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Traumatic Brain Injury in the United States:
A Report to Congress

References

1. Sosin DM, Sniezek JE, Thurman DJ. Incidence of mild and moderate brain injury in the United States, 1991. Brain Injury 1996;10:47-54.

2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Unpublished analysis of data from the 1994 National Hospital Discharge Survey, 1998.

3. Sosin DM, Sniezek JE, Waxweiler RJ. Trends in death associated with traumatic brain injury, 1979 through 1992. JAMA 1995;273:1778-80.

4. Centers for Disease Control and Prevention. Traumatic brain injury, Colorado, Missouri, Oklahoma, and Utah--1990-1993. MMWR, 1997;46:8-11.

5. Max W, MacKenzie EJ, Rice DP. Head injuries: costs and consequences. J Head trauma Rehabil 1991;6:76-91

6. Kraus JF. Epidemiology of head injury. In: Cooper PR, editor. Head Injury, 3rd ed. Baltimore: Williams and Wilkins, 1993;1-25.

7. Annegers JF, Grabow HD, Kurland LT, et al. The incidence, causes and secular trends in head injury in Olmsted County, Minnesota, 1935-1974. Neurology 1980;30:912-9.

8. Klauber MR, Barrett-Connor E, Marshall LF, Bowers SA. The epidemiology of head injury: a prospective study of an entire community -- San Diego County, California, 1978. Am J Epidemiol 1981;113:500-9.

9. Cooper KD, Tabaddor K, Hauser WA, et al. The epidemiology of head injury in the Bronx. Neuroepidemiology 1983;2:70-88.

10. Jagger J, Levine JI, Jane JA, Rimel RW. Epidemiologic features of head injury in a predominantly rural population. J Trauma 1984;24:40-4.

11. Kraus JF, Black MA, Hessol N, et al. The incidence of acute brain injury and serious impairment in a defined population. Am J Epidemiol 1984;119:186-201.

12. Whitman S, Coonley-Hoganson R, Desai BT. Comparative head trauma experience in two socioeconomically different Chicago-area communities: a population study. Am J Epidemiol 1984;4:560-80.

13. Fife D, Faich G, Hollinshead W, Wentworth B. Incidence and outcome of hospital-treated head injury in Rhode Island. Am J Public Health 1986;76:773-8.

14. Fife D. Head injury with and without hospital admission: comparisons of incidence and short-term disability. Am J Public Health 1987;77:810-12.

15. MacKenzie EJ, Edelstein SL, Flynn JP. Hospitalized head-injured patients in Maryland: incidence and severity of injuries. Maryland Med J 1989;38:725-32.

16. Kalsbeek WD, McLaurin RL, Harris BS, Miller JD. The National Head and Spinal Cord Injury Survey: major findings. J Neurosurg 1980;53:S19-24.

17. Kraus JF, McArthur DL. Epidemiologic aspects of brain injury. Neurologic Clinics 1996;14(2):435-50

18. Department of Health and Human Services. Federal Interagency Head Injury Task Force Report. Washington, D.C.: Department of Health and Human Services, 1989.

19. Thurman DJ, Sniezek JE, Johnson D, et al. Guidelines for Surveillance of Central Nervous System Injury. Atlanta: Centers for Disease Control and Prevention, 1995.

20. Gabella B, Hoffman RE, Marine WW, Stallones L. Urban and rural brain injuries in Colorado. Ann Epidemiol 1997;7:207-12.

21. Thurman DJ, Jeppson L, Burnett CL, Beaudoin DE, Rheinberger MM, Sniezek JE. Surveillance of traumatic brain injuries in Utah. Western J Med 1996;164:192-6.

21. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Unpublished analysis of data from Multiple Cause of Death Public Use Data, 1997.

22. Guerrero JL, Leadbetter S, Thurman DJ, Whiteneck G, Sniezek JE. A method for estimating the prevalence of disability from traumatic brain injury. (Submitted for publication, 1999)

23. Association for the Advancement of Automotive Medicine. The Abbreviated Injury Scale, 1990 Revision. Des Plains (IL): Association for the Advancement of Automotive Medicine, 1990.

24. Center for Injury Research and Policy of the Johns Hopkins University School of Public Health. ICDMAP-90 Software. Baltimore, MD: The Johns Hopkins University and Tri-Analytics, Inc., 1997.

25. Brooks CA, Gabella B, Hoffman R, Sosin D, Whiteneck G. Traumatic brain injury: designing and implementing a population-based follow-up system. Arch Phys Med Rehabil 1997; 78(8):S26-S30.

26.  Whiteneck G. Personal communication, 1998.

27.  Research Foundation, State University of New York. Guide for use of the uniform data set for medical rehabilitation including the functional independence measure (FIM) and functional assessment measure (FAM), version 4.0. Buffalo, NY: State University of New York, 1995.

 

Appendix: Methods Used to Produce Estimates for This Report

CDC Case Definition for Traumatic Brain Injury

CDC issued the following case definition for traumatic brain injury in its 1995 publication, Guidelines for Surveillance of Central Nervous System Injury.1

For the purposes of public health surveillance, jurisdictions may elect to ascertain cases of traumatic brain injury from clinical records or from existing uniform data systems. Case definitions are presented for both types of ascertainment.

Clinical Case Definition. For surveillance systems using data from clinical records, a case of traumatic brain injury (craniocerebral trauma) is defined either:

  • as an occurrence of injury to the head that is documented in a medical record, with one or more of the following conditions attributed to head injury:*
        - observed or self-reported decreased level of consciousness,†
        - amnesia,‡
        - skull fracture,
        - objective neurological or neuropsychological abnormality,§ or
        - diagnosed intracranial lesion;||
  • or as an occurrence of death resulting from trauma, with head injury listed on the death certificate, autopsy report, or medical examiner's report in the sequence of conditions that resulted in death.

 

*Injuries to the head may arise from blunt or penetrating trauma or from acceleration-deceleration forces.

†Decreased level of consciousness refers to partial or complete loss of consciousness. This includes states described as obtundation, stupor, or coma.

‡Amnesia may include loss of memory for events immediately preceding the injury (retrograde amnesia), for the injury event itself, and for events subsequent to the injury (posttraumatic amnesia).

§Neurological abnormalities are determined from neurological examination. Examples include abnormalities of motor function, sensory function, or reflexes; abnormalities of speech (aphasia or dysphasia); or seizures acutely following head trauma. Neuropsychological abnormalities are determined from mental status and neuropsychological examinations. Examples include disorders of mental status (such as disorientation, agitation, or confusion) and other changes in cognition, behavior, or personality.

||Examples of diagnosed intracranial lesions include traumatic intracranial hematomas or hemorrhage (epidural, subdural, subarachnoid, or intracerebral), cerebral contusions or lacerations, or penetrating cerebral injuries (e.g., gunshot wounds). The diagnosis of such intracranial lesions is usually confirmed with a computed tomography (CT) or magnetic resonance imaging (MRI) brain scan or by other neurodiagnostic procedures.

The clinical definition of traumatic brain injury excludes the following:

  • lacerations or contusions of the face, eye, ear, or scalp, without other criteria listed above
  • fractures of facial bones, without other criteria listed above
  • birth trauma
  • primary anoxic, inflammatory, infectious, toxic, or metabolic encephalopathies which are not complications of head trauma
  • neoplasms
  • brain infarction (ischemic stroke) and intracranial hemorrhage (hemorrhagic stroke) without associated trauma

Data Systems Case Definition. For surveillance systems receiving case reports from coded death certificates or hospital discharge data, the following International Classification of Diseases, Ninth Revision (ICD-9)2 or International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)3 diagnostic codes are included in the definition of traumatic brain injury:

800.0-801.9 Fracture of the vault or base of the skull

803.0-804.9 Other and unqualified and multiple fractures of the skull

850.0-854.1 Intracranial injury, including concussion, contusion, laceration, and hemorrhage.

Additional cases of traumatic brain injury may be ascertained from death certificates coded as follows:

873.0-873.9 Other open wound of head.**,4

Note: ICD-9 codes are used for coding death certificates. ICD-9-CM codes are used for morbidity data. The codes are comparable except that ICD-9-CM codes include a fifth digit not found in ICD-9 codes.

**Note: This code range should not be applied to intracranial injuries. However, reviews of multiple cause mortality data from death certificates indicate that a substantial number of cases of intracranial injury, especially gunshot wounds, are mistakenly given these codes.3 Suspected cases of head trauma which have been so coded may be confirmed by review of medical records or death certificates.

 

Surveillance Methods Used by States

State health departments in Arizona, Colorado, Minnesota, Missouri, Oklahoma, New York, and South Carolina reviewed hospital discharge data collected from January 1 to December 31, 1994, using CDC guidelines to identify cases of TBI. The review identified all cases of TBI among patients in acute care hospitals who had been discharged with primary or secondary diagnoses consistent with the CDC case definition (i.e., ICD-9-CM code ranges 800.0-801.9, 803.0-804.9, and 850.0-854.1). In addition, the review identified TBI-related deaths and collected information from all death certificates or medical examiner reports that listed TBI or head injury among the conditions associated with death. Records were linked to eliminate duplicate cases reported from more than one source. Surveillance in New York excluded residents of New York City. Surveillance was statewide in all other States. In most States, supplementary information on severity and external cause of injury was obtained from abstracts of medical records or health-care provider report forms for all cases (Missouri and Oklahoma) or from representative samples of cases (Arizona [31 percent sample], Colorado [47 percent sample], and South Carolina [45 percent sample]). The TBI incidence rate for all seven States combined was calculated by using the sum of the number of cases for each State and the sum of the population of each State estimated at the midpoint of 1994 (35.3 million total).

Appendix References

1. Thurman DJ, Sniezek JE, Johnson D, et al. Guidelines for Surveillance of Central Nervous System Injury. Atlanta: Centers for Disease Control and Prevention, 1995.

2. International Classification of Diseases, 9th Revision (ICD-9). Geneva, Switzerland: World Health Organization, 1977.

3. International Classification of Diseases, 9th Revision, Clinical Modification, 3rd ed. (ICD-9-CM). Washington DC: U.S. Department of Health and Human Services, 1989.

4. Sosin DM, Nelson DE, Sacks JJ. Head injury deaths: the enormity of firearms. JAMA 1992;268:791.

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