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CC BY 4.0 · Indian Journal of Neurotrauma
DOI: 10.1055/s-0045-1810436
Letter to the Editor

The Glasgow Coma Scale and Contemporary Neurotrauma Care

Luis Rafael Moscote-Salazar 
1   Department of Research, AV Healthcare Innovators, LLC, Madison, Wisconsin, United States
,
Amit Agrawal 
2   Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
› Author Affiliations
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Neurological examination is the mainstay of care of critically ill patients.[1] The Glasgow Coma Scale (GCS) was originally proposed in 1974 by Graham Teasdale and Bryan Jennett and has been a front-running instrument for over four decades to measure the level of consciousness of traumatic brain injury (TBI) patients.[2] Because it is easy to perform, simple, and reproducible, the GCS became a part of emergency departments, intensive care units, and prehospital care in all corners of the world.[3] But with the days of rapidly changing neurocritical care, there are numerous clinicians and scientists questioning now: is GCS still adequate enough to meet the expectations of modern-day practice, or is it not required anymore to be the gold standard?[4]

Strengths of the GCS

The benefit of the GCS is that it performs a formal evaluation of three of the most significant features of consciousness: eye-opening, verbal response, and motor response.[3] It facilitates rapid communication among providers and is simple to teach and recognize by all medical specialties. In mass casualty operations and in the resource-poor setting, its uses are unparalleled. In addition, the GCS continues to be used in trauma triage rules, severity scoring, and high-stakes clinical trials. It continues to serve as a common denominator to monitor neurological change over time.[3]


 

Clinical Limitations and Real-World Challenges

Although it was historically significant, the GCS falls short on many fronts that are increasingly evident in clinical use, i.e., verbal response cannot be evaluated in intubated or sedated patients, resulting in spurious or inaccurate scores and mild TBI can possess normal GCS score, possibly evading severe underlying pathology like intracranial bleeding or diffuse axonal injury. Interrater reliability is the rule rather than the exception, most particularly in the assessment of the motor component.[5] Divergent scores, even among specialists, can affect clinical decision-making; however, the GCS scale does not have brainstem assessment, which is required in the assessment of neurological deterioration in patients with brain injury.[6] These shortfalls have been the topic of debate concerning the use of GCS as an isolated measure of neurological function.


 

Alternative and Complementary Tools

To address these shortcomings, alternative scoring tools have been advocated to replace or augment the GCS.[6] Perhaps one of the most widely used is the FOUR (Full Outline of UnResponsiveness) score, which includes evaluation of brainstem reflexes and breathing patterns—neither addressed by the GCS.[6] [7] [8] Other instruments, like the Simplified Motor Score and the Pupil Reactivity Score, provide quick and specific testing, especially useful for prehospital and emergency practice. While these instruments do address some of the GCS's specific limitations, none have yet achieved as broad international recognition or trauma system integration as the GCS.[3]


 

A Balanced View: Evolve to Overcome Limitations

Instead of abandoning the GCS, the majority of experts recommend reinforcing its usage through constant integration with additional clinical information and markers. These range from the incorporation of the GCS with pupillary examination, radiologic results, and objective neuromonitoring modalities. The future of neurological testing could no longer be a number but a multimodal strategy that unifies quantitative and clinical evaluation. The use of artificial intelligence, neuroimaging biomarkers, and real-time physiological monitoring will come to provide more accurate and personalized estimation of consciousness and prognosis.


 

Global and Ethical Considerations

It should also be noted that the GCS remains a valid tool in low-resource environments. High-technology diagnostics are available in major parts of the world and the GCS remains one of the only standardized tools by which to assess TBI. It may be retained as a global health guideline option, but there will have to be maintenance of training and familiarization with its limitations.

Finally, GCS has been the bedrock of neurotrauma for nearly 50 years. While its limitations are patent, its advantages remain significant—if utilized prudently and within the appropriate setting. With continuing advances in neurocritical care, GCS must be seen not as a relic of the past, but as a tool that needs to be optimized with advancing knowledge. It may no longer be sufficient as a standalone metric, but it remains a vital component of a more comprehensive neurological assessment strategy. The future of brain injury care will likely depend on our ability to integrate tradition with innovation—respecting what has worked, while remaining open to what could work better.


 

 

Conflict of Interest

None declared.


Address for correspondence

Luis Rafael Moscote-Salazar, MD
Department of Research, AV Healthcare Innovators, LLC
Madison, Wisconsin 53716
United States   

Publication History

Article published online:
09 August 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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