparse. One study showed that for patients who become comatose, the Full Outline of Unresponsiveness (FOUR) score is more discriminating than the West Haven grading system because it includes brain-stem and respiration assessment, which are not further differentiated in the West Haven system.
FOUR
FOUR Score for Comatose Patients
The Full Outline of UnResponsiveness (FOUR) score provides greater neurological detail than the Glasgow Coma Scale (GCS), recognizes a locked-in syndrome, and is superior to the GCS due to the availability of brainstem reflexes, breathing patterns, and the ability to recognize different stages of herniation.