# Presentation: 186980

## Traumatic Brain Injury Classification

**Israel national center for trauma and emergency medicine research**
**Gertner Institute for Epidemiology and Health Policy Research**

- Limor Aharonson-Daniel, PhD

- For
- International Collaborative Effort on Injury Statistics,
- Washington DC, September 7-8, 2006

## In 1995, clinical case definition standardized

- It included any intracranial injury and any reported loss of consciousness or concussion.

- Guidelines for Surveillance of Central Nervous System Injury Thurman DJ, Sniezek JE, Jonson D, Greenspan A, Smith SM Atlanta: Centers for disease Control and Prevention, 1995).

**Notes:**
served as a basis for a TBI surveillance

## The definition encompasses a wide range of conditions which are easily, and with clinical reasoning, classifiable into two very distinctive groups of patients

**Fracture**
**Internal**
**Nerves**

**ICD-9-CM**

## Barell matrix definitions

-  **Type 1 TBI:** recorded evidence of an intracranial injury or a moderate or a prolonged loss of consciousness
- Shaken Infant Syndrome and injuries to the optic nerve pathways.
**Type 2 TBI:** no recorded evidence of intracranial injury and a  loc of less than one hour, a loc of unknown duration or an unspecified level of consciousness.
**Type 3 TBI:** no evidence of intracranial injury and no loc.

**Barell matrix definitions**

**Notes:**
Building
Adding of codes
Discuss names of rows

## Slide 5

## “We highly recommend the development of research  guidelines to standardize definitional, case finding, and data reporting parameters to help establish a more precise description and hence utility of the epidemiology of TBI in Europe”.

*A systematic review of brain injury epidemiology in Europe*
*F. Tagliaferri, C. Compagnone, M. Korsic, F. Servadei, and J. Kraus*
*Acta Neurochir (Wien) (2005) Published online November 28, 2005*

- It was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports.

**Notes:**
It was difficult to reach a consensus on all epidemiological findings across the 23 published European studies because of critical differences in methods employed across the reports.

## Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.

- Langlois JA, Rutland-Brown W, Thomas KE. **Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths***. *Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.

- The ICD-9-CM codes for TBI included in the analysis
- differed slightly from those in the **Barell Matrix**, a recommended
- categorization of ICD-9-CM codes for nonfatal injuries.
- The inclusion of 959.01 (head injury, unspecified)...

**Notes:**
“The ICD-9-CM codes for TBI included in the analysis
differed slightly from those in the Barell Matrix, a recommended
categorization of ICD-9-CM codes for nonfatal injuries.
The inclusion of 959.01 (head injury, unspecified) is
supported by data from South Carolina in 1998 in which 63%
of ED visits and 9% of hospitalizations were identified using
only this code. The increased use of 959.01 was accompanied
by a corresponding drop in the use of 854. Thus, to avoid
underestimating TBIs, we included cases coded as 959.01. This
is consistent with a previous CDC publication on TBI and the
current CDC TBI case definition, and it is in a footnote to the
Barell Matrix”.

## Fracture of the vault or base of the skull			 800.0–801.9 	

- Other and unqualified multiple fractures of the skull		 803.0–804.9
- Intracranial injury, including concussion, contusion,
- laceration, and hemorrhage				 850.0–854.1
- Head injury, unspecified 					 959.01

- ICD-9-CM codes for traumatic brain injury related ED visits (1995-2001)

- Langlois JA, Rutland-Brown W, Thomas KE. *Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. *Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.

- 995.55, 950(.1-.3)

## Epidemiology of Emergency Department-Treated Traumatic Brain Injury in Minnesota 

**Epidemiology of Emergency Department-Treated Traumatic Brain Injury in Minnesota **
**Day H, Roesler J, Gaichas A, Kinde M, **
- Accessed at _[http://www.mmaonline.net/Publications/MNMed2006/May/clinical-day.htm](http://www.mmaonline.net/Publications/MNMed2006/May/clinical-day.htm)_ on aug 4 2006

## ‘skull fracture’ (800.0, 800.5, 801.0, 801.5, 803.0, 803.5, 804.0, 804.5),
‘concussion’ (850.0, 850.1, 850.5, 850.9), ‘intracranial
injury of unspecified nature’ (854.0) and ‘head
injury, unspecified’ (959.0). 

These codes are intended to identify TBI’s that approximate the mTBI clinical definition. They were recommended as the administrative case definition of mTBI for surveillance and research by the Centers for Disease Control and Prevention Mild Traumatic Brain Injury Work Group in October 2002.

- ‘concussion’ (850.0, 850.1, 850.5, 850.9), ‘intracranial
- injury of unspecified nature’ (854.0) and ‘head
- injury, unspecified’ (959.0).
- These codes are intended to identify TBI’s that approximate the mTBI clinical definition. They were recommended as the administrative case definition of mTBI for surveillance and research by the Centers for Disease Control and Prevention Mild Traumatic Brain Injury Work Group in October 2002.

- Mild traumatic brain injury in the United States, 1998–2000

- BAZARIAN JJ, MCCLUNG J, SHAH MN, CHENG YT, FLESHER W & KRAUS J
- Brain Injury, February 2005; 19(2): 85–91

- Includes cases where there is no intracranial injury even if there
- is an extended (>24h) LOC

**Notes:**
On the other hand I found reports from the mtbi
Codes like 800.05 skull fracture with no intracranial injury but with prolonged (>24h) loc without return to preexisting concious level.
803 and others.
Includes cases where there is no intracranial injury even if there is a long loc

## Population and methods

- Patients were included if they had isolated TBI.

- A look at the data

**Notes:**

Isolated meaning injuries only within rows 1-4 of the matrix to ensure that the source of severity is not another injury in the same patient. 

## AGE distribution by type of TBI

- 1998-2005, 7408 patients with isolated TBI

## SEVERITY OF INJURY (ISS) 

- 1998-2005, 7408 patients with isolated TBI

## Type of TBI by injury severity

- Among all TBI
- (n=7408)

- Among ISS 16+
- (n=3077)

## Severity Indicators

- 1998-2005, 7408 patients with isolated TBI

**Notes:**
Separation still seems valid

## Conclusion:

- Groups seem valid.
- Need to touch up definitions and finish the
- work begun a decade ago

- Implications for ICD-11?

**Notes:**
Definitely the American Neurological association is interested

## Partners?

**Partners****?**
**NCIPC**
**ANA**

- Do we agree that it is our business to improve and disseminate
-  a uniform / multi-leveled TBI definition?

**Notes:**
1 do we agree? (enter)
2 partners (enter)

The American Academy of Neurology requests that it be represented
in future deliberations regarding modifications of this Matrix, before this document is fomally adopted or endorsed by CDC.

## Thank you.